.*s p^ 'SfFnSV BOUGHT WITH THE INCOME FROM THE SAGE ENDOWMENT' FUND ^ THE GIFT OF Henvg m. Sage 1891 ..J\,.\US.6.0 Stli.Jrl.mi :; Cornell University Library arV13587 Clinical lectures on mental diseases / 3 1924 031 265 568 olin.anx The original of tliis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924031265568 CLINICAL LECTURES ME^TTAL DISEASES PLATE 1. ^-4^ THE VERThX or THE BRAIN IN ADVANCED FRONTISPIECE, FOR DESCklPIION SEE GENERAL PARALYSIS PAGE IX. CLmiCAL LECTURES MENTAL DISEASES T. S. CLOUSTOX, M.D. Edin., F.E.C.P.E. PHYSICIAN-SUPERINTENDENT OP THE EOTAL EDINBUE8H ASYLUM FOR THE INSANE LECTURER ON MENTAL DISEASES IN THE UNIVERSITY OP EDINBURGH FORMERLY CO-EDITOR "JOURNAL OP MENTAL SCIENCE" AND MORISON LECTURER AUTHOR OP "THE NEUROSES OP DEVELOPMENT." FIFTH EDITION LONDON J. & A. CHUECHILL 7 GREAT MARLBOROUGH STREET 1898 f PREFACE TO FIFTH EDITION. A Medical Book that is coming out in its Fifth Edition should need no Preface. The demand for it has absolved its Author from any further explanation of its existence. That it was needed, and has so far supplied a need, might he held as proved ; and this should be sufficient proof, too, of its merits and exculpation enough of its faults. The study of ^Mental Disease has now entered on a new era. It has, for the first time, become compulsory on all medical students. This should vivify and stimulate the teaching of it, and affect the study and investigation of the subject in ways and degrees as yet unknown to us. Fortunately, the subject lends itself to teaching in which every intelh'gent student will be more or less interested. I have always maintained that no subject in his course will keep the average student so mentally alert as a good chnical lecture on mental diseases, well illustrated by patients. I trust we teachers will be enabled now, more than ever, to present to our students, in addition to the details of our subject, the re- lationship of the disturbed mental functions of the brain to general Medicine and Surgery, and so prevent our department from sinking into a specialty in the bad sense. Mind and brain dominate all else in the organism; and their diseases, if properly studied, can never be narrowing. VI PEEFACE. In regard to how this Edition dilTers from the last, I can only say it is mostly a reprint, but yet I have endeavoured to embody in it the few advances in our knowledge that have taken place during the past two years. I have especially directed attention to the important therapeutic measure of using thyroid extract in certain cases of insanity, in the way devised by Dr Lewis Bruce, now one of our medical staff here. I have taken advantage of the original patho- logical work done here, and in the Scottish Asylums patho- logical laboratory, in that time by Dr "W. F. Eobertsoh, under whose direction the new Plates XVI., XVII., XVIII. and XIX., which illustrate the recently discovered facts about chromatolysis, atrophies, and hypertrophies in the neurons, have been prepared. September, 189S. CONTENTS LECTURE I. PAGE The Clinical Study of Mental Diseases, ... 1 LECTURE II. States of Mental Depkession — Melancholia (Psychalgia), 26 LECTURE III. Melancholia (Psychalgia) — continued, . . .82 LECTURE l\. States of Mental Exaltation— Mania (Psychlampsia), . 137 LECTURE V. States of Alternation, Peeiodicity, Remission, and Re- lapse IN Mental Diseases (Eolie Cikoulaiue, Psycho- IIHYTHM, FoLIE A DoUBLE FoKME, ClKCULAR INSANITY, Periodic Mania, Recurrent Mania, Katatonia), . 219 LECTURE VI. States of Fixed and Limited Delusion (Monomania, Mono-psychosis, Paranoia), .... 251 LECTURE VII. States op Mental Enfeeblement (Dementia, Amentia, PSYCHOPARESIS, CONGENITAL IMBECILITY, IdIOCY'), . 2S0 Vlll CONTENTS. LECTURE Vlir. IIysteuu'AL In'sanity, Insanity ov Mastuhuation, Insanity of Lactation, . In-sanity of Pkegnancy, T'AOK States of J[f,ntal SrcpoR ("Aoute Df,>[e\tia," "PiuMAnY Dementia," "Dementia Attonita," rsYcuoroMA), . 306 LECTURE IX. States of Defective Mental Inhibition (Imtulsive In- sanity, Volitional Insanity, Uncontiiollable Impulse, rsY'CIIOKINESIA, HYPEHKINESIA, InIUBITOKY' INSANITY, Insanity' wiTHori Delusion, Exaltalion oh Exfeeble- MENT, Affective Insanity). The Insane Diathesis, . 3-ii ; LECTURE X. General Paralysis (Dementia Par\l\'tica), . . . :i7!i Pakaly'tio Insanity (Oroanio Dementia), . . 120 LECTURE XT. EriLEPTic Insanity, . . . lofi Traumatic Insanity', . . , . iM LECTURE XII. Syphilitic Insaniiy, . . . . -itu Alcoholic Insanity-, ...... -ISO LECTURE XIII. Rheumatic and Choreic Insanities, . . 49,1 Gouty or Podaqrous Insanity, .... 504 Phihisical Insanity, ...... UO', LECTURE XIV. Uterine ok Amenorriiosal ant> Ovarian Insanity, . .r.^'j 032 LECTURE XV. PuERPER-iL Insanity, . . . . r,j.| U\-2 . f>«9 contexts; IX LECTURE XVI. PACK The L)EVELOrMKNTAL In'SAKITIES. The Insanities of Pubekty akd Aholescekce, . . 570 LECTURE XVII. The Insanities of Decaden( k. Climacteric Insanity, ... . . 611 Senile Insanity, ... . . 622 LECTURE XVIII. Rauek and Less Important Clinical Varieties OF Mental Disturbance. Anremic Insanity. — Diabetic Insanity. — Insanity of Bright.'s Dis- ease. — Insanity of Oxaluria and I'hospliaturia. — Insanity of Cyanosis from Broncliitis, Cardiac Disease and Asthma. — Metastatic Insanity. —Post-febrile Insanity. — Influenza and its Mental Relationships. — Insanity from Deprivation of the Senses. — Insanity of Myxa;dema. — Insanity -with Exoph- thalmic Goitre. — Delirium of Young Children. — Insanity of Lead Poisoning. — Post-connubial Insanity. — Pseudo- Insanity of Somnambulism. — Insanity following Surgical Operations, ....... 6fiO LECTURE XIX. Medico-Legal and Medico-Social Duties of Medical Men in Relation to In.s.vnity, ..... 6C9 LECTURE XX. A Summary of the General Treatment and Management of Insanity looked at as a ■whole, and on the Use of Hypnotics, Sedatives, and Motor Depressants, . 690 Indkx, ........ 719 Description of Plates, ..... 729-74G DESCRIPTION OP THE PLATES. PLATE PAGB I, {Frontixjiictx). — -Appeavanoe of the vertex of one hemisphere of the brain in a case of very advanced General Para- lysis, a, Skull-cap condensed, b, Anterior tliird of brain, as seen when dura mater was first raised, show- ing thickened milky arachnoid dotted over with small wliite spots, with the opaque turbid compensatory fluid under it, and the tortuous dilated veins and congested vessels, the convolutions showing dimly through. c, Middle third of brain, showing the appearance of the convolutions after the pia mater has been removed. They are congested, and the outer layers of grey sub- stance have been torn away in irregular patches, from the most projecting pai-t of many of the convolutions having adhered to the pia mater and been removed with it. The portions so removed have left ragged eroded-looking spaces where the grey substance looks softened, while the outer layer looks rather hard and opaque on its surface, d. The pia mater stripped from middle third of brain, hanging down, concealing poste- rior lobe of brain, and showing the appearance of its inner surface with the piortions of the convolutions adhering to it. It is congested and thickened, so that, instead of being like the normal pia mater, a delicate filmy transparent membrane, it is a tough, thick, spongy-looking texture. II. Five microscopic Drawings, showing pathological changes in (I) Semi-lunar Ganglion ; (2) Cortex ; (3) Epithe- lium of Ventricle ; (4) Artery ; (n) Cortex (atrophy), . 729 III. Facsimile of a letter written by a maniacal patient, show- ing incoherence, rapid change of ideas, delusions, hallucinations of sight, an insane association of ideas, and an insane symbolism. . . 730 Xll DE3CEIPTI0X OF THE PLATE.i. PLATE VKHr- ly. Irregular Vascularity of Anterior Lobe of Brain from a Case of Aente JIania, . . ^''^ ^'. A Chart showing the Eelative Prevalence of Melancholia, llania, and General Paralyiis, . - ''■^'■^ VI, Great and Irregular Thickening of the Skull-caij in a Case of Chronic Insanity with Brain Atrophy, . T'J'^ VII. Absorption of W^hite Substance of Brain due to Syphilitic Arteritis ; with Persistence of Grey JIatter, 734 VIII. Jlicroscopic Drawings of Cortex in a Caie of Gineial Paralysis and a Case of Chronic Mania, . 735 IX. Microscopic Drawings of Cortex in T'.vo Cases of fjj There are a number of more rare and less important clinical varieties of insanity, which I shall just allude to, viz. : — 1. Ansemic Insanity. 2. Diabetic Insanity. 3. Insanity from Eright's Disease. 4, The Insanity of Oxaluria and Phosphaturia. 5. The Insanity of Cyanosis from Bronchitis, Cardiac Disease, and Asthma. 6. Metastatic Insanity, 7. Post-Febrile Insanity. S. The Mental Concomitants and Eesults of Influenza. 9. Insanity from Deprivation of the Senses. 10. The Insanity of Myxoedema. 11. The Insanity of Exophthalmic Goitre. 12. The Delirium of Young Children. 13. The Insanity of Lead Poisoning. 14-. Post- Connubial Insanity. 15. The Pseudo-Insanity of Somnam- bulism. 16. Insanity following Surgical Operations. The classification of the future will be one on a pathological basis. But we are far from that yet, and any premature attempts to construct such a classification, not founded on a sound brain physiology and psychology, must do more harm tlian good. Certain crude suggestions for classifying mental disturbances by means of the vascular and lymphatic changes that can be recognised in some cases, especially in acute insanity, seem to miss the essential relationship of those structures to the neurine. The vessels and lymphatics are the servants of the nerve cells, not their masters, except in rare and exceptional cases. The original stimulus towards vascular and other intra-cranial abnormalities comes from the trophic and vaso-motor centres within the brain cortex. You might as well classify the men and women in a city through the clothes they wear, the houses they dwell in, and the tools they work with. In studying mental diseases, one must constantly refer to the general functions of the brain, and I have thought it might be useful to point out, in the following form, the bearings of some of the most important anatomical, physiological, psychological, and pathological considerations on that study: — 14 CLINICAL STUDY OF MENTAL DISEASES. There is in the brain an extreme complexity of tissues, fibres, and groupings, and an extreme delicacy of structure, these corresponding, no doubt, to the multiformity, com- plexity, and delicacy of its func- tions. There is an obvious inter- dependence of parts, a localisation of stmctures and functions, and yet a real solidarity of the whole brain in structure and function. There is the most direct connec- tion, structurally and functionally, of every organ, of every tissue, and of every function with the brain con- volutions, each being separately "represented" there, and their influence is mutual, powerful, and constant. Developmentally and function- ally one nervous ganglion or group of cells is " higher " than another, and the higher usually controls or stops the action of the lower. Looking at the brain convolu- tions, their neurons, fibres and granules differ in shape and size in different parts of the organ. They are placed in distinct layers, and arranged in groups, those also differ- ing in different regions. They have been demonstrated to be different in appearance in young children, in idiots, in old persons, and in many cases of insanity, from what they are in a healthy adult (sec PI. xiii. figs. 2-6, and PL xv. figs. 6-10). There are some reasons to suppose that parts of the brain convolu- tions can energise in different ways, one part being capable of doing the w^ork ordinarily done by another. Then every part of the brain is double. The brain has a reflex and auto- Hence we are apt to have many functions and structures involved in mental diseases — motor, sensory, vaso-motor, and trophic. Localisa- tion is never complete, and soli- darity is never perfect. Hence peripheral lesions and dis- ordered functions of organs cause mental disturbances, and vice versa. The mental symptoms often take their sjjecial character from the peripheral function dis- turbed. Hence disorder of the higher centres is far more important than the lower. Hence we have a structural basis for certain forms of insanity, and for limited mental disturbances, and therefore a definite jjatliological histology of many forms of the disease may be confidently looked for in the future (see Pis. xiii. and XV.). If this is so, damage to, or ex- haustion of, one portion of brain convolutions [as in Goltz's and Nothnagel's experiments] need not necessarily cause complete or irre- trievable loss of mental functions. In mental disease, this reflex CLINICAL STUDY OF MENTAL DISEASES. 15 matio action. Most of its func- tions are affected by this, and may- be excited into activity or may be disturbed in a reflex manner by in- direct stimuli, as the heart is from stomach derangement. Most of tlie rellox functions of the brain may be unattended by consciousness ; or consciousness without volition may be present in regard to mental acts and to subsequent muscular action. The study of the physiological conditions of sleep, dreaming, and hyimotism, are most important, though as yet many of the phenom- ena are very obscure. Consciousness may be complete, partial, or abolished in health. The brain normally has necessity to energise in some direction or other ; but energising vigorously iu one direction will often suspend energising iu others. The brain has fixed limits of energising in all directions. All sorts of sensations, we must keep in mind, aie subjective, and depend on consciousness. The real import of most sensations, special and common, was originally only learned slowly and by interpreta- tion and experience in childhood. There is a tendency in the brain to propagation, didusiou, and ex- tension of action, normal and ab- normal, and there is much trophic solidarity iu the whole brain, its envelopes, and the nerves connected with it, quite independently of whether the tissues are cellular or fibrous, or whether the function is originating or conducting. function of the brain plays a most important ])art. Many symptoms can only be rightly explained by it. In many mental diseases the brain acts automatically ; even suicidal and homicidal impulses taking place when volition and consciousness arc absent. The psychological facts of those conditions should be kept in mind in studying mental disease. No phenomena of the latter are more obscure than those of the former. In mental disease we see those conditions from pathological causes. In mental diseases we constantly put into active exercise certain healthy forms of energising (e.g., walking, enjoving music, &c, ), in order to diminish other morbid forms. Hence the danger of causing dis- turbance or paralysis of function by coming too near those limits, or overstepping them. Sensations can be misinterpreted, therefore, in mental diseases, and, as a matter of fact, many insane delusions arise in that way. This takes place abnormaJly in disordered working of the organ, disordered functional conditions extending from the encephalic tissue regulating one function to that regulating others. There is a strong tendency to progressive pathological propagation of diseased processes in the brain and along the nerves. Many forms of insanity 16 CLINICAL STUDY OF MEXTAL DISEASES. Every mental manifestation, nor- mal or abnormal, must be assumed to take place directly throngb the energising of the brain convolu- tions. Mentalisation differs so enor- mously in degree, form, and intensity in different human beings, in the two sexes, in different races, in persons of different education, and at different ages, that any correct standard of mental health must allow a large margin of psychological difference, apart altogether from disease. The action of " mind on mind " in healthy brains is direct, intense, and most subtle. The quality, the power of energis- ing and of resistance, the mode of working, the liability to disease, and the recuperative power of the convolutional brain tissue, are pro- bably determined more largely in any individual by his heredity than by any other cause. Bad heredity may affect the whole brain and aU its ftmctious, or only a part of them. The chief of the human instincts, appetites, and organic necessities are — 1. Love of life, with efforts to prolong it. 2. Desire to reproduce the species. 3. Love of offspring, with efforts to nourish and protect it. are, no doubt, explained in this way. tTsually the fanctional pro- pagations, like the structural de- generations, take place in the line of physiological function. Hence, wherever the " origin " of mental disease may be, or whatever may be its "causes," mental or physical, its immediate cause and seat must be in the disordered ener- gising of the brain convolutions. Hence the necessity for special inquiry as to the normal mental power, the normal mode of working, the education, the temperament, and the diathesis in every case of mental disease one has to study or treat. The same is the case when the brain is disordered, and hence in psychiatry mental therapeutics are a most important means of treat- ment. Hence the importance of a study of heredity in mental disease. In some form, direct or indirect, its inflnence is rarely absent in any case. In every case of insanity, atten- tion and inquiry must be directed as to whether any of these are im- paired, paralysed, or perverted, or whether their normal mode of action is interfered with. CLINICAL STUDY OF MENTAL DISEASES. 17 4. Social instincts in innumer- able forms. 5. Necessity to energise. 6. Appetite for food and drink. Some of these are periodic in their intensity or occurrence. The chief faculties, looked at from the mental point of view, are perception, ideation and judgment, volition and mental inhibition, affective faculty or all that relates to feeling and emotion, memory, ])Ower of attention, representation and imagination, association of ideas, speech, and the moral faculties, — consciousness being the basis of them all. The theory of evolution, especially as applied by Herbert Spencer in elucidation of the morals, the social })ractioes, the customs, the beliefs, the ideas, and the feelings of man- kind seem complementary to our knowledge of brain physiology. The studies of Romanes and others in comparative psychology are also highly suggestive and instructive. The studies ofWundt, Ladd, &c., and the experimental school of Physiological Psychologists, are also valuable attempts to co-relate mind and brain function, by formu- lating some of the physical laws and concomitants of conscious states, such as reaction time, liminal sensory stimulation, &c. The great physiological periods It is important in examining a case of mental disease to go over these systematically and test them, because they are affected in dif- ferent ways and degrees in different cases. The doctrine of evolution seems to throw light on many cases of congenital and other mental defects by assuming that in those cases development has taken place in an incomplete or irregular manner, or that ' ' reversions " have taken place to more primitive types of brain and mind. Hughliugs Jackson's application of a complementary theory of "Dissolution" to the nervous and mental functions, also enables us to comprehend certain cases of mental diseases better than we could have done without the aid of such hypotheses. Every fact that enables us to realise the necessary connection of brain-working and mind in health, and which accurately compares their relationsin different abnormal conditions with the normal stand- ard, helps our knowledge of that connection in disease, and enables us to observe the symptoms of mental disease in a more scientific way. Hence these are very apt to be B 18 CLINICAL STUDY OF MENTAL DISEASES. or crises of life (dentition,' puberty, adolescence, the climacteric, and senility), and the great reproductive activities (menstruation, ovulation, coitus, pregnancy, childbirth, nurs- ing, and care of children), bring into intense activity, or throw out of action wholly or partially, great tracts of convolutional brain tissue. Diseased or undeveloped function is usually accompanied by atro- phied structure, and prolonged dis- turbance of function by change of structure. The mode of energising of nervous tissue is normally spasmodic, and even explosive, in regard to certain functions. This quality is often morbidly developed in badly-con- stituted brains. There is reason to suppose that only comparatively limited portions of the brain can be in action at the same time, and that even the whole of the nenrine tissue subserving the game limited function does not all come into activity at once. The blood supply of the brain is enormous, and that of the grey matter of the convolutions five times the amount of the white. This grey matter needs, and uses up, far more blood than any other tissue in the body in proportion to ifc) biUk. The vascular supply of the brain is derived from different sources. The whole encephalon is divided more or less into vascular area^, each area haviog slight anastomoses with its surrounding areas. It is not yet proved, but it is probable, that those areas are co- related to ditferent functions. The whole conditions of the blood attended with danger to the normal mental balance when the convolu- tional tissue is bad in quality, un- stable, or badly nourishefl, or ajjeci- ally liable to morbid explosion h of energising'. In every case of mental disease the possible influence of these should be inquired into. Hence prolonged mental enfeeble- ment is u.sually accompanied by brain atrophy and prolonged mental disturbance by structural brain changes. This explains in some degree the phenomena of mental explo- sions and functional defects being suddenly developed when the struc- tural cause has been a gradually advancing one, «.,9., we see sudden mania, or paralysis, or convulsion, or unconsciousness resulting from softenings, or sclerosis, or inflam- mation that have been going on gradually for a long time till they reached a certain point beyond which normal function could not be performed. Hence, when in certain forrn=i of mental disease there is congestion or vaso-motoT dilatation of those already crowded capillaries, we have serious secondary effects on thi: neurine and its functions. Nothing is more common after death in insanity than to find the brain substance divided into distinct vas- cular and anarmic areas (Plate I^'. ). Certain morbid appearances {e.g., "pachymeningitis hsemorrhagica interna") are found within the skull, which are not found eLse- where at alL T he lymphatic sjawis are often found blocked up by d^brii. Capillary hsemorrhages CLINICAL STUDY OF MENTAL DISEASES. 19 supply to tlio brain and within tho lio.id, arepoouliarand different from any other part of tho body from its being in a shut box not fully sub- jected to the pressure of the atmos- phere, except through tho vascular and lymphatic openings and fora- men magnum, and from its peculiar relation to the cerobro-spinal fluid. The lymphatics are also peculiar in the brain, and this no doubt affects its circulation and nutrition. The vessels of the brain, larj;;c and small, are delicate, having little sup- port but the pressure of a shifting fluid, and the cardiac and vascular pressure and tension are constantly varying. It would seem as if mental emotions had a more diroct and powerful intluonce on the vessels of the head than on those of almost any other part of the body, e.g., as seen in blushing, &c. The various envelopes, and pro- tecting and packing tissues of the brain, are most important in them- selves and iu their normal relation- ship to the brain. They derive their blood supply from the same sources. It may bo said generally that in- flammation and new jiathological formations — tubercle, syphilis, can- cer, &o. — show a greater aflinity for the uou-neurine tissues and blood- vessels than for the brain itself, while the progressive degenerations tend more to affect the true nerve tissue. Changes in tho nerve cells have been clearly demonstrated by Hodge, Maun and others to take place after are common in insanity, and vas- cular disease is frequent, and should always be looked for, in those who die mentally affected. In mental disease we often find more evident and constant disease in the bones, membranes, neuroglia, and epithelial linings of the ven- tricles than in the brain itself. AVIien diseased they affect the neurine secondarily, or are affected by its diseases (see Plates I. II., figs. 8 and 4 ; VI. XIV. and XV., figs. 1 to 5). Hence we must specially examine those nou-neuriue and vascular tissues, and we often find that though they are all'octed primarily by those new pathological forma- tions, yet the neurino has suffered as much, structurally and function- ally, as if it had been first affected. This makes it all the more prob- able that the exact import of the nerve changes and degenerations, so 20 CLINICAL STUDY OF MENTAL DISEASES, exercise and fatigue as compared clearly shown by Bevan Lewis and with rested cells. others in different forms of insanity, will yet be demonstrated. The recent investigations of And already disturbed and patho- Golgi, Cajal, Andriezen and others logical conditions of the whole as to the relationship of the cells neuron in insanity hare been de- to the fibres, and the nature of the monstrated. nervous unit, the "neuron," can- not fail to throw light on the mental working of the brain. The recent investigations of Flechsig has also shown that in Flechsig into the development of insanity his cortical "centres of " nerve paths " in the brain of the associations " and nerve paths are child seem to make more definite pathologically altered, our ideas of mental development. The latest investigations regard- In several forms of insanity we ing the normal appearance and already find " chromatolysis " or arrangement of the "chromatic abnormal appearances in the gran- granules " of the nerve cells as seen ules as well as in the fibrous in sections prepared by the Nissl's elements of those cells (Plate XVI.). method are very important. The dendrites and neuraxons of It has been demonstrated lately the cortical neurons must he of that toxic agents such as alcohol almost equal importance with the produce marked changes in those cells functionally. dendrites and neuraxons (Plate XVII.). Clinical Examination of a Patient. — -As to the general method of clinically examining a patient, insane or supposed to be insane, the following rules may be of service : — • 1. Get all the information about him you can beforehand, and from the most direct sources, especially on the following points: — His heredity, temperament, habits, and generally what sort of man he was, what diseases he has suffered from, what delusions he labours under, how he is changed from his former self, whether he is morbidly suspicious and will resent a medical examination, whether he is suicidal or dangerous, whether his power of self-control is affected and in what way, and his weak points mentally— get, in fact, a good concise history of his case, especially noting the first symptoms and the general course. CLINICAL STUDY OF MENTAL DISEASES. 21 2. In your interviews be in manner natural, frank, honest, fearless, sympathetic, and a good listener, assuming outwardly that your patient is sane. Do not be afraid to lead up to his delusions and mental weak points after you have gained his confidence and interest. Do not contradict or irritate until you want to tost his self-control. Do not deceive him if possible. After you have satisfied yourself he is ill, try and make him believe it too. Take time ; few satisfactory first examinations can be conducted in a hurry. 3. Look on his speech, manner and appearance as being, in themselves, possible symptoms of his disease ; be all the time in a quiet systematic way, unobserved by the patient, testing his instincts and mental faculties (see p. 16) seriatim in your own mind, and be on the look-out for insane delusions or suspicions, depression of mind, exaltation, enfeeblement, lethargy and stupor, or altered feeling towards relatives and friends. 4. Note carefully the expression of the face and eyes, the articulation, the manner, the muscular movements, the writing if possible, the nutrition of the body and the conformation of head. 5. Examine the state of the pulse and temperature. Never think any examination complete without taking the tempera- ture. Many patients labouring under the delirium of fevers and inflammations would have been saved from being sent to asylums had this been done. Examine into the condition of the tongue, appetite, digestion, bowels, and, in fact, go over all the groat bodily functions. ICspecially find out about the sleep — whether he sleeps at all, what kind of sleep, and for how long, and whether he dreams, and of what character the dreams are ; usually the sleep is " broken " and unrestful in the early stages of insanity, the patients dream much, and the dreams are unpleasant. Especially examine into the motor and sensory functions of the brain and cord, asking about headaches and neuralgic pains. Always remember that the ordinary symptoms of bodily disease may be masked by the 22 CLINICAL STUDY OF MENTAL DISEASES. ■brain condition, so that lung and visceral diseases, injul■i<^'^, &c., may exist -witlioitt any consciousness on the part of the patient, or any obvious symptom whatever. 6. Eemember there are three aspects to every case of in- sanity — the medical, which concerns you as a physician about to treat a patient; the medico-legal, which concerns you and the patient in regard to depriving him of his liberty and of the control of his affairs, and aflfects his responsibility to the law; and the medico-psychological, which includes all the mental problems that arise out of a study of the case. 7. Always pass before your minds the following conditions, and by exclusion determine that the case is not one of tliem, viz., drunkenness, drugging by opium or other narcotics, meningitis, cerebritis, brain syphilis, the fevers, sunstroke, traumatic injury to head, hysteria, the cerebral effects of gross brain diseases, simple delirium tremens, the; temporary cerebral effect of moral shock, or the delirium that jtrccedes death. All those diseases and conditions I have known to be sent in to asylums under my care, as labouring under ordinary insanity. Some of these may, however, lead to, or be aK.sociated with, technical mental disease, and require treatment as such. 8. In the cHnical study of mental diseases, try and look on all the abnormalities present, mental and bodily, as being symptoms of the disease, and essential parts of the brain disturbance present, and not as mere accompaniments. Voi instance, in a case of puerperal insanity, it is not merely the delusions and mental exaltation that are the disease but the high weak pulse, the raised temperature, the glistening eye, the constant muscular motion, the dry tongue, the uterine tenderness, the absence of lochia, the sleeplessness, the paralysis of appetite are also symptoms of the disease in a true sense, that is, they are all results or essential concomitants of the brain disturbance, of which the mental symptoms are the most striking features. 9. The patient's account of himself is not always to be relied on. He may be dying, and yet in his consciousness CLINICAL STUDY OF MENTAL DISEASES. 23 have no symptom of it, so that he tells you he never was better in his life ; his bowels may have been moved freely that morning, and yet he tells you he has not had a motion for a week ; he may not be able to write a line, yet he says he never wrote so well in his life, &c. You must, throiigh your reasoning, medical examination, and observation, find out what is true and what is delusion. I had once a case where a medical man certified as a delusion what an examina- tion would have shown him to be a fact, viz., that "she said she was pregnant." Certain things of the greatest import in a case of insanity the patient is very apt to deny, such as suicidal feelings, masturbation, &c. 10. It may be needful in some cases for the patient's safety, or that of his relations, or for the preservation of his property, to practise some amount of concealment of your profession, and of the object of your visit. The man knows so well what a doctor's visit means that he will not see a doctor if he knows him to be one, or he is so dangerous and cunning that risk would be run by announcing to him the object of your visit. But the public and the friends of patients have often a most needless desire that you should practise guile where there is no necessity in the world for it. As a general rule, there is not much to fear from the insane of the respectable classes of society in this country. But cunning and suspicion are marked characteristics of many of those affected in mind. 11. ITegative symptoms — silence, obstinacy, stupidity, &c. — are to be noted, and are valuable in diagnosis and treat- ment. 12. Compare mentally the man as you see him with the man you may have known or had described to you. 13. The chief questions you ask yourself, and the main problems that you have to solve, are the following : — Is the man mentally affected or noti If so, is he sufficiently affected to be regarded as legally insane and irresponsible? What form of insanity does he labour under? Can the brain disease be localised or its pathological character determined 1 24 CLINICAL STUDY OF MENTAL DISEASES. What is to be the treatment? What risks are there in the case, e.g., of suicide, danger to others, convulsions, paralytic attacks, exhaustion, refusal of food, or sudden death ? What is the general prognosis? How long will it be before the case recovers or dies ? Is home treatm.ent suitable or safe ? or must the case be removed from home to the country, or to a hospital for the insane? Can trained reliable attendance be got? What mental therapeutics must be adopted, cheering or soothing, diverting, reassuring, checking, agreeing with him, contradicting him, or avoiding his favourite topics ? 14. It is always well, in a case of mental disease, to make the relations or guardians of the patient very fully acquainted with the risks of the case, to keep them hopeful if there is any hope, to give the patient the benefit of all doubts, to guard yourself in prognosis, remembering that our knowledge of mental disease is imperfect, that the most experienced of us are deceived oftentimes, and that there are few rules in regard to brain disorders to which there are not exceptions, to take no more responsibility about sending a patient to an asylum than fairly can be laid on a medical man, making the relatives take their proper share. It is, as a general rule, better not to be too explicit about the time it may take a patient to recover. If you undertake the treat- ment at home, or in a private house, only do so on the understanding that the purses or attendants are under your exclusive orders. If you have to sign a certificate of insanity for placing a patient in an asylum, or taking the management of his affairs out of his hands, remember there is often a legal risk to yourself from the patient bringing an action against you, a risk that in some rare cases it is well to avoid by even getting a letter of indemnification from a relation before you sign it. 15. In regard to the question of home or asylum treatment, it depends on many other things as well as the patient's condition. His means are the first of these. Home or Ijrivate house treatment of a case of mental disease is montI y CLINICAL STUDY OF MENTAL DISEASES. 25 expensive, from the skilled attendance needed. In tlie midst of a city, home treatment of almost any case is most difficult. Home treatment is often impossible or hurtful from the associations and surroundings aggravating the disease. If there is a very intense suicidal tendency, the risks are much greater in a private house. If there is a noise, maniacal excitement, or constant muscular motion, a private house is seldom a proper place for long. In a good hospital for the insane, most of the means of treatment, safety, skilled attendance, exercise, a properly regulated mode of life, the administration of food and medicines, can no doubt be best attained, but then there are the counterbalancing disadvan- tages of the harm to the patient's prospects from the cruel popular prejudices [about asylums, and the patient's own feehngs about it afterwards. If you can treat a case out of an asylum, and he recovers satisfactorily, it is better for you and him. LECTUEE II. STATES OF MENTAL DEPRESSION— MELAN- CHOLIA (PSYCHALGIA). Nearest Mental health, seen at beginning of nearly all kinds of Insanity — Physiological capacity of feeling— Physiological emotional de- pression — Melancholic phases of existence in all Men — The Melan- cholic variety of the nervous temperament and diathesis — Influence of Heredity — Crises of life — Melancholia is pathologically brain anaemia, want of trophic power, and of nutrition, causing in certain persons dynamic disturbance — First Symptoms : Loss of sense of well-being, of conscious enjoyment of anything, of volitional power, of spontaneity, paralysis of feeling — Afterwards : Delusions, loss of self-control, intense mental pain, emotional depression, psychical neuralgia, restlessness, excitement, suicidal or homicidal feelings and acts — Bodily Symptoms : Headaches, neuralgias, sleeplessness, falling off in flesh and colour, costiveness, indigestion, paralysis of food-appetite, facial and eye expression, attitudes and gestures and postures, skin dry, sinking and pain in epigastrium. First origin of Melancholia may be central or peripheral ; perverted sensations from disease in organs ; how Melancholic delusions arise ; power of morbid attention on functions and organs. No distinct line between the Sane and Insane Melancholy — Simple M. ; " Low Spirits," want of affection, want of interest in and enjoyment of life ; fancies, whims, with impairment of reasoning power ; not much body wasting ; sometimes goes no farther ; often is prelude to severe varieties, or to other forms of insanity ; condition may come and go, and depend on slight Qa.\is&a— Hypochondriacal M. : Patient's depressed feelings centre round himself, and his delusions are about his bodily organs and functions ; fancies innumerable in kind and variety ; seldom very suicidal ; differences between the sane and the insane Hypochondriac ; the one talks only, the other acts and has lost his inhibitory poviev— Delusional M. : Delusions from beginning the most prominent symptoms ; such delusions assigned by relatives as the "cause"; "Visceral" cases, where delusions refer to the stomach and bowels and internal organs often depend STATES OF MENTAL DEPKESSION. 27 on organic or aggravated functional causes ; prognosis in worst class of cases bad, as in all ' ' fixed delusions " ; examples of melancholic delusions. Mental Pain. — All the states of morbidly depressed feeling, or, as more commonly expressed, of mental depression, are c omprise d under the term Melancholia. Like the other symptomatological varrefies of mental disease, melancholia does not admit of an absolutely precise definition. In every case there must be mental pain, but then mental pain does not alone constitute melancholia. As man's experience goes in the world at present, mental pain scarcely implies the idea of disease at all. The causes and occasions of mental pain from within and without are so common, as most men are now constituted and situated, that its presence is the rule with many, and its entire absence the exception with most. To constitute melancholia there must be disorder of brain function. A man's finger is squeezed in a vice, and he feels the most intense pain, but we do not call that neuralgia. He loses a child or a fortune, and feels intense mental pain, but we do not call it melancholia, because there is no disease. All mental brain reactions, within certain limits, in obedience to adequate causes are simply the exercise of physiological function, but when the reaction is quite out of proportion to the cause, or when the exercise of the activity of the brain induces mental pain of a certain intensity, duration, or kind without any outside cause, then we conclude that the mental portion of the organ is disordered, and we say the patient suflfers from melanchoHa. There may be in the case certain excitants called causes — mental, moral, or physical. The man may have suffered losses, or he may have indigestion, or a badly acting liver, or he may be very anaemic, and all these things may cause mental pain and depression in a healthy brain, but they will not cause them in that amount and kind to constitute melanchoha till his brain convolutions have taken on a disordered action — until their dynamical state is that of disease, not that of health. 28 STATES OF MENTAL DEPRESSION. If a man's heart is depressed in its aotion from a fright, we do not give this a name implying disease, unless the depression goes on long after the cause has ceased to act. This illustrates, too, the weak points of the methods of classifying mental diseases from mental symptoms alone. It is as if in cardiac diseases we should classify them as syncopes, palpitations, and anginas. Therefore, we must always keep in mind, in using such terms as melanchoha, that the mental symptoms are not the disease ; we must always consciously refer those symptoms to the hrain convolutions in the diagnosis and treatment of mental diseases, which are simply bram disorders of different kinds in which the mental symptoms predominate. In assigning causes, we may say that peripheral irritations, and moral and mental shocks have caused the disease; but we must clearly keep in mind that the mental symptoms of the disease are the result of the disordered working of the encephalic tissue. If that remains sound in structure and working, no amount of irritation or moral shock will cause any real mental disease. States of mental depression are, in some of their forms, of all mental diseases those that are nearest mental health. They shade off by imperceptible degrees into mere physiological conditions of mind and brain. To be able to feel bodily or mental pain implies an encephalic tissue for the purpose. To be very sensitive to pain implies that the tissue is acutely reacting to unfavourable impressions. In regard to mental pain there can be no doubt that the healthy physiological condition is one between extreme callousness to impressions and extreme sensitiveness. A man in robust health, well exercised, does not feel pain nearly so acutely, and bears it better than when he is weak and run down. Those principles apply equally to the feeling and the bearing of mental pain. The most casual study of the affective capacity in human beings shows us that it differs enormously in different persons. One man will lose his children or his fortune, or see the most terrible sights, and he will not feel keenly at all, because his STATES OF MENTAL DEPRESSION. 29 brain convolutions tliat subserve feeling are not in tlieir essen- tial nature very receptive and sensitive. Another person will be thrown into very great grief, and feel acute agony, at the loss of a favourite dog. I had a lady patient once, A. A., who would be for days depressed, and suffer mentally, if a friend did not receive her as cordially as usual any day. She suffered mental torture if a relative spoke sharply to her, and she was once absolutely paralysed in feeling and volition by the death of a sister. She had several attacks of mild melan- cholia produced by most inadequate causes, from all of which she recovered quickly and completely. There can be no doubt whatever that the finer moulds of brain are mostly very sensitive, and the poetic, emotional, and sympathetic natures have always been subject to states of painful depression of mmdaS the critical periods of life, and when the physical vigour was below par. Half the poets and men of literary genius give ample proof in their biographies and writings and in the characters they have created or founded on their own experi- ence, that they suffered at times intense mental pain. Goethe clearly looked on a period of melancholy as one phase in the development of genius. The lives and writings of Goethe, Schiller, Carlyle, Cowper, Byron, John Stuart Mill, Hume, and George Eliot show that they all had periods in their lives when they suffered intense mental pain, and at least one of them did actually pass the undefined borderland that separates physiological mental depression from pathological melancholia, To feel intense mental pain is mostly the necessary accom- paniment of the capacity to feel intense joy. The brain qualities that give intensity to the one give also intensity to the other. We must take into consideration in every case not only the sensitiveness and the receptivity, but also the power of bearing pain — the inhibitory power against the effects of pain. Some brains possess great sensitiveness and also great power of inhibition. Those are the strong and stable brains. But when a brain is sensitive, and has little 30 STATES OF MEXTAL DEPRESSION. inhibitory power, this combination is a source of weakness and of disease. There is a morbid brain constitution which predisposes to mental pain, but that does not readily feel intense pleasure, and this is common enough among common men. It does not imply genius or strength in any way, and has no com- pensating advantages to its possessors. Persons with this tendency are of the nervous variety of the melancholic temperament, or perhaps, more properly speaking, have the melancholic temperament and the nervous diathesis. They are liable to lose their sense of well-being from slight causes from within and without them. Their surplus stock of animal spirits and vis nervosa is soon exhausted. They want emotional balance and resistive power. They are very often persons with strong unreasoning likes and disHkes, who are swayed by their instincts, which they cannot correct and guide by their reasoning power. They are often morbidly intro- spective and gloomily imaginative, having a faculty for finding out and exclusively looking at the dark side of everything, and are very often irritable. Bodily, they do not lay on fat at the ages when fat is physiological; their digestion is not their strong point ; when tired they are sleepless. Heredity. — Such a brain constitution is markedly hereditary, and, I think, is very apt to be derived in the male sex from the mother, and in the female sex from the father, in about 70 per cent, of the cases. It strongly predisposes to attacks of melancholia as weU as to attacks of mental depression in what may be called a physiological form after many bodily diseases. In such persons, fevers, lung aifections, and cardiac troubles are apt to be accompanied and to be followed during convalescence by mental depression. This is a serious compli- cation in those circumstances, for it retards recovery and tends towards relapses. It is, no doubt, another expression of that lack of trophic and recuperative energy of the brain which we shall see is so marked a characteristic of melanchoha. The great physiological crises of life — teething, puberty, adolescence, STATES OF MENTAL DEPRESSION. 31 the climacteric, senility, pregnancy, cliildbirtli, and lactation — are apt to be complicated by attacks of the neuroses in such persons ; loss of blood, over-work, want of sleep, over-anxiety, and menstruation are also commonly accompanied by depres- sion of spirits. Children of this brain constitution often exliibit a kind of child-melancholy at a very early period. I have known such a child at five years of age become intensely depressed, cry, and moan for hours, because it was afraid of the "hell" which its mother — of the same temperament — had described as being the portion of bad boys who tore their pinafores, sinned against God, and did not obey their mammas. Precocity, over-sensitiveness, unhealthy strictness in morals and religion — for a child — a too vivid imagination, want of courage, thinness, and a craving for animal food, are character- istic of such children. Melancholy v. Melancholia. — It is very difficult to draw a line of definition between mere "lowness of spirits," ordinary "depression of mind," popular "melancholy" or "hypo- chondria,'' and the pathological melancholia. They shade off into each other by fine degrees ; and yet it is most important to make a distinction. The general public, who are very fond of hearing professional gossip in regard to medico-psychological problems, and of restating as gospel the illogical travesties and popularised versions of such problems which some professional men retail, have an idea that those who have studied the subject most deeply have come to the conclusion that " all men are mad " ; and this because we say that no man but has his weak points of mind, and few men but are subject to mental depression or excitement, or to lose their self-control at times. Such a popular beUef does harm, because it is utterly opposed to fact, and tends towards confusion and misconception in regard to a physician's most serious problems. It is necessary, therefore, to attempt definitions, even though they may not cover the whole ground. Definition. — Mere melancholy might be defined as a sense of ill-being, and a feeling of niental pain with no real perver- 32 STATES OF MENTAL DEPEESSION. sion of the normal reasoning power, no morbid loss of self- control, no uncontrollable impulses towards suicide, the power of working not being destroyed, and the ordinary interests of life being lessened, not abolished. Melancholia might be deiined as mental pain, emotional depression, and sense of ill-being, usually more intense than in melancholy, with loss of self-control, or insane delusions, or uncontrollable impulses towards suicide, with no proper capacity left to follow ordinary avocations, with most of the ordinary interests of life destroyed, and commonly with marked bodily symptoms. Typical cases exhibiting these two conditions are totally different and distinguishable, and the only excuses for con- founding them are that they shade off into each other, that we have no absolutely definite scientific test to distinguish them, that they are both in many cases the outcome of the same temperament and diathesis, and that they both have something of the same nature, both psychologically and physiologically. Yet it is not the case that all melancholy -people are liable to melancholia. A typical case of melan- cholia, as we shall see, runs a somewhat definite course, like a fever, and has often all the characters of an acute disease. Frequency.— Though, in the statistics of asylums, melan- cholia does not appear to be the most frequent of the varieties of mental disease (see Plate V.), yet I think that if statistics of the real frequency of this disease in all its forms, mild and severe, could be got, it would be found that it is much the most common form. In its milder varieties it is a manageable disease at home, in this contrasting strongly with most cases of mania. For this reason many cases are treated at home and not sent to asylums. As a general rule, one has less difficulty in the examination of a case of melanohoha than of any other kind of insanity. The whole process of ascertaining the symptoms that are present is more like that in any bodily disease. The patient STATES OF MENTAL DEPRESSION. 33 is usually conscious that there is something wrong with him, which is not the case in most forms of insanity. It is, in fact, the sanest kind of insanity. He can often descrihe many of his symptoms. Many of his subjective sensations are reliable, and are very valuable in diagnosis and treatment. The diagnosis is not all a process of deduction from speech and conduct, and from objective signs. The patient will tell you in the first place, very hkely, that he is ill, very unhappy and feels mental depression. In most cases melancholic patients assign as causes of their misery what are not its causes at all. Here it is where their insane delusions, their false ungrounded beliefs, come in. I have analysed the " causes " assigned by melanchohcs that I have had under my care during the past seven years for their own depression, and I find them to be wrong in most of the cases. As to the evolutional and purely psychological aspects of morbid conditions of depression, or of any other morbid mental conditions, I do not consider a clinical work like this to be the proper field for their discussion, but any one interested in this view of the subject, I would refer to Dr Bevan Lewis's text-book,' where they will find it profoundly and originally treated. He makes an earnest attempt to apply the doctrines of Spencer and the latest knowledge of brain physiology to elucidate the facts of melancholia, bringing in Hughlings Jackson's theories of "dissolution " and "difi'erent levels " of cerebral function. He starts with the thesis that in melancholia "object-consciousness" is morbidly lowered, while " subject-consciousness " is exaggerated, that there is failure in the " muscular element of thought," restricted volition in consequence, going on to "failure of personal identity." No summary could do justice to his views. Varieties. — Melancholia occurs in many forms, with very various psychological and clinical symptoms. The following are, I think, the most common varieties, and I think the study of the disease will be made easier, and its treatment ^ Text-Boole of Mental Diseases, by W. Bevan Lewis, vide pp. 115-136. C 34 STATES OF MENTAL DEPKESSION. become more intelligible, by considering those varieties seriatim, viz. : — a. Simple melancboKa. h. Hypochondriacal melancholia. c. Delusional melancholia. d. Excited (motor) melancholia. e. Resistive (obstinate) melancholia. /. Epileptiform (convulsive) melancholia. g. Organic (coarse brain disease) melancholia. h. Suicidal and homicidal melancholia. If must be clearly understood that those are not distinct forms of disease. Many cases combine the characteristic symptoms of more than one of those varieties. Nothing is more common than for a case to be delusional, excited, and suicidal. It is also common for a case to change in its character as it goes on, e.g., a simple case to become delusional or suicidal. Simple Melancholia.— The best way to begin the study of melancholia is to take a case of what may be called simple melancholia, that is, one that is both mUd and uncompli- cated, and where the affective depression and pain are far more marked than the intellectual or voHtional aberrations. Such cases are very common, and most of them are never sent to asylums or come under the notice of specialists; indeed, many of them never come under the notice of any doctor at all, for it is characteristic of some of them that they have a great disinclination to consult our profession. Siich a ease as the following is a good example of its mildest form : — A. B., a gentleman of 60, of a neurotic but not insane stock, had inherited from his mother a neurotic diathesis and a melancholic temperament, and was of a sensitive, vivacious, sympathetic disposition, and very studious habits. He had kept his brain at too fuU pressure nearly all his life by his ambition and volitional force. This want of adjust- ment I count as really an imperfection of brain constitution where the inhibitory or volitional power is so great as to be STATES OF MENTAL DEPEESSION. 35 able to force the rest of the brain to work or suffer longer than its innate trophic and dynamic power would safely allow. In a perfectly ordered brain the fatigue of exhausted energising should be so absolute as to compel rest. There should be no power in a higher centre to compel a lower centre to do more than it is fitted for. Yet we know that this is commonly counted a great power for a man to possess — to be able to work, or think, or feel, or wake, or walk, not according to his innate capacity for these things, but according to his wish or the imagined necessity of the occasion. Carlyle once wrote to a friend that like his father he "could gar (compel) himself to work when utterly disinclined to do so." It is a dangerous power for those of a neurotic inheritance. All went on well tiU. A. B. was about 50, when, after a big piece of intellectual work, he began to feel that he was always tired, he had a jaded feeling, his work, instead of being a pleasure, became a conscious toil, — indeed, he seemed capable of feeling no joy in life any more. It did not quite amount to a sense of iU-being, but that evidence and crown of the perfect working of every organ, the undefinable but very real feeling of conscious well-being, had left him. The common pleasures of life, the society of his wife and children and friends, were no longer delightful,— indeed, intercourse with his friends by speech or letter was distinctly wearisome, and he avoided it. His courage was manifestly lessened, and he was irritable with his children, an unusual thing with him. It seemed to him as if his wife and children were less consciously dear to him, and this alarmed him and made him ashamed. He had a feeling as if he had done something wrong to cause this — that it was a wrong to them in itself, and must be a judgment on him for some sin. His favourite authors and poets seemed to have lost much of their charm. His religion brought little comfort. His appetite was dulled ; food and drinks did not tempt him, and after a meal he was uncomfortable. His sexual desire was much lessened. Some of his instincts and propensities seemed to be altered. 36 STATES OF MENTAL DEPEESSION. His bowels were costive ; his skin seemed to be harsher and drier than normal ; he had not the same feeling of reaction after cold bathing ; he could not sleep soundly all the night through, and awoke unrefreshed; he was losing weight a little. But all this time he was not very thin or weak, and he could appear in public or to his friends just as usual. He had the power to conceal all his symptoms from those to whom he did not want them known. There were certain curious features, too, in his case. He was always worst in the morning, — most persons with any sort of mental pain are, — but if he set himself to write a letter, or took a brisk short walk in the sunshine, or took a cup of hot coffee, he would feel better and happier. In the evenings, too, he would, often, in bright light, after a good dinner with a glass or two of wine, and in the society of friends, be quite himself again, and feel almost gay for a time. He stopped work, travelled and rested, and was well in three months. Since then he has had several such attacks, some of them more severe, during which the mental pain was more positive and intense, the conscious mental prostration greater, and the paralysis of volitional energy more complete, so that at times he could not possibly see his friends or put on before them any appearance of cheerfulness. At those times the beginnings of delusions showed themselves. He believed, and could not correct the false belief by reasoning, that ho was lost and his prospects ruined, and that his life had been wasted and a failure, and that he had not done his duty by his profession, or his wife, or his children. At those times, too, his intellectual processes would be slow and torpid, his power of attention weakened, and the arrival at any con- clusion impossible to him from any data whatever. When he consulted me in one of those attacks I recommended absolute rest, a sea voyage, — which I would not have done had he been in the least suicidal, — almost no company, plenty of easily digested but fattening diet, some good claret, and STATES OF MENTAL DEPBESSION. 37 animal food only once a day. I told him lie miglit live on bread, butter, milk, eggs, fish, fruit, and fresh vegetables if they agreed with him and he felt that they digested well. A tonic and aid to digestion, in the shape of quinine and nitro-muriatic acid, was all the medicine I gave him. I did not think he needed stimulating nerve tonics, and warned him against opium, which some one had recommended, as against his worst enemy. I told him to live out in the fresh air, as being nature's great sleep-producer, appetiser, and tonic. I counselled him against any expenditure of nerve energy whatsoever, either in seeing company, travelling too fast, walking or talking, — in short, he was to 'take mental, affective, motor, and sexual rest. I warned his friends against the common delusion that a man in that state needed to be " cheered up " specially. My experience has been that such cheering up is a natural process that will come of itself when the brain attains its normal trophic and energising power. I have seen many patients still further exhausted by the violent and continuous efforts made to cheer them up. I gave my opinion as to the prognosis that he would probably get over each attack as they came on him, but that he should be extraordinarily careful when he came towards old age, and said he would probably be an old man before his time. As to prophylaxis, I recommended him, when he got better, to do his work with great system and order, cutting up his day, like the face of a chess board, into regular divisions, and filling in each with regular work, or recreation, or rest. I told him to weigh himself every month, and whenever he found he had lost 3 lbs. to stop work and take a change or a sea voyage. I recommended the bromide of potassium for sleeplessness, in 25 grain doses, if fresh air would not do, but I should now say paraldehyde in drachm doses. That is the type of a very mild case of simple melancholia. 38 STATES OF MENTAL DEPRESSION. caused by over brain-work in a person predisposed to it by heredity. In such a case it seems as if brain ansemia was present, the morning exacerbation after the physiological sleep ansemia pointing to this, relief being obtained by anything that determined more blood to the organ. As an example of simple melancholia with partial paralysis of volition, and of that particular kind of morbidness which consists in never "making up one's mind," in being subject to " fixed " and " imperative ideas " taking unwilling possession of the mind, along with a subtle kind of morbid introspection and morbid magnification of small things, the following graphic case of A. C. is of much interest : — She was a young lady who had worked far too hard at school, and so had probably pro- duced impaired nutrition of her convolutions. I quote from her own description of her mental state. "I watch every action, word, and thought, constantly questioning them, accounting for them, excusing them, or deprecating them. Every day I rise I wish to be happy like the others. I will not torture my brain. It is a sin to steal my own happiness and that of others. I reason, resolve, and hope; but the greater the effort to be free the greater the struggle. I have been so oppressed with this unspeakable distress that I feel as if I were two persons — the one tyranni- cally demanding to be gratified, the other protesting and pleading. I am often in despair, and feel my life a burden. At night I am glad the day is done ; in the morning I am in terror the day will be a repetition of the former. The most trivial incident will occupy my mind ; I discuss it in all its bearings, teUing myself all the time it is not worthy of my consideration. Some one speaks to me, or some one is talking. If the former, I answer (often very abstractedly) with the feeling that there is something on my mind ; then I return to the triviality. If I have forgotten it I must remember it, and then with a distinct eff'ort put it away from my mind. It steals back. I tell myself that I have already discussed it, but I must repeat the whole matter to myself STATES OF MENTAL DEPRESSION. 39 and that with no ordinary process of thought. I seem to feel a strange strain on my memory, and again I have to use an eifort to banish this nothing. Again it will arise and be dismissed ; and I number the times as carefully as if much depended on it. The efforts to dismiss the subject cause the blood to rush to my head, the perspiration to break, and I often find my hands clenched in the struggle. All through this I can bear a calm exterior, no one knowing how I am tortured. This fret goes on in every circumstance. I try to divert myself, and go here and there, seek the conversation of some one, seek solitude, try the piano, then a book, until I feel like a hunted creature. This strain upon my mind I cannot endure. I seem paralysed. I cannot perform anything I wish to do, though I spend any amount of energy in fretting. " In the most critical moments of my life, when I ought to have been so engrossed as to leave no room for any secondary thoughts, I have been oppressed by the inability to be at peace. And in the most ordinary circumstances it is all the same. Let me instance the other morning I went to walk. The day was biting cold, but I was unable to proceed except by jerks. Once I got arrested — my feet in a muddy pool. One foot was lifted to go, knowing that it was not good to be standing in water, but there I was fast, the cause of detention being the discussing with myself the reasons why I should not stand in that pool." The morbid " watching of herself," as she calls it, is a very common psychological phenomenon. The morbid doubting, too, and inability to make up her mind to action, is also common. I know a young man of a very neurotic fa,mily, A. D., whose sister, C. E., was insane and laboured under the Variety of mania that I shall describe, who suffered from simple melanchoha, but still more from this "insanity of doubt," for he would stop half an hour in dressing to decide which stocking to put on first, and has been known to stand for two hours where three roads met, trying to decide which 40 STATES OF MENTAL DEPRESSION. to take. If hurried or forced during those morbid periods of doubt, he suffers intense mental pain, and is inclined to resist dictation. Such cases throw much light on many of the resistive and apparently "obstinate" moods of the insane, who are often too much affected intellectually to describe their feelings, or to give their reasons for their conduct. To return to A. C, whose letter I have quoted. She could not walk far, had palpitation when she ran, had no courage to ride, had much confusion and pain at vertex of head after reading or thinking hard. She was fairly nourished, slept well, menstruation was regular, and she looked a sweet, bright, intelligent girl. During adolescence she had suffered much from neuralgia, severe headaches, depression of spirits, and a few attacks of hysteria, and had no surplus stock of nerve energy or trophic power. She had used up in school-work the energy that ought to have gone to build up her brain and body. I prescribed hfe in the open air, no reading, no work amongst the poor (that had strained her by over-sympathy with them), to live largely on non-stimulating fattening food, to take bromide and iodide of potassium in small doses, and strychnine meantime till she could get to Schwalbach and take the baths and chalybeate waters there. This she did, and improved greatly. I have on several occasions met with cases of this type in women of a nervous diathesis or heredity, both before and after marriage, in which the morbid doubting and introspec- tion were very prominent features. I have met with many other cases very similar to this, but each one with its own individual features. It appears to me no diseases are so individualised as mental diseases. It seems as if the brain showed its infinite complexity over every other organ by this extraordinary variety in its derangements. Such attacks of simple melancholia sometimes occur in young persons at puberty or adolescence. In such cases there is always a strong hereditary tendency towards the neuroses STATES OF MENTAL DEPRESSION. 41 if not to mental disease. I was asked to see A. E., a girl of 15, some of whose mother's family had been insane, who was clever and studious, though at one time wild and mismanaged, who, after hearing a sermon one Sunday, became very de- pressed, insisted on praying with the other girls in the school, and was a little excited and demonstrative. The great feature of her case was one which, in different forms, is very common in young brains that are subject to the psychoses, viz., a sort of automatic, rhythmical, emotional movement. She became what she and those about her called " agonised " when left alone, that is, she would get into a state of in- tensely depressed brain action, — kneeling, uttering over and over again rhythmical expressions of prayer, swaying her body backwards and forwards, and wringing her hands at intervals. When with others, or at her lessons, she would appear to be quite well, but reserved and shy, and could not learn her lessons so well as before, and had no tendency to romp. She was becoming paler and thinner, though she ate well. She had never menstruated. Her intelligence, when I saw her, was normal ; and she said she was quite well, and would admit no depression. She said she had headache in one temple, and felt her back weak. I sent her at once to the country, to ride, walk, live in the open air, to take aloes, iron, and quinine, to read Uttle, not to go to church for a short time, to give up coffee and tea, and animal food, but take milk and eggs ad libitum,. At first, for a month or two, she used to feel depressed, and slightly agitated before people, but soon got girhsh, romping, and quite well. After a tour in Switzerland she returned fat, cheerful, and vigorous, with no imdue religious emotionalism. She menstruated soon. If one had the guidance of such a life, much, I think, might be done by prophylaxis to ward off attacks of the neuroses. But one great contingency it is most difficult to know how to meet, viz., marriage. If such a woman marries, she runs many risks in pregnancy, childbirth, and lactation, and she is likely to have weakly children ; if she remains single, 42 STATES OF MENTAL DEPRESSION. she has nearly as many hazards in unused functions, hysteria, unsatisfied cravings, ohjectless emotion, and want of natural interests in life. For herself she would get more happiness in life by marrying ; for the world it is better that she should not. But prophylaxis in mode of living, attention to keep the body nutrition at all times up to the highest mark, and early treatment of the beginnings of the evil would, I am sure, often ward off an attack. I need hardly say that the " cause " assigned— viz., the sermon she heard— had in reality less to do with the disease than the brain she took to church, predisposed by heredity, exhausted by study and the unnatural life at a boarding-school, starved of fresh air, and rendered unstable by the physiological crisis of commencing menstrua- tion. And here I would say, once for all, about unusual religious services, exciting preaching, and "revival meetings," that, as a physician, I have no special objection to them, but I think they are only suited to stolid healthy brains, and should on no account be attended by persons with weak heads, excitable dispositions, and neurotic constitutions. • The immense variety that the combination of different mental or nervous symptoms is capable of producing comes out in this, the simplest of all mental ailments. In some cases the mental pain is, as it were, negative rather than positive, there being simply absence of pleasure; in others there is a simple blunting of the emotions, with a tinge of depression ; in others, again, the normal gaiety disappears ; in others there is a paralysis of energy ; in others a sudden ceasing to care anything about the usual interests of life ; in others a natural suspiciousness of temperament becomes morbid or a new morbid suspiciousness arises ; in others a natural diffidence of disposition increases so as to become a disease and to cause intense unhappiness ; and in others it is a morbid fearfulness. It would swell the bulk of this lecture to utterly impossible proportions were I to give cases illustrative of all these conditions, but, to show the ordinary types, I give one or two. I was once consulted about a lady, STATES OF MENTAL DEPRESSION. 43 A. F., about 40 years of age, who was said to have had a similar attack some years before, and to have recovered. She had given up her business, and had, therefore, no serious interests in life. She had been for some months ill. "When well, she had been a clever active woman in body and mind, had conducted a business enthusiastically and profitably, was sociable and a favourite with her- friends. "When I saw her she had little conscious mental pain, but she had no mental or bodily pleasure. She had no energy — no interest in any- thing. She had no delusion, except an unreasoning belief that she could not get better. She was utterly careless about her dress, or appearance, or cleanliness. She was obstinate about some things ; she cared for nothing or nobody, not even for her Hfe, and was perfectly conscious of her condition. The only thing in which she took any interest was talking about her symptoms. Her memory was good, her reasoning power was, in the main, good. She was thin and flabby. She would do nothing she was told, and needed the guidance of others for her recovery. She recovered after about three years, having then passed the climacteric. I have seen many cases where the mental symptom of depression was so subsidiary to general nervous prostration, incapacity to walk, work, to digest food, or to fatten, that it was overlooked. I knew one case, A. G., where, as the result of many causes of nervous exhaustion, along with mild mental depression, indigestion, and the most distressing weakness, the cardiac innervation became so weak that the recumbent position had to be kept almost constantly for a time in case of syncope. She recovered in two years under tonics, changes of scene, ana a warm climate. Many of these cases are of the same essential nature as typical mild melan- cholia. American medical authors have much to say about such nervous exhaustion and prostration— the Neurasthenia of Beard. Eor the cure of some of these cases a plan of treatment has been revived, which is certainly not applicable to many cases of melancholia in my experience. It is that 44 STATES OF MENTAL BEPKBSSION. of ma.ifiaor thoughts and conduct towards him iluring his life. This she talked of from morning till night, in fact would speak of it to strangers, and would talk of nothing else ; when pressed, her improper conduct was found to have consisted in smoothing his hair when ho was lying in bod very ill, and even that may not lia,ve been a fact. She would not employ horsidf, lost all interest in her work, or in anything. I saw her in consulta- tion, and advised a good trained nurse, change and travel, and visiting near relations. But she got steadily worse, and was very obstinate indeed, and would take no medicine. Thinking that perhaps some uterine disease or disturbance might be present and detormiiio the character of her delusions, I wished her examined, but she would on no account consent. She ate heartily, and looked fat and well. She made one or two futile attempts at suicide by twisting her hair round her throat. When well, she had been a bright, agreeable-looking woman; when suffering from this illness her expression of face was totally changed. One would scarcely have known her to be the same person. This absolute change and reversal of the characters of the facial expression is very marked in STATES OF MENTAL DKPEKSSION. 70 such melancholia. Sho had to bo sont, after about threo months, to one of the villas attached to the ^Vsj-lum, and for the first wook she did nothing bvit repeat her delusion and fret about it ; sho thought of nothing else. Sho took up tho idea then that sho ought not to have loft home or come here. Sho was sleepless and restless at night, and' very obstinate. She got tonics, lived in the fresh air, and walked long distances each day with her attendants j ate well, and got 45 grains of bromide of potassium at night. She improved for three weeks and then had a relapse during menstruation, which was abnormally scanty. She felt as if sho had a shock on her head one night, and after that she felt as if her braiu was '■ completely gone." Such neuroses of sensibility are very common in and before melancholia, and this feeling as if the brain was "gone" is particularly so. I suppose the patients are conscious of a mental incapacity, a paralysis of tliinkiug and volition, along with a strange feeling in the head, and that this is tho foundation of this delusion. After this she changed somewhat. Sho was more obstinate and very sleeji- less, and unable to read or employ herself; but, instead of having caused her brother-in-law's deatli, she began to blame herself for having left home and her husband, and harped on this from morning till night, reproaching herself for what she had nothing to do with. I looked on this change of delusion as a very good sign, and my prognosis was better after that. She menstruated regularly but scantilj', as she had done from the beginning of the attaek. She was put on dialysed iron, and got it steadily thereafter. In four months there was a very great improvement, and in six months she was well enough to go home, and completed her recovery there, having gained about a stone in weight dm-ing her convalescence, though slie was never very thin from tlie beginning. Xext to tho convulsive and organic varieties of melancholia, the fixed delusional is on the whole the least hopeful as regards recovery. The following are actual examples of delusions of about 80 STATES OF MENTAL DEPRESSION. 100 female melancholic patients, and they far from exhaust the list : — Delusions of general persecution. „ „ general suspicion. „ „ being poisoned. „ „ being killed. „ „ being ruined. „ „ being conspired against. „ ,, being defrauded. „ „ being preached against in church. „ being pregnant. ,, ,, being destitute. „ „ being followed by the police. „ „ being very wicked. ,, „ impending death. „ „ impending calamity. ,. „ the soul being' lost. „ „ having no stomach. ,, „ having no inside. „ ,, having a bone in the throat. ,, ,, having lost much money. „ „ being unfit to live. ,, that she will not recover. „ „ she is to be murdered. „ ,, she is to be boiled alive. „ „ she is to be starved. „ „ the flesh is boiling. ,, „ the head is severed from the body. „ „ children are burning. ,, „ murders take place around. ,, ,, it is wrong to take food. ,, of being in hell. ,, „ being tempted of the devil. ,, „ being possessed of the devil. ,, „ having committed an unpardonable sin. „ „ unseen agencies working. STATES OF MENTAL DEPRESSION. 81 Delusions of her own identity, being on fire. having neither stomach nor brains, having skin disease and infecting others, being covered with vermin, letters being written about her. property being stolen. her children being killed, having committed theft, the legs being made of glass, having horns on the head, being chloroformed, having committed murder, fear of being hanged, being called names by persons, being acted on by spirits, being a man. the body being transformed, insects coming from the body, rape being practised on her. having venereal disease, being a fish, being dead, bavins committed " suicide of the soul.'' LECTUEE III. STATES OF MENTAL DEPKESSION — MELAN- CHOLIA {PSYCHALGIA)—Coy!TmvEi>. Excited {Motor) M. : Restlessness, noise, agitation, wringing hands, moaning, shouting, tearing clothes, violence, insane obstinacy ; difficulty of management, hallucinations ; Delirium Tremens a typical and exaggerated variety of this state ; muscular expressions of mental state ; trophic changes, boils, irritations of skin causing soratchings, erosions of surface, pulling out hair, &o. — Resistive {Obstinate) M. : Unreasoning resistance to everything ; trying and difficult form to manage ; to overcome resistance forcibly often causes excitement ; such obstinacy usually delusional, with element of stupor — Convulsive M. : A rare but serious and usually incurable form, with a few attacks of severe convulsions usually at beginning of the attack ; usually pia mater adherent to convolutions — Organic {Gross Brain Disease) M, : Occurs sometimes in the first stages of organic brain diseases ; can usually be treated at home ; seldom suicidal — Suicidal and Homicidal M. : In every case of Melan- cholia, however mild, look out for suicide, and guard against it. Meaning of suicidal feeling — infinite variety of motive and delusion, and of modes of suicide ; concealment ; cunning ; act depends much on natural courage of patient, and partly on his religious and moral principles ; prevalent modes of suicide in individual cases, in nations, and In sexes ; suicide by suggestion, from seeing means at hand ; subtlety and liability to recurrence of the impulse. Homicidal and Suicidal impulses and acts frequently combined — Lack olpost mortem appearances in Melancholia ; period of life at which most frequent ; hereditary laws — Treatment: Diet — tonics, nutritives, sedatives (use and abuse), stimulants, quinine, iron, strychnia, phosphorus, the bromides, mineral acids, laxatives, mineral waters ; fresh air, exer- cise, baths, change of air, scene, and association, rest, travel, occupa- tion, amusement, music, avoidance of excitement or noise or strain of any kind ; many attacks will " run their course," and "take their time," like a fever ; nursing, watching ; removal to Asylum — STATES OF MENTAL DEPEKSSION. 83 Prognosis : Considerations — youth ; general state of body ; fixed delusions or not ; mode of onset ; hallucinations ; trophic symp- toms in skin ; effect of treatment ; convulsions ; suicidal ten- dencies ; persistent refusal of food. Hygiene and prophylaxis in children of melancholic and neurotic families — Diet ; mode of life ; schools ; occupations and professions ; sleep ; cramming and com- petitive examinations. Excited (Motor) Melancholia. — This, like all the other varieties of the disease, may be one stage in the complete clinical history of a case, or may be the type from beginning to end. The motor centres are evidently affected to a greater extent in this than in any of the other varieties, except the one I shall describe as the melanchoha -with epileptiform attacks. The patients rush about, are violent to those about them, wander ceaselessly, walk up and down like tigers in a cage, or roll about on the floor, bite their finger-nails, or wring their hands, or shout, or groan, or moan, or weep loudly, or tear their clothes, and in all their attitudes and motions ex- press strongly their mental pain. In short, the muscular expressions of the pervading emotion are strong and uncon- trollable by volition. Some of the very worst and most incurable cases of melancholia are of this type — certainly tlie most troublesome to manage. The motor expressions are partly determined by the intensity of the disease in the brain centres, and partly by the amount of inhibition possessed by the individual when well. It must be remembered that active motor acts done when the patient either "loses control over liimself," or does not exercise that control, often give sensible relief to the mental depression, just as shouting, weeping, or rushing about will give relief to bodily pain. In such a case the nerve-storm is " irradiated," as Meynert says, into other centres, and not inliibited so strongly as before. It is not uncommon to see cases of melancholia with symptoms that closely resemble convulsions. All the people about the patient say she is in " a fit " ; but it is not a true convulsion. Women very frequently present the motor type of the disease. The Celtic race does so markedly. The wailing 84 STATES OF MENTAL DEPRESSION. and weeping, the gesticulations and motor grief of an Irish- woman are usually out of all proportion to the mental pain- that is, if we take the Teutonic type as our standard. Here, is an example of c.r.ritcd melancholia : — A. v., fut. 28, an Irishwoman. Patient had been oonfinod a week previous to admission. The day before lier admission she suddenly became very unsettled and careless about hor child; she also attempted suicide. On admission she was greatly depressed; she confessed to feehng exceedingly miserable, and could be got to answer the .simplest questions only with difficulty ; she had a woe-bogone appearance, and her bodily health was very weak. She slept very little the first night, but seemed considerably better next day; con- versed readily and clicerfully ; said she felt much bettor, and that her strange behaviour previous to admission was due to something which came over her and confused her. In a week she got worse, being much depressed ; thought she was to be killed ; and that everything was going wrong with her ; did not take her food well ; attmupted to drown herself by jumping into the Asylum shallow curling pond. In a month she was somewhat improved, but still con- tinued much depressed in mind. She did a little work. In six weeks, after seeming to improve for a time, patient relapsed. She became the embodiment of utter misery and wretchedness, which she exhibited in a most demonstrative way. She wrings her hands ; sways backwards and forwards, contorting her body ; rushes about from place to place, and cannot settle for a minute. But the most striking things about her are her countenance and the noises she makes. She has a large mouth, and as her visage assumes the most doleful aspect, expressing the intensest misery, her mouth begins to open until it is a great gaping cavern, and she howls—" Oil, John dear 1 doctor, darlin' 1 and me childer I and me persecuted in this jail 1 oh, I'm punished 1 dear darlin' doctor 1 oh, me two brothers ! oh, kilt and murdered they are I Oh ! oh ! oh ! " All this time there is seldom a tear, and it ST.VTKS OV MKNTAI, DKrUKSSlON. ^5 goos on from morning till night, !\nd somotimos all night, so that you cannot hoar yoursolf spoivk within 10 yards of her. Thongli tho misory is vovy roal to hov. yot tlu> otVoot is ofton huliorous, as if yon woro looking at tho ovordoi\o misory of an Irish wako on tho stago. Sho ato woll, and hor bodily IvosUth impivvod, though sho had prohif\'>ui> ntori, for which no troatmont could bo adopted. .Vt'tor fourtoon years sho diod of heart disease, but with hor demonstrations of grief much subdued. Here is a fhtxiiiir ro^z' of flu' ,nm«|(' .-'.'W thot lir,\i (7<'#v» jjiwy : — .\. \V., a^t. 45, deaf and dumb, but educated. A " volaiivo " is insane. For seven years he was in a condition which, to jvll out- wanl ajipearanco, was that of misory as great as any painter has ever depicted as tho lot of the danmed in hell. Ho was uovor at rt'st> but pjiced about with an uneasy ner\x>us gait>. His hands wors^ always moving, tearing his clothes or un- bnttouing them, or masturbiiting, which ho did in the most shameless open w-;\y : indeed, ho was doing it half the time. He made a hideous noise nearly all the time between a groan and a hiss, ami his expression of face was tliat of aWohite misery and lierco desperation. At times he ruslied about, and if any one came in his way he knocked him down ; in fact-, he had a distinct honvicivlal impulse, which uu\do him atfeick those near him. .Vt times ho tore his flesh aT\d boat his head. He seemed to feel no pain. Ho was the worst p;itient in 'Morningside Asylum, and, in fact, was about the worst 1 have over soon, taking tho long time he w-as atrcoted into account. Ewrytluivg had l>eeji tried in vain for his recovery and amelior:ition. Not.lnng would interest him; scAFcely anything would quiet him. 1 tried hyoscyamine, and it nearly jv>isouod him. 1 gave him bromide of potassium in dcv?es up to (5 drachms a day. I tried c;\nuabis indica with it, and ho n\eroly fell off in flosli, without being benefited. He was Wivlke^l in the fresh air till two strong atti?ndants 86 STATES OF MENTAL DEPRESSION. were done up. He was tried to wheel heavy barrows of soil, but the fight to get him to do so threatened to run some risk of killing him. I often wished I could castrate him, for the constant masturbation, or attempt to masturbate, seemed to show that the centres of generation were in a state of morbid excitation, and I think it might have done him good. For the last three years of his life he was more quiet and de- mented, and he died of exhaustion, with some tubercular disease in his lungs. This is another chronic case of motor melanchoKa, of a kind jfhich it very common in old age : — A. X., ast. 77. Single ; gentlewoman. Disposition active, but passionate. First attack. No exciting cause known. Had a fall down stairs six months ago. Became very restless and sleepless, and lost appetite. This condition had lasted for three months. On admission she was very depressed and unsettled. Could not sit down or rest for a moment. Walked about the room the picture of despair, and took no interest in anything. Was enfeebled in mind, and behaved in a silly, miserable way. Her physical condition and general health were poor, and she was very anxious about her state of health and her soul's salvation. She had no sleep the night after admission, and was very noisy and restless. She was very depressed ; begged to be sent home ; wrung her hands and wept. This continued with little change. Her nights, with few exceptions, were sleepless, unless narcotics were given ; and she was also very noisy, beating at her bedroom door and shouting loudly. During the day she was in a constant state of miserable unrest. She was suspicious and despondent; wished she were dead ; refused hor food ; would not settle to any work. This state of unhappy restlessness and excitement became fixed and chronic, while her mind became more enfeebled. She got plenty of food, but never could be fattened. After three years she began to show distinct signs of partial hemi- plegia, which was first on one side and thou on the other, STATES OF MENTAL DEPRESSION. S7 eacli attack passiug off in a fow days. Two of tlie former assistant physicians to tlio Asylum, l~>i-s Hayos Nowington and J. ,1. Brown, liavo described this condition and its pathology, attributing it to capillary apoplexies ooourriiig in sueeession.^ But she could never sit down for any length of time till near tlie very end, a year after the commeueement of the paralysis, when she went to bed and soon died. She would eat her meals standing .and moving. She swore and used blasphemous language to lier- self. She said slie would " burst " if slie was made to sit down. The couvolutional motor excitement was unceasing, tmd nothing oauM exhaust it. It was connected with an irritivtiou in the process of tho decay and degeneration ajid atrophy of the brain in old age — a long-continued brain-storm tliat ended only wiUi life. Such old people are most difficult to treat. If we. by mechanicul means, restrain their move- ments, my experience has been that it is no real conservsition of energy, but the excitement, finding no motor outlet, reacts inwards and makes the mental stote worse. AYheu iiisMnti/ in ?)t),i!,x and girlg /(iA' an fjKi m i>l f : — A. Y., a>t. 12. Disposition excitable: habits "old- fashioned." sedentary, tlioughtful, and stuilious for his age. Several brothers and sisters died in infancy of liead affections, and a paternal uncle had been melancliolic. Mother nervous and eccentric. Father died of consiuuption. Had been brought up ill a poor way alone with tax old gnvndfatlier, living on t<>a and colTee and no miDc. Had not romped and played enough. Had been in the habit of wetting the bed. His father died a few months ago. Seemed to feel it keenly ivs a grown-up man would, and has never been the s:\me since. Of late lias dre;vmed mucli, and awoke in the middle of the ' Eiin. M^t JoHr., Angvist 1$74. aud Jour, of J/t-M,^j7 ^^•l<•Hsyehologioal condition is only soon when the convolutions are wasted or destroyed struotTirally. This con dition is often seen in old persons. The brain is more pro- foundly disturbed in it^s functions in tlie excited than in any other form of mehmcholia except that witli epileptiform convxjlutions. I'rciiimt'Ht.- Kogarding the treatment of exeitod melan- cholia, it might at first sight appear that moohanicAl restraint of tlie movements of such cases, or at all evoi\t.s narcotic and temporarily paralysing drugs, would be indicated, to conserve tlie energy and to s;ivo exhaustion, lu former times this plau of treatment was acted on habitually. In very exceptional c^»se« we do so still, but a closer study of the atVootion and the results of exporionce show us that evil results of the gravest kind are apt to arise by tlve indiscriminate restraining of motion either mechanic;vlly or chemically. We see that the motor otTocts are tlie natural expression and outlet of morbid energi|- generated in the brain idoo-motor centres. If they are restrained, the condition of tlie hraiu seems to suffer, tlie 90 STATES OF MENTAL DEPRESSION. excitement to increase, and there is much greater risk of its exhausting and killing the patient, or of the brain condition becoming incurable. So we let the patients walk, shout, even at the risk of tumbling and accident, and we try and send the motor energy into normal directions by much hard walking in the open air, free scope, garden work, wheeling barrows, &c. I take the following case as a good example of the effects of such rational treatment in motor melancholia in what was a very severe example, and of the possibility of treating such a case tO a favourable termination out of an asylum, during the whole of its course, when circumstances are favourable : — B. A., set. 60, a retired professional man, who had been in many climates. Temperament was sanguine, diathesis nervous, disposition very lively and social ; habits active. He once before had a short attack of depression, and had recovered at home. The present attack began by simple depression and falling off in weight. He then passed through a hypochondri- acal stage, complaining constantly of his bowels and digestion and liver. Those ideas increased until he had fixed visceral delusions. He had, as a matter of fact, prolapsus ani, but in imaginatioi?. his bowels were all diseased, and his powers of swallowing gone. His next stage was that of active motor excitement, showing constant restlessness by night and day, shouting, tearing out his hair, and picking his skin into holes. He recovered rather suddenly in about a year from the bo- ginning of his illness, after he had gained about 28 lbs. in weight. His treatment was throughout tonic and nutrieBt'— quinine, the mineral acids, arsenic, iron, the bitter natural waters, and strychnine. He took as much as eleven tumblers of milk a day, and the only thing that at one period of his case made us not give up hope was that he was able to digest this, and that he gained weight, except during the most excited stage, which lasted for four months. He took Tr. cannabis indices and bromide of potassium for the excitement with marked benefit, and I once, when he was very excited but improving in strength, had his occiput shaved and a large STATES OF MENTAL DEPRESSION. 91 blister applied, also with benefit. He took no animal food during his illness. AVarm baths, with cold to his head, pro- duced temporary quietude during his excitement. He had a first-rate male attendant and a devoted wife, and lodged in a suburban villa with a large garden, where he stayed nearly all day, driving and walking out when quiet. I have never treated a worse case of melancholia out of an asylum. Resisfire (Obstinate) Melancholia. — In many cases of melan- cholia, obstinacy, with an unreasoning, passive, or active resist- ance to anytliing that other people want them to do, is the marked feature of this disease : to dressing, to undressing, to taking food, to going to bed, to getting up, to going out, to moving about, to micturating, &c. When this resistance is very extreme, as it sometimes is, it is a trying and very dangerous complication, from the difficulty of overcoming it and carrying out necessary treatment without hurting the patient. I have often had nurses and officers come and report to me — " "VTe will not go on dressing except a doctor is present. There is great risk of breaking his bones or injuring him." It is evident, too, that overcoming the resistance, and making the patient do things contrary to his will, is often attended with aggravation of his mental pain, causing excitement, and even violence. As a general rule he cannot say why he resists, but he does so persistently, doggedly, unreasonably, and in some cases 'with fierce violence. It is one of the symptoms that try most the patience of attendants and nurses, especially of the less gentle and reasonable sort. They cannot under- stand that it is a mere symptom of disease, and are apt to treat it as if it were sane obstinacy. Resistance is sometimes combined with active motor agitation, but most frequently it is passive obstinacy. It is often one direct result of the delusions present. One patient fancies he cannot pay for his clothes or food, and so wUl not wear the one nor eat the other ; another fancies that she is taken to execution, and so will not walk ; another is to be made a spectacle of, and so will not associate with other patients. Some have vague feelings 92 STATES OF MENTAL DBPEE3SI0N. of distress that the house is falling and that the ground is unsteady, and so will not move. One very resistive woman I have now as a patient— B. B.— who will not do anything that is good for her. She will not put on her clothes or shoes, and says, in a vague, incoherent, fearful way— "It's awful, I'm trampling myself down under the ground" — and eo she will not walk. " I'm in a hole to serve other people, I've neither meat nor drink " — she had both before her, but in re- gard to those she had not the sweet sense of possession. — " I dinna ken the beginning o't, and I dinna ken the end o't. I never thocht I was to be the key o' the earth. Every- thing's naething. I've come miles and miles. It's awfu'. I was forty when they changed me into this state. I dinna ken what age I am now. They've greased me a', and gin' me oil" — castor oil — "and done a' kinds o'thinfjH, and there's no a bit o' wit in me." She shows that there is some delusional doubt in her mind as to her own personal identity, as to the ground on which she stands, as to time and space, and as to her own age ; and she puts a bad construction on every act done by others, accusing them of all her ills. Her sensibility and muscular sense are perverted. Extreme obstinacy in cases of melancholia is usually, in my ex- perience, the result of a complicated and deep delusional state such as this, or to an insane stupidity, confusion of mind, want of power of comprehension or attention. There is an element of stupor in many of them — delusional stupor. One may not at the time be able to make out what the delusions are, but patients can, after recovery, usually tell what they were. In somo of these cases I am reminded of the resistance of a wild animal when first caught. Fear, the instinct of self-preservation, unreason, suspicion, and the instinct of freedom, are all mixed up in the case. An evolutionist would have no difficulty in seeing in those phenomena a reversion to primitive instincts. I have often seen, as clinical accompaniments of such cases, a hot-feeling perspiring skin and a particularly offensive strongly smelling STATES OF MENTAL DEPEESSION. 93 perspiration. Women liave often greater mental confusion and obstinacy at the menstrual periods. Ma^t iirhation in both sexes often causes, aggravates, and accompanies this condition. They often admit afterwards that it was this habit which aggravated their confusion and obstinacy during the illness, but say that it was almost involuntary and automatic at the time. I have now a lady — B. C. — under my care, whose obstinacy is so extreme that it sometimes takes six attendants to dress her, yet, when the first article of clothing is put on, she will sometimes finish her dressing herself. A locked door makes her furious to open it, so we allow her to go where she likes, and almost do what she likes. She will stand in a passage for hours, evidently un- certain what to do, but any attempt to make her go one way will certainly tend her to go the other with all her might. When opposed she is fiercely resistant, attacking those about her violently at times. Kosistance to taking food in such cases is common and very prejudicial to their recovery. They are unpersuadable, but sometimes when the first mouthful is forced into their mouths they will then finish the meal. In other cases, if food is left near them in an outof-the-way place, they will go and eat it by stealth, denying the fact afterwards. We often take advantage of this peculiarity to get them to take food. In some of those things they are exactly like a wild animal beginning to be tamed. This condition sometimes has more of confusion and stupidity than resistance or obstinacy, and when that is so it is allied to melancholic stupor, of which I shall speak in another lecture. In fact, I have seen resistive melancholia as a stage in a case passing into stupor, and then again a furtlier stage in passing out of it towards recovery. Tlie following was a prolonged case of rcsUtivc melancJioUa wIm recovered: — B. D., »t. 40. Married. Temperament bilious; diathesis nervous; disposition cheerful; habits active, No children. First attack : duration eleven months. Assigned cause, depression from diarrhoea. Slight symptoms 94 STATES OF MENTAL DEPEESSION. at first suggesting epilepsy, but no true convulsion. Her father was epileptic, and a sister insane. She became de- pressed, and refused food, requiring the use of the stomach tube for two months. Had delusions, e.g., that her husband was near her when he was far away. At first she was treated in a private house, but her extreme obstinacy about eating, dressing, undressing, walking out, and coming home when out, implied more attendance at times than could be got in any private house. On admission to Morningside Asylum she was found to be labouring under melancholia, and to be in fair bodily health. Two months after admission it is noted : — " B. D. continues very restless, suspicious, and obstinate, and it is with difficulty she can be got to do anything. She occasionally plays on the piano, but only does so to get a newspaper, which she seldom reads, but carries about with her and will not give up again, believing it contains messages from a friend. There is no active excitement or any other symptom, simply passive resistance to almost everything. She constantly imagines that some relative of hers has come to see her; and, when out walking, will look into all sorts of improbable places for this person. She sleeps fairly at nights, but awakes very early in the morning, and is then very restless. Takes her food well; gets tonics of all sorts." Continued, after eighteen months, as restless and obstinate as ever, and could not be got, without much trouble, to do any work. Slept badly, and was often restless at night. Took plenty of food, and kept in fair bodily health. She was addicted to masturbation, and after recovery believed that caused her bad symptoms. Looked sometimes very demented, and could not be got to do much work. Slept rather better. Prognosis seemed very doubtful. During the latter half of the second year she was able to go out into town on several occasions; and in the end of it she was more settled and tidy in her ways, but still full of the delusions about people being present who were not, &c. STATES OF MENTAL DEPRESSION. 95 In three years, after various trips to the seaside, and a tour in the Highlands, she had improved sufficiently to leave the Asylum on a year's probation, going first to live in a family for a year, then taking a tour on the Continent, and, finally, being able to take up housekeeping for herself, getting rid of her mental disease, becoming very stout, healthy, and cheerful after about five years from the commencement of her attack, and continued so for twenty-two years. Unfortunately, at 65 she became again melancholic with somewhat the same symptoms and delusions as before, but much milder in char- acter, and tliis attack was the prelude to her dying of malignant disease of the liver. This case shows that treatment should he continued, and hope should not be given up for a long time in this disease. Tlie folloioing if probabli/ an ineurable case : — B. E., set. 46. Single. Education good; disposition cheerful; habits active and industrious. No known hereditary predisposition to insanity. First attack : duration two months ; predisposing cause, change of hf e. She became depressed and had melan- cholic delusions, e.g., that she had committed some crime, and must be punished ; complained of headache, neuralgia, and uterine disorder. On admission she had a look of stolid misery, was evidently much depressed in spirits, was very obstinate and intractable, refused her food, was very taciturn, and showed a good deal of motor excitement. Her physical condition was poor, but there was no evidences of organic disease. From the beginning there was the greatest difficulty in nourishing her, and for nearly ten months the nose tube had to be used regularly. She resisted the operation of feeding in the most obstinate and dogged manner, the services of some half dozen attendants being usually required before a meal could be given. In the same manner she resisted being dressed, undressed, taken out for exercise, going to the water- closet, or leaving it when there. Her resistance was not passive, but very active indeed; she would often strike and 96 STATES OF MENTAL DEPRESSION. kick those who wished to make her go out, and she would seize hold of anything near, and nothing but force would overcome her resistance. Her condition improved considerably for a few months, and the nose tube was dispensed with. She gained in weight, did a little useful work, and at times talked rationally and cheer- fully. This improvement, however, did not persist. The prognosis is bad now after ten years. Dirty habits developed eighteen months after the commencement of the attack. A hsematoma which appeared is in such a case almost sufficient to warrant a verdict of incurability. Melancholia with Epileptiform AttacTcs (Convulsive Melan- cholia). — In the excited form of melancholia the motor move- ments are ideo-motor and volitional — that is, co-ordinated motions and indications of emotional depression without necessary loss of consciousness and memory. But in the form I am now to describe, which is very rare indeed, and has not been before described, the motor affection is a true convulsion with unconsciousness, occurring once or twice, seldom oftener, in the course of the attack ; and it differs in no way in some cases from an ordinary epileptic fit, and in others in no way from a general paralytic epileptiform attack. This form of melancholia is in my opinion one of the most serious varieties of the disease. In it the whole of the functions of a brain convolution are affected — mental, motor, sensory, trophic, and vaso-motor. The mental depression is very intense, accom- panied by muscular agitation and excitement, and usually by great obstinacy. There is usually much insensibility to pain, and a tendency to skin irritations, so that the patients scratch themselves and pick holes in their skin, or rub off their hair or pull it out in patches. They are all prolonged and prac- tically incurable, for I have seen only two make even modified recoveries, and none of them have ever been able to work afterwards. It must be understood that I do not include in this variety convulsions of syphilitic or alcoholic origin. Con- vulsions are present in certain cases of those two kinds of STATES OF MENTAL DEPKESSION. 97 insanity, but I shall refer to tliem under those headings. This variety of melancholia seems to have a distinct pathologi- cal basis. I have never met with any case but one -where, after death, some cause of irritation or some limited adhesion of the pia mater to the convolutions was not found, just as in general paralysis, not at the vertex, but on some of the basal convolutions. The structure of the convolutions is altered on microscopic examination, there being proliferation of the nuclei of the neuroglia, especially seen round the arterioles and capillaries, with destruction of many of the nerve cells. I have seen over a dozen of these cases, but of eight I have records since I realised that this was a distinct pathological variety of melancholia — almost the only variety that can be correctly so described. Of those eight cases five had only one epileptiform attack, two had two, and one had many. In six they happened within three months of the beginning of the disease, in one after three years, and in one only after twenty years. In three of them the patients died within three years ; in five they lived — one for twenty-four, one for ten, one for nine, and one for eight years. They differ entirely from ordinary epileptics, and from the cases with occasional epileptic fits that sometimes occur in advanced dementia, as the brain gets wasted ; and they are certainly not cases of general paralysis, for the speech is not affected. The follotciiig are examples of convulsive melanclwlia : — B. F., ;vt. 61. Single. Temperament melancholic. Educa- tion good; disposition cheerful, with periods of irritability; habits perfectly steady ; teetotaller. One previous attack of melancholia. Hereditary predisposition to insanity ; exciting cause unknown. The attack began by a running down of bodily health generally. Duration of existing attack three or four months. Has been depressed, and lately has had two epileptiform seizures, each lasting about five minutes. Attempted to cut his throat the day before admission. On admission was very depressed, and had many melancholy delusions. Said that he had lost all his money and was G 98 STATES OF MENTAL DEPKKSSION. entirely ruined, that lie was hundreds of pounds in debt, and that he can never pay what ho owes. He was taciturn, obstinate, and reticent, and displayed a confused impairment of memory. He was in feeble health, afid had slight kidney and liver disorder. The prominent feature in this case came to be a curious, unreasoning, automatic obstinacy. When dinner is announced, for example, no persuasion will get him to go down to the dining-room ; and when requested to go out to walk he simply will not go. He can give no reason for his refusal, and when force is used he resists with all his strength. In other respects he behaves in a very quiet and sedate manner. He is a very diligent reader, wakening up to activity when fresh news- papers or periodicals are brought in. He is usually little given to conversation, and he is slow to reply to any observa- tion made to him. He is still very despondent, believing that he is ruined, and that he has not a penny of his own, but he has occasional outbursts of fun, and even plays little practical jokes at times, and laughs at the result. Now and then he will talk as animatedly and intelligently about things as ever he did in his life, and one could not then say there was any- thing wrong with him. Yet, in the midst of this, if his dinner is announced, or the time comes to go out to walk, he will become confused and obstinate, and will need to be taken out ■ of the room by force, no amount or kind of persuasion at all availing. Has had no more epileptiform seizures, but did not improve or change mentally. After eleven years of this con- dition he died of bronchitis at 72, but no post-mortem examina- tion was allowed. The following was a case of convulsive melancholia become chronic, ivith muscular oxprrtssions of mental pain, hut no real feeling. Enfeehlement of mind; two epileptiform attacks- one i'wenty years after the other. V,. H., 8et. 36, when admitted, laboured under melancholia, Had been treated in the Asylum ten years before, and had recovered. Insanity supposed to be duo to too free use of STATES OF MENTAL DEPRESSION. 99 stimulants. After eight years' residence slie was discharged improved, but within throe years she was brought back. She was greatly excited — crying, moaning, wringing her hands, and displaying generally a picture of the most intense misery, and had an epileptiform fit soon after admission. She has now been for twenty-one years in a condition of melanchoha; but with the lapse of time her feelings have become so blunted, and her intellectual faculties so dull, that while she still wears all the trappings and the suits of woe, her face drawn and furrowed, and in a fixed state muscularly of utter misery, her attitude that of utter dejec- tion, and constantly wringing her hands and uttering a sound between a wail and a groan — she is inwardly, if not happy, at least free from real conscious remembered mental pain. For about two days in each week she is wonderfully bright and sensible. At other times she is very stupid and helpless. At her best she is much enfeebled in mind, and is childish and forgetful. She rubs the hair off parts of her head incessantly, and often for hours she calls out — " Oh dear ! oh dear ! " in the most doleful tones. But when asked if she is imhappy, she smiles and says — " Oh, no ; " and she will chat away in a pleasant, garrulous manner, and will sing a snatch of a song or play a tune on the piano, or beg for a bit of cake. She had her second general epileptiform seizm-e in 1880, twenty-one years after the first. She died at the age of 71, and several bony spicules were found in her dura mater projecting into the motor area of the cortex. There were no adhesions of the pia to the cortex, and no granulations of the ventricles. But on microscopic examination the pia was found thickened, with blood betweeji its two layers in some places. There was a sclerosed layer on the surface of the cortex. The pericellular spaces were enormously enlarged, with much atrophy of the cell substance in all the layers of the cortex, and there was much pigmentary degeneration of the large cells of the tliird layer. Organic Mdanclwlia (tJie Melancholia accompanying Gross IQO STATES OF MENTAL DEPEESSION. Organic Brain Disease). — There are mental symptoms, often only amounting to depression of spirits, which accompany ' coarse organic disease of the brain, tumours, softenings, and wastings. It is usually in the first stages of those diseases that we have the mental depression, though in some cases it continues till death. In some of those cases I have seen the mental symptoms the very first to appear, long before cephalalgia or paralysis, or even before great bodily weakness made its appearance. A paralysis of the sense of well-being and the enjoyment of life, a diiBculty in coming to decisions, a loss of mental energy, an intolerance of the usual work, if not an actual incapacity to do it well, an irritability of temper, a tendency to make slight mistakes in small things, a loss of memory, and a subacute mental pain, I have seen to exist for two years before men showed any diagnostic signs of brain ramoUissement or tumour. The melancholia is usually of the simple type, seldom assuming the excited, delusional, or distinctly suicidal form. I have seen it of the hypochondriacal kind in a few cases. Organic melancholia commonly ends in organic dementia as the brain disease progresses, if the patient lives long enough. But the patients seldom need to be sent to asylums if they have money enough to pay for home nursing and attendance. The following is a typical case of organic melancholia, interesting from the bodily as well as from the mental point of view : — B. J., aat. 35. Melancholic temperament, nervous dia- thesis, cheerful disposition, and very industrious habits. An unusually intelligent man, who after his business hours— and they were long and hard— read books on philosophy and science. There was no known heredity to mental or brain disease. He had mental worry and business disappointment, followed by a weariness, lassitude, and loss of energy. The disease began by his being forgetful of things. This he was conscious of, and it worried and depressed him, and from some expressions he used his friends feared suicide. He STATES OF MENTAL DEPRESSION. 101 had at the same time headaches, then he smelt bad odours where none existed — a grave symptom always — then he began to take short unconscious attacks, without convulsion or falling down, sometimes several times a day. When I saw him first, eight months after the symptoms had begun, he was depressed, but without any intellectual delusion. He could not read nor apply himself to anything ; his memory was bad ; he had terrible headaches, and a feeling of a band round his head ; his head was not pained by tapping with the finger ; his right face, arm, hand, and leg were weaker than the left, and he had a peculiar slow mode of speech, a difficulty in remembering words, and a tendency to use wrong words having the same general sound to those he wished to use. Sexual desire and capacity had ceased for six months. He was constantly sleepy and yawning, and would go to sleep as he sat and talked to one ; in fact, all the time he seemed like a man half asleep — a grave symptom too. He had a perpetual weariness. Face very heavy and expressionless. When very bad one day, and he wanted to say he never had a foul tongue, he said — " I never was hke some folks that show that they have a strong colour on the tone — on the tongue." His bowels were excessively costive. My diagnosis was serious brain disease affecting the convolutions, but chiefly confined to the left side. I thought it was either softening or tumour. In case it might be of syphilitic origin, and also because I had found this treatment gave reUef in cases of this kind of nonspecific origin, I put him on large dbses of the bromide and iodide of potassium, with Jj-grain doses of corrosive sublimate. I also blistered his head severely behind. This treatment undoubtedly relieved the intensity of the pain, and stopped the epileptiform attacks. His temperature was at this stage subnormal, seldom exceeding 97°. In three weeks after I saw him he had got distinctly worse. He walked worse, staggered, and would fall backwards and to the right if left alone. He spoke worse, and wrote worse, 102 STATES OF MENTAL DEPKESSION. e.g., when I asked him to write " my hat," which was hefore him, he wrote slowly " mhate." His ' temperature was 100° one evening. He died suddenly next morning. On post-mortem examination, I found on removing the dura mater that the convolutions hulged, and were flattened, especially on left side. The whole of the middle lobe of the left side felt baggy and fluid on pressure. On section the lateral ventricle of that side was enlarged, and almost all the white substance of that lobe was gelatinous, stringy, with a pale straw-coloured fluid oozing from it. It was, in some respects, unlike any case of brain softening I had ever seen. The grey matter forming the gyri of the middle lobe was pale and soft, but not diffluent or gelatinous. The pia mater stripped off it very readily. The corpus striatum and optic thalamus of that side were softened to some extent. I could find no embolism nor thrombosis of any of the arteries to account for the softening. The anterior and posterior lobes were pale and wanting in consistence, but not gelatinous. Broca's convolution was not greatly affected. The right hemisphere was pale and soft, especially the whole of the central white substance, but was not gelatinous like the left. In the pons, just under the floor of the fourth ventricle, was a small recent apoplexy, the size of a split-pea. None of the current vascular or emboUc theories explain such a case of brain softening. I think such a disease is the result of morbid trophic changes of purely nervous, and not of vascular origin. Some of the modern authorities would apparently deny the nerve tissue an inherent power to waste, or disintegrate, or become diseased or softened independently of the blood supply or the packing tissue changes. I beheve in no such theory. Over mental work or worry does not primarily affect the blood-vessels, yet it causes brain changes of the most serious kinds. Even when vascular changes -are found, I beUeve them to be secondary in great measure to the alterations of nervous structure. The blood-vessels and the neuroglia are, after all, the servants of the brain tissue J STATES OF MEXTAL DEPRESSION. 103 proper, and this has not been kept sufficiently in mind in some recent nerve pathology. On the vascular starvation theory of brain necrosis it has been always assumed that some mechanical obstruction of a vessel by embolism or thrombosis is required. I have seen most of a hemisphere softened and bloodless, with every vessel fully patent. There had evidently been a spasmodic closure of the vessels, a true vaso-motor spasm of a prolonged and complete kind, starving one hemisphere of blood and killing the patient. I believe that sometimes happens, and is the cause of softenings, apoplexies, epilepsies, spasms, and mental afTections in different cases. Suicidal and Homicidid Mdanclwlia. — The question of the patient being suicidal should never in any case of melancholia be left unconsidered, and the risk of his becoming suicidal should never in any case be left unprovided for. No tendency to suicide exists at all in many melancholies from beginning to end of their disease, but it does exist in some form or other — in wisli, intention, or act — in four out of every five of all the cases, aiid we can never tell when it is to develop in any patient. The intention and the act may come on suddenly, by suggestion from without or within, or by the sight of opportunity or means of self-destruction. "When a man takes away liis own life, or even when a serious attempt is made, it is so distressing to every one connected with the patient, so hurtful to his prospects, and so damaging to the reputation and foresight of the doctor in cliarge, and so in the teeth of the radical medical principle to obviate the tendency to death, that no pains should be spared to guard against its occurrence. WhUe it prevails so commonly in all forms of melancholia, there is a variety of this disease which is specially characterised by the suicidal intent and impidse, and of all the forms of mental depression this is one of the most striking and most important. When the love of life, that primary and strongest instinct, not only in man but in all the animal kingdom, through which continuous acts of 104 STATES OF MENTAL DEPEESSIOlif. self-preservation of the individual life of every living thing are performed— when that is lost, and not only lost but reversed, so that a man craves to die as strongly as he ever craved to live, we have then the greatest change in the instinctive and effective faculties of man that is possible, and we have reached the acme of all states of mental depression. Suicide in some cases is a desperate impulse, in others an insatiable hunger, in others a fixed resolution to be calmly and deliberately carried out, and in others a frantic attempt to escape imaginary calamities or tortures. The determination to commit suicide is in some cases one come to in the calmest and most reasoning way. A patient says — "I'm utterly miserable. I'm not going to recover. Why should I live in torture 1 " and so determines to end his life. Such cases are nearest in character to the suicides among sane persons which Morselli's statistics ^ show are increasing in nearly all the civilised countries. Next to this mode of arriving at the suicidal purpose, in my experience, come the attempts to commit suicide from the motive, illogical as it seems, to escape imaginary torture or persecution. This, too, causes one of the most common mistakes made in not taking precautions against it. A man is desperately afraid he is going to be hanged for some imaginary crime, and his friends think it would be absurd to have anyone watched against taking away his own life who seems so morbidly fearful that some one else is going to do it for him. But this is one of the most dangerous class of cases. The psycho- logical condition of such a person, when analysed, is found to be this, that there coexist a paralysis of the life-love, a suicidal longing, with delusions of persecution or torture side by side. They are mental symptoms of the same brain disorder. A very suicidal lady — B. K. — in this state wrote a friend : — " If my soul and body could both die, this would be my salvation; but no, this will not be. God ! how dreadful seems my case. Sadness, terror, tortures intolerable will be ^ Suicide, Henry Morselli. STATES OF MENTAL DEPRESSION. 105 my portion." In other cases there is a direct delusion or hallucination leading to the act of self-destruction. The patient thinks himself too bad to live, that he pollutes the earth, is a source of misery to his relations, that he must sacrifice liimself to save others ; or he hears voices — of God, of the devil, of friends and enemies, dead and alive — saying to him, "Kill yourself;" "Cut your throat;" or there is a longing for death simply, so intense as to overpower all other motives and considerations, without any delusion — a death- love that acts as a fascination. Then there are cases where there is no love of death at all, but rather a fear of it. Yet an ungovernable morbid impulse impels the patient to commit suicide against his will, and contrary to any resolution he is able to form. Then there are cases where, without loss of consciousness, the suicidal feeling comes suddenly on, as in the case of a boy of six I knew, who would suddenly tell his mother to put away the knives as he might cut his throat ; at eighteen he had an attack of adolescent mania. Lastly, there is the epileptic suicidal impulse while the patient is in a state of false consciousness, with no memory of the act after- wards at all. But the last two I shall treat of under the heading of impulsive insanity. Naturally it follows, such being the immediate motives to suicide, the act is carried out or attempted in a great variety of ways. Sometimes it is sudden, the desire to do it arising in a moment, without warning ; in other cases, it is led up to by the clinical history of the case very gradually ; in other cases most elaborate preparations have been made to accomplish it. Twice in America — one, I think, in imitation of the other — men have constructed an elaborate apparatus, taking months to make, by which the contriver gave himself chloroform first, and when unconscious an axe was let loose and chopped off his head. In other cases much cunning and mendacity are used to throw friends off their guard, so as to enable patients to effect their purpose. As a general rule, the more it is talked of by a patient the less danger is there of its being carried out ; 106 STATES OF MENTAL DEPRESSION. but to this there are exceptions. In most really serious cases this is less talked of by the patient than any other symptom of melancholia. The most absurd precautions are sometimes taken in doing the act. Very often patients take off some of their clothes when about to cut their throats. I had a patient once who, in his own house, arranged himself most carefully over the seat of his water-closet before he opened a vein in his arm with a penknife. Amount of Risk. — Various things determine the real amount of risk ; the intensity of the disease ; the amount of conscious- ness and volition left ; the sex and temperament of the patient ; the means available ; the suggestions offered in the shape of opportunity, that is, the sight of knives, ropes, water, open windows, poison, which ia certain cases can rouse into activity a till then dormant suicidal desire ; and, above all, the natural courage and resolution of the patient. The effect of the last element is overwhelmingly proved by the fact that only one woman commits suicide for every three or four men in all countries, the suicidal desire I find being more frequent in women than men. There are some hypochondriacal and simple melancholies who are always talking of suicide, and who never go further than talk and ostentatious preparation. I have referred to the hypochondriac (A. L., p. 51) who tried to hang himself by pulling himself up a flagstaff with one end of the rope round his neck and the other in his hand. I knew a patient alarm his friends by drinking a liniment which he knew to contain only a little Tinct. Saponis; another who went and bought no less than 30 yards of rope, hinting his fell purpose to the shopman ; another who was always tying thread and garters round his neck, just tight enough to make a mark; and many who tried to end their lives by holding their breaths. In some suicidal cases there are curious automatic suicidal movements quite unconsciously done. I have always many patients who, at times, put their hands to their throats and compress them slightly. Some patients regularly " work at their throats " in that way. I have seen STATES OF MENTAL DEPKESSION. 107 continued in a patient, as an automatic muscular habit, the mere organic memory of a melanchoHc suicidal state which had then passed away, the patient being at the time cheerful and convalescent. So I have seen patients gently strike their heads against walls, and play with dinner knives, as if to end themselves, long after any real suicidal desire had gone. Methods of Suicide. — Regarding the modes of committing suicide, there are eight most common — drowning, hanging, starvation, wounds, firearms, poisoning, precipitation from a height, and asphyxia. But other and rarer methods are as diversified and original as human imagination can conceive. Some things seem to go contrary to the radical instincts of human nature, e.g., going into boihng water, or swallowing it, or putting a hot coal into the mouth and attempting to swallow it. But I have seen one example of each of all these modes of attempted self-destruction. " Each country," says Morselh, " has certainly its particular predilections." He says, too, — "In the choice of the means of death man is generally guided by two motives — the certainty of the event, and the absence or shortness of suffering." I disagree with this. I think he is guided by the readiness and the simplicity of the means at hand, by the absence of ideas connected with them repugnant to the instincts of human nature, by his natural temperament, and by the suicidal traditions of his country, or race, or profession. In China and Japan the means used are entirely different from those in Europe. But one fact is of great practical and prophylactic importance. The same patient very often sticks to one means of suicide. A man who wants to cut his throat or drown himself will frequently pass unattempted innumerable opportunities of hanging. Even the vanities, follies, and eccentricities of human nature come out strongly in the modes of committing suicide. I knew a man who was very particular about his linen, and could not bear the idea of cutting his throat because it would soU his shirt front, and people might say he had not had on a clean shirt that day, while he was very 108 STATES OF MENTAL DEPRESSION. anxious to get poison. Patients frequently starve, or attempt- to starve, themselves in order to terminate their hves ; yet food is by no means always refused in insanity with that direct object. Modes of Forcible Feeding. — It may be convenient here to refer to the best means of forcible feeding. If persuasion, a little starvation in strong patients, and fresh air and exercise do not make them take food, patients will frequently masti- cate and swallow when it is put into their mouths. From very long experience I say that a liquid custard of new milk, cream, and three or four eggs, flavoured with a dash of nutmeg or sherry, is the very best and handiest form of liquid diet at first, and for a time at least. If feeding has to be long continued, the best way is to have a big mortar, and pound into a liquid form, with beef-tea, the ordinary diet. Beef, mutton, fowl, fish, and vegetables of all kinds can in this way be liquefied. Always add \ lb. sugar to each meal, a teaspoonful of maltine, and liaK a glass of brandy, and feed twice or thrice a day. If the patient will not swallow, the simplest and most available of all apparatus is about 6 inches of india-rubber tubing from a baby's feeding bottle, that can be got at any chemist's, and a small funnel of any sort. With this latter inserted into one end of the tube, and the other end well oiled and passed along the floor of the nares to the pharynx, we can pour down the custard in tablespoonfuls, and the patient must swallow it. But this mode of feeding won't do for long, for patients soon get into the trick of expiring just as the fluid is entering the pharynx, and so blowing it out of their mouths. There are now made French red rubber elastic tubes, like longer stouter catheters, which can be passed along the nasal cavity and down into the oesophagus and so overcome this difficulty. A small funnel inserted into the free end enables us to pour any kind of liquid food into the stomach. If the abdominal muscles resist, and the liquid will not flow down, then a "Yellowleos' bottle" attached enables one to blow the food STATES OF MENTAL DEPRESSION. 109 into the stomach. This implies no forcible opening of the jaws, and will succeed in almost all the patients. I always use this method now, and I am satisfied it is by far the best. But in case this method fails, we must use the French rubber tubes of large size to be passed into the stomach by the mouth, which must be first opened by a suitable instru- ment (to be got from all good instrument-makers). This mouth-opener should always be tightly wrapped round at the points with strong tape to protect the teeth. Never bring the steel in contact with the teeth. If there is very great difficulty in opening the mouth, two openers, one put in at eacti side of the mouth, and both screwed up at once, obviate all difficulty. For such forcible feeding have plenty of assistance. Use a large stomach-pump, or a funnel at the end of the tube held above the patient's head, or the bottle mentioned, to pass the liquid nourishment into the stomach. Take care the patient does not get up and tickle the throat and vomit the food after the meal. With good tubes and instruments, and plenty of assistance, the patient being placed on a bed or sofa, with his head raised, he can be fed quickly and easily. I seldom have any difficulty. 1 must say, however, that I have met with two patients where I could not pass the French soft rubber tube, and where I had to use the old stififer gum elastic tube, so that it is well to have one on hand. Period of Greatest Danger. — My experience is that the greatest danger of suicide is near the commencement of the attack of melancholia. The impulse is then commonly strongest, and its presence and danger is less realised. Like any other disease, .its intensity gets spent after a time. So with refusal of food. It is generally most troublesome at the beginning. As showing the contradictory feelings in a mildly suicidal case, this is the letter of one (B. E.) : — "I wish you would come to see me. I never sleep at all now. I am very ill, and I am in despair about my soul's salvation. I wish I had 11 STATES OF MENTAL DEPRESSION. an opportunity for suicide. I hope to see you soon. I am very mucli afraid of hell. I am getting worse, and I see no chance of getting well. I sometimes wonder how much money I have lost. I am afraid of losing money by being fined for blasphemous writings or whisperings (which he indulged in often). I wish I was dead. The keepers have been very kind to me. I hope to live with you soon. If you lived in Edinburgh I would be very glad to see you. I am afraid of dying suddenly. I would be happier with you. I hope to be better when you come. Write soon. I am afraid of hell very much. Is your health good ? Keep your money safe beyond my reach. — Yours affectionately." Degree of Intensify of Suicidal Feeling. — It is most impor- tant to estimate the degree of intensity of the suicidal feehng. Is it obviously over-mastering? Is the power of attention and of reasoning greatly impaired ? Are the natural habits or propensities changed ? The likings and antipathies interfered with or reversed ? Is the sense of the ludicrous gone ? — But it must be remembered that the sense of the ludicrous may not be gone, and yet a serious suicidal intent may be present. I have seen outbursts of gaiety in a suicidal melancholic. — Is the capacity for ordinary social enjoyment gone? Are the delusions wholly believed in and dominating, or only partially so ? Is the patient cunningly trying to throw you off your guard ? Is he subject to relapses and remissions ? Is he more suicidal in the morning than at night ? The following is a record of one of tJie most persistently and strongly suicidal cases I ever had under my care : B. L., a professional man, aged 25, of melancholic tem- perament; nervous and reserved but kindly disposition; temperate and industrious habits; had been a hard student. A cousin of his mother and one of his maternal great-aunts were insane. Comes of a professional family. There was no exciting cause for his illness. Nine months ago he got dull and sleepless. He first thought he did not do his professional work well; then, by a natural transition, as his disease STATES OF MENTAL DEPRESSION. Ill acquired more power, that he had committed some crime and ought to die, and that his soul was lost. He took a poisonous dose of helladonna with suicidal intent before admission. He had fallen off in bodily strength and flesh. On admission he was perfectly coherent, and his memory good, but much depressed, with no interest in anything, and with the delusions above-mentioned. In spite of treatment, which consisted of nutritious food and tonics, and attempts to get him employed and his attention aroused to healthy objects of interest, he got steadily worse. His pulse was weak, his temperature low, his muscles flabby, his complexion pale, and his bowels costive. He walked rapidly about, and could not sit down long and settle himself. He said he was troubled much with seminal emissions, and this seemed to depress him further. He had a dislike of animal food. He made in- numerable attempts at suicide in quiet, reasoning, deliberate ways. He put his fingers down his throat ; he swallowed berries of the Arbor vitce picked in the grounds ; he swallowed eighty-two small stones gathered in the gravel walks (weighing twenty-four ounces), and passed them without doing him any harm ; he tried to push a nail, picked up and secreted for the purpose, into his heart; he seized a bottle of whisky one day and drank part of it. Even when intoxicated with this he was miserable ; and his dreams, he said, were only a little less depressing than his waking thoughts, which were always that he was wronging everyone by allowing himself to live, and that he ought to take away his life and so end his misery and lessen his punishment in the other world. He refused his food for a time, and had to be fed with the stomach- pump. I was singularly unfortunate in the attendants I placed in charge of him, for they got very careless, and one or two I dismissed on his account. He was so quiet and reasonable and nice a man, and tried so successfully to throw them off their guard, and his attempts were so carefully planned that, no doubt, a man unacquainted with disease from the physician's point of view was very apt to abate his 112 STATES OF MENTAL DEPEESSION. watchfulness. An attendant will be very alert for a few weeks, but when it comes to months, and when the man he has to watch seems as reasonable as he is himself, and is quiet, it is almost impossible to get one who will not give such a man a chance some time. The whole mental energy of B. L. was employed all the time in scheming suicide. And when such a man is a doctor, it simply is a question of how long he will take to get a chance. He drank some turpentine used for polishing, once, and nearly died. He was weak and threatened with bed-sores, and his attendant got a solution of guttapercha in chloroform to paint over his skin. B. L. seized the bottle and drank a quantity of it. We had to use artificial respiration by Sylvester's method and the interrupted current for 14|^ hours, when, to our surprise and delight, he began to breathe, and told us to " go to hell." ^ That case taught me many lessons, practical and medical. I have never trusted one attendant continuously on duty in such a case since. I have never believed anyone to be dead, since my experience of B. L.'s resuscitation, merely because he could not breathe and his pulse could not be felt. Six months after admission poor B. L. died of slow exhaustion. Food would not nourish him; stimulants would not rouse him. The disease arrested all his trophic energy. He determined to die, and seemed to accomplish his object by the strength of his volition. The following was a case of acute suicidal melanclwUa coming on suddenly, caused by prolonged affective strain, anxiety, and want of sleep, with intense suicidal feeling, and many attempts; no sleep ; exhaustion and death in a fortnight:— B. M., set. 55, a man of a melancholic temperament, nervous diathesis, rather over-sensitive disposition, great intellectuq,! power, and good education. For months he had had too little sleep, and very great domestic anxiety. This 1 A full account of this case was published by Dr J. J. Brown, then one of my assistants, in the Edinburgh Medical Journal for November 1874, STATES OF MENTAL DEPRESSION. 113 did not seem to tell on him till a sudden outbreak of intense melancholia, with suicidal feeling, came on him without any outward warning. But, no doubt, he was a man of immense power of inhibition, who had the capacity to work his brain up to the point of complete exhaustion, and also conceal from others any evidence that he was doing so. This phenomenon is very often seen in women nursing those dear to them, or "keeping up" themselves and others under loss or calamity. They look cheery up to the last, and do their work, but they break down suddenly, and sometimes incurably. He asked one morning that his razors should be put away, and within an hour or two he had entirely lost his power of self-control, gave expression to the intensest melancholic delusions — that he was too wicked to Uve, and could not Uve ; that he was lost, ruined, (fee, &c. When placed in charge of attendants, as he was at once, he made many and desperate attempts at suicide, so that he could not be left for a moment. He could not be roused to attend to anything ; he was restless, moaned, and never expressed any interest again in his wife, or family, or concerns. There was a sudden paralysis of his love of life, of wife, and of children — of his interest in anything but his delusions. His tongue was furred and tremulous, his facial expression that of despair, his pulse feeble, his temperature 100°, his appetite gone, his bowels costive, and his skin ill- smelling. He never seemed to rally, and died within a fortnight of the acute brain condition, though he had every care and attention, with plenty of food and stimulants and nursing. The cells of the grey matter of his convolutions were found extensively degenerated. Frequency of the Suicidal Impulse.— Iha prevalence of the suicidal tendency in melanchoha can only be correctly brought out by taking large numbers of cases. I have taken the last 729 cases of melanchoha under treatment. These were from all classes of society, and this is a valuable point in the Morningside Asylum statistics, as compared with those in an asylum for paupers only. The disease in all those patients 114 STATES OF MENTAL DEPRESSION. was decided and marked, otherwise the patients would not have been sent to the Asylum. All the very mild cases would be kept at home, and many of the decided cases, too, among the richer classes. In regard to melancholies treated at home, I have no means of ascertaining the prevalence of the suicidal feeling, and it must be kept in mind that many of my patients are sent to the Asylum on account of their suicidal tendencies chiefly, and but for these would have been at home. It may fairly be regarded, then, as far more common among asylum melancholies than among those labouring under the disease out of asylums. Among those 729 cases there were 283, or about two-fifths (39 per cent.), who had actually attempted to commit suicide. In many. cases, no doubt, the attempts could scarcely be regarded as being very serious. In addition to this number there were 301 cases, or two-fifths more, that had spoken of suicide, or given some indication that it had been in their minds. That makes 584 out of 729 melan- cholies, or four out of five of the whole, that were more or less suicidal. No wonder, therefore, that the loss and perver- sion of the instinct of the love of life is regarded as one of the chief symptoms of melancholia. I am quite sure, how- ever, from what I know of the disease, that the actual risk of suicide being seriously attempted or accomplished is much less than those figures would seem to show. The really typically suicidal cases, in whom the desire to die is very intense and the chief symptom present, any one of whom would certainly put an end to his life if he had the oppor- tunity, are not so frequent. As near as I can estimate, one melancholic in twenty only is of this intense and very danger- ous kind. There is one peculiarity about the suicidal feeling which it, is well to keep in mind, and that is its liability to return suddenly or to be called up by the sight of means of scKt destruction. I had a patient who was all right so long as he did not see a knife. That set up the demon in him at once. Homicidal Feeling. — The homicidal feeling is much rarer in STATES OF MENTAL DEPKESSION. 115 melancliolia than the suicidal. They frequently coexist ; but in some few cases the homicidal feeling exists alone without the other. At the beginning of acute alcoholism we all know how common are those tragedies that shook us in our news- papers, men killing their wives and children, and then them- selves. We shall also see that in puerperal insanity there is a strong tendency in many of the cases towards child-murder ; but, apart from those two special forms, only a few melan- cholies have Iwmicidal feelings, of which the follotoing case is an example. She had, too, hallucinations of hearing voices telling her how to commit suicide, and she made a homicidal attempt: — B. P., set. 30. Widow ; of a sanguine temperament ; frank and cheerful disposition; temperate and industrious habits. First attack. Cause : annoyance at some legal proceedings three days ago. Became depressed, very restless, sleepless, and her appetite disappeared. She began to think her children were murdered and that people were going to kill her. Whenever you see such delusions, look out to prevent suicide. It is a most common accompaniment. She had hallucinations — hearing voices telling her to commit suicide, which she attempted by drowning. Had been taken to the police-office on emergency, and was at once sent to the Asylum. On admission she suffered from intense mental depression, crying, saying she had been drugged at the police-office, and by a servant. She said that a chimney- can turning with the wind said to her — " Drown yourself, prepare yourself, drown yourself." She was excited and restless in manner, and jerky in her muscles. She could answer questions, and her memory was not gone. Her expression was depressed, suspicious, and alarmed ; her skin muddy and spotted ; pupils unequal ; eyes glistening ; was fat and muscular ; tongue furred ; bowels constipated ; appetite gone ; refused food absolutely ; was menstruating. Temperature, 100-1°; pulse, 108. Was rest- less the first night, which she spent in the dormitory with the attendant, who twice during the night sent a report about her to the assistant-physician. At 5.30 a.m. next morning she 116 STATES OF MENTAL DEPKESSION. made a most severe homicidal attack on the attendant, nearly strangling her. Her motive for this was not expressed. It might have been a pure homicidal impulse, or it might have been, and I think it was, from the delusion that the attendant was going to murder her. The assistant-physician after this, finding that it was to be a continuous struggle with the attendants, had her placed in a bedroom alone, with the shutters locked and everything made secure, as he thought, with an attendant to look in every ten minutes. He reported this to me, and I approved of the mode of treatment. She refused breakfast, breaking her dishes, and fighting with the attendants. She was seen at 12.30 or 12.35 by the attendant lying quietly in bed, but at 12.45 it was found she had hanged herself to the shutter bar, which had not been properly constructed, with a piece of her sheet, her feet being on the ground. The efforts at artificial respiration were unavaihng. This is an example of an acute suicidal and homicidal melancholia, the worst of all cases to manage. If you keep attendants with such a patient there is a struggle and much danger to both ; if you place him alone there is always some risk of suicide. What I do now is to put on such a patient clothing of strong untearable linen, to give for bedding blankets quilted in soft untearable canvas, and put him in a room padded if necessary, lighted and with an inspection opening, an attendant being outside the door. It will be seen, from the temperature and whole conditions of B. P.'s case, that such a condition has many of the characters of an acute disease. Such acute symptoms do not usually last long. If we can tide over the first week or two, we then expect all the symptoms to abate. The hallucinations of hearing in such a case may disappear, and are not of such grave import in prog- nosis as in less acute cases. The unspeakable agony which such cases may suffer was well illustrated in B. P. A., a man of 25, who had led a good life and taken a high place by examination in his profession, but who had been attacked by STATES OF MENTAL DEPKESSION. 117 acute suicidal melancholia. The patient often needed three and four men to manage him when rolling about on the floor of the padded room. In the fearful agony this was his prayer to the devil— "Oh, devil, come and take me! Oh, devil, come and take me! Oh! oh! oh! oh! Are you asleep? Oh, devil ! devil ! the judgment day has come. Oh, devil, take me ! Oh, I have no will ! I feel sick ! Oh, devil, take me ! Thou knowest all about me ! Oh, come here or I'll kill myself! Bloodthirsty devU ! damned devil! pull down the house ! These men (the attendants and doctor) have come for me ! " &c., &c. Eepeated hypodermic injections of hyo- scine of ^ gr., with doses of sulphonal in 20 grs. in between, had to be used at first to produce a sedative effect on his brain. But, then, all this agonised dehrium scarcely sounds much worse than Carlyle's "semi-delirium sad as Golgotha," his " spectre chimaeras," "bottomless abysses," "Gehenna within," " spectre fighting," and his " mad primeval discord " in Sartor Resartus. The homicidal impulse in a slighter form is more common. I have now two ladies imder my care — B. Q. and B. E. — who kick, and pinch, and strike their attendants and fellow- patients, declaring they cannot help it. One of them, B. Q., has the suicidal impulse too, and strikes her head and breast. She cries to be put in a strait-waistcoat to prevent this. I tried this once, but it had no good effect, and it gave her no more sense of security, and she did not sleep any better. In the other case, B. R., she only has the homicidal feeling in the morning. In the evening she is quite lively, dances, plays on the piano, and smiles. The homicidal feeling seems a reversion to the human instinct of slaughter and destruc- tion that is so strong in many savage peoples, and is seen in most men when enraged. I had a case in whom it seemed to result from an excessive production of motor energy in the nerve centres, for any mode of expending this — by tearing his clothes, digging in the garden, fighting, or gymnastics — would relieve his homicidal feeling for the time. Such a case is 118 STATES OF MENTAL DEPEESSIOK. very analogous to the physiological instinct of breaking things in children. Many of the excited melancholies tear and break things, fight, and attack those near them. My oxporience ia that not more than one in fifty melancholies is homicidal in any degree, and not more than one in a hundred is dangerously so ; but when the suicidal and homicidal tendencies are com- bined in a strong degree, such a patient is worse to manage and more unsafe than any other. Anomalous Cases.— li must always be remembered that a large number of patients do not conform strictly to any of those varieties of melancholia, and may pass from one variety into another, or have the characters of two or even three of the varieties. The following is such a case, with dvsquamation, high temperature, and sudden death : — B. S., set. 50. Single. No occupation. Fair education. Disposition reserved. Habits correct and temperate. One previous attack of melancholia, duration under a week, treated at home. No hereditary predisposition to insanity or other nervous disease. Predisposing cause : previous attack. Exciting cause : change of life. First mental symptoms : had some domestic grief which greatly upset her; became un- settled and depressed, and assigned groundless reasons for her grief. Has since become taciturn, and refused food for two days; sleepless; not epileptic, suicidal, or dangerous. Dura- tion of oxisting attack : six days. Great depression, constant restlessness, moaning and complainin.n, taciturnity when questioned, refusal of food and medicine. On admission : great depression, will not answer a single question, keeps constantly moaning and crying " Oh ! oh ! " looks very miserable, wanders about the room incessantly wringing her hands. Memory and coherence cannot be tested ; will not attend to questions. Seems to have delusions of a melancholic character. Is a thin middle-aged lady. Muscularity and fatness poor. Appetite absent. Dulse 108, regular but small. Temperature 99'4°. General bodily con- dition very weak. STATES OF MENTAL DEPRESSION. 119 First niglit in the Asylum was very restless, kept up a con- stant wail of "Oh! oh!" Could with difficulty be got to swallow a little fluid food. "Typhoid" expression; very sallow look ; dark rings round eyes ; dry scaly lips ; tempera- ture 99"2°. This state continued and increased for about a fortnight without improvement. Very sleepless; constant piercing wail, very distressing to other patients. Her weak- ness was extreme. She was entirely confined to bed and fed every half hour with liquid food, milk, eggs, beef-tea, and a large quantity of wine. She then began to improve and was much better in the mornings, and got worse in the afternoons. Could be induced to speak intelligently; looked less depressed; took a fair quantity of food; slept better. Within another week she was quite convalescent, gaining in flesh and strength very rapidly. At the same time desquamation occurred (tliis I have seen in several patients after such short acute attacks). Still a want of appetite. Two weeks later sent out on pass. Appetite and general health improved. Eesidence in Asylum, four weeks and ten days. She had a relapse four years after- wards, and was admitted with the same symptoms, and in spite of all treatment, died in five days. Temperature often 102 '5° ; was fed ; got abundant stimulants. Xo pathological appearances beyond congestion were found in her brain. There are a few cases of depressed feeling with exalted in- tellectual condition. Many patients exaggerate their former happiness, wealth, and position by way of contrast to their present misery. I had a woman in excited melancholia, groaning all the time, who fancied herself a queen ; another who had immense wealth. Some few of the cases are of the nature of what the French call megalomania, that is, an ex- pansive grandiose exalted state of mind, coupled with ideas of persecution, and with depressed feeUng. Hie Inception of MelanclwUa. — It begins in most patients as simple lowness of spirits, and lack of enjoyment in occupa- tion and amusement, and loss of interest in life. This may be premonitory of the disease by months, or even years, and 120 STATES OF MENTAL DEPRESSION. happy is the man who then takes proper warning and adopts proper treatment. The next stage is that of the simple melanchoHa described in A. B.'s case (p. 34), and this may be of long or short duration, and may pass into one of the other and more serious varieties. As a general rule the hypochon- driacal variety is longest and slowest in inception. I have seen the delusional, the suicidal, and the excited varieties fully developed within a week of the commencement of the first symptoms, but this is rare. I have seen the loss of self- control take place quite suddenly, a man being calm exter- nally, though dull, in the early morning, and by 10 o'clock A.M. in the acutest stage of suicidal and excited melancholia. Many patients exercise self-control strongly for a time, and then at once lose' it. This, however, is not common. The duration of the disease previous to the admission of the case into an asylum is a good test of the rapidity of progress of the disease in its full stages up to the time that self-control was so lost as to require treatment and restraint in an institu- tion. Of 365 cases in which information on this point was obtained, 40 per cent, had been melancholic for periods under a month before admission, 16 per cent, for periods from one to three months, 8 per cent, from three to six, and the re- maining 36 per cent, over six months. The delusions in many cases take their shape, if not their origin, in painful or disagreeable sensations in the organs, which are misinterpreted by the disordered mind, and attri- buted to wrong causes. Continuous attention to morbid feelings is very apt to aggravate them, and they often origi- nate from purely mental suggestions. In some cases a paralysis of the consciousness of natural affection is the first symptom of melanchoha, and the patients, thinking that they no longer love their children, get depressed. I have known in many cases a craving for stimulants to be the first symptom. I knew a lady in whom this was so each time she became melancholic, which she did at each pregnancy and at the climacteric period. STATES OF MENTAL DEPKESSION. 121 Age. — The ages at which melancholia comes on are mote advanced ages on the whole than in the case of mania (see Plate v.). Four per cent, only come on under 20 ; only 20 per cent, under 30. The largest proportion of cases in any one decennial period — 25 per cent. ^occurred between 40 and 50, while there was 23 per cent, between 30 and 40, 18 per cent, between 50 and 60, and 14 per cent, over 60. Bodily Symptoms and Precursors of Melancholia, and the Relationship of Mental to Bodily Pain. — I think ib a reason- able inference that the condition of the brain cortex which directly causes the subjective feeling of bodily pain from a burn of the finger is the same as that which causes the pain of typical neuralgia of central origin, and that the cortical state cannot be very different in a woman who is prostrated with grief on account of the loss of a child from that of another who is equally prostrated with grief from the delusion that she has by her misconduct imperilled the salvation of her family. Meynert's theory of the cause of the pain in all these four cases is that we have a strong inhibition in the grey matter causing increased arterial pressure, and " dyspnoetic " phases of nutrition of the tissue, this being roused by sensory impressions, or by recollections of painful impressions, or by processes of thought exciting psychical pain. Whenever we have strong inhibition exercised by the cortex, it is attended by depressed emotion. There can be no doubt whatever as to the close connection of bodily and mental pain, whether the mechanism of their production in the cortex is the same or not.^ Clinically they are closely related, and, in my opinion, they are really parts of the same disease. All sorts of sensory disturbances are connected with melancholia. They commonly precede it ; they sometimes accompany it, and they often alternate with it. One patient will suffer from ordinary neuralgia for long before the emotional pain comes on; another will have creeping '^ See the Author's Address as President of the Section of Psychology, Brit. Med. Assoc. Meeting, Aug. 1886, Brit. Med. Jour., Aug. 1886. 122 STATES OF MENTAL DEPKESSION. feelings or "indescribable" sensations in the head; others will have a sense of fulness there, or a sense of weight or of emptiness. Spinal pains and discomfort, sciatica, changed feelings as to heat and cold, sensations of sinking in the epigastrium, I have known to usher in an attack of melan- cholia. During the attack it is common for patients to have hallucinations of the senses. One lady told me she saw the water in her bath blood red, and that stationary objects and persons would appear to enlarge and diminish as she looked at them. Food often tastes bitter, or as if " poisoned." Some patients feel as if their bodies or their limbs wore unusually large or very small, or that they could not move again if they tried. There is a close hereditary connection between neuralgia and melancholia. For prophylaxis attention to sensory disturbances in those prone to melancholia has a special value. Many attacks might thus, I believe, be averted. The premonitory bodily symptoms that I have most com- monly met with have been headaches, neuralgia, confused feelings in the head, want of appetite, indigestion, costiveness, a feeling of weariness and languor, in some cases restlessness, in others " biliousness," oxaluria, and, above all, the two symptoms of sleeplessness and loss of body weight. When the mental symptoms became fairly developed, the headache and neuralgia, if present, usually disappear, and we have instead a brilliancy of the eye, a tendency for the temperature to rise a little at night, a depression or some other change in the facial expression, a furred tongue, which, in four cases out of five, is neurotic, resulting from the deficient innervation of the stomach. The want of appetite often becomes a re- pugnance to food, the sleeplessness becomes complete, the constipation great ; in about 15 per cent, there is a tempera- ture over 99'5°. The pulse rate often rises in a most un- accountable way. It is common to have it 100 or even 120 with no corresponding rise of temperature. One can only attribute it to the cortical excitement. I think there is a STATES OF MEXTAL DKrEESSlOX. 12o rliaracteristio " melancholic " pulse in those cases. Taking 365 cases at raiidom, I found constipation in 50 per cent., sleeplessness in 60 per cent., want of appetite in 60 per cent., pyrexia in 15 por cent., and hallucinations of the senses in 25 per cent. ; epigastric pain and sinking in a few, headaches and sensations of hinding, of weight, and emptiness in the head in a few, hoiirt disease in a few, suppression of discharges in a few, disappearance of skin disease in a verj' few. Taking the general hodily health and condition, I find I had put 36 per cent, as heiug in fair general bodily condition on admis- sion, 57 per cent, as weak and in bad condition, and 7 per cent, as very weak and exhausted. The heart's action is markedly affected in all the acute cases and in many of the otliers. In the former the condition of hyperaction in the brain seems to exercise an inhibitory influence on the cardiac motor innervation in a few cases, causing the pulse to be small, tlxe arterial tone to be low, and the capillary circulation to be very weak indeed. Those are tl\e cases in which the use of digitalis, strophanthus, and iron is often very useful. The skin is in some of the acute cases greasy, perspiring, and ill-smelling. In most patients, however, it is dry, harsh- feeling, and non-perspiring. Sometimes we have boils — a good sign often — and subacute inflammations. Eevan Lewis ' has sliown tliat the reaction time, espedally as to optic stimuli, is markedly prolonged in melancholia. Causation of Melancholia. — The causes of the disease are always popularly supposed to be some calamity, some affliction, some remorse or religious conviction, that has produced grief and sorrow. As physicians, we know how utterly far this is from the truth. If I were asked my opinion, I should say witiiout hesitation that more melancholia results from innate brain constitution, than from aU outside calamities and afflic- tions of mankind put together. If a man has a well-consti- tuted brain, he will, like Job, bear calmly all the afflictions and losses that the spirit of evil c;vn invent for him. It is » Op. at., p. aS5. 124 STATES OF MENTAL PEPRESSION. impossible to bring on melancholia in siicli a man. That needs some innate weakness, some predisposition, some poten- tiality of disease, some trophic or dynamical defect. The friends of melancholic patients -will always assign an outside cause for their disease. To them the occurrence of such a state of matters without some manfest cause seems an im- possibihty. Whoever saw a newspaper account of a suicide without either a cause being stated or a remark implying that there must have been some outside " cause " ? A hereditary predisposition to mental disease was admitted in about 30 per cent, of the cases of melancholia sent to the Eoyal Edinburgh Asylum, but that is very far from representing the truth. I have no official statistics on the point, but my general experience agrees with that of others, that states of depres- sion of mind are hereditary more than most morbid mental symptoms. I have known several families where for four generations a considerable proportion of each was depressed in mind more or less. Certainly the tendency to suicide is very hereditary. Next to heredity come as causes disordered bodily functions, and after them, at a long distance, moral and mental causes of depression. Of the mental causes domestic affliction is by far the most frequent in the female sex, and business anxieties in the male sex. Prognosis. — Out of the last 1000 cases admitted into Morn- ingside Asylum, 54 per cent, have recovered. Within the past seven years, under 1 per cent, have died of the direct exhaustion from the disease while recent. The liability to relapse after recovery is best represented by the number of previous attacks, which had existed in about one-third of all the cases. It must be remembered that those statistics refer to cases so ill as to need asylum treatment. I have no doubt that if tlie milder cases treated at home were included the recovery rate would be much greater. The things that enable us to form a good prognosis are youth; sudden onset; an obvious cause that is removable; want of fixed delusion ; absence of prolonged hallucinations STATES OF MESTAL DEPRESSION. 123 of hearing, taste, or smell ; no visceral delusions ; no strongly- impulsive or epileptiform symptoms ; no picking of the skin, or pulling out the hair, or suoh trophic symptoms ; no long- continued loss of body weight in spite of treatment ; no long- continued inattention to the calls of nature, |and no dirty habits. Almost never pronounce a patient incurable while depression continues. But be guarded in giving a definite prognosis in almost every case. The greater my experience becomes the more guarded I am. Some of the most favourable-looking cases will deceive you, while some that look most hopeless will recover, as in the case of B. S. A., a patient of mine, fcho liad been seven yeaiv melaiicJwUc, suicidal, and deephss, and who recoi-ered af 74, tra^ quite well, and did her Iwiisehold worhfor seven years, but then relapsed and died melancliolic. The bad signs are a slow gradual onset, hke a natural evolution; fixed delusions, especially visceral and organic delusions ; gradual decay of bodily vigour, like a premature old age ; persistent loss of nutritive energy and body weight : convulsive attacks and motor affections generally, not merely ■ideo-motor; persistent hallucinations, especially of hearing, smell, and feeling ; a tendency to enfeeblement of mind ; picking the skin or hair ; a growth of hair on the face in women ; persistent refusal of food ; an unalterable fixity of emotional depression of face or persistence of muscular expressions of mental pain (wringing hands, groaning, &c.) ; persistent suicidal tendency of much intensity ; arterial degeneration ; senile degeneration of brain ; no natural fatigue following persistent motor efforts in walking, standing, i^'c. Duration of MelancJiolia. — Of the 540 cases that termi- nated in recovery, 50 per cent, recovered within three months, 75 per cent, imder six, S7 per cent, under twelve months, leaving only 13 per cent, who took more than a year to recover. In most cases recovery is gradual In my experience an improvement in the bodily condition and looks, in the 126 STATES OF MENTAL DEPRESSION. vascular condition, and an increase in the body weight and appetite, nearly always precede the mental improvement. The motor restlessness generally passes off first. The patients sit down and do work of some sort, then they begin to eat better, then the delusions lose their intensity, then the sense of ill-being is less oppressive. There is often an irritable stage as improvement sets in. I have one patient whom I am always glad to hear swearing : I know then that he is going to recover. The return of the sense of well-being is the last to come, and along with it that surplus stock of nervous energy in all directions that constitutes Health. A man whose nerve capital is always running low can never be said to be in really good safe health. When I see a recent case taking on flesh at the rate of three or four pounds a week I know he is probably safe, and will make a good recovery. The only exceptions to this are in the long- continued cases, where the mental functions of the convolu- tions are permanently enfeebled and damaged, and in whom, as the depression passes off, we have a fat dementia resulting. This, however, is much more uncommon in melancholia than in mania. Some patients — a few — make sudden recoveries" in a few days. I have even seen a patient go to bed very melancholic and get up quite well, saying — "I see that all these fancies were mere nonsense. I wonder I could have been so foolish as to believe them." Such eases describe their sensation as being ''a cloud lifted off their mind." But on the whole I hke slow recoveries better than sudden " cures." A few of the cases pass into the chronic melancholia I have described. They were nearly all middle-aged or old people. Many of the cases pass into mania, a few become alternating insanity, and a few pass into dementia, which, in that case, is never so complete and absolute a mental enfeeblement as when it follows mania. Summary of Treatment of the States of Mental Depression. —If the brain and body conditions that accompany, if they STATES OF MENTAL DEPEESSION. 127 do not cause, states of morbid mental depression are those of trophic deficiency, as we have seen is undoubtedly the case in most instances, then it necessarily follows that what will remedy those conditions is indicated, and all things that will aggravate them must be avoided. Even in the patients where there is no demonstrable lack of brain or body nourishment, and where the disease is more of a purely dynamical brain disturbance, and of a disordered energising of the convolu- tions from hereditary instabihty, there is lack of force and general vitality in the brain. We make the conditions of life of a melanchohc, therefore, as physiological and favour- able as we can. Every therapeutic agent whose effect is tonic, hunger-producing, digestive, vaso-motor, and nerve- stimulating we give. Quinine I place in the first rank ; iron, the phosphates, hypophosphites, strychnine, phos- phorus, &c., in the second ; and the mineral acids, vegetable bitters, aloes, arsenic, digitahs, strophanthus, gentle laxatives, cholagogues, diuretics, and diaphoretics in the third. Not that I have not seen quinine and strychnine over-stimulate and have to be stopped, and iron determine blood to the brain in a way to do harm, but those ill effects are rare, and they can be stopped as soon as observed. The mineral waters of our own country, and especially those of Germany, come under the same category as those tonics. Many a commencing melancholic have I seen cured most pleasantly by a short stay in Schwalbach, Wiesbaden, Carlsbad, &c. Of course the particular kind of water must be determined by the diathesis — the chalybeate to the neurotic, the salines and the sulphur to the gouty and rheumatic, &c. The continued current, applied not too strong, and passed through the great nervous centres, is greatly trusted by some continental physicians, and I have seen it do good in patients with the elements of stupor present. Diet and regimen are of the highest importance. If I were as sure of everything else in therapeutics as this, that fresh air and fattening diet are good for melancholic people, I 128 STATES OF MENTAL DEPRESSION. should have saved myself many medical questionings. Such patients cannot have too much fresh air, though they may have, too much walking, or gymnastics, or muscular fatigue. It is the best sleep-producer, the best hunger-producer, and the best aid to digestion and alimentation. Without it all the rest is totally useless in most cases. Patients cannot fatten too soon or too fast, though their stomach and bowels may be overloaded, and their livers and kidneys may be too engorged. Fatty foods, milk, ham, cod-liver oil, maltine, eggs, farinaceous diet, easily digested animal food such as fish, fowl, game, &o., are my favourite diet for melancholies. Milk, in very many cases, is my sheet anchor. I have given as much as sixteen tumblers a day with surprising benefit. The nervous diathesis does not put on fat naturally, there- fore we must combat the tendency to innutrition by scientific dieting. Adipose tissue and melancholia I look on as antagonists ; therefore, when we want to conquer the latter we must develop the former. This is no new doctrine. " Make a melancholy man fat, as Ehasis saith, and thou hast finished the cure." i Mrs Carlyle once wrote, after she had recovered from a fearful attack of "nervousness," with much mental depression, " Oh, thank God for the precious layer of impassivity which that stone-weight of flesh has put over my nerves." I need hardly say that the capacity of digestion, the peculiarities of digestion, and the dietetic likings, and even the idiosyncrasies of our individual melancholies must be studied. A good cook is an aid to all cases, a pleasure to most, and a necessity to some. Concerning dimulants, I certainly haVe found them useful in many cases. The fattening appetising' ales and porters work wonders on some lean anorexic melanchohcs. Good wines do the same. Claret and Burgundy are the chief, when suitable to the circumstances of the patients, that do good. The stronger stimulants and champagne are only needed in the exhausted cases, except, indeed, when whisky ' Buvton'a Anatomy of Melaricholy, 16th ed., 1836, p. 449. STATES OF MENTAL DEPEESSIOX. 129 and water at bedtime is a good soporific. Be sure, however, that it is not the hot water alone that causes the sleep. I have seen a tumbler of hot water taken at bedtime cause sleep as quickly as when mixed with a glass of whisky, and have a better effect altogether. When a patient has fairly gained weight, all alcholic stimulants may be discontinued, except as mere luxuries. Change of air; mountain or sea breezes ; change of scene ; quiet in most cases ; active travel and bustle in a few of the less serious cases ; long voyages, if we are quite sure that the disease does not threaten to become acute or suicidal, — all these things are helpful. We enjoin rest from exhausting or irritating work ; above all, escape from worry. We bring a different set of faculties and a different group of muscles into action from those that have been employed before. Do not push anything that is too great a conscious effort for the patient to do. Do not send a man to fish if fishing is a disagreeable toil, or make him go into "cheerful society " when this is a real torture to him. Pleasant society with no bustle, beautiful scenery, music, and sunshine, are all healing to melancholy. In most cases some occupation that is a pleasure has to be encouraged, and does much good. Fishing, easy mountaineering, shooting, boating, golf and outdoor games, are most suitable for certain cases. We try and make the impressions received by the senses agreeable, and therefore harmonious with the well- being of the organism. We try and substitute pleasurable feelings for painful ones by every means known to us. Slow travel, with a cheery sensible companion, who is of course twice as valuable if he is a doctor, saves many a man from an asylum. In most cases we remove a man temporarily from his 'wife and family, for paralysed or perverted affection to a melancholic is itself a painful thing and a source of depression. But there are marked exceptions to this rule — cases where a man's wife is the best nurse, his children his best companions. In bad cases a cheerful trained attendant and a young doctor make a capital team for the melanchoHc 130 STATES OF MENTAL DEPRESSION. who needs attention, company, and medical supervision. We try to remove the patient from surroundings that are de- pressing to those that will rouse pleasant thoughts, and to take him from the place where his malady arose. Every- thing and every person there may suggest pain to him. But he must not always have his own way. Quite the contrary. In most instances another will must overcome his own, and he substituted for it. This is a reason why mothers, wives, and sisters so often do harm, because they let the patient have too much of his own way. It is certainly well if those about him have physiologically a surplus stock of animal spirits to infuse into him. Much tact is needed in personal intercourse with melancholies, as, indeed, with all the insane. Seldom argue with them or contradict their delusions. Do not agree with them, but change the subject. Discourage introspection, encourage observation of and talk about things without. Don't let the hypnotists only take advantage of the powerful aid of "suggestion"; never cease to assure them they will get well and are getting well. In a few cases the use of hypnotism by Dr G. M. Eobertson here has overcome persistent sleeplessness, and "hypnotic suggestion" has introduced cheerful ideas. Every neurotic man should have an outdoor hobby. That would save many of them from melancholia. Precautions against Suicide. — Guard against suicide, and make the friends and attendants feel that there is a real risk of its being committed. They get into the state of mind of railway porters, who are so accustomed to risks that they forget all about them. I have seen suicidal melancholies by the dozen, about whom I have given warnings as strong as I could make them, that every article by which suicide might be effected should be removed, with knives in their pockets and razors in their dressing-cases. The bad cases should never be left alone. I once had a suicidal patient under the charge of an attendant, who was said to be experienced, and I found my patient in a top-storey room alone, with a loaded revolver in his pocket and a razor-case in his room, STATES OF MENTAL DEPRESSION. 131 and yet his mother and his attendant did not in the least realise the risk. Why an Asylum does good. — Many melancholies are intensely selfish, think of nobody but themselves, bore their friends with recitals of their own feelings, and crave sympathy with a morbid intensity. Too much expressed sympathy in most cases feeds the disease. To distract the attention from morbid thoughts and feelings by any means should be the one great aim in personal intercourse. Strangers often do better with melancholies than friends or relations. Many of them take most strong and unfounded morbid dislikes. They exercise more self-control before strangers, and the strengthening of the power of self-control is half the cure. That is why removal to an asylum is sometimes followed by immense benefit. A patient who at home has been groaning, noisy, idle, and unmanageable, finds himself among strangers, subjected to rules and discipline and ordinary living, and has objects of fresh interest presented to him, and he becomes a different man at once. I asked a man who had been very ill and unmanageable at home, and who seemed to come round in a few days in the Asylum, what had cured him. His reply was — "1 found myself among a lot of people who did not care a farthing whether I was miserable or not, which made me angry, and I got well." Being by far the most conscious form of insanity, it would seem the hardest on the patients to send them to an asylum, but, in reality, removal to an asylum does more good to certain melancholies than to any other class of the insane. What is good is not always pleasant in moral as well as in medical treatment. There is no use dunning a patient to "rouse yourself," to "throw off your dulness," to " drop those fancies," for in many cases it would just be as wise to tell a hemiplegic to "move that leg." As regards sending a patient to an asylum, and when to do it, no rules can be laid down. Among the poor it must be done in most bad cases, and soon ; though nowadays a work- ing man can get a complete change of air and scenery for a 132 STATES OF MENTAL DEPRESSION. shilling. Among the very rich few melancholies are sent to asylums till their relations are tired, out with them or until they become very suicidal or unmanageable. JSTo doubt the risks of suoide are much less in an asylum. There is discipline, order, a life under medical rule, suitable work, much amusement, and the means of carrying out what is good for the patient. When from any cause you cannot get the treatment carried out that you know is necessary for the patient, then an asylum is needful. When the symptoms persist too long without showing signs of yielding, when the risk of suicide is very great, when the patient has foolish friends who will not carry out any rational plan of treatment, or when he gets too much sympathy or none at all — in all these cases an asylum is indicated. Many patients who resist all right treatment at home will submit to it at once in an asylum. Nursing. — Good experienced mental nursing in the weak cases, just as you would nurse a fever patient, is of the last importance. A nurse that will insist and persist till the insane opposition and the repugnance to food is overcome, is what we want. It is very easy to let a melancholic slowly starve himself, while he yet takes some food at every meal. Baths are most useful, especially Turkish baths. I have seen many chronic incurable melancholies much improved and some cured by a course- of Turkish baths. The wet pack is often useful. Hypnotics and Sedatives. — Some of our greatest difficulties in treating a case of melancholia are whether to give narcotics and sedatives, when to give them, what to give, and when to stop them. Opium I greatly disbelieve in. I performed a series of elaborate experiments with it in melancholia,i and it always caused a loss of appetite and loss of weight in every case, and Dr Mickle has confirmed these results.^ I have seen very few melancholies in whom I was sure opium did permanent good, yet in a very few it certainly gives immense relief to the misery. "Fothei-gilliau Prize Essay for 1870," Brit, and Foreign Med.-CMr. Mevim, October 1870 and January 1871. ^ Practitioner, June 1881. STATES OF MENTAL DEPRESSION. 133 Chloral is very useful as a temporary expedient to get sleep. I now always give small doses — never more than 25 grains, generally keeping to 15, combined with from 20 to 50 grains of the bromides of potassium, sodium, or ammonium. But I now seldom give chloral long. I am satisfied that one effect of its prolonged use is to reduce the tone of the nervous system, and to lessen the power of enduring pain, mental or bodily. I very often use paraldehyde in doses beginning with 40 minims and going up to 4 drachms, with great confidence that its sleep is a more natural one than any other hypnotic known to me. I have lately had several oases where the patients gained in weight and improved in mind steadily, while getting some sleep, by taking a drachm of paraldehyde every night, while they at once fell off when this was discon- tinued. They all made good recoveries. Fifteen or 20 grains of the bromides added to the paraldehyde will sometimes prolong the sleep. Sulphonal, in doses of from 20 to 30 grains, is a most valuable drug, because it acts as a hypnotic and motor sedative combined, its effects are prolonged and its after-effects are seldom bad. In some of the excited cases it is invaluable. Hyoscine, in doses beginning with -j-^ grain hypodermically and going to -j-^ of a grain, is often very sedative in the excited cases. We combine tonics and sedatives very often. Lately I prescribed for a very intract- able case of agitated melanchoha with hallucinations, over- powering "suggestions" from her sexual organs, and deep misery — altogether a bad case of over a year's duration — a mixture of bromide of soda, arsenic, and iron with the most astonishing and immediate benefit. The bromides when long given are depressing. Tincture of henbane, in doses from 1 drachm to 4, is very useful as a temporary expedient in the very agitated cases, and so is conium; but, of all the day sedatives, I have found a mixture of Tinct. Cannabis Indicse (from x. min.) and bromide of potassium (from xx. grs.) or sulphonal do the most good and the least harm to the appetite for food. We have not yet discovered a perfect narcotic 134 STATES OF MENTAL DErEESSION. that gives brain quiet combined with increased appetite and body weight. Tinct. Lupuli I have found of much service in some mild cases, and it did no harm whatever ; and of chloral- amide and urethane I would say the same. Nature's counter-irritants and alteratives. — I have seen many cases cured by a crop of boils, a carbuncle, or an attack of erysipelas, and in one case by an attack of dysenteric diarrhoea. I think we shall some day be able to inoculate a septic poison, and get a safe manageable counter irritant and fever, and so get the " alterative " effect of such things, and the reaction and the stimulus to nutrition that follow febrile attacks. A new method of doing this has lately been devised by Dr Lewis C. Bruce, now one of the assistant physicians here, which is sometimes followed by astonishingly good results. He uses thyroid extract in doses of 60 grains a day, putting the patient through a course of this, lasting for from four to nine days in different cases. The patients must be put to bed during the treatment, and kept there for some days afterwards, for they become feverish, the temperature rising to 99° or 101° in different cases, the heart's action becoming lowered, and the patient rapidly losing flesh. The extract clearly acts as a direct cortical stimulant, as well as an excitant of fever and an alterative, for I have seen patients change from a melancholic to a maniacal condition during its use. After the extract is discontinued the appetite usually becomes ravenous. The weight runs up from half a stone to three stones, and a surprising mental improvement, ending in recovery in some cases, takes place. It should be used in every case that threatens to become chronic. Prophylaxis in Melancholia. — I think our profession could diminish the amount of melancholia if they were consulted sooner and more often as to the prophylaxis in patients who have had, are threatened with, or who aro predisposed to, states of mental depression. Especially is the preventive aspect most important in the dieting, regimen, education, and .work of the children of this class. If we could make all these STATES OF MENTAL DEPEESSION. 135 measures counteractive of tlie temperament and heredity, instead of accentuating them unduly, we could do much good, and prevent an enormous amount of unhappiness in the world. It is surprising how soon such children show their hrain instabihty. A " too sensitive " child should always be looked after. Children of this class take " crying fits " and miserable periods on slight or no provocation. "We do not call these things melancholia, but depend upon it they often have a close kinship to it. Such children should be kept fat from the beginning; they should get Httle flesh diet, and much milk till after puberty. Their brain should not be forced in any way. They should be much in the fresh air. They should not read much imaginative Uterature too soon. They should be brought up teetotallers and non-smokers. They should sleep much. Public school life is often most detri- mental to them. If they are bullied they suiTer frightfully. (Read poor Cowper and Lamb's lives.) If they are taught masturbation it takes a frightful hold of them, and it is they who are ruined by it in body, mind, and morals. The modern system of cramming and competitive examinations is one of the most potent devices of the evil one yet found out for the destruction of their chances of happiness in life. Such children are often over-sensitive, over-imaginative, and too fearful to be physiologically truthful, and tend under fostering to be unhealthily religious, precociously intellectual, sensuously artistic, and at first hypersesthetically conscientious. !N"ow, a wise physician will fight against the average schoolmaster in all these things. Such children should be taught to systema- tise their time and their lives, to develop their fat and muscle, and to lead calm hves of regular orderly occupation. As regards the prophylaxis in those who have already suffered from melanchoha, at the risk of being thought to ride a hobby, I tell such persons, one and all, to keep fat, and keep their brains quiet. Let them take precautions in time. The falling off of a few pounds in weight may be to them the first real symptom of the disease returning, even though they 136 STATES OF MENTAL DEPRESSION. feel at the time as well and hearty as possible. It is at this stage that change and rest do most good. I always advise my recovered melancholic patients to weigh themselves regularly, and keep a record of their weight, to lead a regular life, and to practise system and order in their work. Reducing their ordinary lives to a routine is the safest thing for them if they can do it. Like leanness, want of system and method goes with a tendency to melancholia, in my experience. Thoy should not work, or think, or feel in big spurts. And as the great epochs and crises of life — pregnancy, childbirth, the cHmacteric, and senility — approach, let special care he taken by them. Do not let them get to depend on soporifics for sleep. Nothing is more dangerous. An hour's natural sleep — " tired nature's sweet restorer " — may be worth eight hours' drug-sleep. A country life, with much fresh air, is no doubt the best in most cases, if it is possible. Regular changes of scene, "breaks" in occupation, and long holidays, are of course most desirable for such people. Though travel and change are very often harmful to actual melancholic patients, yet to many persons who merely have the temperament and the tendency, they are most effective in warding off attacks. I know several people who in that way seem to keep well and moderately happy. The great thing to be avoided is too fatiguing travel — seeing too much in too short a time. LECTUEE IV. STATES OF MENTAL EXALTATION— MANIA (PSYGHLAMPSIA). Physiological exaltation — Sanguine variety of neurotic temperament ; "excitability" of disposition — Mental exaltation physiological in childhood ; delirious exaltation easily excited by increased tempera- ture in childhood — Exaltation and delirium occur at beginning and acme of febrile disorders ; depression at end and afterwards —Sane V. Insane exaltation • — Exaltation of function follows increased circulation, oxygenation, and heat in brain — Mania defined objec- tively, Melancholia subjectively. Chakacteks. — First Stage: Sleeplessness ; unsettledness ; talkativeness ; constant muscular action ; changeability ; irritability ; diminished self-control ; extrav- agance ; loss of the sense of the proprieties, fitness, and conven- tional moralities ; change in the natural affections and habits ; "common sense" gone ; increase in imaginative power and amount of mentalisation ; ' ' whole man " diflferent ; loss of body weight ; denial that anything is wrong — Second Stage : Total loss of self- control ; incoherence ; violence ; destruotiveness ; filthy habits ; taste, smell, and common sensibility perverted ; shouting ; roaring ; facial expression totally altered ; rapid loss of weight, and exhaustion of strength ; tongue and mouth dry ; secretions altered, and men- struation stopped- — The association of ideas in incoherence ; pre- sentation and representation — Differential Diagnosis : From alcohol ; poisons; " suppressed " and " masked " fevers and inflammations; injuries to head ; excited melancholia — Prognosis : hi per cent, recover from mania (Royal Edinburgh Asylum). Varieties. — 1. Simple Mania : First stage of ordinary mania or distinct condition — Treatment : Largely preventive and regulative, giving outlets for morbid brain energy — Prognosis : Good. 2. Acute Mania : Onset sudden or gradual ; forms Spereent. ofadmissionstoEoyalEdinburgh Asylum ; not so common or typical as of old — CJiaraders : Within six weeks' duration — sleeplessness; appetite gone or perverted ; mus- cular movements constant and purposeless ; gesticulation; violence; unmanageability ; unconsciousness; delirium; total incoherence; loss 138 STATES OF MENTAL EXALTATION. or perversion of memory ; presentation, representation, and attention ; expression of eyes and face ; high temperature increased at night ; functions of skin, bowels, and digestion disordered— DcZmoMS Mania—Treatment : Food ; stimulants ; open air ; sedatives ; skilled attendance ; general management ; safety ; anything that impairs appetite or digestion bad ; give muscular outlet to cortical storm— Prognosis : 60 per cent, recover, 7J per cent, die, and 324 per cent, become demented, or pass into chronic mania or mono- mania. 3. Delusional Mania: Delusion the esseutial element, usually fixed, with excitement— Progrwosis ; Not good; greatly depends on fixity and intensity of delusion. 4. Chronic Mania: Acute mania continued in a modified way over a year, with the usual elements of dementia — Treatment : A lunatic asylum — Prog- nosis: Bad — Preventive and hygienic treatment of tendency to morbid exaltation— " cutting short "an attack. 5. Mania Tran- sitoria (Ephemeral Mania) : A rare form ; coming on suddenly, and lasting a few hours ; commonly a " mental epilepsy," or a " masked epilepsy." It means great instability of mental cortex. 6. Homi- cidal Mania : Maniacal excitement, which chiefly takes the form of desire and attempts to take away life — Prevalence of Mania : It is more common in Asylums (not in general practice) than melancholia, and it occurs at earlier ages. Physiological Exaltation. — Like conditions of mental depres- sion, states of mental exaltation, up to a certain degree, may be normal and physiological. This is especially apt to be the case in persons combining the sanguine temperament and the nervous diathesis. Every one has met vifith the sort of person of high spirits who is easily elated, has little power of control- ling the outward manifestations of exalted emotion, is quite carried away by joyous news or pleasurable feeling, so that he talks loud and fast, cannot sleep, cannot rest, acts in strange excited ways, and perhaps dances and sings — all with- oat cause that appears sufficient to produce these effects. Such conduct may be perfectly natural and physiological in any man, if the cause be sufficient ; but, in the Teutonic races, at all events, such causes do not occur very often in the adult lifetime of an ordinary man. If such mental exaltation does occur in any one on quite insufficient cause, or if it continues to manifest itself long after the cause has operated, we say that such a person is of a very " excitable temperament." Many STATES OF MENTAL EXALTATION. 139 bodily diseases in persons of this constitution are apt to be accompanied, and are often much comphcated, by sucli brain excitement. Mental exaltation is perfectly natural in childhood. It is, in fact, the physiological state of brain at that period. Hence, whenever the temperature of the brain rises, from febrile disorders, in children, we are apt to have delirious mental exaltation. I found on investigation at the Sick Children's Hospital here, that by far the majority of the cases of dehrium in the young patients there are characterised by pleased or exalted feeling, and by pleasant hallucinations, the few exceptions being usually severe burns or such very pain- ful affections. But if a grown man exhibited the same symptoms of mental exaltation as are normal in a child it would be accounted morbid, and he would almost be reckoned insane. In children of neurotic constitution this is apt to become a most serious complication. While a high tempera- ture is apt to cause violent delirium in such children, it is in them, too, that reflex peripheral irritations, such as teething, rickets, worms, undigested or indigestible food in the stomach, cause convulsions. The delirious and the eclampsia point of different children is a field well worthy of attention, and a knowledge of it might be most useful in their after life- history and disease-history. In adults of this constitution a febrile catarrh, a mild attack of rheumatism, or gout, or inflammation may be very serious matters, from the sleepless- ness, nervous excitement, intensity of the pain, or the delirium present. All febrile affections act as a match to gunpowder in such a brain. The exaltation and delirium are usually contemporaneous with the beginning and acme of febrile attacks, while depression of mind follows the disease. I consider that the bodily temperature at which delirium begins in a child is a good index of its brain constitution and temperament. I have known a very nervous child always delirious at night if its temperature rose to 99°, while in most children this does not take place till it is 102° or over. 140 STATES OF MENTAL EXALTATION. Apart from increased temperature, such children are subject to gusts of unreasoning elevation, during which they are quite beside themselves, rushing about wildly, shouting, fighting, and breaking things, not really knowing what they are about, this coming at intervals like the "attacks" of a disease. Most sorts of blood-poisons, many drugs, such as opium, henbane, Indian hemp, and alcohol, as well as an increase of body temperature, readily cause maniacal exaltation in the brains of which I am speaking ; and I have seen such usually temporary exaltation not pass off, but become a prolonged attack of mania in several patients — one after a dose of cannabis indica, another after opium, and very many after alcohol. All those were strongly predisposed to insanity by heredity. I believe that convulsions, night terrors, and " hysterical " affections are, in children of neurotic heredity, the equivalents of maniacal attacks at adolescence and after in tlie same kinds of brains; while chorea, somnambulism, asthma, and epilepsy are the special cerebral neuroses of puberty and early adolescence in similar cases.' Sana and Insane ExaUation.— There is much less difficulty in drawing the line in most cases between sane, or even between delirious exaltation and pathological insane exalta- tion, than between the conditions of sane and insane de- pression of mind, though many individual cases of difficulty are met with. The reasoning power — that of judging rightly and comparing— is affected sooner and more decidedly in mania, and the loss of control in action, conduct, and muscular movements is also sooner seen. That stage of loss of memory and consciousness where the personality is lost, and the former mental life and experiences have disappeared, where, in fact, the metaphysical ego has fled, and a false conscious- ness—an unreal ei^o— has taken its place, is far sooner reached in mania than in melancholia. Eevan Lewis ^ has "little doubt that the process of reduction is the same for both (i.e., melancholia and mania), but in maniacal states the dissolution ' The Kmroses of Development, by the Author. 2 Op. cii., p. 193. STATES OF MENTAL EXALTATION. 141 is to a greater depth; the difiference is one of degree." I do not agree with this hypothesis. It seems to me that a con- dition which causes pain must result from a different kind and not merely a different degree of cortical action from that which causes an exaggerated sense of well-being. The name " mania " is apt to be used both professionally and popularly in a loose way, as synonymous with insanity, or even to indicate a mental craze or eccentricity that falls short of that. Nothing is more common than to see in medical papers "suicidal mania," when "suicidal melancholia" was meant. It is necessary, therefore, to define the term. Mania might be defined as "morbid mental exaltation or delirium, usually accompanied by insane delusions, always by a com- plete change in the habits and modes of life, mental and bodily, by a loss of the power of self-control, sometimes by unconsciousness, and loss of memory of past events, and almost always by outward muscular excitement, all those symptoms showing a diseased activity of the brain convolu- tions." We think of melancholia chiefly from the patient's subjective point of view, taking his affective change and his conscious mental pain chiefly into consideration, while we think of mania more from our own objective point of view, and picture the patient's talkativeness, his restlessness, and his manifest changes of personality and habits : just as in neuralgia we think of the patient's sensations, and in tetanus of the convulsions which we see for ourselves. The definition of mental exaltation, too, must not be taken as if it were the mere opposite of depression or of mental pain. I would, therefore, describe insane mental exaltation as being a morbidly increased and irregular production of mental acts by the brain with or without an increased sense of well-being or pleasure, but distinctly without a conscious sense of ill-being or mental pain. Dr G. M. Eobertson has pointed ^ out that ' Journal of Mental Science, July 1890, " Does Mania include Two Distinct Varieties of Insanity, and should it be Subdivided," by G. M. Robertson, M.B. 142 STATES OF MENTAL EXALTATION. in different cases of mania, the emotional conditions are of two kinds, joy and rage. The word excitement, used medico- psychologically, refers always to outward visible muscular acts, such as restlessness, muscular resistance, acts of violence, shouting, facial contortion, or movements or expressions of the eyes, or to an intense desire towards such acts only restrained by a strong exercise of self-control, to which we use the term "suppressed excitement." Most melancholic patients can tell us how they feel. They know there is something wrong with them, even exaggerating their mental pain ; while in most cases of mania the patients affirm they are quite well, probably that they are better than they ever were in their lives, and we have to judge of their mental condition from their speech and actions, which become to us the symptoms of the disease. Varieties. — If we look at a number of patients who are classified as labouring under mania, we see at once that there is a very great difierence indeed between different cases. Without going into pathology or causation at all, the outward manifestations show not only far greater intensity of morbid action in different instances, as is the case in all diseases, but a certain difference of kind of symptoms, mental and bodily, which I shall endeavour to assort for clinical and practical purposes into varieties of the disease; it being understood that these varieties are not necessarily distinct diseases or pathological conditions, but merely groups of similar symptoms that may be combined with other groups, or may be different stages in the same disease. The great advantages of classifying mania into those varieties are, that thereby a student is less confused in seeing patients so very- different from each other, and more especially in the guide that is thus obtained in treating and managing patients. The varieties I propose to describe and iUustrate by clinical cases are : — STATES OF MENTAL EXALTATION. 143 a. Simple mania. h. Acute mania. c. Delusional mania. d. Chronic mania. e. Ephemeral mania (mania transitoria), f. Homicidal mania. Simple Mania. — When a man of common sense, who has been of the ordinary type as to conduct, demeanour, and speech, undergoes, without sufficient outward cause, such an intellectual change that he becomes loquacious, talking con- stantly to every one who will listen to him about anything under the sun, especially his own private affairs — when his judgment is manifestly not to be depended upon, and his views as to himself, his prospects, his capacities, mental and bodily, and his possessions manifestly exceed what the facts warrant — when he becomes fickle, restless, unconventional in his conduct, and foolish in his manner — when he acts without motive and without aim — when, in fact, his common sense has gone, and his power of self-control has become manifestly lessened, and when this lasts for days or weeks, we say he labours under simple mania. This condition would seem at first sight an easy one to describe. But it is not so ; for though it seems simple, yet, when we come to analyse the mental faculties involved, and how they are affected in different cases, we find an immense variety of combinations. No one case is quite like another any more than any one man's mental development is like that of another. A con- dition of morbid mental exaltation may exist, and I believe does occur, among persons of a nervous heredity far more frequently than is commonly supposed, in slight forms, that are not considered insanity at all. I would go the length of placing the "lively moods" to which some people are subject in the category of a direct kinship to simple mania, just as I would place the " dull moods " of some people among the relationships of simple melancholia. The longer I hve the more I am impressed with the fact that some of 144 STATES OF MENTAL EXALTATION. the important acts in the lives of certain persons are the result of brain conditions that cannot be reckoned as being quite normal. The men whom one knows as subject to restless, energetic, boisterous fits lasting for weeks, who do childish, extravagant, or foolish things at these times, whose natural peculiarities are then much exaggerated, and whose common sense seems to ebb and flow in an unaccount- able way, are of' this class. If we inquire into the family liistory of those persons we are almost sure to find a nervous strain. We will usually find, too, that the more we take to studying the practical psychology of our fellow-men from the point of view of heredity and brain function, the more will those peculiarities impress us as being the same in nature, but less in degree, than those greater mental peculiarities that we call insanity. Not that for a moment I want to lessen the moral responsibihty of such persons to society or the law, or to confuse the great assumption that underlies all social arrangements and all law, that all men are sane and responsible until proved by good evidence not to be so. Still the field I am indicating is a most interesting one in the study of human nature. I have known great fortunes lost and even made, great enterprises undertaken, great speeches made, great reputations impaired, unsullied characters stained irretrievably in the public eye, ancient families degraded, marriages contracted, adulteries committed, and unnatural crimes perpetrated by men and women whom I considered to be labouring under mild attacks of simple mania, but whom the world in general simply looked on from the ethical and legal point of view. Those persons were the victims of " the tyranny of their organisation " ; yet our medico-psychological knowledge wUl have to be far more accurate and more widely diffused before we can save them from it or its direct consequences. In such cases we find that at a certain period in their lives a mental change took place. In some way their " characters " underwent an altera- tion. In my experience by far the greater number of the STATES OF MENTAL EXALTATION. 145 cases of "moral insanity" were of this kind. Most of Prichard's cases of moral insanity I look on as examples of simple mania. As we shall see, morality, with its inhibition of lower instincts and tendencies, first disappears in simple mania. Being the last of the great human faculties to be evolved, as Savage pats it, it is the first to be lost. It is the highest brain "level" that first undergoes "dissolution." Of course I am not referring to those cases where no morals had ever come to a person by heredity, education, or example, or where the morals and self-control had been dehberately destroyed by the mode of hving. Case of Simple Mania, Oliange of Life, Immorality, no Legal Insanity. — I knew a gentleman, C. A., who was famed in his neighbourhood for his prudence, probity, and devotion to business, for his wisdom, morality, and religion, who, at a certain period of his life, after middle age had come on, underwent a total change. He became rash, indifferently honest, utterly careless of his business, foolish in his schemes, very doubtfully moral, and careless of religion. He changed in his mode of dressing, in the company he kept, and his way of living. His affairs got entangled, and he lost a fortune by foolish speculation, this being entirely new to him. Yet he mingled in society all the time ; never said a particularly foolish thing ; transacted business in a large way of the utmost importance to himself and others; and I should have been very sorry indeed for any one who had called him insane to his face, or taken steps to abridge his personal liberty or deprive him of his civil rights as a citizen. No jury in the empire but would have held him sane, and no judge but would have made his case a text for a homily on the danger of medical views in regard to insanity and the liberty of the subject. I venture to say that you will not have been in practice for many years before you will have seen men and women whose conduct will be utterly inexplicable except on the theory that it is the result of a morbid brain condition, — "motives," as K 146 STATES OF MENTAL EXALTATION. ordinarily understood, having little to do with it. Well, C. A. got through his fortune, ruined his reputation, and scandalised and estranged his friends, all without any "motive" of the ordinary kind; and all this came on suddenly and in entire opposition to the whole tenor of his life and to every principle that had ever held sway over him for twenty years. Yet legally sane he was, just because the brain change that I assume was the cause of all this did not go far enough to make him lose his seK- control entirely, and to act manifestly as an lunatic. But, can any one who has studied mind from the brain point of view doubt that the man's mental acts and conduct during his changed period were morbid, and the result of morbid brain action 1 And this conclusion was vastly strengthened by the fact that his heredity was a nervous one, he coming of a family in which insanity and eccentricity had been prevalent, and that he had procreated epileptic children. And, by tracing his future life, we find that, stUl without any "motive," he again changed and settled down into a quiet-going, slightly senile man, with the fine edge of his faculties and dispositions somewhat taken off. In this, as in several others similar that I have met with, such a mild attack of mania came on shortly after widow- hood. I have seen this in both sexes. My idea is that this was not a coincidence, but that the sudden deprivation of sexual intercourse had something to do with it in this case as an exciting cause. Such is an example of simple mania in its mildest form, not being reckoned insanity at all by the law or by society. You may perhaps save a fortune, or a reputation sometimes, and will certainly save much uncharitable recrimination and useless indignation on the part of relations by putting them in possession of your knowledge. When I am consulted in such cases now, I often recommend a long sea voyage in a slow ship, or a change of residence for a time, and try and get business matters settled on some sort of sure STATES OF MENTAL EXALTATION. 147 footing, so that unsafe speculation or falKng into tlie hands of scoundrels may be avoided. There is no class of case ■where harpies seem to fix on a man so inevitably as in tliis. Such men are easily led by adroit and unprincipled people, who flatter them and take advantage of their weakness. The sort of persons whom the man in his " right mind " would never have associated with get round him then. He tends to seek persons in a lower social and ethical position, and very often the loss of his self-control is shown by an excessive use of stimulants, or by frequenting bad company, both being mere symptoms of his mental disorder. The lower and baser parts of a man, kept under before, now come uppermost. Especially is undue excitation of the ' sexual desire and disregard of morals and appearances in gratifying it very common. I have found this to exist in nine-tenths of such cases. I once saved a business and a reputation by getting a man in the beginning of an attack of mild mania to take a partner, give up business meantime, go to spend a year with a friend on a sheep farm in Australia, hve out in the open air, take much exercise, eat httle animal food, and take bromide of potassium in 20-grain doses three times a day. This, in fact, sums up about all I can tell you in regard to treatment. The great difficulty is that such patients do not know that there is anything wrong with them, and will not believe it ; in fact, are often very indignant, and quarrel with you if such a thing is hinted at. They sometimes look well, but they do not sleep well, and all of them are restless, and often worn-looking. They often eat twice and thrice as much as usual, and digest their food well. They often have their bowels moved twice and thrice a day, even if naturally of a costive habit. Their tastes usually change. They lose their fine feelings and delicate perceptions of things in taste and smell and sensi- bilities. I have known a man who needed to use highly magnifying spectacles to be able to do without them, and even to be able to read small print, when passing through an 148 STATES OF MENTAL EXALTATION. attack of simple mania. In fact, I knew a man who, as the morbid brain excitement gradually passed away, had to use spectacles of greater and greater magnifying power. The body temperature is always, I have found, higher by about •5° or 1° during such an attack.^ The following case of simple mania was one of great interest, ^ from the natural power of the brain affected. C. B. was a man of very high intellectual and scientific attainments, with a heredity to the neuroses. — I have attended two cousins ^ suffering from melancholia. He was of a sanguine tempera- ment and robust bodily constitution, great mental energy and acuteness, prudent, discreet, and held the opinions of others in great respect. He had written much and done very good work. At the age of forty-five he lost his wife, whom he had sleeplessly nursed, and within a week proposed marriage to another lady, became excited, took two girls out of a brothel, got lodgings for them, tried to reform them, spent money on them, prayed with them, and slept with one of them, intending, as he said, to make her his wife. And he did some work in a sort of sporadic way, not sticking to anything. He slept little, and kept very late and irregular hours. Then he developed great brilliancy and social faculty, for which he had never been distinguished before. He especially liked ladies' society, and he was witty, clever, and had a miraculous memory, indeed a better memory than he ever had before. (I knew one man who, as he was passing into mania, would repeat a whole play of Shakespeare or a book of jVIilton, which when well he could not do.) He could quote long passages from every author he had ever read. Then he began to evolve wonderful schemes of all sorts — not quite insane schemes, but very nearly so. He got irritable with those who opposed him, and said they persecuted him. He went and called on all his casual acquaintances of any note, and made new acquaintances on slight cause. He had been ' "The Temperature of the Body in the Insane," Jour. Menl. Sci., April 1868. STATES OF MENTAL EXALTATIOiST. 149' very fond of his children before, and now he spoke much of his affection for them, but really he neglected them. He quarrelled with his relatives because they remonstrated with him and tried to control him. He exhibited a morbid expansive benevolence. He gave away his money foolishly to the poor, or to anybody whom he thought needed it. He propounded to the philanthropists marvellous plans to terminate the world's misery. He went one night with his Bible in his hand to a brothel to convert its inmates from the error of their ways ; but, after reading and prayer, the vice he hated was in one short hour " Endured, then pitied, then embraced," and he had to leave his Bible in pledge, as he had not sufficient money in his pocket ! All those things he spoke of openly. Soon after this his conduct became so uncon- trolled that he was certified as insane and sent to the Asylum. He had succeeded in wasting nearly all his available means. When he arrived he was indignant, and made out that his friends had ruined his prospects by placing him improperly in a "madhouse." But his indignation was transient and skin-deep. He soon entered into the hfe of the place. He was an admirable and interesting talker, a copious and sparkling author in the Morningside Mirror, a hearty if not an elegant dancer, a great walker, a scientist, and a devoted admirer of all the fair sex, making love indiscriminately to lady patients, nurses, kitchenmaids, and paupers. And yet he could propound maxims as wise as Solomon's proverbs, and he was a stern and sarcastic censor of morals in others. But he had no common sense ; and he could not help "making a fool of himself " if he had the chance. He could not be trusted anywhere out of the Asylum. He talked about his most private concerns to any one who would listen to him. He was very credulous, and in conduct he showed small reahsation of the difference between meum and tuum, or of the sanctity of the virtues generally. His memory was 150 STATES OF MENTAL EXALTATION. prodigious but not exact j and ho was never at rest. His sexual appetites were strong, but not really so strong as his erotic imaginations and likings. He told most disgusting stories " for a moral purpose " to others, and he was better up in the sexual history of great men than any man I ever knew. After having one morning abused me most heartily, he sent towards evening a letter addressed — "Immediate. The sun has not gone down. Morningside. From my prison, where, like Joseph, and Peter, and Paul, I was put on false accusations. My dear Clouston, I beg your pardon for speaking to you and of you as I have done. I want some liberty. Try and let some patients out, and you will become the greatest man of the day. Give the excited ones sedatives like tobacco or better food. Dismiss such men — et audi alteram partem, that is, hear my version of things. Let me get to town to-day. I need a change. Think who I am. Since 1847 the friend of Thomas Carlyle and Alfred Tennyson; of Owen since 1838; of Darwin, of Sir John Eichardson, Kae, &o., &c., &c." (He had casually met these men or called on them as he was becoming ill.) — "Yours ever. " P.S. — Why have you not shown me your children? I do not bite, I only bark. " P. P.S. — Read this to any who may be concerned." Persons labouring under simple mania always think them- selves in the right, and are very sensitive to criticism and indignant at it. There is much of what one can only call cunning. C. B. could control himself for short periods when he wished, or when self-control was to bring any advantage ; he would pretend to be most friendly with the powers that be, in the Asylum, before their faces, and then turn and abuse them behind their backs. He would, to strangers, most cleverly make things appear extreme hardships that he did not feel as such. He ate enormously and slept badly, but did not fall off very much in flesh. After six months he was so much better that he was sent STATES OF MENTAL EXALTATION. 151 to a distant part of the country, where he stayed for far too short a time. He made an unsuitable marriage with a woman below himself in social station and education, had children by her, but soon got tired of her, saying she was a prostitute. He then lived an eccentric life for twelve years, getting syphihs, as he said, from "using an unclean handker- chief " ! At the end of that time he had another attack of simple mania of the same general character as the one described, but all the symptoms more severe. He was more incoherent, less brilhant, less interesting, more disgustingly immoral — his brain, in fact, had the fine edges of all its qualities taken off. He died, after a few years, still maniacal, and with some of the mental enfeeblement of dementia. Such a patient must be regarded as suffering from simple mental exaltation with mild excitement, the result of a hereditary instability of brain. My belief is that brain-work and education tend towards this condition in those predisposed. One cannot speak dogmatically, but I think if such a man's brain had never been highly educated, or if he had not taken to intellectual work, or even if his wife had lived, he might never had developed the morbid brain elevation at all. It might have remained all his life, as it had done for forty-five years, a mere potentiahty. Such cases are very difficult to treat and manage. They will not be controlled outside an asylum, they create scandal and waste money, yet it is for a long time impossible to certify them as insane ; and when sent to asylums it is undoubtedly hard on them, for they are sensible and irritable, and capable of enjoying life to a large extent. Such attacks are usually over six months in duration, but I have seen them very transitory and pass away within six weeks. I do not know any method as yet to influence favourably such morbid energising of the brain except quiet, exercise in the fresh air, non-stimulating food, warm baths at night, the use of sulphonal in small doses, or the bromides. The following case of simple mania, of short duration, was undoubtedly benefited by restraint in an asylum. It was that 152 STATES OF MENTAL EXALTATION. of C. C, a member of a learned profession, aged 59, of a sanguine temperament, and cheerful and frank disposition, in apparently good bodily health, and of good habits. He had been morbidly excited in mind on four or five previous occa- sions, the excitement passing off in six weeks, being treated by his being sent oif to a lonely country place to "walk it off" among the hills. There was no admitted or known heredity — such facts in family histories are kept very secret and are soon forgotten, so that they are often really not known to the younger members of a family — except that his mother had been in a state of senile dotage for ten years before her death at a very advanced age. Six weeks before admission he had become changed in disposition, altered in conduct, unsettled, much elevated, always talking about the Turco- Servian war that was going on then, restless, sleepless, changed in his appetites and tastes for food, and he began to dress in an entirely different way from what was natural to him. In his case the most striking alteration was in his truthfulness. Naturally a truthful man, when his illness began he took to telling lies by wholesale about everything, and for no purpose or "motive." He was boastful to absurdity, bragging of qualities nearly the opposite to those needed in his profession. This human nature tendency to be very proud of things out of one's line — the lawyer of his medical skill, the parson of his worldly wisdom — you will find in an exaggerated degree in mania. He was a marvellous swimmer, a splendid boxer ; he would dilate with circvimstantial detail on the numbers of expert swordsmen he had overcome and killed, and on the pugilists he had thrashed to within an inch of their lives. He said he was going out to the war, and would soon be made the general of the Servians, and he actually purchased some appro- priate weapons. Yet there was a Httle method in his madness, for he was somewhat careful about whom he told those wonderful tales to, and his manner of telling them was not quite that of a lunatic who fully beheved them. He drank too much, and his habits were not orderly or cleanly. An STATES OF MENTAL EXALTATION. 153 hour before be was taken to the Asylum he had, to some persons, of whom I was one, whom he thought congenial spirits, told his best stories, and had exhibited a mixture of extravagance, lies, boastfulness, and obscenity that quite con- vinced two of the company — doctors there to examine him — that he was very insane, and they certified him at once. From the way he had been talking, those who took him to the Asylum were prepared for a desperate resistance. But there was nothing of the kind. With a verbal protest, and a manner as meek as Moses, with no resistance and no fight at all, this wondrous pugilist went to the Asylum. He collapsed at once, and his whole eifort was to explain away his conduct, and apologise for his language. It seemed to act like a charm on him, and to restore much of his power of self-control. He again, and at once, assumed the speech and manner of an elderly parson — this pugilist of an hour before. And he never again indulged in quite such violent speech, or exhibited such extraordinary conduct, though he dressed queerly for a few weeks, did not sleep well, and was elevated in his de- meanour. He tried hard to attach unreal meanings to his tales, and to apologise for his extravagant conduct. In three months he was quite well, and kept well for several years, when he had another very mild attack, and this time his morbid energy found an outlet in publishing a book. The sudden pulling of himself up by a patient on being taken to an asylum is often seen, both in mania and in melancholia, but it does not always last. The brain pace breaks out again, and sometimes far harder than before, because at home, per- haps before children, as much self-control as possible is exercised, while in an asylum a man frequently thinks there is no object in exercising it and does not do so. In other cases of simple mania a viarhid vanity is exhibited, as in the following case. I have no doubt that the weak points of normal character are those that are usually exaggerated in simple mania : — C. D., a tradesman, was sent as a patient to the Royal Edinburgh Asylum, and at first he seemed to he 154 STATES OF MENTAL EXALTATION. merely a talkative and egotistical old gentleman. But it soon appeared that authorship, and poetry in particular, was his special weakness ; whUe, along with this, there was a peacock- like vanity in dress and demeanour that was very ludicrous. By a pompous manner, a sesquipedalian speech intended to be impressive, a combination of the juvenile and the Byronically poetic in dress, and a very big book always carried under his arm, he showed his morbid vanity. He was most touchy when interrupted in his long speeches, and he tried to be very wither- ing in his contempt. He used to write me a letter of fifty pages of foolscap in the prosiest style if he had a simple matter to bring under my notice. Indeed, his speeches, which he tried to inflict on me every day, used to try me pretty nearly up to the point of my own power of endurance, though I am pretty well seasoned in the art of "bearing fools gladly." His poetry was trash, which he produced by the ream, thinking it Avas equal to Shakespeare's, and he tried to read it with due dramatic effect to the ladies in the drawing-room in the evenings. Yet, with all this, he was not incoherent. He had periods of intensified excitement, when he would scold much. He was very thin when admitted, and his nervous and nutritive power and tone low, so I fed him well, gave him a hberal allowance of good London porter, extra milk, and cod-liver oil, and insisted on his being in the open air most of the day. He got fat ; and as this took place his foolish vanity and ex- citability diminished, and he grew into a moderately rational human being, who left the Asylum with the full intention of returning to his business. But the loss of external control seemed like taking off the governors of a steam-engine ; he got thin, poetic, and morbidly vain, and had to be sent to another asylum, where surely they did not give him as much paper as we did, for he abused the place most heartily, and wanted badly to come back to Morningside, but we had no room for him, and he died in a year or two, still insane. I have met with cases of simple mania where the lack of con- trolling power was seen, not so much in speech or ordinary con- STATES OF MENTAL EXALTATION. 155 dud as in toant of muscular inhibition. I had a yonng lady, C. E., under my care once, who came of a very nervous family, and whose brother's case I have referred to (A. D., p. 39) as ex- hibiting such morbid indecision and paralysis of volition that he could not make up his mind which stocking to put on for half an hour. She seemed perfectly well when one spoke to her, but when left alone she would make faces, jump about, tear her clothes, turn heels over head, scream, pick her skin, and masturbate apparently automatically without much erotic intent or much sexual feehng. In the midst of all this, if one addressed her she would sit up and talk as inteUigently and quietly as possible. She had no delusions, no tendency to violence, and was gentle and lady-like. She came into the Asylum as a voluntary patient, and declared she could not restrain these movements. Like chorea, they were apt to come on in an aggravated way at the menstrual periods. They were unUke choreic movements in their real character, being, if one might use a contradiction in terms, automatically volitional. She did not sleep, and could not employ herself for any length of time. She recovered from the first of these attacks in a few months, but then had a more severe one, on which no treatment had any permanent effect, and she got thinner and more attenuated, and died of exhaustion in about two years. She was free from delusions, and, in a way, intel- lectually sound up to the last, during the periods when she picked herself up. Every sort of treatment was adopted, everything to fatten and improve the nerve tone that we could think of — cod-hver oil, maltine, the phosphates, hypo- phosphites, arsenic, strychnine, &c. All the usual sedatives and narcotics were tried — the bromides, opium, henbane, cannabis indica, lupuline, camphor. She was aucesthetised by ether and chloroform. She had blisters, warm baths, exercise almost to exhaustion, &c. That was an extreme and pure example of a symptom which we see commonly enough in mania, viz., automatic co- ordinated movements that are ordinarily voluntary, but result 156 STATES OF MENTAL EXALTATION. evidently from morbid exaltation of function in the highest motor centres in the convolutions. It is a muscular mania, the intellectual and volitional power being comparatively- intact, but the highest ideo-motor inhibitory centres being paralysed. It was a curious fact that her brother should have been affected in such a different and psychologically contrasted way, — in the one, the will not being able to put the muscles into action, in the other, not being able to stop them. I have seen the same motor phenomena in melancholia. I said that simple mania assumes the form of " moral insanity '' at times, without apparent intellectual aberration. The system of clieclcs on inclination, doing duty for its own salce, and efforts after the good, which by the constant strivings of years has become a habit, and constitutes the man's moral character, sometimes vanishes like the early dew at the begin- ning of an attack of mania. I shall give an example. C. F., a lady of good education, good morals, refined disposition, and lady-like tastes, had several attacks of mental disease, of which the following were always the symptoms : — She slept much less than usual, and got thinner. Her expression of face changed. Instead of being a pleasant-looking woman, her features acquired a coarser look. She ate twice as much, and lost the delicate ways of a lady. She lied, stole, whored, and took pleasure in annoying or hurting every person she came across. She was cruel to animals. She was such a blister and firebrand that she could live in no private house with others, and in the Asylum she could set up ten patients in as many minutes. She had the most extraordinary instinct in finding out the weak points of her fellow- creatures I ever saw, and she remorselessly used this for their annoyance, this being her chief delight. She did not court a fight, but never declined one with any person whom she had roused to fury, enjoying it too; and yet, with all this, she was plausible, always with a ready excuse for her scrapes, could make herself most agreeable at an evening party, and would often have defied any doctor to find facts indicating insanity STATES OF MENTAL EXALTATION. 157 ill an hour's conversation. It was only by continuously watching her conduct that such facts could he got, and she could be certified. She was such a nuisance that asylums passed her on from one to another as too troublesome to keep, though she seldom got into a rage or became outwardly excited. And all this came on her at intervals like any other disease, passing off, and leaving her the same refined moral and pleasant lady she had ever been. Case of Sudden Immorality in a Girl. — I had once under my care a girl, C. G., aged 17, the daughter of a gentleman, her mother being intemperate. Had been well brought up, and, up to within a week of her admission to the Asylum, a well-conducted girl. She was of a robust and perhaps rather sensual constitution, who, without showing any previous sign of insanity, except conduct that was called wayward and dis- obedient, left her home, wandered to where some workmen lived, in a lonely place many miles off, and passed the night with them. She showed no other signs of mania, when taken home, than utter disregard of her parents' feelings, bad language and violence to them, want of right feeling of any sort, and threats to commit suicide. Those symptoms were recognised as constituting insanity, and she was sent to the Asylum. This state of matters passed off in a few days, and she became apparently well in all respects, except that she seemed blunted in her feelings, incapable of applying herself to any work, and at times sullen and stupid. Her oatamenia had been irregular, and she had suffered from severe head- aches before the attack. She remained free from excitement, though not considered well, for about six weeks, when, just before menstruation, and preceded by frightful cephalalgia and a day or two of dulness and mental torpor, she had an acutelymaniaoal attack of great violence, coming on like an explosion, and lasting for a few days. She had three of those within a month ; then she had in the next two months several sullen stupid attacks. In five months she recovered. Each maniacal attack was accompanied by a foul tongue, deranged 158 STATES OF MENTAL EXALTATION. bowels, flushed face, total loss of memory and power of atten- tion. After she recovered she had no recollection of any- thing that occurred during the attack. Thus the immorality and the disobedience and disregard of her parents' wishes were clearly shown to have been symptoms of an attack of simple mania which preceded the three acute attacks. Case of Maniacal Immorality in a Boy. — I once saw a hoy, C. H., of 14, whose father was a drunkard, wife-beater, and of a most ungovernable temper, though a clergyman, and his mother a down-trodden, rather soft woman, his elder brother being just like the father. His father used to make C. H. drink when a mere boy, and taught him to smoke. When a child, he had been of a very ungovernable temper, utterly undisciplined, and disobedient, assaulting his mother, swear- ing, shouting, breaking open locks, knocking about furniture, threatening to shoot first his sisters and then himself, buying a pistol and practising with it. He could not be got to go to school, or to do anything useful. His habits were irregular. He would stay in the house for weeks at a time, and was unsocial and un playful. When I saw him he was quiet and apparently reasonable. He was a delicate, nervous-looking boy, with a restless elevated expression of eye and face. When I said he would be sent to sea if he did not behave better, he replied the man who came for him would get the contents of his revolver. I recommended that he should go and travel with a sensible tutor, and this was attended with benefit to him. Not only are the morals affected, but the whole character is altered. I have seen some people improved vastly in certain respects during a slight attack of simple mania. I knew a naturally reserved, proud, unsocial, rather cantankerous, selfish, stupid, miserly man become for a time genial, bright, good-mannered, and generous during such an attack. The changes in the tastes, instincts, and even in the organic appetites are often marked and most peculiar. Most patients do not hke the same food as when in health. They often STATES OF MENTAL EXALTATION. 159 take to excessive smoking, and sometimes to drinking, in- dependently of their habits in those respects when in health. The delicate hkings are not only lost, but new repugnances develop themselves, and former friendships are commonly altered or lost. The personal habits tend to become imtidy, slovenly, and dirty; unconventionahties of all sorts are in- dulged in — and, by the way, this applies to most of the insane. The higher intellectual tastes also change. I knew a man who could not appreciate, and, as a matter of fact, neglected his favourite authors, taking to their exact opposites. When well, he read Gibbon and Hume ; when ill, he took to Burns and Swinburne. The sort of brain evolution into insanity at an early age, which the Germans have called " Primdre VerriieMJieit," in which changes of character, foolish insane conceits, wayward- ness, unreasoning extravagances, unsocialness, gradually develop into delusional insanity or dementia, may at the beginning usually be classed as simple mania. Many cases of " Paranoia " seem to be of this character, with or without delusion. The Folie raisonnante of the French corresponds in a general way to the milder cases of simple mania. Transition Stages. — Simple mania is very often the first stage of acute mania, which we are to consider next. The following letters of a young unmarried man, C. J., who naturally was of a modest, rather shy, disposition, but who had for a month laboured under simple mania with strong exaltation of the nisus generativus, and was passing into acute mania, illustrates the mental condition of such a person. The first two letters are elevated and delusive, but nearly coherent ; the third, a month afterwards, very much more extravagant. EniNEnEGH, 7th December. Dear Dr Cloustox, — I had a good night's sleep last night after the pleasant evening I had, and feeling sure, after the kindness I have met with here, that the best way of getting a perfect cure is to make a clean breast of it, I now try to do so. I believe that I am a married man, and that a lady called Miss , the reputed daughter of , is reaUj- 160 STATES OF MENTAL EXALTATION; ray wife, further that she has had children by me, one of which is dead. I believe I have ten children by her still alive, three of whom I used to believe the children of my late undo , who now live with his widow, at , four who were brought up by , and three who were brought up by my reputed parents' friends . I have long had this belief, but not having any proof but instinct to guide me, I refrained from stating it. I believe it is true. Should it not be so, why, it only proves my love for her and them, and I feel sure you will try and cure me of the delusion. I write as one Christian to another older and more experienced one. — With all respect and confidence, — Yours . Ith December. Dear Dr Clouston, — In my last letter I put the cart before the horse. I believe Mr ■ (a fellow patient) to be Duke Constantine, my father and Miss ■ to be , but I am wrong there I think, — Yours faithfully . MoENiNSSiDE, Edinburgh, Sth Januarg. My Dear Old , — I have at last fallen in love with the prettiest girl you ever saw. I got your letter, thanks, old man, and the quota- tions which I enjoyed, and went to look for it in an old coat, but couldn't find it — well but this girl you know I'm a bit of a student and a selfish brute, but for all that I love the girl, you may call a thing two names, but it's the same nearly ? Wow the fact of the matter is they are so uncommon kind to a fellow here women and men, it's a fact, but then I was far far below the normal point of sanity, that even although I was doomed to remain here all my natural life, I could do it with ups and downs, but you see this girl, . Were I pronounced sane enough to be out, she might have me. The fact is, , I'm such another uncommon agreeable fellow at times, but then it's the liver, as an Irish friend of mine, that I suspect one may say it as a joke. Dr Clouston, who paints his face, keeps me here as a profit to the concern. Now this girl . If in a fortnight Clouston doesn't let me up to Craighouse, that's the superior house where we get tarts, but there is a very black hole of a boot-house yet, would you as an S.S.C., is it, or no, a writer, take up my case as a sane man, for the girl's sane you know. I have enough to pay you some £1600 I think and over, and I'll spend it all for the sake of the honour of the sex. The Christians here all love one another, though we fight at times like the Kilkenny cats, but try afterwards and bury one another's remains for the sake of the health of the remainder. There are a few dear little children here, pigs and rabbits. I'll let you hear in a fortnight, if the powers will let the epistles pass. You never sent me marriage cards. — Your aff. friend. P.S. —How's the little boy. Acute Mania.— The " raving madness " of the older authors, STATES OF MENTAL EXALTATION. 161 or acute mania, is perhaps the typo of all insanity, both in the popular and professional mind. Being the least rational, least conscious, most noisy, most unmanageable, and some- times the most dangerous variety of mental disease, it affected the conceptions and the treatment of all other varieties in a most unfavourable way. In it, many patients had no more "reasoning power than a wild beast," and all persons concluded to be insane — the conception of insanity was then a much narrower one, embracing much fewer persons — were accordingly treated by manacles and chains, stripes and darkness. Small compassion was felt for them, few laws protected them, little medical skill or study was exercised in their behalf, for they were reckoned beyond the pale of ordinary humanity. Even in Esquirol's time, at the beginning of this century, such patients are pictured in wild contortion and fury of look and action, and are represented heavily hound in his illustrations. Yet, this is a type of disease that is nowadays not at all so common as others. Statistics. — Out of the 2377 admissions into the Eoyal Edinburgh Asylum during the seven years 1874-80, only 297, or about 8 per cent., were classified as acute mania, and there were not twenty of these that could have sat for Esquirol's pictures. Acute mania may be defined as intense mental exaltation with great excitement, complete loss of self-control, with sometimes absolute incoherence of speech and loss of consciousness and memory. After twelve months it is by some authors arbitrarily no longer reckoned acute but chronic mania. Some authors set up a period of forty days, during which alone the disease was to be called acute mania, but this has no foundation in any clinical fact. Inception. — Acute mania begins in various ways. The most common is by its commencing as simple mania, and then passing into the acute form. But I have seen it begin quite suddenly, the patient being one hour a sane rational respon- sible being, and the next acutely maniacal. It often has a melanchohc prelude. It sometimes begins by the patient's L 162 .STATES OF MENTAL EXALTATIOIT. expressing a delusion out of which, as it were, the extrava- gances seem to arise. Sometimes it begins by emotional, sometimes by intellectual exaltations and perversions, some- times by both. At other times it begins by alterations of habit, appetite, and propensity. It commonly has premoni- tory symptoms, bodily and mental, such as headaches, a confused feeling in the head, a muscular fidgetiness, an unrest of body and mind, a feeling that something is going wrong or dreadful is to happen, a consciousness of impending insanity, a feeling of wild commotion in the head, as if it were to burst, an impulsive desire to do something, to break glass, or do violence to those within reach. There is usually disturbed sleep and constant dreaming, commonly of an unpleasant kind. I have known the temperature to rise to over 100° be- fore even the patient could be said to be in any way maniacal. All those symptoms in a typical case are soon replaced by great restlessness and muscular agitation ; a complete change of emotional state, this often becoming very joyous; a rapid and uncontrolled passing of the ideas through the mind ; vivid kaleidoscopic mental pictures of the past; scraps of former life and experience suggested by chance associations; a tendency to constant talking whether any one is present or not; passing from one thing to another and soon becoming incoherent of speech. The manner is utterly changed, being usually jolly or fierce. There may be ceaseless laughing, or scolding, or swearing. Conversations are held in loud tones with imaginary people whose voices are sometimes heard or their forms seen. Sometimes, too, there are hallucinations or perversions of smell and touch. The common sensibility and all the senses may be hypersesthetio at first, but soon become dulled. Sometimes there is a rhythmic action of mental and muscular centres evinced by rhyming all the ordinary con- versation, or by regular movements of the limbs and body. Frequently there is a tendency to shut the eyes so as to exclude the real impressions of the senses, and live in the false consciousness created by the morbid energising of the STATES OF MENTAL EXALTATION. 163 brain. Conversations with old friends now dead will be carried on. Scenes of cliildliood and years gone by will be vividly realised. The temperature is over 99°, often over 100°, the pulse quick and sometimes full, and the skin moist at this stage, the tongue getting furred, the appetite usually gone, the tastes and sense of decorum and decency perverted. At the end of this stage the power of self-control may be utterly lost, though by rousing him the patient may by an effort pick himself up and talk and behave rationally for a few minutes. The memory may at this stage be good, and the patient remember afterwards what happened then. Delirious Mania. — A still further stage is when the patient gets more actively excited, shouts, sings, attacks those about him, mistakes their identity, calhng them by different names, thinks they are "acting" on him, rushes about, and would sometimes injure liimself or those near him. The tongue gets more and more foul and soon dry, with sordes on the teeth and lips ; the appetite is not only gone, but there is a strong revulsion against food, so that forcible feeding has to be resorted to. The speech becomes absolutely incoherent, till a stage is reached where there is no consciousness, memory, power of attention, or any care for the calls of nature. This is the " delirious mania " of some authors, which they main- tain to be a distinct form of mental disease, and say is a very fatal disease indeed. I think, on the contrary, that the worst cases very often recover. Memory, Incoherence, Hallucinations, Illusions. — The degree to which there is remembrance afterwards of the events oc- curring during acute mania differs greatly in different cases. The friends of patients will usually be most anxious on this point, fearing the effect, when recovery has taken place, of the recollection of being taken to the asylum, of being fed, &c. I advise you to be careful in predicting on this point. In some cases the whole period of the disease is a complete blank afterwards ; but more commonly things heard, seen, and ex- perienced during the almost delirious period, are remembered 164 STATES OF MENTAL EXALTATION. afterwards in a sort of distorted, exaggerated way. Patients often rememlier and complain of the restraint and the force needed to overcome their violence, the compulsory walking, dressing, and feeding, hut have no recollection of their own condition at the time which made all these things necessary. I think that the memory- of events during the disease is regulated hy the degree in which the power of attention is unaffected. In health you know how much memory depends on attention, which, like a muscular act, implies much fatigue in its prolonged exercise. There may be a presentation of an object to the eye, or a sound to the ear, yet if there is no attention there is no brain registration, and no after power of reprettentaiion or conscious memory. The late Professor Laycock's ^ views in regard to memory, organic or inherited, in regard to synesis or the registration of an impression, in regard to the recollection or the act of calling up the impres- sion to consciousness afterwards, are very important in our study of the clinical symptoms of mania. The ravings of a maniacal patient are often well worthy of study, both as a medico-psychological problem, as affording an insight into the man's mental history and constitution, and as a symptom of much practical import to the physician. There is seldom such a thing as real "incoherence." The words and the ideas cohere by some bond or other. They always relate to former perceptions, thoughts, and experiences, that have been registered in the brain tissue. Those are represented to the altered consciousness in quick succession by chance, not real association. A careful study will often succeed in discovering the association of even the most apparently incoherent ideas. The ideas have had some former connection in the conscious- ness of the patient. They come with great vividness, so that memories — representations — are taken for actual presentations to the senses. I had a maniacal patient who had kept dogs, and their mental images were evidently as strong as the real 1 Journal of Mental Science, August 1875, "Some Organic Laws of Personal and Ancestral Memory." STATES OF MENTAL EXALTATION. 165 sight of the aaimals hefore his eyes had ever heen. He called them by their names, pointing to where they stood, talked to them, and heard them barking. His reasoning power being perverted, he could not correct those impressions, and he believed the cerebral images of his former presentations to be present realities. We may either suppose that, through morbid activity in the nutrition and energising of the centres of sensation, those molecular changes which each previous perception had left are rendered more vivid and more like the original, as when a photograph by the stereoscope is made to look real and solid, or that, through failure in the comparing and judging power of the brain, those faint images, which we in health call memories, are actually mistaken for real percep- tions of real impressions on the senses, just as when in a dim light and dreamy humour the pictures on the wall stand out as real men and women. In insanity those false beliefs in sense impressions are called Hallucinations, to distinguish them from insane delusions, which are false beliefs of a more abstract kind. If a man of fifty lelieves that he fought at Trafalgar, it is a Delusion ; if lie believes that he sees hefore him Nelson looking through his glass, that is a Hallucination. There is a false belief affecting sense impressions, to which the term Illusion has heen applied hy some authors, but this term will have to be given up in this sense now that j\Ir Sully has written his book on Illusions used in a different meaning.^ In the sense I refer to, if tlie person really saio a man hefore him and said that he ivas Nelson, it would have been an Illusion, — there being a real sense impression, hut this being misinterpreted into something quite different from what it really teas. Certain cases of acute mania are greatly characterised by the prevalence of hallucinations of different senses. All those symptoms most of us now believe to be in some measure explained by the theory of the morbid excitation of Ferrier's and Hitzig's localised centres in the cortex of the brain, those centres where the impressions from the senses are received, ^ Illusions, by James Sully. 166 STATES OF MENTAL EXALTATION. and where co-ordinated motions arise. As further progress in brain physiology is made, no doubt we shall be able to localise in the brain the causes of perverted mentalisation of different kinds. As illustrating extreme incoherence, I give a small bit of a "letter " of twenty pages, containing a string of 14,000 words, almost all adjectives and nouns, with no more connection or aim than those in this specimen : — " Mediterranean, horses, anathematised, Athanasius, propagated, emphatic, monasteries, diocese, Egypt, hermit, biographer, abuse, furor, fury, medium, policies, police, bobby, sacred, phrase, administration, minis- terial, monasticism, counsel, conviction, revelation, moderate, junior, transact, absurd, disinherit, repudiate, maternal, instinct, claimant, reiterate, clever, rumour, demurred, finesse, illusion, abstruse." Now you see that there is a sort of association of ideas between a great number of those words, and you can imagine how one arising before the mental vision would suggest the one next it. Here is another letter, from G. K., of a more usual kind of half incoherence : - — "Dear Durham's Allah, You will please see that Eliza and Bella are out. Mr Swan (his attendant) is to give you this in a few mimates. Compts. to Victoria and my mother Queen Elizabeth. I am putting 'John 'before John Addison, as I think him entitled to it. No kilts my bonnie Durham. My 'charm of life.' More than India's goods to me. Blessing on my bonnie wife. I will love you till the day I die. Compts. to Louise and darling Beatrice, Jane Shore, and Elizabeth. Come into tlie garden, Maud, "The tear fell gently from her eye, When last we parted on the shore, My bosom heaves with many a sigh, To think I ne'er should see her more. ' Weep not, my love,' I trembling said, ' Doubt not a constant heart like mine ; I ne'er can find a prettier maid, ■\\'hose charms can fill this heart of mine.' STATES OF MENTAL EXALTATION. 167 'Go then,' she said, 'and lot thy constant mind Oft think of her you leave in tears behind ; ' ' Dear maid, my heart's embrace my msh shall be. The anchor's weighed ! The anchor's weighed ! Remember me.'" There is no difficulty in seeing the association of ideas, or the verbal or alliterative suggestions running through this "incoherence." A rhyming speech, a poetical way of putting things, a misquotation of poetry, can all be seen in the above letter. The effective condition in this, as in every variety of mania, is one of perversion or paralysis. We would describe the con- dition in most instances by saying that those dearest to a man are most dishked, those most trusted are the objects of suspicion, those most intimately associated with the patient are most shunned. It is this which, more than anything else, makes its occurrence such a terrible calamity. Conjugal affec- tion is most and first apt to give way; and it is a very common fact that where we have prolonged and incurable insanity the conjugal affection of the sane husband or wife, in most instances, ceases long before the maternal or sisterly affection of the sane blood relations. A shrewd old Morning- side head attendant, of an observant if somewhat cynical turn of mind, was the first to point this out to me in regard to those who came to visit the chronic patients in the Asylum. He said he noticed that wives and husbands were the first to diminish the frequency of their visits, and soon came very seldom, then brothers and sisters, then fathers, and, last of all, mothers and old aunts, who never ceased to come, how- ever uninteresting the patient might be, however long he was insane ! ISTo rebuffs from the patient would discourage them ; no want of reciprocity would cool their love and interest, which never failed. I commend this observation to students of the affections. The actions of patients labouring under acute mania differ as much as their speech. They can all be referred to the 168 GTATES OF MENTAL EXALTATION. morTDid excitation of tlio motor and the idco-motor centres in the brain. One man is simply restless, nnothcir shouts, another sings, another rushes about wildly, another attacks those near him, this being usually the result of delusions that they are going to injure him. Some violence on slight or merely imaginary provocation towards those nearest and dearest to them is common. In Plate III. (the facsimile of a patient's letter) there is seen incoherence, rapid cha,nge of ideas, and hallucinations of sight. Sometimes the patient would injure himself in his wild fury by dashing himself against walls, through windows, &c. But it is surprising how much more rarely than is usually supposed maniacal patients are really or to any extent very dangerous, either to them- selves or others. In this matter old opinion and prejudices, the fact that a few patients are dangerous, or that a dangerous stage occurs in some few cases, have given a wrong general impression, and done very much harm in the treatment of acute mania. But we are slowly getting over this, for now we endeavour to assume that any patient labouring under this disease is not dangerous till he is proved to be so, instead of the opposite old maxim that he was to be regarded as dangerous till he proved himself to be safe ; which had this unfortunate result, that the restraints and restrictions and supposed safeguards imposed on him so irritated him that, if he was not dangerous at first, he was probably made so by them. No safe outlet was proviilod for his morbid motor energy, so that, like all pent-up force findjng no outlet, it became dangerous and often killed the patient. The motions and gesticulations of an acutely maniacal patient are often in an exact degree the muscular equivalents of the ideas and emotions passing through his brain, just as they are in the case of a savage or a born orator when he makes a speech about a subject which excites him. The most awkward of men often becomes easy in his motions when maniacal. The expression of the face is always changed, and also the appearance and expression of the eyes. Usually the STATES OF MENTAL EXALTATION. 169 man is so changed tliat lie looks " a different " man. He is always worn-looking, and this is more particularly the case in the female sex. There is no natural beauty of face that will persist during acute mania. Commonly the face is flushed, the skin muddy and less delicate in tint and texture, the features unpleasant to look on. As might he expected, the infinitely delicate co-ordinations and fixations of the small muscular strands that in the face mirror forth and express the mental and emotional states are, in this disease, inhar- monious, and express instead inco-ordinated mental acts. In this disease, and in insanity generally, the expression of the face closely follows the mental disturbances. We may have exaggerated expression, diminished expression, asym- metrical conditions, partial or complete paralysis of the muscles of expression, and every degree and kind of dissolution of facial expression. Dr John Turner has given us a very careful study of this subject, which admits of still further elucidation. i The eyes are more especially charac- teristic. They usually glisten somewhat as in fever; the eyelids are more widely dilated, so that the white is seen round the cornea ; and their expression is that of excitement and turmoil. Bodily Symptoms. — The whole digestive tract is affected more or less. The secretions of the mouth and the saliva are altered in character, and when inoculated produce a septic or irritating influence. The sores resulting from a bite of such a patient are apt to be angry, the inflammation running up the lymphatics. The most recent investigations show the septic character of the saliva. The tongue is usually furred, and the breath foul. When the condition becomes delirious there is always a tendency to have a dry mouth and tongue, with sordes on the teeth. The appetite for food is usually paralysed, though not always, that for drink. The digestion is often vigorous enough, though not 1 '■' Asymmetrical Conditions met with in the Faces of the Insane," &c. By John Turner, M.B., Jour. Ment. Sci., Jan. and April 1892. 170 STATES OF MENTAL EXALTATION. in the exhausted stage. I have foiind the stomach full of iindigested food in patients who had died of exhaustion from acute mania. The howels tend to be costive, though this is not always so. The temperature is usually from one to two degrees above the normal, especially the evening temperature. As we shall see, it runs far above this sometimes ; but if it rise much above 100° we look out for a febrile or inflam- matory cause, or for general paralysis, or other organic disease. The skin is usually clammy and ill-smelling, though sometimes harsh and dry. In women the menstrual function is almost always interfered with, being usually stopped after the excitement has continued for a few weeks. The odour from a woman both menstruating and maniacal is most ofl'ensivo. I find tJiat out of the last fifty women admitted to the Asylum labouring under acute mania, three-fourths had irregular menstruation, and in most it ceased till they became convalescent or demented. The common sensibility is much diminished in such cases, patients not feeling pain acutely, some not feeling it at all. Injuries, cuts, boils, whitlows, and such painful affections are borne without much complaint of pain. With their feet inflamed they will walk, with their hands bruised and sore they will use thom freely. The continuance of this condition is, of course, attended with rapid and great loss of body weight. I have known a patient lose a stone of flesh in a week, notwithstanding that ho was getting plenty of food. But after losing any redundancy of fat it commonly happens that the intensity of the disease diminishes and the loss of weight is less rapid. It usually takes a considerable time, always provided a sufficient quantity of proper food is given, and proper treat- ment adopted, before extreme emaciation and weakness result. The more intense the attack the shorter is usually its duration ; in fact, a great prolongation of very acute delirious mania, with a temperature of over 100°, no sleep, and constant violent motor excitement, is dangerous to life. Few cases die in the first week of the attack ; some do in the STATES OF MENTAL EXALTATION. 171 first fortnight, and some in tlie first month. In a subacute form it is -wonderful how long it may last, -without producing fatal results, or even reducing the patient very much, if he eats enough — and enough may mean four times his usual amount of food — and is sufficiently in the fresh air, and is not restrained in his mo-vements. Restraint v. Non-Restraint. — In by far the majority of instances such mechanical restraint as used to be employed in this country, and is still employed in many places else-where, — by strait- jackets, camisoles, gloves, straps, &c., — ca-use such a feeling of degradation, irritation, and resistiveness, that the good effects of any actual conservation of force by such restraint is in my opinion far more than counterbalanced. The disease, if it does not kill, is more apt under such treat- ment to run on into chronic mania and dementia. To restrain the mere outward muscular movements, while the motor energy is all the while being generated in the brain convolutions, is eminently unphysiological. Almost as well restrain the movements of the choreic or the convulsions of the tetanic patient by binding them tightly and expect a good result. Our great efforts in the treatment of such cases now is to find suitable outlets for the morbid motor energy, to turn the restless, purposeless movements into natural channels, to get the patients to dig and wheel barrows, and to walk long distances, instead of shouting and gesticulating. We find that this saps and exhausts the morbid energy and excitement, producing healthy exhaustion and sound sleep, vigorous digestion, and due excitation of the skin, the glands, and the excretory apparatus generally. This is the chief physiology and philosophy of the modern British "non- restraint " treatment of mental diseases. No doubt there are exceptions to all rules. I have seen cases where restraint had to be applied to prevent the patient exhausting or hurting himself, and I have had two or three patients die suddenly from exhaustion, one of them " dropping down " after long walking, but they are amazingly few in a well-equipped 172 STATES OF MENTAL EXALTATION. asylum, with large grounds, a farm, good attendants, and plenty of them, and a padded room. Under those circum- stances not one case in a thousand is found to need restraint. But it is quite different when we have to treat a patient in a private house, or with insufficient attendance. Then mechanical restraint may be unavoidable. It often happens that, at the commencement of a case, where the symptoms have developed rapidly into an acute form, you may think it advisable to give the patient a chance of its soon passing off, or arrangements cannot be at once made for removal to an asylum through the absence of those who can authorise it, or the relations of the patient may absolutely insist on his being treated out of an asylum. In these circumstances you have to do the best you can with the means at your disposal, carry- ing out to as great an extent as you can the principle of providing an outlet in the open air for the morbid motor energy that is being generated in the brain convolutions, but using, it may be, restraint to some extent. Stages. — Acute mania is in some cases divided into three stages : the first that which I have described as simple mania, the second that of ordinary acute mania, and the third that of delirious mania, with a tendency to dry tongue, &c. But a case may be one of acute delirious mania from the beginning. The aggravated and fatal cases of this form were described by Dr Luther Bell as typho-mania. We seldom see such cases here. Pathological Rinks. — As you can readily understand, from the delicate constitution of the grey brain substance — that highest evolution in nature of function and structure— and the infinite complexity of its balanced and interdependent functions, the continuance of such an abnormal brain-storm as that which exists in acute mania may be followed by permanent and irretrievable damage. Such a storm, be- sides all the bodily symptoms and disturbances which I have described, is accompanied by intense congestion and over-action in the grey neurine and brain generally, the STATES OF MENTAL EXALTATION. 173 congestion being usually seen in limited areas (see Plate lY.), those probably tending soon to pass into structural changes. The cells tend to get granular, chromatolysis takes place in them (see Plates XVI. and XVII.), and varicose hypertrophy and atrophy of the dendrites of the neuron with disappearance of the gemmulse (see Plates XYIII. and XIX.). There is a proliferation and enlargement of the nuclei of the neuroglia, the lymphatic spaces and perivascular canals get over-dilated and blocked up with debris, and an enormous number of micro- scopic capillary extravasations may take place in and around the convolutions in bad cases. Some writers speak as if the cortical liyperaemia constituted the disease, and that treatment should be chiefly directed towards diminishing the blood in the capillary vessels, Krafft-Ebing recommending leeches to the head. What we want is to alter the mode of energising of the cells, so that, instead of being explosive and morbid, it may become normal. The capillary congestion is a secondary matter, and will soon come right in most cases when the cells cease to make extraordinary calls for an undue amount of blood. The vessels may get thickened in their coats and tortuous, the fibrous matter of the pia mater becomes hyper- trophied, the arachnoid milky, the dura mater thickened or adherent to the bone, and the bony case dense and thickened. All those things may happen through prolongation of the acute symptoms. Therefore it is of the last importance to shorten, if we can, the acute stage. Every week of this adds to the chances of the acutely excited state being followed by more or less permanent mental defect. Even the present risk to life is not so grave a risk as that ; for which of us, if we had the choice, would not prefer death to a degradation from our mental eminence in creation to a state of per- manent mindlessness, in which we would be dead to the love and hatred and to the joys of life, oblivious of the past and unconcerned for the future, stirred by no ambi- tion, capable of no e£fort, and unmoved by any motive ? Por such is the dementia, of which I am to speak after- 174 STATES OF MENTAL EXALTATION. wards, that sometimes follows and results from mania. My experience has been that 60 per cent, of the cases of acute mania recover, 7^ per cent, die, and 32J per cent, become demented or pass into chronic mania. There is, perhaps, more opportunity for right treatment and manage- ment in acute mania than in any other kind of mental disease. General Indications for the Treatment of Acute Mania. — In the beginning of the attack, and sometimes, when the patient is wealthy, all through it, we have to treat the case at home. Now, no doubt, the first thing to be done is to get proper trained attendants — one, two, three, or even four, may be necessary for night and day work. Patient, sensible, experienced, cool, and kindly men and women are what we want. Then proper arrangements must be made, ■ — a good suite of two large rooms on the ground floor of a house, with a garden, and not too near a public road, being required. Small breakable articles must be removed, but do not make the rooms quite desolate or unattractive- looking. Fasten windows not to open more than five or six inches, and see that no knives or lethal weapons are too handy. But do not do all this demonstratively to attract the patient's attention. Next, you must look to the feeding with suitable nutriment very often ; sometimes you can give it only little and often, sometimes in ordinary meals, with beef-tea and milk in between. IMilk, eggs, beef-tea, ground beef, custards, strong soups with plenty of vegetables, and porridge, are the best, as often as the patient can be got to take them, and in as large quantity. As Dr Blandford says, "We can hardly give too much." Do not for a moment be afraid of a dirty tongue, and think it contra- indioates food. Nothing could be a greater mistake, in acute mania at all events. The furred tongue is not from an overloaded alimentary canal, but results from perverted innervation of the digestive tract. Malt liquors, such as porter and ale, can be given freely with advantage. Good STATES OF MENTAL EXALTATIOK. 175 ■wines, too, if tliey can be got. Even wliisky or brandy will act as a direct sedative to the excitement in some cases. Anstie tauglit us some good therapeutics, in bis Stimulants and Narcotics, on this point. But alcohol, you wiU find, will sometimes flush and cause excitement. In that case use it sparingly. I have seen a pint of beef-tea, representing all that was soluble in a pound of beef-steak, and a glass of whisky, reduce the temperature 2'3°. To show the quantity of food that such patients can take and digest, I mention that at the Asylum I am never satisfied except the bad cases get at least six eggs a day beaten up in liquid custards, in addition to their ordinary food and beef-tea, up to convales- cence. I have known many patients take a dozen eggs a day for three months running. The constant motion and fresh air enable them to digest and assimilate most of this. So long as a patient is losing weight, the physician should never be satisfied. When he becomes stationary, then one may begin to think that the disease is being overcome by nature and treatment. When he begins to gain in weight, and the temperature becomes normal, then convalescence or dementia has begun. The patient should be weighed every week during the acute stage. Next to good food and nursing, fresh air is most essential to treating a case. No patient must, on any account, or in any weather, except he is excessively run down or exhausted indeed, be kept in bed or in the house for many days. Herein is the essential difference between the treatment of this disease and that of acute bodily complaints. I often keep patients out all day in the summer time. When they are recovering they all say that they feel better out than in. There is no soporific, no calmative, and no digestive like the fresh air. And the attendants must not restrain or interfere more than is necessary. There should be no nagging and small interferences, and little arguing, but a kindly, firm mode of dealing with a patient —coaxing, when coaxing will .do, and firm insistencCj and force suflicient to overcome 176 STATES OF MENTAL EXALTATION. resistance wlien necessary. There is a certain kind of tact which some people have, and which may be partly acquired, but which is mostly a natural gift, and, when present, is of the greatest avail in overcoming resistance, persuading patients to take food, &c. "Women have it more frequently than men, and women will often persuade male patients when their own sex fails. It does not do to let patients have too much of their own way. A happy mean between that and too much interference should be pursued. It is better to be honest, and not deceive patients into doing things. That often makes them lose confidence, and does harm afterwards. Medicine when given should, as a general rule, be given as medicine, and not put in food surreptitiously. The safety of the patient and those about him must of course be provided for. For the bowels it is sometimes necessary at first to use laxatives and onemata, and even strong purgatives, such as croton oil, but I try first such mild medicines as castor oil, Tamar Indien lozenge, liquorice powder, warm water enemata, &c. Do not insist on a stool every day ; one every second or third day is quite enough. Depleting remedies of all sorts are in my opinion bad. Baths. — There is one remedy that I have seen do good in many cases, and in a few act like a charm, and that is pro- longed warm baths with cold to the head. The effect of this is to fill the capillaries all through the body, and to withdraw blood from the brain, to depress the heart's action — and hence its danger — to soothe the nervous irritation, and to produce sleep. I have the highest opinion of its efficacy, but unfortunately it is attended with danger in some cases. A man, whom I could not detect to have heart disease, once died in my hands, as it were, when I was sitting beside him, after being less than an hour in water at 103°. I know of two other cases where syncope and death resulted in the same way. I used to keep the water up to 110°, but I never do so now. In fact, I now prefer 99° as the proper tempera- ture. But the effect with this is not so quick nor so marked. STATES OF MENTAL EXALTATION. 177 Baillarger used to keep his patients steeping for days in water at 96° or 98°. I do not think, however, the treatment is so much in vogue now in Paris as it was twenty years ago. Dr Eees Philipps has taken to the use of the very prolonged tepid bath at the Sanatorium, Virginia "Water, and speaks enthusiastically as to the good results. Shower baths of a mild kind are sometimes useful when the mania threatens to become chronic, or when the earlier symptoms of dementia show themselves, and the patient is strong and can react after the bath. The great trouble is that patients are apt to look on the shower bath in any form as a punishment, and so its use may have a bad moral effect on them. Sedatives and Hypnotics in Mania. — One difficulty in treat- ment is to use narcotics and hypnotics rightly. The greatest differences of opinion have existed, and do prevail at present, about them. What we want and have not yet got is a medicine that will cause really natural, restful, refreshing sleep, and one that will stay or slacken the morbid energising of the brain cells in the convolutions without affecting the appetite or the nutrition. That, however, is not known to us in a perfect form. All medicines that markedly lessen the appetite or impair the digestion or nutrition 1 condemn in this disease. In ninety-nine cases out of a hundred opium -"-\ does this, more or less, and should not be employed except as a mere temporary placebo or for a special purpose. My experiments with it, and practical experience of it is, that it has those objectionable effects in most cases where given. Chloral we all believed in and used very extensively in mania after its discovery. It seemed a perfect sleep-producer. Numbers of cases have I kept under its influence day and night for weeks, and many of them certainly got well. But I do not beheve so much in it now. Its sleep is sound and seems natural, but somehow is not refreshing like nature's sleep. I am inclined to think that an hour or two's sleep naturally after a day's exercise in the open air is more than equal to eight hours' drug sleep. My experience is that it M 178 STATES OF MENTAL EXALTATION. has a subtle influence for harm on the hrain when long given, by which the organ loses that quality which we call tone. The patients cannot bear pain so well. They have not the resistive power, and they are apt to look pale and unrefreshed in the morning. Besides this, I had two patients who died suddenly, each of them during a sudden gust of excitement, when under the influence of moderate doses of 30 grains; in both of them I found the blood dark and fluid, and the right side of the heart &nd the lungs engorged, as if there had been a sudden paralysis of the breathing centre in the pons. I could not certainly say that the chloral caused their deaths. One had decided brain disease, and sudden deaths do occur in acute mania when no medicine has been given, through, as I believe, epileptiform conditions causing paralysis of the breathing centre. I have never given chloral as a sedative during the day since. Now I give it at night, or after or during convulsions, and always in small doses of from 10 to 25 grains, with from half a drachm to a drachm of bromide of potassium. I much prefer paraldehyde as a pure hypnotic, in doses of from 40 minims up to four drachms or even more. It may be com- bined with the bromides. It is an almost certain producer of sleep, it does not weaken the heart's action, it leaves few after-efl'ects, and it is in my experience quite safe. Sulphonal I look on as being on the whole the most valuable medicine of the kind lately discovered. It soothes, it causes sleep, its eff'ects will often last for forty-eight hours, and in some few cases it makes directly for restoration and sanity. I give it in doses of from 10 to 40 grains. I have now had so many cases where the direct arrestment of the maniacal symptoms by this drug was followed by immediate recovery, without any tendency to recurrence, that I am satisfied of its directly curative influence. If its use is prolonged, the dangerous condition of hEematoporphyrinuria must be looked for in rare cases. Urethane is in my experience a weak and uncertain hypnotic, except in very mild cases indeed. A combination STATES OF MENTAL EXALTATION. 179 that I have found most useful has been the bromide of potassium and tincture of cannabis indica, -with which I have made careful and prolonged experiments. It soothes during the day and sometimes permanently allays the brain excita- tion, and it causes sleep at night, without diminishing the appetite much or impairing the digestion, though it depresses the vascular action. I have used the bromide alone in acute mania extensively and experimentally. In small doses it seems to have no effect. In very large and continuous doses, say a drachm every three hovirs continued for many days, it will cause bromism, and quiet the patient, but when its influence is over he becomes as bad as ever. Hyoscine, in doses of from -^^ to y j- grains, is an admirable quieter of motor restlessness, and often does good. Its great merit is tliat it can be given hypodermically. I have seen nitrite of amyl — a drop inhaled — produce calm in a suddenly epileptiform case of mania. Morphia may be subcutaneously injected if refused by the mouth, but I advise you to beware, and not use too large doses in this way. It may be justifiable in treating cases at home to tide over severe paroxysms with those drugs, and sometimes in that way to keep the patient out of an asylum as long as possible. When a maniacal patient is sent to the Asylum, I now frequently use for a few nights small doses of the bromides, sulphonal or paraldehyde, and give warm baths ; but after a fortnight, when I see that the attack is not going to be cut short or run a very short course, I am more apt to trust to the nursing, diet, and con- ditioning of life I have mentioned, with continuous tonics. Conium is a good sedative in some cases, and tincture of lupuhne, in the milder cases, I have known to produce sleep. Camphor in some women does much good. Tonics. — I now give nearly all my cases quinine from the beginning, adding iron in some cases that are manifestly anaemic, with sometimes the phosphates of lime and soda. The bitter tonic and digestive medicines with nitro-muriatic acid I use largely in cases that run on for long, and during 180 STATES OF MENTAL EXALTATION. convalescence. Strychnine is most useful at the later stages of the disease where there is a tendency to stupor and brain torpor, but is too stimulating at first. After - Symptoms. — When the acute symptoms pass off, especially if they have lasted long, there is apt to be a stage of reaction, attended, in some cases, with complete prostra- tion, in others with depression, in others with an apparent mental enfeeblement which very closely resembles dementia ; in fact, it is a stupor of a transitory kind. You must on no account confuse it with the real dementia, for while the one is quite amenable to treatment, and requires treatment urgently, the other is an incurable brain condition. I once showed a girl, who had just passed through a prolonged attack of acute mania, and who was stupid, dirty in habits, and seemed' demented, as a typical example of newly -begun dementia, in a clinical lecture, and pronounced her a hope- lessly incurable case ; but she gradually picked up in flesh, got enormously fat, her brain roused itself into almost its former activity, she was discharged recovered, and remained well for nine years. The treatment for this stage of acute mania is tonic and nerve stimulant, stimulating medically and fattening dietetically — use beef and animal food at this stage as much as possible. Eousing and occupation, and " cheering up" by amusements, &c., are most useful, too, as brain stimulants and restorers. Sometimes patients have to leave the asylum to get cured of this result of mania. Their brains need to be subjected to the natural stimuli and interests of outside natural hfe. There is a process of re-education of their damaged but recuperable brains that must be gone through. They are in the state of a joint damaged by an acute rheumatic inflammation, that may take a long time and much exercise and friction to get it working as it once did. Unfortunately certain mental peculiarities remain perma- nently in many cases. The following was a typical case of acute mania, running through its three stages loth in its onset and as it passed away-. STATES OF MENTAL EXALTATION. 181 The intensity of the brain storm was so great at its acme as almost to kill the patient : — C. L., set. 36. Married. Temperament sanguine. Biatliesis nervous. Disposition cheerful, frank, and exceedingly enthu- siastic when he took anything up. Habits very steady, and almost over-industrious, for after his work was done he would spend all his evenings in doing church work. Education fair. Father died at 70 of paralysis ; brother had an attack of acute mania at 27 from over brain-work, from which he recovered, and then again had another attack and died in it. Mother had an attack of puerperal mania after the birth of one of her children, and her maternal grandfather and aunt were insane. Tliis is the first attack, and has assumed an acute form for three days. He became depressed, reserved, and altered three or four weeks ago, and this was aecompanied by thinness and sleeplessness. Then he began tO' be excited, elevated, talkative, and restless, and quickly passed into wild delirious excitement, which had existed for two days before admission. He was very dangerous to his wife and children. He had taken little food for two days, and never slept during that time, though he seems to have had enormous doses of morphia. On admission he was very exalted, singing hymns, quoting passages of Scripture and swearing in the same breath J shouting and raving. His excitement was intense. He threw himself about the padded room into which we had to put him. It took four or five strong men to manage him safely, though he was a small man. He had hallucina- tions of sight and hearing. He was thin and sallow. He was covered with bruises, and one rib was broken, all got in his struggles at home. His tongue was clean and dry, bowels costive, appetite gone. Pulse difficult to count, on account of his excitement. Temperature 99° on admission, and 100-6° at night. He felt no pain. He would put his feet up on the walls, with his head down, and run so round the room. He would leap up and then fall down. He would seize those near to him, and try to throttle them, thinking 182 STATES OF MENTAL EXALTATION. tliey were devils. He tore liis blankets and bedding. At times lie would be quiet, and in a way rational, then he would get maniacal in a moment without warning and with- out outward cause. He was fed regularly with custards and sherry by force, as he had a great aversion to food, saying it was poison. Patients who are maniacal often have this delusion, the idea being suggested to them by their own perversion of the sense of taste. To such I have no doubt that all food tastes ill. This brain condition exhausted him very much, so that I feared he was going to die. He got twelve eggs a day and much milk. We could only get him into the fresh air for a short time each day, his struggles and the risk of injuring himself being so great. He almost never slept. After three weeks he began to improve, and he had lucid intervals, during which he was quiet. He had several boils on his arms and legs at the time, and I looked on this as a critical event. His temperature never rose so high after this, his appetite returned, and we were able to give him solid food in a mixed form for the first time. He was able to walk round the grounds in four weeks, being then talkative, lively, chaffing everybody he met, full of fleeting delusions, especially as to the identity of those near him- He took most violent antipathies to his attendants, and would accuse them of quite impossible cruelties to him, such as putting him into a mill and breaking every bone in his body, so that we had to be constantly changing them to soothe him. He was weak, pale, thin, and haggard, but said he felt strong when he began to go out to walk. After that he was never in the house except at night. He walked, and when tired he sat or lay down on seats in the grounds. He continued excited, noisy, singing, and very exalted in feehng during the second month of his stay, still taking his twelve eggs a day, in addition to his ordinary diet and other extras, and he gained a stone the second month of his residence. He had several short relapses for a few days. In two and a half months he began to have a glimmering consciousness of his STATES OF MENTAL EXALTATION. 183 position, and a faint return of natural feeling. His first letter to his wife at tliat time was a model of conciseness : — "Dear Wife, Where are you? C.L." In three months he was in the condition I have described as typical in simple mania — gay, humorous, careless, talkative, hut with no delusions, sleeping well, and rapidly gaining in weight and strength. He was during this time getting all sorts of tonics — quinine, iron, phosphates, cod-liver oil, &c. This state lasted other three months, all this time his brain getting more normal in its working, and at the end of six months from his admission he was discharged well in mind and stouter than he had ever been in his life, having gained two stone in weight since admission, and he has kept well and done his work ever since. I seldom believe in the perfection of a recovery from acute mania unless the patient is fat; and when he is so I always think his chances of not having a relapse for some time are good. I like a gradual steady recovery, too, not perhaps so long as this, rather better on the whole than a sudden recovery. Tlie following is another characteristic case of acute mania running through a typical course : — C. L. A., set. 47, of a sanguine temperament, cheerful and frank disposition, and industrious and temperate habits, but of a very fiery and ungovernable temper. This was her first attack. Her mother was insane. This heredity and the nearness of the climacteric period may be considered as the predisposing causes, while the exciting cause was exhaustion from want of sleep and mental anxiety in nursing her mother on her death-bed. The first mental symptoms occurred about fourteen- days before admission, in the shape of restlessness, unsettledness, and getting up in the middle of the night to wash. For four days she had been worse, seeing visions, constantly talking, imagining that people were under her bed, and never sleeping. On admission there was great exaltation, incessant and almost incoherent talking, much excitement, walking about, gesticulation, singing, saying she saw the 184 STATES OF MENTAL EXALTATION. "heads of people" about her. She addressed the people about her, whom she had never seen before, as her friends, mistaking their identity, making saroastical remarks about them — "Oh! Kitty, is that you? That's a fine gown you have on. Who gave you it? Is it paid for!" &c., &c. At times she was quite incoherent. In person she was fat, weighing 11 stone 6 lbs. Her organs were healthy, except 'that her tongue was much furred, and her bowels were costive. Pulse, 112; temperature, 99'6°. Soon after admission she suddenly, in obedience to a delusion, took up a chair and threw it at one attendant, while she seized another by the hair and hurt her considerably, screaming out and saying they were going to murder her, and that there were devils in the room. She refused to take food at first, saying it was poisoned. She had to be secluded in a bedroom, where she would some- times shout and gesticulate and make speeches, and carry on conversations with imaginary persons ; then she would lie flat on her back on the floor, keeping her eyes tightly shut, smiling, and never speaking at all or answering questions, evidently living in her morbid imaginations, and trying to exclude external sensations — a very common example of exalted " subject-consciousness " and depressed " object- consciousness " in acute mania. She did not sleep, and was noisy all night till the third night, when she slept two hours. On the first day she was so violent, and so strong, and so resistive, that it was thought desirable not to dress her or send her out. She was got into a warm bath with great difficulty. Her temperature rose to 100°. It was the fourth day before she began to take more food than a little milk, or before we could get her dressed and out in the open air much. Her bowels had been costive till then, as she could not be got to take any medicine. She then had croton oil given her and an enema, and had a free evacuation of most offensive fseces. Her breath had been very foul. On the sixth day, though she was drinking a good deal of milk and custards, her tongue and mouth got dry and cracked, her STATES OF MENTAL EXALTATION. 185 pulse weak, and she showed signs of exhaustion. She was put on four glasses of wine, and still kept out in the fresh air, while a little milk was given her every half hour. She was very excited, noisy, destructive, and absolutely delirious and incoherent. She had passed into the "delirious mania," which some authors set up as a special variety. On the tenth day the excitement began to abate, her tongue and mouth became moist ; she became more manageable, and got a good night's sleep for the first time. In a month from the time of her admission she had lost twenty-four pounds in weight, but then the acuteness of the brain exaltation passed off. She had "a good day and a bad one," could sit down to meals, and eat her food. She could walk about, looking moderately sane to anyone at a little distance. She could answer simple questions correctly. She began to have doubts as to a delusion about my being her husband, saying, in answer to my question as to who I was — " You're John , at least you look like him ; but I'm thinkin' you're no him." She made a perfect recovery in four months. The following is a case of acute mania coming on in an hour .with great intensity, and gradual hut not complete recovery in three months. Relapse after three and a half years, attach of ten months' duration, complete recovery. C. M.. ast. 17. Diathesis nervous. Disposition excitable and sensitive. Comes of a nervous stock and a maternal cousin is insane. He had been in low spirits, and rather more sensitive and shrinking than usual. There was no proof of masturbation, though I supposed that his thoughts had been erotic from various small indications. Being very strictly brought up, all the outward influences had been in favour of severe repression of the nisus generativus. The exciting cause was said to have been a fright, but I scarcely think there was sufficient proof of this. One day he suddenly began to roar and shout, and say he was first Christ and then the devil, and to be very violent to those about him. He got so ill and so unmanageable that he had to be removed to the Asylum the 185 STATES OF MENTAL EXALTATION. same night his attack began, which in most cases would be considered a premature measure, considering the possibility of mania transitoria, the public feeling existing about hospitals for the insane, and the harm a residence in one may do to a man's prospects, however much it may be true that the best treatment for the patient can be got there. His delusions were transient, most of them being of a religious nature. His condition was that of typically acute delirious mania when let alone, but when his attention was roused by questioning he could answer some simple questions coherently though not correctly, his memory being much impaired. He was slightly built, not so fat as he should have been; his pulse very weak, 116, and his temperature 99'6°, and 100° in the evening. He had a warm bath at 98°, with cold cloths to his head for fifteen minutes, and a draught of 10 grains of chloral and 45 grains of bromide of potassium, with 2 drachms of tincture of valerian. He scarcely slept at all, and next day his condition was still very excited and violent, but he was kept walking about by two attendants for five hours, though very intractable, throwing himself about, &c. Next night he got a bath for twenty minutes, and the same draught, and slept six hours. N'ext day his temperature was normal. He was less excited, and walked better. The same treatment was continued, in three days he was still better, and in eight days he was playing cricket. He had a relapse on the tenth day, though he did not get nearly so excited as at first. He had two or three milder relapses within the next two months, but at the end of that time he was practically well, and in three months he was discharged recovered. His treatment consisted of an indefinite allowance of milk and eggs, almost no animal food, fresh air, exercise to fatigue all day, baths, warm at first, and mild shower baths as he recovered, and cod-liver oil emulsion, with the hypophosphite of lime. He gained almost a stone in weight, but did not grow any more manly in his form, nor did his beard grow. He kept well enough not to be sent to the Asylum for three STATES OF MENTAL EXALTATION. 187 and a half years, but during that time he constantly had threatenings of his complaint, and was at times unable to follow any continuous occupation. After that time he had another attack of a much more mild kind of acute mania. He was delirious, not violent, early ceasing to take any interest in anything, seeming to live in a morbid subjective mental atmosphere of disordered imagination ; talking to himself incessantly, not sleeping well, was constantly grimacing, gesticulating and fighting imaginary persons in the room round the wall. "When he was spoken to he would pick himself up and answer pretty rationally. This is a condition that puzzles many persons. It looks like dementia, while in reahty it is a subacute form of mania, which makes all the difference in the prognosis and sometimes in the treat- ment. He was tried at home, in charge of an attendant to control him, to get him to walk out, &c., but he rather rebelled. Patients are, of course, never so easily controlled at home as away from it ; especially it is hard for the master or mistress of a household to be controlled in their own house, where before every one was under them. In an institution, on the contrary, among strangers, under certain definite rules of living, and where there is obviously the means of enforcing medical orders, a patient must be very insane not to conform to the orders given as to his treatment, and to the general way of living of the place. This is very often seen when patients come to asylums. At home they had been difficult to manage, or very obstinate, while from the moment they came into the institution they gave little trouble. He had again to be sent to the Asylum, and he was found to have lost in weight, and to be ill-nourished and wanting in nervous tone and nutritive energy. His muscles wer^ flabby and his skin pale, and his appetite for food not keen. He was put on quinine and iron, cod-liver oil, milk, and eggs in large quantities ; his skin was well rubbed night and morning with a dry towel ; he got mild shower baths, and took much and increasingly vigorous exercise. He gradually gained in 188 STATES OF MENTAL EXALTATION. weight, in nervous tone, in self-control, in power of applying himself to work, in his interest and power of attention ; he got more manly in form, and filled out into a strong vigorous- looking young man. It took him ten months to recover. This was a case in which I was very much afraid of dementia. I think this would have resulted had not right treatment been vigorously adopted. In such a case the brain is in much the same state as in certain forms of dementia, plus a little maniacal excitement — but that makes all the difference. Almost never pronounce a case incurable while there is exaltation remaining. A very Acute Case with High Temperature. — I had ones under my care C. N., a young lady of twenty-three, of a nervous diathesis, and with a strong heredity to insanity, who, bathing while menstruating, became slightly depressed, then had an attack of slight exaltation every month, followed by a day or two of modified stupor, at the time she should have menstruated but did not. After a few months menstruation returned, but came on every fortnight, this ■ reducing her strength, and causing anaemia. At the usual time of menstruation on one occasion a most violent attack of acute mania came on, with incoherent delirium and such ex- cessive violence that she nearly killed a relation. Two trained female attendants could not control her at home. Her tempera- ture was 103°, one of the highest I ever saw from uncomplicated brain exaltation not puerperal, and she had to be taken to the Asylum within twenty-four hours after the commencement of the attack. For the first fortnight she remained in the most acute state of excitement I think I ever saw. It took five attendants to restrain her, dress, undress, and have her walked out, which we did every day. When she would not walk she was allowed to roll on the ground. She soon became less excited, but at the next menstrual time she had a relapse, and was as ill as on admission. Though apparently absolutely delirious and without power of attention when excited, yet, when the attack passed off, she could describe what had STATES OF MENTAL EXALTATION. 189 occurred very accurately for the most part, though distorted in some respects. She had no reahsation that she had been so ill, and therefore thought she was unnecessarily detained in the Asylum, and that the attendants' restraint of her violence had been simple cruelty on their part. This is a psychological fact with which we are very familiar in asylums, which was most marked in her case, though it occurs more or less in most cases of mania and melancholia. As the patients first become coherent and sensible they are much more unreasonable about "going home at once," and about getting all they fancy, and about being controlled, and about all sorts of things, than when they get quite well. They usually attribute any nervous symptoms they have to their being " kept in the asylum," and aver with daily iteration that, if kept much longer " in a mad- house'' or " among maniacs," they will certainly become insane. The stage of convalescence is the stage of irritabihty and unreason in many cases. Their friends do not understand that this is the ordinary half-way house to complete recovery, and sometimes remove them home, often with very bad results. When they have quite recovered, such patients are commonly reasonable about going home, and often recognise how necessary restraint has been. Some patients never do this, however. C. N. had relapses of a less severe character about the men- strual periods, getting more and more reasonable during the intervals. In six months she was so well that she was taken home, not exactly against my advice, but not quite with my concurrence, as she had not menstruated, and was excitable. Tests of Recovery. — The question of when recovery has taken place is often a difficult one to decide in mental diseases. You have to take the temperament, disposition, and normal state of- mind and conduct into account. The same standard cannot be applied to persons of diflerent education, tempera- ment, or nationality. 1 lately had a young lady patient who was so excitable and lively, so reckless in speech and conduct, after all the acute symptoms had passed off, that I had to send for her relations to tell me whether she had returned to 190 STATES OF MENTAL EXALTATION. her normal state or not, and I found she had done so and was well. She soon got married and had children, and settled down into a staid and sensible matron and mother, her surplus stock of nervous energy finding its natural outlet, and her organic cravings their physiological satisfaction — but alas ! for the world's stock of future sanity in such cases. Menstruation. — The relation of menstruation to mental disease is a very important one, of which I shall treat more fully under uterine insanity ; but I may say now generally that in most cases of acute mania cessation is the consequence and one symptom of the morbid brain excitation, and not its cause, and the restoration of the function is the result of improved brain and bodily health and condition. I seldom adopt special means for its restoration until the patients are strong and have become fat, but at the same time I regard mental recovery in a woman as being likely to be much more .stable and less liable to relapse after the menstrual function has become normal. I always like to see it normal before I recommend the patient's removal from the Asylum. The treatment in G. N.'s case was exactly the same as that of C. M. Unfortunately, she was threatened with a relapse after going home, but it was summer, and I sent her to vegetate and live in the fresh air at the sea-side, where her recovery was completed. She then went to work, and worked too hard, and has since had several attacks of the same kind, but of shorter duration and slighter character, in the ten years that have elapsed since her first recovery. Both of these last two cases (C. M. and C. N.), though cases of acute mania in the classification founded on mental symptoms, are cases of the insanity of adolescence when looked at from the chnical point of view. Though recovery from acute mania is usually a gradual process, yet at times it is sudden. Why this should be in certain patients I am quite unable to tell, nor have we any means of predicting beforehand in any case that it will terminate in recovery in that sudden way. Tliis is an STATES OF MENTAL EXALTATION. 191 example of acute mania loliich was cured suddenly hy a local inflammation. C. O., set. 44, a married woman, -vvitli several children. No hereditary predisposition, the sole cause being over-work in her household and over-anxiety about her family. She was of an " anxious disposition " and a nervous diathesis. She became irritable, quarrelsome, restless, sleepless, excited, and totally changed from her natural ways about a week before her admission, and this condition has quickly passed into one of acute maniacal exaltation, noisiness, singing, fleeting delusions, violence, and excitement, with no memory, no self-control, and no affection for her children, of whom she had been passionately fond. Sometimes she would be taciturn and obstinate for an hour or two, would not open her eyes, answer questions, eat, or walk about. She had not slept for several nights before admission, and had refused food. When brought to the Asylum she was acutely excited, noisy, shout- ing, singing, gesticulating, struggling, resisting, violent, making faces and facial contortions, putting her tongue out, but would not answer questions or attend to anything said to her. The common sensibility seemed quite blunted, so that she felt no pain. Her skin was dry, tongue furred and dry, appetite gone. Pulse 126, small and weak. Temperature, 10r2°. For the first four days she remained in this state, taking scarcely enough food, and that with extreme difficulty, and spending her time partly out of doors, under the care of two attendants, and partly in the padded room when in the house. On the fifth day, having refused food altogether, she was fed with the stomach-pump. This was done with extreme difficulty on account of her holding her teeth together most closely. The steel mouth-opener, though padded with tape, she crushed through a tooth by the force with which she bit it. This caused a good deal of inflammation in the gums and jaw, spreading back to the parotid gland, which became enormously swollen and suppurated. But as the inflammation spread the maniacal condition subsided, so that on the tenth 192 STATES OF MENTAL EXALTATION. day, when the temperature was 106° and the patient very weak and exhausted indeed, the restlessness and excitement had quite ceased, and she took both food and stimulants. She was confused in mind, but not otherwise maniacal ; and, though she nearly died from the combined general exhaustion and local inflammation, she never became maniacal again, steadOy progressed towards recovery, mental and bodily, and was well in a month. Parotitis. — The inflammation of the parotid gland which occurred in the case I have met with in various forms of mental disease — acute mania, melancholia, puerperal insanity, &c. In two cases it caused death from suppuration and septicaemia. The cause of it varies in difi'erent cases. It cannot be often caused, as is alleged by one author, through attendants holding the head during feeding. Septic Fever cutting short Attaclcs. — That is one example of very many cases I have met with, where a local inflammation, a fever, an internal disease, a carbuncle, a crop of boils, or septic blood-poisoning, have cured insanity. We try to do the same thing sometimes in cases that are strong in body by severe blistering, but seldom succeed in producing the same marked and immediate effect. I have always believed that some day we should hit on a mode of producing a local inflamma- tion or manageable septic blood-poisoning, by which we should cut short and cure attacks of acute mania. Dr Lewis C. Bruce has, by means of his heroic doses of thyroid extract (see p. 134), largely succeeded in this mode of terminating many attacks of mania. I have been much impressed by some of his cases. But such intercurrent diseases do not always cure mental attacks. I have often seen them occur in cases of acute mania and do no good. I suppose, in fact, the failures may be more numerous than the successes, but the latter naturally make more impression on one's mind and loom larger in one's conscious field of experience. The following was a very striking ease of cure, sudden and unexpected, after hope had been nearly given up, through septic fever : — STATES OF MENTAL EXALTATION. 193 C. P., set. 26, a married woman, who had for nine months suffered from acute mania connected with lactation. The symptoms had come to have some of the mental enfeeblement of dementia about them, but still there was the maniacal ex- citement, the presence of which prevented, in my mind, an absolutely unfavourable prognosis. She had been discharged from another asylum as virtually incurable. She had several cuts on her hand on admission, caused by her having broken a window. Fortunately for her one of them got some dirt into it, and the hand inflamed badly, with a nasty septic-looking inflammation that ran up the lymphatics, and was attended by intense pain and great general disturbance and prostration. It suppurated, and discharged a dirty sanious pus. But the effect on the brain condition was magical. This nine months' maniacal, destructive, dirty, violent woman, caring nothing for her husband or children or the common decencies of life, became quite gentle and manageable as the septic fever and the local inflammation progressed. At first confused in mind, then awakening to all the former associations of her life, she inquired for her children, and became in a fortnight a sane, pleasant, lady-like woman, with all the charms and graces of womanhood. Such cases puzzle one exceedingly. That period of nine months, during which the neurine of the brain convolutions had been energising morbidly, so that every mind function — intellectual, affective, instinctive, and mnemonic — was utterly disordered, clearly left no trace of struc- tural change. Unfortunately I have to give the sequel, which is not so pleasant. She kept quite well for three years, had a child, and, while nursing it (neither of which she ever ought to have done), another child died, causing her great grief. She again became maniacal. I blistered her head repeatedly and severely, and rubbed in irritants with marked benefit, but not with such absolute and striking effect as on the first occasion, because probably I could not set up a really septic fever. I put her on bromide of potassium and cannabis indica with very marked benefit. She got better in four months, 194 STATES OF MENTAL EXALTATION. and went home quite well in all respects. In a year she became maniacal again, and this time no treatment has been of any avail. She remains ill and is now incurable. Hot Baths. — The good effect of treatment of acute mania by hot baths was well seen in the follmoing case of C. P. A., a young man who, as the result of over-work and too little fresh air and relaxation, became morbidly exalted in mind, restless, sleepless, talkative, and changed in general mental demeanour. While in this state he was more active mentally than he had ever been in his life. He wrote an article for the most brilliant weekly journal of the time, which was accepted and inserted — the only such article he ever wrote in his life. His condition soon passed into violent excitement, constant extravagant talking, and fleeting delusions of ambition and extravagance. His conduct became violent, destructive, and unmanageable, and he was in that condition when I saw him. I got a first-rate, strong, trained attendant, and we gave him two baths of about 104", with cold to his head. The immediate effect of this was lowering, and he nearly fainted before he was taken out of the second, but his excitement and talkativeness and his delusions were calmed and diminished. He got drachm doses of the bromide of potassium repeated three times during the night, and for the first time for about ten days he had a good sleep. By the way, I should have mentioned that between the baths he was taken out into the open air and walked about for several hours till he was pretty nearly exhausted. Xext morning all the most violent and unmanageable of the symptoms were found to have passed off, and under the treatment of baths and bromide, with plenty of exercise and unlimited milk and Uquid nourish- ment, he made a speedy and perfect recovery in about a week or ten days, without relapse and without complication. In a fortnight he was able to go away for a change, and for ten years was as vigorous, mentally and bodily, with two short and shght exceptions, as he ever was, conducting a large business. STATES OF MENTAL EXALTATION. 195 Death from Exhaiistiun. — Acute mania sometimes exhausts tlie strength of the patient, and kills in spite of treatment, as in the following case of C. Q., set. 34, suffering from the third attack of mental disease, the two former having been attacks of melancholia. She had a sister insane, and a brother an imbecile. She had been ill for about a month, being much excited, and refusing food. On admission she was acutely maniacal and delirious, with no memory, and no power of attention. Her pulse was 98, her temperature 99'6°, and her general condition weak. She refused food, and, though fed regularly with the stomach-pump, the excitement continued, and she got more and more exhausted, though after the first feeding with custard, wine, and quinine she was less ex- cited, and slept for the first time for a week, but this good result did not continue, and she died on the fifteenth day. The most common post-mortem appearances in the brain in those cases that die of acute mania are intense hypersemic conditions, as represented in Plate IV. The constant occur- rence of such hypersemia in limited areas shows that the vaso-motor disturbance is not uniform all over the brain. In the case from which Plate IV. was drawn the congestion occurred along the whole inner layer of the grey substance of the convolutions as well as in areas. I have always looked on this irregularity of blood supply to the brain, resulting from such vaso-motor spasms at some parts and paralysis at others, as being most important in throwing light on the general pathology of acute insanity, but I scarcely regard any vascular disturbance as a primary cause of the disease, believing that the blood-vessels are the servants and not the masters of the brain-cells. I had a case of acute mania lately who died within a fortnight of her attack, in whose cortex the cells were in a state of marked degeneration similar to those shown in Plate XIII. figs. 3, 4, and 6. By the use of the Nissl and Golgi methods of preparation we are now able to demonstrate cell and dendrite changes that we could not discover some years ago (see Plates XVI., XVII., XVIII., and XIX.). The 19 6 STATES OF MENTAL EXALTATION. question occurs— To what extent can such neurons recover their normal appearance? An Undescribed Deposit in Cortex in Acute Mania. — The following case of acute mania was accompanied by a patho- logical deposit, of a kind yet undescribed, all through the convolutions. C. Q. A., set. 50, had been insane for only a few days, and was acutely excited and maniacal on admission. Her temperature was 98°, and her pulse 88. She was deliriously maniacal, unconscious, restless, sleepless, and noisy. In a fortnight she became more rational and quiet, and could do some work. Then in another week the .acute deliriously maniacal condition returned. She got more stupid and irrational, and died four weeks after admission and, five weeks after the commencement of her insanity. With the late Dr Joseph J. Brown, then the assistant physician in charge of the department, I made the post- mortem examination ; and the naked-eye appearances were, like the microscopic appearances afterwards discovered by Dr Brown, quite unique and hitherto undescribed. The pia mater was milky and thickened, and stripped readily off the convolutions. The convolutions were somewhat atrophied. ]n the convolutions, scattered around the island of Eeil, there were seen a number of small pellet-like bodies the size of pin-heads, and of a glistening appearance. "When closely examined it was seen that those sago-like bodies were more or less distributed over the grey substance of nearly the whole of the convolutions of the cerebrum. The outer layer of the grey matter of the convolutions was quite distinct from and stripped like a sheet of wet paper off the under layer. Dr Brown prepared many beautiful carmine-stained sections of the convolutions so affected, and, but for his lamented and premature death, was to have fully described the lesion, which was new and very interesting. A deposit of a new materia] had taken place, as represented in fig. 2, Plate II., all through the grey substance of the convolutions, but chieily in its inner layers, and extending in some parts into the wliite STATES OF MENTAL EXALTATION. 197 substance. It was in some places in single spots, with a nucleus in the centre of each, but no other trace of organi- sation visible; in other places in immense lobulated masses, or in great oval bodies with a nucleus in the centre of each, quite visible to the naked eye. In was deposited in masses round the arteries in many places. It seemed as if at the least two-thirds of all the grey substance of the convolutions affected were replaced by this deposit. It took on the carmine stain strongly, and looked more like a waxy material than anything else, but its exact composition I do not know. It was evident that it was a chemico- vital product deposited round nuclei. Many questions suggest themselves in considering such a case. What a comfort it would be were the pathology of every case of acute mania as definite as this seemed to be ! The discouraging thing is, that no such deposit is needed at all to produce mental symptoms like those of C. Q. A. How long was this deposit in forming 1 Surely longer than the five weeks she was insane. And she became wonderfully rational and coherent after the first three weeks, with her brain convolutions diseased in this way, just as a general paralytic often gets almost rational for a time with his con- volutions diseased. It is clearly not only a deposit of this kind, or a pathological change in the cells, but the morbid energising that such lesions give rise to, that really produce the symptoms of acute mania. Dr Blandford ^ describes " acute mania " as being " a very different disorder " from "acute delirious mania." Bucknill and Tuke ^ incline towards this distinction, but do not clearly describe them as distinct from each other, while Savage ^ and Bevan Lewis * describe " acute delirious mania " as distinct from " acute mania." Lewis gives three cases, one of whom ^ Insanity and its Treatment, by 6. Fielding Blandford. 2 Psychological Medicine, by J. C. Bucknill and D. Hack Take. 2 Insanity and Allied Neuroses, by G. H. Savage. » Op. cit. 198 STATES OF MENTAL EXALTATION. was admittedly in the first stage of general paralysis. Ball^ and the French authors are definite in their descriptions of the delire aif/u, as distinct from ordinary acute mania ; and Krafft-Ebing is equally decided. Dr Luther Bell's Typho- mania is commonly quoted as if it were an extreme example of this disease. I cannot agree that there is any such real distinction between these forms of mania as even to enable us to make them distinct clinical varieties, for the following reasons: — 1. In almost all cases of "acute delirious mania" there is at the beginning or end a stage of ordinary acute mania. 2. Savage's psychological and clinical differences, so far as they exist, are in degree, not in kind. 3. The differences in prognosis are not according to fact. 4. There is no real pathological difference so far as we know. Krafft- Ebing's theory that the delirious form is due to cerebral hyperaemia puts a result as a cause. Delusional Mania. — This is a condition analogous to what I have described as delusional melancholia, the general symptoms being maniacal instead of melancholic, and centring round a fixed delusion or set of delusions. I have now under my care a woman — C. Q. B. — who shouts, scolds, and is violent almost all day, alleging as the reason of her con- duct that her children are below the boards of the floor, and that she hears them being tortured by villains who are to kill them. I have a man who shouts and preaches, and warns the sinners of the world in a most riotous and noisy way of the doom that awaits them, saymg that the Lord had com- missioned him to do so. Delusional mania is in fact delusional insanity plus maniacal conduct. Such cases sometimes recover, but when the fixed delusional condition has lasted long the prognosis is bad. Chroma Mania. — This is simply acute mania running into a chronic course. The division line that marks off acute from chronic mania must always be an imaginary, arbitrary, and unscientific one. The term of twelve months that I have ' Lemons sur Lcs Maladies Mentales, by B. Ball. STATES OF MENTAL EXALTATION. 199 adopted has this disadvantage, that after that time many cases are curable, while we usually think of chronic mania as being virtually an incurable disease, ending in death or dementia. The long continuance of a maniacal condition of the brain always causes an alteration of the symptoms, as compared with those of recent acute mania. We seldom or never have any tendency to delirious mania, with dry tongue, high temperature, and risk to life, from the intensity of the disease. To be able to live long, suffering from chronic mania, implies a strong constitution, with good digestive and assimilative power. Though the absolute sleeplessness of acute mania is not present, yet many cases of chronic mania sleep exceed- ingly little. It may seem incredible, but we had once at Morningside a woman suffering from chronic mania, who for eighteen months was never found asleep by the night attend- ant, who visited her every two hours every night. She must have slept, of course, but her sleep was so light and so short that she was always awake every two hours. Not only did she not sleep, but she was restless, noisy, singing, tearing her bedding, and when she had nothing else to do, gnawed with her teeth and scratched with her nails the wood-work of her room, into great holes. But some cases of chronic mania sleep quite well, and almost the natural time, and yet during the day they continue excited, restless, and destructive. There is usually a spice of the enfeeblement of mind of dementia in chronic mania. Notably the memory is impaired, a rational interest in anything cannot be roused, and the habits, instincts, and fine feelings are degraded or dulled. The affective power is usually almost paralysed. There is no proper care for children or tender affection for anybody. Yet some of the cases remain most acute and observing for many years. One such case I have, of many years' duration, who will always notice and remark on any little change in my dress before any one else does so. Some of the pathological appearances found in chronic mania are depicted in Plate XIII. figs. 2 and 6. They consist 200 STATES OF MENTAL EXALTATION. of degenerations and partial atrophy of tlie cortex cells, with vascular and lymphatic changes. Treatment of Chronic Mania. — As regards treatment, an asylum is the only proper place for such patients. I have seen them kept at home, or boarded in private houses, but I have seldom seen a patient very happy there, or the arrangement very satisfactory. I shall never forget a visit I once paid to a case suffering from chronic mania — C. E. ■ — with short aggravations each day of wild delirious fury. To provide against these, two large rooms in a handsome villa had been divested of furniture, the windows boarded up, and the walls left to the unrestrained destructiveness of the patient. I stayed with her in this apartment during a paroxysm of her disease, and, in thirty- seven years of life as an asylum physician, I have never seen anything so completely parallel to the famous maniac scene in Charlotte Bronte's Jane Eyre. The patient tore her clothes to ribbons, shouted and howled, and made a barking noise like a dog, bit her skin, dashed herself against the walls, and dug into the plaster and wood-work with her nails till they bled, while she smeared the blood over her face and body. After many years of this life her relatives at last got over their prejudices against an asylum, and sent the patient to Morningside, where, after a few months of hard walking in the open air, occupation, dancing, and a regulated life, she is an ornamental and amusing member of our community, very happy, and always averse to tlie idea of leaving the Asylum. She takes her paroxysms still, but they are shorter and less severe. One of the great improvements that has taken place in modern asylum management has been that rational physiological outlets are provided for the morbid muscular energy of the cases of chronic mania. They are neither confined in their rooms nor within "airing courts" enclosed by high walls. They are made to walk about. They are made to wheel barrows and dig on farms. They are encouraged to dance, and they are well fed. ]\Iost of STATES OF MENTAL EXALTATION. 201 tliem eat enormously, and if tliey have not enough to eat they fall off, get worse in their mental state and in their habits. Many of them can be got to expend their energies in hard regulated work, and are the very best workers on the farms and in the laundries of asylums. They are not all, of course, furiously maniacal. Some of them simply have a slight morbid excess and exaltation of function of the brain convolutions, shown by talking or scolding, restless- ness, want of affection, and want of self-control, but are not incoherent. If they are kept at work, the most objec- tionable and repulsive parts of the older asylum life is avoided in great measure, and "refractory wards," with their noise and danger, are not much needed. The scenes ■vidth such patients — attendants holding them down and removing them into the seclusion of their own rooms — are few. No doubt there are risks run in the present system, to patients and their guardians, but I believe the risks are much less in reality than under the old system, for the patients are not so irritable, not so revengeful, and not so dangerous generally. The following was a case of mania, acute at first, with temporary recovery, tlien a relapse, and chronic mania for three years, then death, — all the mental symptoms being those of the ambitious delirium of general paralysis : — C. Y., set. 67. A man of a sanguine temperament, very frank and enthusiastic disposition, and industrious habits. For many years he had devoted himself with zeal, enthusiasm, and industry, as to a real business in life, to the study of a particular department of knowledge, until he was one of the acknowledged authorities on the matter. He was a man of much individuality of character, amounting almost to eccentricity, and he evidently had a high opinion of himself and of what he had done. His habits were so industrious in following his special work that he gave himself too little sleep, and this, I think, was the exciting cause of the attack I am about to describe ; the predisposing 202 STATES OF MENTAL EXALTATION. cause being a heredity to the neuroses, which some of his relations vrere so anxious to deny that I concluded it must exist — in fact I had evidence, by seeing some of them, of its existence. His disease consisted of a gradual evolution and exaggeration of certain points in his character into excessive and morbid prominence. His good opinion of himself and the value of his work, which before had merely been apparent in small thiiigs, now became evident beyond what sensible men ordinarily display. He became restless; his sleep power seems to have gone, so that he sat up all night, and he became irritable without reason. He went about among his friends, and talked all the time, his natural enthusiasm about his special work taking ridiculous forms. He developed openly an idea that he seems to have vaguely held, but did not speak about it, that he was the heir of a great Scotch historical house. In a certain nascent degree, the idea that they are the heirs, or at all events the members, of great historical or well-known families is a most common psychological peculiarity of vast numbers of perfectly sane Scotsmen; and when they have attacks of morbid mental exaltation this vague fancy, and perhaps longing, which before had no more practical elTect on their lives than heightening their self-respect, becomes a foolishly expressed delusion. If I have had one Lindsay as a patient who was the rightful heir to the earldom of Balcarres, I have had certainly a dozen, and every insane Stewart is of the royal clan. In about a fortnight C. Y. was absolutely incoherent, swearing, and fancying he was in heaven, this condition being attended with great violence to those about him, and destruction of objects that he had valued most highly. In another day or two he became quite delirious, would take no food, and had to be sent to the Asylum. On admission he was maniacal and furious, attacking those near him very violently, and at times dashing himself on the floor in a way that might have hurt him. He was almost incoherent, but his ideas were all very exalted. He STATES OF MENTAL EXALTATION. 203 had millions of money, could make us all dukes, &c. He ■would make a man a duke one moment and strike him suddenly the next. His case was certainly very exceptional in its tendency to impulsive violence. He was in this respect more like the dangerous maniac of the popular imagination than most of our ordinary patients. With this intense excitement, and with much muscular strength, his pulse was feeble, his tongue dry, his face haggard, and his whole bodily condition one of great weakness and danger to his life. By dint of feeding, stimulants, and taking him into the open air under the charge of trained attendants, he gradually improved. His mental state was all the time exactly that intense exaltation, that morbid mental " expan- sion," that "ambitious delirium," or "mania of grandeur," which we find so commonly in general paralysis, and which some physicians suppose to be characteristic of that disease. Everytliing about the place was of the finest, his treatment was ^very skilful, the physicians were most eminent, and the attendants were most kind. In the beginning of his disease I often was on the look-out for the motor symptoms of general paralysis, without which it is, of course, utterly unjustifiable to diagnose that disease. In three months he had become quiet in manner, self-controlled, and rational, but had just a suggestion of his former state of mind in being too pleased with things, and too grateful for little kindnesses. His friends thought him quite well, and he was removed home with my approval. But he had not been home a day when he set to work to his old employ- ment and studies with a sort of unreasonable enthusiasm. Sitting up nearly all night, he soon got unsettled, his exalta- tion of mind came back; he became dirty in his habits, impulsive, and utterly impatient of contradiction. If his orders were not at once carried out he would get into a sort of maniacal rage. In seventeen days he had to be removed back to the Asylum, and, though not so dehrious or so weak as on his first admission, he was very excited. He would come up 204 STATES OF MENTAL EXALTATION. and be very pleased to see you, and in a moment, sometimes witli some little provocation, such as your not agreeing at once with him that he was an earl, or sometimes without, he would strike you suddenly, very often going down on his knees immediately after, and in a theatrical manner begging your pardon, and hoping he had not offended you. In meet- ing you he would come up with a profound bow, and place his hand on his breast, and hope "Sir is well." His insane grandeur of manner was often very grotesque. He would talk for a minute in this high-flown way, and ask per- haps for a book or a newspaper. When he got it he would turn round, and in a surreptitious way would tear it up. He was given to impish tricks and mischief of all kinds. His habits were dirty in the extreme ; he tore his clothes and his bedding, and he never could be left for a moment without getting into some mischief. He reminded me of the clown in a pantomime, only combining with his mischief a far more magnificent manner than any clown could assume. This went on in spite of all treatment, medical, moral, or dietetic, for three years, at the end of which time he died of internal cancer. The chronic mania, no doubt, weakened his brain functions, and he presented some few of the symptoms of brain enf eeblement towards the end. His memory was worse, he was not so coherent, he was more silly and childish in his ways,' and the maniacal symptoms were not quite so intense. On post-mortem examination we found some thickening of the membranes, some convolutional atrophy, some disease of the coats of the vessels, some local congestions, and some few spots of ramoUissement, but nothing pathognomonic, nothing so characteristic that by seeing it one could say that the man laboured under chronic maniacal exaltation. This, of course, merely shows the insufficiency of our then means of brain examination, for assuredly there must have been organic changes after so long a disturbance during life, and by our present methods we could have demonstrated them. That any pathological changes will ever show the special mental STATES OF MENTAL EXALTATION. 205 peculiarities of such a person — his ambitious mania, his lofty opinion of himself, his destructive tendencies-^is more than we can expect, for such things were the evolutions of his temperament and the skeleton of his normal mental frame- work, which the self-control that we call sanity and the customs of civilised life induce men to hide and keep under, just as they do their day dreams and their pet ambitions. The onset of the cancer, with its cachectic and exhaustive tendency, may have been the exciting cause of the maniacal attack, and also the reason why recovery did not take place. Element !S of Prognosis. — Tho chances of recovery from mania after twelve months' duration diminishes very much as time goes on, more so than in the case of melancholia ; but we do not pronounce a case incurable for a long time, so long, in fact, as the morbid brain exaltation lasts, and dementia does not supervene. In the prognosis of mania, where there is exaltation there is some hope. I had a patient — C. T. A. — • discharged recovered five years ago, who had been for eight years suifering from chronic mania of an extremely bad type, with, as I thought, many of the signs of dementia. I had shown her to my clinical class on several occasions as a typical case of chronic mania. The chances of recovery are in inverse ratio to the length of the disease after the first two years. After five years recovery is the rare exception, but I have known it take place after even twenty years. Epliemeral Mania {Mania Transitoria). — This term is used to describe a somewhat rare form of maniacal exaltation, which comes on suddenly, is usually sharp in its character, and accompanied by incoherence, partial or incomplete uncon- sciousness of familiar surroundings, and sleeplessness. An attack may last from an hour up to a few days. I was once called in to see a young man in Carlisle, C. Z., a patient of the late Mr Eobert Brown, who suddenly, without premoni- tory symptoms and without any apparent cause, had in the afternoon, in the midst of his work, become incoherent in his speech, talking continuously, restless, pushing about the 206 STATES OF MENTAL EXALTATION. furniture, did not know his relations, and expressed many fleeting unconnected delusions. He was not very violent or difficult to manage. He would take no food or medicine, and there was no means of making him do so, and no warm bath to be got, so he was left alone under the charge of an attendant. He did not sleep that night, but towards morning he became less talkative and restless, he began to know those about him, then there was an hour or two of stupidity, con- fusion, and lethargy, and next day by mid-day he was himself again, went to his work, and had no relapse. That was the first case of the kind I had ever seen, and it was very in- structive to me, for I always since ask myself, when called in to any suddenly occurring case of mania — Is it a case of vMitia transitorial Since then I have met with many some- what similar cases, both among patients who were convalescent in the Asylum, especially among epileptics, and also in patients who were not in the Asylum. I think cases of mania trait- ffitorla result from the following causes. Most of them are epileptiform, are, in fact, of the nature of the mental epilepsy of Hughlings Jackson, in cases whore distinct motor epilepsy does not exist. I believe the case of C. Z. was of this character. Others are examples of the epilcpsic lurvre of Morel, — masked epilepsy, where a mental explosion takes place instead of an ordinary epileptic fit. A few of the cases result in young persons from slight moral or physical causes upsetting brains of intense instability that have a strong neurotic heredity. There are some such brains so easily upset that a gust of passion, a sudden stoppage of menstruation, a slight excess of alcohol, of sexual intercourse, or of masturba- tion will make them delirious, and this may only last for a short time. All the symptoms of mania transit.! nia may be seen in the incubation of and during febrile and inflammatory complaints, such as scarlet fever, typhus, and typhoid, local inflammations, influenza, &c., in unstable brains that are upset by very little, through a process of what the oklon authors called metastasis. I have seen ephemeral mania after ery- STATES OF MENTAL EXALTATION. 207 sipelas. After the dynamite explosion in January 1885 in London, the policeman Cox was tirst unconscious and then maniacal and deaf for a few hours. The great question in regard to ephemeral mania is this— Can we tell it by any special symptoms? There are no definite symptoms that I know by which we can tell that any maniacal attack is going to be ephemeral. There is always a presumption that when an attack begins very suddenly it may end suddenly, and if such an attack occurs in a youno subject with strong heredity to insanity, whose diathesis has been very neurotic, and whose brain has manifested unstable tendencies, it is right to keep this form of mania in mind, and not be in too great a hurry in sending such a case to an asylum. The treatment is the same as that I have recommended for acute mania, only the bromides, sulphonal, hyoscine, and cold applications to the head are especially indicated. I imagine that family doctors who attend many nervous families could tell of attacks of what are really ephemeral mania, but are naturally called by all sorts of euphemisms, — " nervous attacks," " hysterical attacks," &c I once saw an attack of ephemeral mania come on and last a few hours in a girl who had usually exhibited her neurosis by attacks of hysteria. Homicidal Mania. — In popular, and sometimes in medical phraseology, " homicidal mania " means any kind of mental disease where there is an attempt or desire on the part of a patient to kill. But, as you have seen, the homicidal desire may occur in melancholia, and is often associated with the suicidal feeling. As we shall see, it may occur as an uncom- plicated impulse, not accompanied by depression or exaltation of mind, and it then stands as one of the varieties of impulsive insanity. But at present we are to view it as one of the chief symptoms of certain forms of maniacal exaltation. In this it occurs in four forms : — First, and most commonly, from delu- sion, e.g., that persons attacked are persecuting the patient, or are going to kill him. Second, from sheer excess of motor energy, which vents itself, as it were, in killing, as it does 208 STATES OF MENTAL EXALTATION. more ordinarily in smashing, fighting, or tearing. Third, from a distinct morbid desire, impulse, and craving to kill. Fourth, homicidal attacks are made in the unconscious delirium of acute mania without "motive," without "intent." Of the ^rs< kind was the case of C. K (p. 188), when she attacked the attendant, on admission, under the delusion that she was her enemy and going to injure her, and also the following cases. A Remarkable Case of Homicidal Mania. — We had in Morn- ingside Asylum, when I was an assistant physician there in 1860, a remarkable case of homicidal mania, a most graphic account of which was published by my friend and then col- league, Dr Yellowlees.^ The man's name was Willie Smith, who, beginning with an attack of what was evidently simple mania in 1829, and taking to publishing his own effusions, wrote thus : — " There's Willie Smith, the carpenter, Become at last a publisher ; You'll find his -works in rhyme and prose . Throughout this land o' cakes and brose ; " and because his contemporaries laughed at him, and the boys called him "Whisker Willie," broke his glass, and blew " smoke out of a horn full of lighted tow into my shop," he applied to the law. And, by the way, what a psychological study is the boy's instinct in finding out weak points of inhibition, his altogether uncontrollable impulse to probe them when found, and his delight at the result ! The magis- trates would give Willie no redress. Because of these things he imagined he was persecuted, and planned to execute revenge all the rest of the thirty-two years of his life. He was a perfect example of French megalomania,— elevated ideas about himself and his powers, combmed with ideas of persecution, — and, in addition, with strong and persistent homicidal tendencies. With loaded guns, daggers, spears, axes, swords, extemporised weapons of all sorts, he meditated ' Edin. Med. Jour., August 1862. STATES OF MENTAL EXALTATION. 209 and tried revenge and homicide. In tlie gaol, the poorhouse, the Asylum, he made repeated, persistent, and numerous attempts to murder attendants and physicians, and was the terror of all who knew him. "It is scarcely possible to find language strong enough to describe the bloodthirsty passion "which possessed the man, the devilish intensity, deliberation, and determination with which all his attacks were made, or the fiendish dehght with which he gloried in relating them." Yet all the time he had " exaltation of the feeling of pride, and high ideas, and delusions regarding his own powers and capa- bilities, particularly as an engineer, architect, and musician." A visit to him was the sight of the Asylum, and a tiling to be remembered for many years. I do not know how it is, but such picturesque cases of insane would-be murderers do not seem to occur now. The fewer precautions that are taken, the less need there seems to be for them. — "When he died his head was found to have undergone great changes in shape, as compared with a cast taken twenty years before, and his brain was much atrophied. Homicidal Act the First Symptom of Mania. — I had a patient once, C. Z. A., set. about 2S, with a strong heredity towards mental disease, who had been working too hard at brain work that was uncongenial to him, had also had a disappointment, and who had previously shown only a httle mental confusion for a week, when suddenly, without warning, he made a homicidal attack on his brother when taking a walk, under the delusion that his brother wanted to do him harm. This was really the first distinct symptom of an attack of subacute mania. There were strong reasons why he should not be sent to any asylum, and I got a first-rate attendant for him, who kept him out in the open air, walking, fishing, &c., for ten hours a day. I put him on milk diet, with warm baths, Parrish's syrup, occasional draughts of bromide of potassium and chloral at night, and used occasional blisters to his head. He used often to attack his attendant from delusions about him, who, however, never lost his nerve and 210 STATES OF MEXTAL EXALTATION. was not afraid of him. He always apologised afterwards. Gradually the excitement passed off, and in about eight months he recovered. A certain mental irresolution, and tendency to change was the last symptom to disappear, as is the case commonly in mental disea.se. A full power of volition, spontaneity, power to originate, are, in fact, th<5 highest mental faculties, and are the last to return and the most apt to be left impaired. I could scarcely have believed at one time that such a patient as C. Z. A. could possibly or safely be treated out of an asylum. The second kind of maniacal homicidal attack, viz., that from sheer excess of motor energy, is often seen both in acute and chronic cases. We had a young man, C. Z. B., in the A.sylum, who, when he first became insane, attacked a man on the street, and got his own eye knocked out, and for many years did little by night and day but groan and shout in creHcendo movement, box the walls so that his hands and knuckles were hard as horns, swollen, and often cut. He would often attack patients and attendants and officials violently. He was wonderfully rational amidst all this, saying he could not help it, that the steam would out, and that he had no desire to hurt any one or any feeling of revenge against any one. I liave now a lady who is subject to paroxysms of acute mania, during which she screams in an unearthly howl, tears her clothes, bites her own hands, and will, if you will allow her, take your hand into her mouth and bite it a little all round without really hurting you. The Udrd form, that, namely, resulting from a distinct morbid impulse to kill, without conscious motive, I shall treat of more fully under impulsive insanity, the homicidal variety of which it is, with maniacal exaltation superadded. The fourfJi., or merely delirious form, is not really very dangerous, because it is purposeless and aimler-:s, and the violence is not co-ordinated. It seldom is seen except when delirious patients are unduly controlled. A physician or a good attendant in an asylum generally walks up to a maniacal STATES OF MEXTAL EXALTATIOX. 211 patient quite unconcernedly as to danger, thinking only of the symptoms present, just as one would going in to see a case of pneumonia. Prevalence of JIania. — The relative prevalence of conditions of mental exaltation is brought out by the fact that out of 2o77 cases admitted into the EovaI Edinburgh Asylum in the seven years 1S7-1-80, 1310, or 55 per cent., were classified as mania, while only 729, or 36 per cent., were cases of melanchoha. The relative prevalence of the two conditions I have shown in Plate V., which also shows the ages at which they occur. MentivL exaltation is there seen to prevail more at earlier ages than depression, and to occur most at two periods, viz., at the end of adolescence, and then about ten years afterwards. Insane Ddusioiif: in J/a.««i.^The most important thing to ascertain about delusions in mania is whether they are " fixed " or fleeting. A fixed delusion is usually the concentrated ex- pression of a delusional condition of mind. I mean that it is seldom a patient, e.n., has merely the one delusion that a person works an electric battery to annoy him. Such a delusion is generally the expression of an organic or nervous sensation of discomfort or pain, which makes him. have his natural suspicions heightened, he being morbid also on other points. He will not trust any one. He is apt to think the air of his room or his food is poisoned. If the person whom he beheves to be working this battery goes away, he will soon fix in his morbid imagination the same thing on another. A patient usually not only beheves himself to ba a king, but his whole state of mind is that of delusive grandeur. Such fixed delusional states, that last for more than a few months, in mania, are unfavourable as to prognosis ; but do not put down either a single delusive fancy that is repeated con- sistently a few hundred times, or a delusive condition that merely lasts a few weeks, as a fixed delusion. The fixity of a delusion depends on two things, the hold it has — whether it dominates the mental life — and the time it has existed. 212 STATES OF MENTAL EXALTATION. Fleeting delusions are most typically seen in that delirium where nothing that is said has any relation to facts, and where no fancy nor untrue statement is repeated ■ often. In very many cases of mania a delusion persists for a few months or longer, and yet passes away, and should not be counted a fixed delusion. There is no doubt, however, that the less fixed and the more fleeting a delusion is, the better is the prognosis. Delusions take innumerable forms in mania. One of the most common forms is mistaking the identity of persons, calling them by wrong names, and recognising old friends in persons never seen before. Certain kinds of insanity, such as the puerperal form, are specially characterised by this sort of delusion. Emotional Conditions in Mania. — Dr G. M. Eobertson^ has pointed out that the cases of mania divide themselves into two varieties when looked at from the emotional point of viQW. In the one class the prevailing emotions are those of pleasure and joy, — hilarious mania ; while in the other the prevailing emotions are rage and anger, — furious mania. The facial expressions, gesticulations, and delusions are very different in the two. But the same case may change from joy to rage, and vice versd. Indications of Prognosis in Mania. — The following are in my exTpevicnce favourable indications in prognosis : — A sudden onset of the disease ; very acute symptoms coming on soon ; a short duration ; youth of the patient ; no fixed delusions nor delusional conditions; appetite for food not quite lost; no positive revulsion against nor perversions of the food and drink appetites ; no indication of enfeeblement of mind ; no paralysis nor paresis, nor marked afl'ection of the pupils ; no epileptic tendency; no complete obliteration nor alteration of the natural expression of the face or eyes; the instincts of delicacy and cleanliness not quite lost ; no unconsciousness to the calls of nature ; the articulation not afl'ected ; the disease ^ Journal of Mental Science, July 1890. STATES OF MENTAL EXALTATION. 213 rising to an acme and then showing slow and steady signs of receding ; no former attacks, or only one or two that have heen recovered from. The effect of a strong and direct hereditary predisposition is not, as is commonly believed, sufficient to lessen the chances of recovery, especially in the first attack. On the con- trary, hereditary cases are often very curable, but relapses are more probable. A brain so predisposed is more readily upset by slight causes. The following are unfavourable indications in prognosis : — A gradual and slow onset, as if it were an evolution of an innate bad brain tendency, — e.g., if a naturally suspicious man has gradually become insanely and delusionally suspicious, or a naturally vain man has become affected with insane delusions of grandeur; great length of duration of the attack, such as twelve months' persistence of fixed delusions or delusional states and especially of hallucinations ; extreme and increasing exhaustion of the patient in spite of proper treatment ; paralysis of the trophic power, so that his body nutrition cannot be restored ; persistent refusal of food, requiring forcible feeding ; extreme failure of the cardiac action and circulation, so that the extremities are always blue and cold; persistent affections of the pupils, especially extreme contraction ; persistently dirty habits ; a tendency towards dementia ; a tendency towards chronic mania ; an utter and persistent deterioration in the facial expression, especially if it be towards vacuity ; persistent and complete paralysis or perversion or degradation of the natural affections, tastes, habits, and appetites; many former attacks; convulsive, paretic, paralytic, or inco-ordinative symptoms; such per- verted sensations and localised trophic disturbances as cause patients to pick the skin, pull out the hair, bite off the nails into the quick ; marked changes in the skin, hair, and secretions long continued ; a restoration of sleep and bodily nutrition, without in due time an improvement mentally ; very per- sistent insane masturbation ; a tendency for the exaltation to 214 STATES OF MENTAL EXALTATION. pass off, and fixed delusion to take its place ; excitation of the limbs and subsultus tendinum; a "typhoid" condition. Termination of Mania. — There may he said to be five usual terminations. 1. Complete recovery ; this takes place in about half of all the cases of mania. 2. Partial recovery, the patient becoming rational and fit for work, but with a change of character or affection, or an eccentricity, or slight mental weakness, or want of mental inhibition, or lack of fixity of purpose, or a partial paralysis of the social instincts, or some inability to get on with people, or a lack of or lessening of some mental quality which the patient possessed before. This is unfortunately a by no means uncommon result of an attack of any kind of insanity, but more especially of an attack of mania. Such persons count often among the recoveries, and are reckoned legally sane. It is quite impossible to find out how many such cases there are, but I fear that at least one- third of all those who "recover" exhibit some such mental change as compared with their former sane selves. I think it is of the utmost importance to have the cure completed, therefore, if possible, by prolonged medical care, by getting the whole bodily state, in regard to nutrition and nourish- ment, up to the highest possible mark before a patient returns to work or subjects himself to the causes of a relapse. It is the existence so often of this condition of mental change or mental twist, and the liability to relapse, that makes the public suspicious of a man who has been insane ; through which suspicion great hardship and injustice are often done to those who have already suffered from one of the most terrible of human diseases, 3. The substitution of fixed delusions or delusional states — monomania — for the exaltation as the latter passes off. It is difficult to find out statistically how often this occurs. The patients may live long when this takes place, except the delusional condition be that of morbid suspicion in which case there is a risk of dying of phthisis within a few years. 4. Dementia supervenes. This happens in about 30 per cent, of the cases of mania generally. It is the event we STATES OF MENTAL EXALTATION. 215 most dread. It is equivalent to a mental death, wliile the body may live for many years, especially if the dementia has come on in youth. We have had many patients live so for fifty years in Morningside. The bulk of the chronic patients in asylums are of this class. 5. Death occurs in about five per cent, of the cases from exhaustion, or from causes directly traceable to the disease. It must be understood that those are the terminations in cases of mania so severe as to require asylum treatment. If we could include the slighter cases treated at home, the recoveries would be more and the terminations in dementia and death fewer. Prophylaxis of Mania. — A very important question often needs solution by medical men in practice. There are young people growing up in the families they attend with neurotic heredity, with manifestly unstable brain constitution, with "excitable" dispositions and nervous diathesis; and the all-important question is asked — How can such persons best avoid the tendency to attacks of mania ? They have patients who have already bad attacks of maniacal exaltation, some decided and some only nascent — How can those be avoided in the future ? If our present knowledge enabled us to answer these questions, no doubt there would be less insanity in the world than there is. We cannot do so surely, but we can do something in the direction of lessening the tendency of a brain to mania, I have no doubt. Beyond question, persons with this brain constitution should not enter on exciting and hazardous occupations. To take extreme examples, they should not be stockbrokers, election agents, or speculators. Quiet routine modes of life suit them best ; positions with fixed work and fixed salaries are most desirable for them. ■Much outdoor life, living according to rule, dividing up their day into regular portions for work and idleness and amuse- ment. As regards diet, the same advice I gave about children predisposed to melancholia applies here. It should consist largely of milk and farinaceous diet for the young. I lately 216 STATES OF MENTAL EXALTATION. saw a very excitable boy of six, very thin, restless, not sleopinR much, and, of course, very bright and quick for his ago. I found he was getting animal food three times a day, and his guardians deplored the fact that he could not take milk ; my advice was to starve him into taking it, to make him walk much and keep him out, and give him when he came in only bread and milk. Of course it was disagreeable at first, but the boy soon acquired an appetite for such food, his bodily conformation largely changed, and he got fatter, less active, less nervous, and slept far more. Children with this disposi- tion are nearly always flesh-eaters, and I have sometimes found them fed on beef-steaks and port wine, with strong beof-tca between meals ! I look on strong beef-tea drunk alone, with- out bread or potatoes, as simple poison for such children. T do not of course mean this to apply when they are ill, and need a stimulant. Such persons should take as much sloop as possible ; they should cultivate quiet hobbies ; they should select country occupations, and avoid stimulants, tobacco, and sexual intercourse till after adolescence. "While ordinary well- constituted brains may stand moderate excesses of all kinds, in work and in pleasure, and may even in a way be said to bo sometimes the bettor for thom if not too often repeated, this is unquestionably not the case with those I am now describing. The excess of power beyond the daily needs, the capacity of quick recuperation, the tendency to stop working and to sleep when tirod, the power of being satisfied with only a slight or an occasional excess over what the strict laws of nature would dictate, which characterise healthy well-constituted brains, are all wanting in those predisposed to maniacal attacks. I cannot help thinking that for such persons to take to study or to occupations that imply much brain-work is a risk, though they have often bright intellects. It seems to me as if, instead of that, they should go back to nature and mother earth, and become farmers and colonists. I once knew two brothers, twins, alike in mind and body, who had a strong lieredity to mania. They both became medical students, and STATES OF MENTAL EXALTATION. 217 one had an attack of acute mania at twenty, which ended in dementia. At the beginning of his brother's attack the other had distinct premonitions of the same disease — was sleepless, restless, unsettled, had queer sensations in his head, and felt as if he would lose his self-control. But he at once fled, as for his life, from books and brain-work, and went to be a land- surveyor in the Ear West. His neurotic symptoms passed off, and he grew into a strong and happy man. I think it is the instinct of mental self-preservation that makes young men sometimes fly from the influences of civilisation and take to the backwoods, the " Planomania " of some authors. But what about young women 1 Alas ! the prospect for them with such heredity, and particularly when they are well off and live in cities, is often lamentable. So far as my experience and observation go, the regulated life of a convent or sister- hood, or systematic religious and philanthropic work, fulfil the conditions of prophylaxis, when the tendency is very strong, better than anything else. I am often profoundly impressed with the physiological and medico-psychological character of many of the observances and regulations of the Eoman Catholic Church as to modes of life and outlets for the emotions. The framers of these observances had often anticipated modern physiological inductions. But suppose there is not merely a predisposition, but that the actual prodromata of the disease are showing themselves, let us say sleeplessness, want of full power of self-control, and general unsettledness, should medicinal hypnotics be taken — opium or bromides, paraldehyde, sulphonal or chloral, or hen- bane? I think I have seen these do more good as sleep- producing prophylactics than as curatives after the disease had actually begun. There is no doubt that in the matter of its rest-in-sleep power, like many of its other faculties, the brain forms habits, and gets into bad and morbid as well as into good habits. A man falls off his sleep at his regular time or awakes at too early an hour, and he cannot get rid of this habit his brain has got or is getting into, and if allowed to go 218 STATES OF MENTAL EXALTATION. on uncorrected he will become exhausted and insane. Now, while I should in such a case invariably try first nature's simple sedatives — sea or mountain air breathed all day, muscular fatigue, hot drinks at bed time, warm baths, cold or fiot to the head or feet experimentally before going to bed, change of scene and work, &c., yet I have to aid these often by a few doses of paraldehyde, sulphonal or chloral, and the bromides, or even by a grain or two of opium at night. Camphor and tincture of liipuline are often sufficient sedatives, or a few drops of tincture of belladonna, — in fact, any sleep-producer. But do not, if possible, let the brain get into the evil habit of depending on such drugs for sleep. LECTUEE Y. STATES OF ALTERNATION, PERIODICITY, REMIS- SION AND RELAPSE IN MENTAL DISEASES {FOLIE CIRCULAIRE, PSYCH0RH7THM, FOLIE A DOUBLE FORME, CIRCULAR INSANITY, PERIODIC MANIA, RECURRENT MANIA, EATATONIA). I'hysiological alternations and periodicity; the law of "action and reaction " — Reproductive and sexual periodicity, with their mental changes of periodic elevations, perversions, irritahilities ; the perio- dicity of neuralgia, epilepsy, sleeplessness, &c. — Folic Circulaire a distinct disease ; first described by Falret and Baillarger ; three conditions in the circuit ; depression, exaltation, and comparative sanity — Duration of these varies in different cases ; a very incurable disease — Psychological interest of this disease ; the same brain in different states ; other symptoms periodic too, e.g., cephalalgia, vomiting, &c. — A few relapses in mania or melancholia do not con- stitute this disease — Treatment : complete the cure in all insanity in youth and adolescent insanity — prevent a "brain hatit" being formed, or a " vicious circle " being got into ; the bromides ; non- stimulating diet ; marriage, exercise, regimen — Heredity the strongest predisposing cause ; good brains ; old families — Relapse or Periodicity occur in most forms of mental disease ; from 40 to 50 per cent, of all the cases ; most common in youth and in the female sex, and in hereditary cases ; prepare minds of relatives for relapses ; counsel prolonged rest or control in relapsing cases befoi'e work resumed ; get health, fatness, and dynamical equilibrium of brain thoroughly established. Physiological Periodicity. — One of tlie most fundamental of the laws that govern the higher functions of the nervous centres in all vertebrates is that of alteration and periodicity of activity and inactivity. In all the higher species of the 220 STATES OF MENTAL ALTERNATION. class the periods of inactivity— sleep — are marked by un- consoioiisnesSj and are often combined with the mental phenomena of dreaming and muscular expressions or equiva- lents of ideation; which things are quite as strange and inexplicable in their essential nature as the phenomena of mental disease. Both may be in a general way understood by reference to mentalisation as a brain function. Neither are in any way comprehensible on any mere mind theory apart from brain. The sleep and waking periodicity of the higher brain functions is the foundation and type of all the other periodicities which exist in nervous action, and they are not a few. The yearly hibernation of many animals, the daily periodic rises and falls of body temperature, the daily increase and decrease of the pulsations of the heart and of the cardiac pressure, the periodic returns of the appetites for food and drink, and of the activities of the glands and involuntary muscles through which food is digested and assimilated, are all examples of secondary nervous periodicities which occur in the course of the daily life of the organism. When we look at the function of reproduction of the organism, we find that its every activity and process is subject to laws of periodicity of the most marked character; and there can be no doubt that these all have their origin in the nervous centres, chiefly in the brain. The period of reproductive activity is always, in both sexes, the period of greatest physiological mental exaltation. The periodic rutting season in male animals, with its courage, pride, activity, display, pugnacity, and restless- ness; the young-bearing and suckling period in females, with its increased courage, skill, cunning, protective and providing instincts, show how the mental functions of the brain are affected by the reproductive periodicity. So much are they affected that the mental characteristics of some animals are then completely changed from their natural condition, and reversed, the timid becoming bold and the shy obtrusive ; hereditary and natural antipathies and fears disappear for the time, the habits change, night-feeders become day-feeders. Sic STATES OF MENTAL ALTERNATION. 221 We should not approach the study of the periodicity of symptoms in nervous and mental diseases without keeping in mind these laws and facts of the physiological periodicity of normal nerve function, wherever we have a higher nervous system. Looking at the mental activities of human beings, we find them strongly influenced by the physiological periodicities. What man is there who is not emotionally more elevated or depressed, more active or inactive in mind at certain times, and at his periods of almost regularly recurring reproductive desire and capacity 1 What woman is exactly the same in mind before, during, and after menstruation, and during pregnancy or lactation 1 And the instant we pass from absolutely healthy brains, all those periodicities count for more in the mental life, their effect in dulling, elevating, and depressing being far greater. There are thousands of sane men and women who are regularly duller in the morning and more lively in the evening, or the reverse ; or who are duller in the winter and more elevated in the summer ; or who are more irritable — that is, have diminished inhibitory power — at periodic intervals, or who are subject to "moods," "cravings," and "tempers" periodically. There are many persons whose mental life is one long alternation of "action" and "reaction," activity and torpor, by a natural law of their organisation. When we look at diseases of the nervous system other than the mental, we find many of them often markedly periodic in their symptoms and times of recurrence. I need only instance neuralgia, asthma, megrim, and, above all, epilepsy, that motor analogue of many mental diseases. FoUe Cireulaire. — Two French writers, Falret and Bail- larger, were the first to describe as a special form of insanity certain cases in wliich there are regularly alternating and recurring periods of mental exaltation, depression, and sanity, and to call it folie cireulaire. Each of these periods may vary in absolute duration from a day to several years, and in relative duration to the other conditions in the circuit in 222 STATES OF MENTAL ALTEKNATION. different cases ; but they always recur and follow each other with more or less regularity. In some the period of exaltation is long and the depression and sanity short ; in others this is reversed. But in the really typical case the periods are each about the same length in each psychological circle, and the recurring circles all about the same size. Usually there is something special in each case about the exaltation and depression. The exaltation is commonly very pure brain exaltation, with often hyperesthesia and exaltation of many of the nervous functions, with much reasoning power left but little self-control or common sense, the lower in morality being elevated the higher depressed, the condition described by the French as foUe raisonnante, or Prichard's moral insanity, being well marked in the early stage. There is then in nearly all the cases great increase of the reproductive nisus. The phases of the exaltation, down even to small things, recur regularly in different attacks at the same time. The depression is apt to be characterised by apathy and torpor rather than by intense mental pain : there are seldom any strong suicidal feelings or impulses, though to this there are marked exceptions. And the period of sanity is apt to be a sort of stupid, inactive sanity, wanting in volitional power, fidl affectiveness, and spontaneity. The mental balance goes on oscillating between melancholia and mania, standing still at the happy mean of apparent sanity just long enough to raise hopes that recovery has taken place, till the nature of the disease is apparent to the physician, and as often as they occur to ever-hoping relatives. It is mostly an incurable disease, and the bad cases are usually sent to asylums rather than treated at home. The interest of this form of mental disease is small when it is merely looked at as a rare psychosis of typical form ; but it is very great indeed to the student of psychiatry when, in the first place, we make it a means of studying the clinical differences in the whole brain and body state of the same patient in exaltation, depression, and sanity respectively ; and STATES OF MENTAL ALTERNATION. 223 when, in the second place, we look on it as a pathological illustration of the great physiological periodicities to whiili I have referred, and of the frequent tendency there is in nearly all cases of insanity, or at least in most of those that are hereditary, towards relapse, alternation, periodicity, or sympathy with exalted or depressed physiological function. The following are some illustrative cases of folie circulaire : — T). A., set. 49 on admission to Asylum. He had never been placed in a hospital for the insane before, though he had had from his boyhood dull times and active times, and many slighter attacks of the kind I am about to describe for five or six years previous to his admission. In one of the periods of exaltation, while holding an important position in India, h& had got two tiger cubs and tried to drive them in harness through the streets of the Residency. His education was good, his temperament sanguine. He had been reckoned proud and retiring, and he was of an old and distinguished family. In bodily conformation, carriage, and bearing he was the type of an aristocrat.' A paternal uncle, at least, had been insane, and had shown periodicity. His family had been a very artistic one, but he had never, when sane, shown any talent in that way. He had married and had children. Just before admission he had been spending money reck- lessly, proposing marriage to many suitable and unsuitable persons, getting into passions and using threats about trifles, reckless, eccentric, changeful as the winds in intention and execution. The attack was coming on, but had not come to a height till a week after a domestic loss. When admitted he was much excited and very indignant, calling on all to witness that he was illegally imprisoned, threatening the dire vengeance of the law on all who had to do with it, but in about ten minutes he was quite jolly and E^musing himself with a game of billiards. At first he was merely exalted mentally, but h^d much self-control. His excitement consisted in a constant restlessness, a perpetual twisting movement and play of his facial muscles. He could 224 STATES OF MENTAL ALTERNATION. not sit still, or read, or engage in a game for long. He talked much, but could not stick to one subject ; he was boastful in a way that was to him unnatural; he spoke of his private affairs, and would indulge in very pointed questions and remarks, without much regard to your feehngs. To a good bilhard-player, " I'll give you fifty points, and bet a pair of gloves I'll beat you. I don't want to hurt your feelings, but I suppose you know your style of play is not very fine." To a man who had been in trade, " What do you think of my stockings, Mr 1 That was in your line." He was often extremely amusing, fluent, and witty, which he had never been when well. He would rattle off Scotch to the pauper patients in the grounds, French to the ladies, and Hindustani to himself in a way he could never do when sane. In dress he was untidy, and in habits dirty. To the ladies, of whose society he was extremely fond, he was exaggeratedly polite, with the grand air of the olden time ; but if they gave him any encouragement he would soon become too familiar. He was always giving them flowers, which he had stolen, and writing them notes, or trying to kiss the maid-servants. If he had any request to make from a lady in the drawing-room, it was no uncommon thing for him to go down on one knee, with his hand to his heart, and all this done most gracefully and amusingly, as if half in fun and much in earnest. He smoked as much as he could get, and was always grumbling he did not get cigars and tobacco enough, and beg- ging, borrowing, or stealing more. He ate enormously, but not nicely, of everything that came in his way. He picked up and appropriated everything belonging to others that he had a fancy for, and did this also most gracefully, as if it was the most natural thing in the world. He was irritable when controlled, contradicted, or refused requests, and he was always making innumerable and impossible requests. He slept badly, and would, if allowed, sit up all night, or get up and move about by three or four o'clock in the morning. He was not susceptible to cold, sitting with all his windows open in winter. STATES OF MENTAL ALTERNATION. 225 He passed gradually out of one stage into another. The next stage was a more maniacal one. He dressed more grotesquely, and always wanted to put on three or four coats, vests, or trousers on the top of each other. He would come in to a dance with four vests, would go behind a door or another man, and slip one and then another off as he got warm. His habits and ways got more dirty and disorderly. His irritability took violent forms, assaulting his attendants, smash- ing furniture, &c. His conduct became so uncontrolled that he could not go to the drawing-room or to church. His whole tastes as to food were the opposite to what they were in health. He liked porridge, which he could not abide when well, and if he did not feel inclined to take it he would turn it out on to his newspaper, put it in his pocket, and eat it when he felt hungry. He would mix up soup, milk, and claret, and take them together. Scarcely anything was incongruous or disgust- ing to him. He wore his hair very short, and would singe it or cut it himself if he could get no one else to do it. He would, in playing cricket, strip himself almost naked, or put on the most ridiculous things, a woman's hat or shawl, or a cap turned outside in. He turned up at morning prayers one day in buckskin tights, a red vest, a blue cap, and black swallow-tail. His bowels were moved twice or three times a day. During all this time he was losing or tending to lose weight in spite of all he ate. He had his better and worse days all through, usually in alternation. He used to paint and draw pictures and portraits at this stage, producing the vilest daubs, spitting on the paper to moisten his colours, and using his hand and fingers to spread his paints. These he would carry in his pockets by the dozen, showing them to anyone he met — and he could pass no one without speaking. He said he had never known he could paint before. So with singing : he would sing in discord, and think he was doing splendidly. Yet with all this there never left him a certain jauntiness and grace of manner. No one, at his worst, could have taken him for anybody but a high-bred gentleman. P 226 STATES OF MENTAL ALTERNATION. As this brain exaltation came on and increased in every successive attack, each little phase, each little morbid way, such as smoking, eating certain kinds of food, cutting or singe- ing his hair and beard, painting, putting on one coat on the top of another, would recur with the regularity of the bud, leaf, and fruit of a tree each successive year. The next stage was the gradual subsidence of all these symptoms of maniacal exaltation, and a resumption of his former habits and ways and appearance. The first stage, corresponding to simple mania, lasted for about a month ; the second, with the symptoms of mild acute mania, about two months, and his recovering stage about three months, so that the whole period of exaltation lasted six months ; but he did not stop at the same stage. He at once passed into a condition of great mental depression. To see him in that, one would scarcely have known him to be the same man. His hair well grown, his whiskers trim, his features and eyes dull and inexpressive, his dress most scrupu- lous and neat, his manner distant and nervous ; in speech reticent, and never venturing a remark ; in feeling depressed, fearful, and unreliant. He thought he was so wicked that he should not see anyone. He now disliked most of the people he had cultivated during his exaltation, especially relying on the chief attendant, who had controlled him most, and whom he had most heartily abused. His habits were sedentary — he could scarcely be got to go for a walk ; his appetite was now moderate, and his tastes very particular, not being able to bear the smell of tobacco, nor to look at porridge nor messes of any kind, and most sensitive to dirt and bad smells. He became very penurious about money. He was always think- ing he was doing wrong or giving offence, and did not like company, while he was moral and very religious in his feelings and habits. His whole intellectual and affective life was far more unlike hie exalted self than one average man is unlike another. He was stationary in weight at first, but soon began to gain. He was very sensitive to cold and draughts and STATES OF MENTAL ALTEENATION. 227 loud noises, in all of which he had delighted before. He was full of a morbid sorrow and regret for his previous conduct ; but he was morbidly suspicious at this stage, and used to think that the things he had given away or destroyed during his excitement had been stolen. This condition lasted for about three months, gradually passing into one of complete sanity, without depression or elevation, but with some inertness at first, and without much capacity for business. This lasted about six months and then the signs of elevation again began. Altogether this circle of elevation, depression, and sanity lasted about fifteen months. There was no marked line any- where, though the most distinct and sudden transition was between the elevation and the depression. The development of the exaltation next time was a slow process, taking about two months before it got so bad that he had to come back to the Asylum. The sort of things he did were going out to ride at 10 o'clock p.m., never going to bed, smoking all the time, foolishly wasting his money, proposing to marry ladies and women suitable and unsuitable, sometimes two in a day, telling one, as an inducement to accept him, that if she would marry him she could put him into an asylum and enjoy his pension ! He went into a shop to buy a pair of gloves, and the shop-girl taking his fancy, he went down on his knees to her, teUing her he had fallen in love with her. His nisus generativus was always exalted during the excite- ment, but seldom assumed very gross forms. He often said that if he could be castrated he would be cured. The great difficulty at this stage was to get " facts " indicating insanity to put in the medical certificates for his admission to an asylum, for he was very acute, and knew what a doctor's visit meant quite well ! In the second circle of his disease, after coming to the Asylum, all the symptoms were similar to the first, and de- veloped themselves in the same order. The excitement was more acutely maniacal than it ever was before or has been since. The whole period of elevation lasted a year this time, 228 STATES OF MENTAL ALTERNATION. the depression six months, and the sanity six months, the circle taking two years to get through. The third circle had a period of excitement of ten months, of depression of six months, and of eight months of sanity — in all, two years. The fourth circle had a period of excite- ment of thirteen months, of depression of about nix months, and of sanity of fourteen months— in all, two years and nine months. He was out of the Asylum Kving at home, for a year and eight months during part of the depression, the whole period of sanity, and the first month of the commencement of the excitement. He did not enjoy the society of his relations during the depression, and they said he would have beon better to have been in the Asylum ; and at the beginning of the excitement, when they had to remonstrate with or control him, his affection for them ceased, and he got on worse with them than in the Asylum with strangers. He said cruel and unkind things to them. In the fifth circle the excitement lasted two years, the de- pression twelve months, and the sanity fifteen months — the whole thus taking four years and three months. In the sixth circle the period of exaltation lasted for three years, with the usual symptoms, but none of them were, so severe as they were on previous occasions. It seemed as if at sixty-two, his brain was not capable of taking on so ncute an attack of excitement, the nisus generativus not being so keen. During tlie last period of excitement ho was capable of being sooner tired, and took rest, which he never did before, and diurnal changes were very marked. He had one good and then a bad day. But the eroticism, the alertness and grace of movement, the klepto- maniacal tendencies, and all the small phases of his exaltation were still present, there being no trace of the mental enfeeblu- ment of dementia, of bodily exhaustion, nor of chronic mania. The period of depression lasted about two years, and he then kept well for a year, when at the time the period of exaltation should have come on he took a fearful attack of neuralgia in the branches of the fifth nerve, which seemed as if it would STATES OF MENTAL ALTERNATION. 229 kill liim. In a few -weeks it passed off, and lie has remained sane for two years. He has very slight and irregular periods of elevation, not of sufficient intensity to require asylum treat- ment, and it seems as if with advancing age and diminished nisus generations he has got over the disease, and will remain at home leading a fairly normal and happy life. The damage done to the organ by the previous attacks of exalted morbid energising has evidently been repaired in the intervals of sanity, during which he lays on flesh greatly. The bromide of potassium alone, and combined with cannabis indica, did not influence any of the attacks of excitement. The following is the record of a case of most prolonged, and, on the whole, one of the most regularly alternating cases of folie circulaire in short circles I have ever seen : — D. B., set. 30, was admitted to the Royal Edinburgh Asylum in 1847 without any liistory whatever, and she died in 1886. She was a person of education and intelligence, though sent as a pauper patient. She laboured under all the symptoms of acute mania at first, and in a few days it was recorded that she was "imbecile," then in a few days more that she was quite well. From that time till her death, forty years after, she had regularly recurring short attacks of acute mania, during which she was restless, incoherent, excited, destructive to her clothing, violent, and with no memory or consciousness of familiar things or persons, this lasting from a week to four weeks usually. This was succeeded by a few days of a condition with all the symptoms of dementia with a little depression, and she then became practically sane for a period of from a fortnight to eight weeks. Her circle took from four to twelve weeks to complete, enfeeblement of mind taking the place of the more usual depression. We have a wonderfully complete record of her symptoms all these years ; and though once or twice there are such entries as "She is now almost continuously excited," as in 1852 for a month or so; or " Periods of excitement more frequent, of quiet shorter," as in 1853 and in 1861 ; " Intervals of quiet longer," as in 1862, 230 STATES OF MENTAL ALTERNATION. yet the irregularities are no greater than are common in regard to menstruation in the average woman. There can be no doubt that this was an example of mental alternations governed in their times of occurrence and duration by the menstrual periodicity. For long she had amenorrhoea, but the return of the catamenia made no dilTerenco, and, move strange, the ceasing of menstruation at the climacteric made no diflference. For four years before her death the regular alternations of acute exaltation, mild stupor, and sanity were not so regular as before, and the symptoms of the exaltation were scarcely so acutely maniacal as at first. In 1883 she had an attack of severe general convulsions, succeeded by a comatose period, which seemed to come on instead of one of the usual attacks of excitement. She recovered from the excitement, and the usual alternations then went on as before. This is what constantly happens in epilepsy, the excitement being thus once in forty years " larvated." The whole case is otherwise instructive, for, though it shows the known tendency in a brain for acute excitement to exhaust and destroy the normal power of energising of the convolutions and leave that diseased mentalisation which we call dementia, it also shows this, that even severe attacks, when short, produce only a short enfeeblement, which is recovered from soon. Most instructively of all, it shows that over 220 of such attacks, continued for such an enormously long period as forty years, need not necessarily destroy the mental power of the brain and produce complete and permanent dementia. The brain in this proves the recuperative and resistive power that it shows in many other ways, if the periods of the exalted energising, or the strain, or the poisoning, or the morbidness is only short in time, and the organ gets rest between one attack and the next. Vi'e all know that periodic sprees may be continued with im- punity in many people for a lifetime, and that many men may safely work their brains at full pressure for many years if they give them a Sunday rest and an annual holiday. I had another case, a lady, D. C, who was for ten years in STATES OF MENTAL ALTERNATION. 231 the Asylum, who had all that time attacks of excitement, lasting about a fortnight, alternating with periods of depression for a week ; but in her case, as in that of D. B., the depression immediately preceded the excitement, and the periods of sanity were about three weeks' duration. But, like all the rest of the cases, the length of the periods of the different conditions was not absolutely uniform. In her case, also, the regular alternations went on up to the age of seventy-eight, when she died, occurring only in a mild form during the last six months of her hfe, when she had a broken leg, an ulcerated and sloughing ankle, and was very exhausted. But her mind was rather enfeebled during the quiet "sane" periods for the last ten years of her life, and she had sexual delusions about men wanting to seduce and marry her. The exhausting effects of the excitement on her brain, as in many of the alternating cases, were aggravated by her addiction to masturbation during the exalted. periods. I have now under my care a gentleman, D. D., aged 49, who for the past twenty-six years has been subject to the most regularly recurring brain exaltation every four weeks almost to a day. It sometimes passes off without becoming acutely maniacal, or even showing itself in outward acts ; at other times it becomes so, and lasts for periods of from one to four weeks. It is always preceded by an uncomfortable feehng in the head and pain in the back, a mental hebetude and slight depression. The nisus generativus is greatly in- creased, and he says that if in that condition he has full and free seminal emission during sleep the excitement passes off ; if not, it goes on. Full doses of the bromide and iodide of potassium have the effect sometimes, but not always, of stopping the excitement, and a very long walk will at times do the same. AVhen the exaltation gets to a height it is fol- lowed always by about a week of stupid depression. It seems as if the depression in those cases always meant a reaction after morbid over-action — a muddy mental calm after a storm, an ansesthesia after a hyperaesthesia. 232 STATES OF MENTAL ALTEENATION. In the following case the alternations hegan in old age :— D. E., set. 74 on admission, unmarried, had had several attacks of excitement in the three years previously. A sister is in- sane, and brother hemiplegic, with periodic attacks of mild mental exaltation, -which also came on in advanced life. The patient had been a staid industrious man, who had been in business all his life, and done his work well till he was over seventy, leading a sober life. He has been excited for three months. It began at first by great mental exaltation and hilarity of manner. He was very fond of the ladies, but never erotic. Especially he used to laugh most immoderately at nothing in particular, putting down his stick into the ground, and bending forward and roaring with laughter from five to ten minutes running. This had exactly the effect of a man laughing well and continuously on the stage, at a cause of which you are ignorant, — it was catching, and you could not help laughing too. This gradually passed into a stage of violence, delusions of being insulted, shouting, sleeplessness, and suspicion. During the exalted period his temperature was always over 99°, he ate enormously, craved stimulants, his bowels were moved twice a day, and he slept httle. His conduct was extremely ridiculous for an old man. His de- lusions were mere fleeting fancies and suspicions. In four months from the beginning of his attack he became depressed, and then he never spoke, looked dull and heavy, slept well and got fat, but his bowels became very costive. All his brightness and curiosity and much of his intelligence left him. He took no interest in anything. There was much of stupor in his state. He felt little mental pain. After about two months he got over his dulness, and became practically sane, cheerful, chatty, and contented. After three months of this condition, or about nine months from the beginning of the attack, he gradually got exalted, passing through exactly the same phases as before. The excitement lasted about six months, from March to December, being very mild for the last three months ; he then passed into a two months' attack STATES OF MENTAL ALTERNATION. 233 of stupid depression as before, and was fourteen months well, his whole circle thus taking twenty-two months to complete. He next got exalted in December, and was acutely excited for about three weeks only, and then had an attack of extreme stupor, depression, weakness, and prostration for three months. He then became sane, but almost at once passed into another attack of excitement. The whole duration of this circle was only four months. The excitement that followed was more acute than it had ever been before; it lasted five months, and was followed at once by great depression lasting for six months. He was then sane for three months, this circle taking fourteen months to complete. This time he became exalted in May. This circle took twenty-one months to com- plete. In December he became exalted again, his irritability being very great this time, and his hilarious happiness less marked. He remained so for nine months, and then became depressed rather suddenly, passing into a condition of nearly complete stupor, and leading an almost vegetative life. He remained so for almost five weeks, and then, without the usual intermediate period of sanity, he suddenly one night became delirious, with hallucinations of sight, but this only lasted for one day. He was after that four days depressed, and again got exalted, with more decided delusions than he had ever had before. This lasted less than two months, and he then passed into an attack of stupor again. By this time he was eighty-two years of age, and he had an epithelioma of one of his great toes, with irritation and suppuration, which acted as a drain and irritant. The toe v/as amputated by Mr Bell, and he made a good recovery, and he gained in ilesli and strength, but remained in the condition of depressed partial stupor for three years, lying in bed mostly. He would answer questions when spoken to, but never ventured a remark or took any notice of anything. He remained in this state of complete senility and mental torpor till his death at eighty-five. AVhen carefully observed his torpor was seen to be more intense at times than others, and he signed his name difierently at 234 STATES OF MENTAL ALTERNATION. dilBFerent times, showing a certain kind of passive periodicity till his death. In this case, as in most of the others that I have seen with prolonged alternations, they were irregular ; hut in him the periods of excitement always began in cold weather, from October to May. The most striking circumstance about the case is its commencement at seventy-four, after the intensity of the sexual period of life was past. It is only the third case of that kind I have known. The excitement coming on in spurts for a few days at the last attack, as if the senile brain had no longer vigour enough to keep up a prolonged exalta- tion, would seem to be one of the endings of alternating insanity. In tliefolloicing case of D. F., the attacks of excitement and tlwse of depression ceased at the age of sixty-five, after alter- nations of the tioo had lasted for tioenty years. He was an artist, but could only paint at the beginning of the period of exaltation and at the end of it. He never could finish a picture, and if he attempted to do so he got worse mentally. So long as painting was spontaneous or pleasurable he did it, and it did him no harm. If he could not catch a likeness, or tried to elaborate or paint in details, or had nothing but drudgery to do he got worse. In his case there was very marked exaltation of the memory, and his fancies always took the pleasant form of a loss of his own personal identity and the assumption of that of the author whose works he was reading or repeating. As he got better ho would tell me that he was very happy indeed as he lay awake at nights, for he would fancy he was Shakespeare, Burns, or King David, as he repeated aloud their works. He could vividly recall the events of his boyhood, and repeat long conversations he had held with his friends then. His eyesight and hearing became very acute, so that he could read small print, and paint without spectacles, and hear whispers ; while, as the exaltation wore off, he had to use stronger and stronger spectacles, and was very deaf. "When depressed, all his bodily STATES OF MENTAL ALTEENATION. 235 functions, appetites, and propensities -were torpid and sluggish. There was a difference of 2 "2° between his average temperature during exaltation and depression. There is in the case-books of the Carlisle Asylum a careful record of his condition from 1862, till his death in 1876. Mt. 54, 1862, January, exalted ; July, pretty well : 1863, July, quite well ; October, depressed : 1864, February, exalted; July, depressed; October, quite well: 1865, April, depressed; August, exalted: 1866, January, quite well, and remained so till 1867, when in July he got depressed, and in December his alternations were diurnal, he being one day depressed and the next very excited, this lasting for a month or two : 1868, July, became depressed ; October, quite well : 1869, April, depressed, and was so till October, when, instead of the usual and expected exaltation, he got quite well, and kept so for over three years, till January 1873, when he had a short attack of mild exaltation, lasting for three months. He then kept well till January 1874, when he had a few occasional days of slight excitement, at irregular intervals, and then got quite calm and rational, though not energetic, — in fact, he got into a typical and normal senile condition of mind and body, his brain remaining in this quiet haven of rest after its twenty years of violent alternations of storm and sluggishness, till he died of bronchitis in the end of 1876, at sixty-eight. In this case it will be observed that there was a distinct tendency for the periods of exaltation to occur in the early part of the year, in January and February, and the periods of depression to come on towards the end of the year, from Oclober to December. The periods of depression did not follow, but precede, the exaltation in this case, contrary to the usual experience. One should perhaps say that the excitement followed and seemed to be a reaction from the depression. The following dates of the admission and discharge of D. I. show the length of the attacks in his case, for he is sent to the Asylum whenever he gets exalted, and is sent home when the excitement passes off. He is then not very painfully depressed, 236 STATES OF MENTAL ALTEKNATION. quiet, penurious, and unsocial, sluggish for two or three months, and then gets quite sane and does his business very- well. His exaltation is of the typical kind — talkative, energetic, passionate, quarrelsome, abusive, restless, sleepless, but never incoherent, and very fond of spending his money lavishly. He once got off to London about the beginning of an attack with £1000 in his pocket, with the deliberate intention to spend it in a month and enjoy himself, as he said he had " led too quiet a hfe at home," and he pretty nearly got through it. I have reason to believe that he once made a large sum of money during one of his exalted brilliant periods, just as he was passing into the elevated part of a morbid mental circle. Hopefulness, superabundant energy, mental subtilty, argumentativeness, wildness, a strong leaning towards the other sex but not an offensive eroticism, characterise this period. The dates show the irregularity of the seasons at which the attacks came on, and of their duration. He was forty-five when first admitted, and he had had a few attacks previously. Admitted October 1866, discharged January 1867; admitted April 1870, discharged May 1870 ; admitted August 1871, discharged September 1871 ; admitted December 1872, discharged February 1873; admitted February 1875, discharged May 1875 ; admitted August 1877, discharged September 1877; admitted November 1880, discharged January 1881 ; admitted December 1881, discharged March 1882. Duration of Periods. — An examination of the exact periods during wliioh the exaltation, depression, and sanity persist, their relation to each other during different recurrences, and the sizes and regularity of the successive circles in each case, shows this far more than I had supposed previously to more exact investigation, viz., that the periods are not often always the same in the same patient at diff'erent times, and that, in fact, very few of them are perfectly regular and typical in their symptoms. I only find about one or two out of forty cases of folie circulaire that were absolutely regular. In others STATES OF MENTAL ALTEPINATIOX. 237 the periods of excitement were often twice as long in one circle as in another, and the periods of depression and sanity varied also. The age, state of the general health, conditions of life, critical periods, diet, medicines such as a combination of the bromides and Indian hemp and sulphonal, have all the power of modifying the length and the intensity of the periods of exaltation, ^\'e shall see how important those facts are, taken in conjunction with the views as to the essential nature of the alternations which I am to speak of. While a typical case of alternating insanity is not hopeful, yet, in prognosis, we must not conclude that a case is incurable merely because there are recurrences and alternations for a few months or for a year, or even for two or three years. Differences, Mental and Bodily, hetween Periods of Exaltation and Depression. — It is very interesting and most important to study minutely the exact psychological differences in the same brain when morbidly elevated, and depressed, and sane ; and it is almost equally important to compare the differences in the bodily symptoms of the two former conditions. The cases I have recorded show many of these differences and symptoms. In the elevated stage, either at the beginning or all through it, there is an actual exaltation of many of the mental faculties, notably of memory, of general acuteness and ability to reason in a way. The mentalisation is almost unceasing in some form, but the common sense is gone ; the power of self control and of carrying out definite mental work is gone ; the power of attention, while it may be very acute in some ways, is not under the control of volition ; there is often great subtilty of reasoning and a marvellous capacity to explain away eccen- tricities of conduct ; there is intolerance of contradiction ; there is a childishness of mental condition in some respects, with a foolish credulity ; affectively the patient is morbid, though he feels happy, yet his emotions are always shallow, and directed in fits and starts chiefly towards objects and persons that are present, being always weakened towards or withdrawn from their natural objects — wife, children, &c. 238 STATES OF MENTAL ALTERNATION. There is a most remarkable change in the appetites, which are usually quite perverted from what was natural to the patient. Difl'erent kinds of food, drink, and stimulants are sought for and enjoyed. The general feeling of hien-etre is exaggerated. The courage is exaggerated, and there is little caution left. There is an intense desire to attract attention. The reasonable conventionalities are not observed. There is always extravagant and morbid generosity. The social instincts are enlarged, lowered in tone, and they become somewhat pro- miscuous, a man nearly always seeking the company of his inferiors in station. In the stage of depression the natural affections towards children usually return or flow into their natural channels with much force, but the subjective feeling of the patient is one of misery and ill-being ; he has no courage, no power to resolve, no general activity of mind. In all the typical cases there is a sort of torpor and inactivity of mind, there is niggardliness in money spending, in wearing clothes, &c. There is often a feeling of profound disgust and regret at the extravagant and foolish acts of the excited period. The changes in the bodily symptoms are very marked. The patient, when exalted, loses weight ; when depressed he gains weight ; the difference in weight between the two periods beinf often two stones. When excited he takes much exercise, is restless, and never tires. When depressed ho is sluggish, and dislikes exercise, and is soon tired. In the former statre his temperature is above the normal, especially in the evenin" • in the latter below it, the average difference being \'\°, and in some individual cases 3'6°. In the former he can bear cold well, and likes it; in the latter he cannot bear cold, and dislikes it much. In the former his bowels are very regular and often moved more than once a day ; in the latter they are costive. In the former his face is mobile and expressive, and his eyes glistening; in the latter they are heavy. In the former he is always hungry, and his capacity for eating and digesting everything almost unlimited ; in the latter he may STATES OF MENTAL ALTERNATION. 239 eat well, but is very particular as to food. In the former he craves stimulants and tobacco ; in the latter he often loathes them. In the former he is not sensitive to disagreeable odours, sounds, and sights ; in the latter he is usually hyper-sensitive. In the former the skin is moist and perspiring ; in the latter it is usually dry and often hard, and skin diseases, such as psoriasis, not unfrequently appear. While exalted the patient's pulse is usually full and hard; while depressed, small and compressible. In the former the sexual appetites and capacity are always increased ; in the latter they are often paralysed ■ — one gentleman told me that for two years he had no sexual feeling or power. The sight and hearing are often much more acute in the former than in the latter. In the former state the patient sleeps little and lightly ; in the latter long and soundly. Many ordinary nervous symptoms follow the periodicity and alternation of the mental. I had one woman whose circle took about six weeks to complete, and whose period of elevation was always preceded and ushered in by severe cephalalgia and then by vomiting. I have had several women in whom the depressed period was preceded by neuralgia. Several of my patients can tell beforehand when they are going to get excited, by their bodily feelings. Katatonia. — One form of alternation has been called katatoniaby Kahlbaum. It is an alternating insanity in which there are either epileptiform symptoms or those resembling catalepsy, hallucinations of sight and hearing, unconsciousness, with trophic symptoms, such as oedema and weak pulse, these preceding or accompanying the melancholic stage. It is simply a variety of the disease in which the functions of the motor and trophic centres are specially involved. RelationsTdp to Physiological Periodicities. — I have for along time been impressed with the relationship of the mental and bodily alternations and periodicity in insanity to the great physiological alternations and periodicities, and I have gradually been led to the conclusion that they are the • same in all 240 STATES OF MENTAL ALTERNATION. essential respects, and only differ in degrees of intensity or duration. By far the majority of the cases in women follow the law of the menstrual and se.\ual periodicity ; the majority of the cases in men follow the law of the more irregular periodicity of the nimt: generatirus in that sex. Many of the cases in both sexes follow the seasonal periodicity, which perhaps in man is merely a reversion to the seasonal generative activities of the majority of the lower animals. Relapseii in OnUnan/ Iiisdiiiti/. — A careful clinical study of mental diseases reveals the fact that there nxists in the majority of all the acute c(ine,-<, at some time or other, in some form or degree, in the course of the disease, a tendency to alternation, periodicity of symptoms, remissions, or recurring relapses. I have taken the 338 cases of mental disease admitted to Morningside Asylum in 1881, — 181 of them being cases of mania, and 129 of melancholia, the rest being general paralysis, dementia, &c., — and I find that in 81 of the female cases, or 46 per cent, in that sex, and in G7 of the men, or 40 per cent, of that sex, there was relapse, alternation or periodicity of symptoms in the course of their attacks. Many of the 338 admissions were chronic on admission, so that of the recent cases the decided majority showed those symptoms. 50 of the 129 cases of melancholia, or 39 per cent., and 98 of the 181 cases of mania, or 54 per cent., were alternating or relapsing, or showed diurnal, or monthly, or seasonal, or sexual periodicity. It may therefore bo concluded that insanity in the female sex has more of this character than in men, and that the cases of mania have it to a greater degree than those of melancholia. In some patients it was a morning aggravation and evening improvement, those being usually cases of melancholia ; in a few it was an evening aggravation, those being, contradictorily, also cases of melan- choha. Very many cases of mania were more exalted one duy and less so the next ; many sleeping and waking on alternate nights, these being usually cases of mania. The attendants are very strong on this point of the "good" and "bad" days STATES OF MENTAL ALTEENATION. 241 of tliese patients, and calculate m\ich on them. Many of tlia patients had remissions and relapses of a few days regularly for a time. Some had monthly or menstrual aggravations. In some cases these periodic remissions occurred at the beginning of the attack, but in the majority towards the end of it and during the convalescence of the patient. I had a lady lately under my care, convalescing from acute mania — D. K., a strong, healthy woman of 38, who had recently recovered from a bad attack of rheumatic arthritis. First attack, duration ten days, with a heredity to insanity. She remained in a state of acute excitement for about a week after admission, getting, however, at intervals sufficient sleep and sufficient nourishment. An abatement of the disease then set in, and from that period there was a slow but steady improvement until seven weeks after admission, when she was discharged, having made an excellent recovery. The most striking feature in the case, during the latter weeks of its course, was the distinct daily morning exacerbation and evening remission. Each morning showed a distinct improve- ment on the previous morning, but a distinct relapse as compared with the previous evening, while each evening she appeared to be further on the road to recovery than she was the evening before. In the morning she would be full of doubts, suspicions, and querulousness, while the evening would find her sensible, cheerful, and grateful. The change would come on in a few minutes without external cause. Even when convalescence was well advanced, the morning was for her a period of distress and distrust, but with the evening came quiet, rest, and a thankful heart. I have now under my care a gentleman — J. M. — who for over two years has suffered from melancholia with regular diurnal changes. One day he is fairly cheerful, plays games, reads the papers and expresses no delusions. Next day he is very depressed, says he is going to die, that I shall certainly not see him again, he is suicidal, cannot fix his attention on anything, makes grimaces, and is restless. The change from the bad to Q 242. STATES OF MENTAL ALTERNATION. the good or from tho good to the bad state takes place in the evening. Such a case is merely a typo of whab is very common in all forms of mental disease, especially during convalesconco. A medical man in .attendance should always prepare the minds of relatives for this tendency to relapse and alternate. Nothing is more discouraging to both the doctor and the relations when it persists for a long time ; but it is our duty to keep up their hopes and ours, and to think of and refer to examples where the tendency has been quite got over, even after a long time. I once had a young man of twenty who took regular relapses for five years, and after that made an admirable recovery, lie has to my own knowledge done his work well and has kept well for ten years. Taking the chronic incurable cases now in the Asylum, I find that about 40 per cent, of them are subjoot to aggravations of their mental condition at times. Causation. — I find that the younger the patient the greater is the tendency to periodic alternation, remission, and relapse. The phenomenon finds its acme in the cases of pubescent and adolescent insanity. I also find that tho stronger tho heredity the greater the tendency to periodic relapses and alternations. I havo never met with a single case that could be called typical folie circulaire where there was not hereditary predisposition to insanity. It seems as if there were certain brains so con- stituted as to be incapable of energising except irregularly, swinging between elevation and depression. Tho above facts and statistics refer to ordinary remissions ; but, on the other hand, the infrequency of cases with such regular and con- tinuous alternations as to be properly called folii: cirndnire may be seen from the fact that, out of 800 patients in the Asylum at Morningside now, there are only 16 of this kind, or 2 per cent., and of the last 3000 new admissions, comprising about 2000 fresh cases of insanity, less than 10 have as yet turned out of this character. But of course I do not include STATES OF MENTAL ALTERNATION. 243 the cases witli merely long remissions, or tlie cases with re- lapses for the first year or two, or the demented cases with occasional spiirts of excitement, or the women with a few irritahle days at menstruation, though many of these are of the same essential nature as the most typical cases of foUe circulaire, following the same laws of physiological periodicity in an irregular way. Statistics. — I have had under my care altogether over forty cases of typical folie circMlaire. Of these about one-half followed a more or less regular monthly periodicity. About one-third obeyed the law of seasonal periodicity, all in an irregular way ; and the remaining sixth I could bring under no known, law, on. account of their irregularity. I had lately such a case, a lady, who was for a year deeply depressed, then for several years quite well, then, for seven years more deeply depressed, then for three months passed for sane, but was mildly exalted, then was depressed for a year, and was exalted, with all the typical symptoms of typical folie circulaire, for two years, and then, soon after passing into the depressed condition, dying of cancer of the mamma. Commencement of tlie Alternating Tendency. — There are a few cases that begin with attacks of melancholia, but in my experience at least 90 per cent, began their actual insanity with attacks of maniacal exaltation. The ages of the patients on the first breaking out of the disease, were all the way from fifteen to seventy-four ; but every one, except the one D. C. (p. 230), began within the actively sexual and pro- creative period of life. I find no record of a woman's case beginning- long after the cUmacteric period. Termination of Tijpical Folie Circulaire. — As this cannot be determined till after the patients have died, it is impossible for me to give accurate figures ; but, of forty cases, five ceased to be subject to alternation in old age after sixty ; one of these was above eighty, two being women. The men were left in a condition of mind and brain that might be legally 244 STATES OF MENTAL ALTERNATION. reckoned sanity, though in all cases there was some mental enfeeblement or a tendency to bo easily upset, with lethargy, want of spontaneity and of volitional power. One case terminated in complete dementia. Two ran on into chronic mania. Two died of exhaustion during a maniacal period. Pive things may be said about the prognosis— 1st, its utter uncertainty; 2nd, recovery cannot be looked for at the climacteric period in many cases; 3rd, about 20 per cent, may be expected to settle down into a sort of quiet, comfort- able, slightly enfeebled condition in the senile period of life ; 4th, in my experience very few indeed become completely de- mented ; 5th, the tendency to death is very slight. Oeneral Conclusions. — Looking at all those facts and con- siderations, therefore, I come to these conclusions — That periodicity, or a tendency to alternations of elevation and dc- j)ression, is a very common characteristic of mental diseases ; that it is much more marked where tliey are very hereditary than in any other cases ; that it is more common in youth, puberty, and adolescence than at other periods ; that it is in its essential nature merely the exaggerated or perverted physiological diurnal, menstrual, sexual, or seasonal perio- dicities of the healthy brain ; that the cases that have been called folic circulaire, katatonia, &c., are merely tyj)ical or exaggerated or more continuous examples of patho- logical periodicity. Another remarkable fact about the typical form of alternating insanity is, that by far the greater number of patients who suffered from it were persons of education, and far more than a due proportion of them were members of old families. I never met with a fine case in a person whose own brain and whose ancestors' brains had been uneducated. It seems to me that the tendency to alternation of mental condition, to energise at one time with morbid hurry and then with morbid slackness, is one of the forms of brain instability which specially results from too much " pure- ness of blood," or from the heredity of many generations of gentlefolks, all of whose brains had been more or less edu- STATES OF IIEXTAL ALTERNATION. 245 cated. Possibly it is one of tlie modes by which nature brings that kind of stock that has become degenerate by overbrain cultivation for many generations to an end. Real work can sometimes be done during the sane periods. D. D. has done some literary work, in the intervals of his attacks, for the twenty-six years he has been ill. "Lunacy." — I have no doubt that it was the sexual and menstrual periodicity of mental diseases, seen in so many cases, that formerly originated the absurd idea that insanity was influenced and caused by the moon's changes, and which gave it the name of " lunacy." Treatment. — The great point in treatment is to prevent the brain getting into the vicious circle of continuous alternation by endeavouring really to complete the cure in all cases of mania — especially in all cases of adolescent mania — and to enforce prolonged quiet and brain-rest after attacks in- persons who have shown a tendency towards recurrence and relapse. In them particularly the whole organism should be kept up to physiological perfection. I believe that a toon-stimulating farinaceous vegetable diet and no alcohol is the best for them, with an outdoor life and plenty of muscular exercise. A regular mode of hfe, too, without excitement, is best. One thing which I have heard recommended, and which is very liable to be resorted to in the beginning of the exalted stage, when the patient is very erotic, is marriage, but I have never seen any good come of it either by cure or prophylaxis. I once, with Dr Heron Watson, had to stop the banns in the case of a lady who had been seduced in the beginning of the exalted erotic stage of this disease, and was going to be married for her money by a scoundrel who had taken advantage of her mental condition. I mentioned in the case of U. A. that he usually proposed to many ladies at the beginning of his exalted attacks. There are only two medicines that I know which have any power of stopping or cutting short attacks, and of sometimes averting them for a long time and of even curing them, and these are the bromides, especially combined at the 246 STATES OF MENTAL ALTEKNATIOX. more acute stages with Indian hemp, and sulphonal. The following cases illustrate this action : — D. F., set. 23. This young woman has had six attacks of exaltation in four years. She had been insane for four weeks previous to admission. All the attacks had begun during menstruation, and while maniacal she was always very erotic, especially at the beginning of the excitement. She was violent, incoherent, noisy, dirty in her habits, and sleepless before admission and for about three months afterwards. She then got well, but in six months had another similar attack of mania, lasting for two months. She lost 28 lbs. in weight during this attack, and her temperature was always Ta" above its normal rate during the excitement. She remained free from excitement for nine months, and then had another similar attack. After four months of sanity she one night suddenly got up, smashed the windows of her dormitory, saying that the devil was looking in, and became violently excited, her temperature that day being 100'8°, pulse 108 and strong. She was ordered drachm doses of the bromide of potassium every three hours, with a drachm of ammoniated tincture of valerian with each dose. She was put into a dark room at her own suggestion. On the following day her temperature was 99'6°, and her pulse 108. She was still much excited, but not so much so as on tlie day before. On the second day her temperature was 99"3'', and her pulse 130 and. weak, the excitement being much allayed. The medicine was after this given only three times a day. She was left in bed for a fortnight in a dark room, as she said that if she got up she would get worse. At the end of that time she was still rambling, partially incoherent, and full of delusions, but nearly free from active excitement, and the medicine was discontinued. She remained slightly affected in mind for another fortnight. At the end of a month from the day the excitement began she was well, and was discharged from the Asylum six months thereafter. I heard that she was still keeping well a year from the time of her attack of mania, STATES OF MENTAL ALTEENATIOX. 2-47 wliich was thus cut sliorfc — as it seems to me — by bromide of potassium. I added the valerian because she was beginning to menstruate at the time the mania began. It will be observed that the excitement in this attack only lasted about three days, and she had never been less than two months excited at a time in her nine previous attacks. The excitement disappeared as the patient showed signs of coming under the influence of the bromide, and its constitutional symptoms were developed. I must say, however, such a favourable result is rare. I have now tried sulphonal in doses of from 20 to 40 grains in three cases of old establislied folie circulaire and in many cases where a periodic recurrence of excitement and insomnia seemed to be establisliing itself, and the general results are sufliciently strilcmg to have left a very strong impression on my mind in its favour. The first case of folk circulaii-e was that of D. G. A., a woman of 37 on her admission into the Asylum in 1S69. Before that she had had several attacks of maniacal excitement, and had been treated in two asylums. For twenty years she had regularly recurring attacks of intense maniacal excitement lasting from a week to six weeks, each succeeded by a week or ten days of melancholic stupor, and then by a few weeks of comparative sanity, and in- dustrious habits. The excitement was very intense, accom- panied by continuous noise, violence, tearing clothing, and unmanageability. She usually needed to be secluded in her room for a few days at the height of each attack. As time went on the attacks became on the whole longer and more violent, while the sane intervals were shorter. The bromide and cannabis mixture produced a slight diminution of the excitement, while the effects of hyoscine were only transient. The menopause produced no marked change in her condition. In tlie end of 1SS9 we began the use of sulphonal in 30 grain doses, repeated twice or even thrice a day till she got fairly under the influence of the drug, at the beginning of each attack of excitement. The result was that the attack was modified at first, and after a few months quite arrested. '248 STATES OF MENTAL ALTERNATION. Gradually one or two single doses were sufficient to stop an attack, and in twelve months the attacks ceased to recur, and she required no more sulphonal. During the year (1890) she gained continuously in weight, until she was three stones more in January 1891 than she had been in January 1890. During 1891 she kept quite free from excitement or depression, and needed no sulphonal. She was a quiet, industrious member of our community after her twenty years of recurrent excitement, but she was not sane. The disease seems to have undergone a transformation. Instead of typical /(^/t'e nirulaire it became marked monomania of unseen agency, her delusions being that when she was asleep at night men camo in and thrashed her, and almost broke her bones, leaving her sore all next day. I cannot, of course, say whether, if given in the early stage of the foUe ciirulalre, during the menstrual life, it would have arrested or changed the disease. She was so quiet and manageable that in 1894 we recommended her to be "boarded out " in the country. On leaving the Asylum she at once became violently excited, and the alternation has ,been set up again and we now find sulphonal imavailing to stop the periods of excitement though they are modified through its influence. The next case of D. G. B. was not so striking, but the effect of the drug was essentially the same, in its tendency to arrest regular recurrences of maniacal excitement. She was admitted to the Asylum in 1847, at the age of 16, and from then till April 1890— that is, for a period of forty-three years — she was subject to regularly recurring attacks of maniacal excitement, lasting from four to seven months, alternated with periods of stupor for two or three months, and compara- tive sanity for other two or three months. "When excited she could not be managed out of seclusion all day for several weeks. In April 1890, when beginning an attack, she was put on sulphonal in 30 grain doses twice a day, and after getting nine powders the excitement ceased and she became .quiet, sensible and manageable. She showed occasional ten- ■STATES OF MENTAL ALTEENATION. 249 dencies to get excited during 1890, tut one 20 grain powder always had the effect of stopping the attack. She got one such powder ahout once a month. The change in her was marvellous. In January 1891 she developed Tubercular Peri- tonitis, and died in February. Pathology. — Of all forms of mental disease this is the one ■which illustrates best the distinction — often forgotten — between the pathology of insanity and its pathological anatomy. If we can show that from any hereditary, developmental or reflex cause, or that through any undue or insufficient mental stimulus, a certain morbid mental condition is caused, if we can co-relate certain clinical groups of mental and bodily symptoms with such causes, and if we can show reason why such symptoms are associated with, and due to, morbid work- ing of the brain cortex, even though after death no abnor- mality can be discovered in any brain cell, capillary or lym- phatic, we are entitled to say that we know something of the pathology of the disease. It implies a narrow and a most un- scientific conception of mental diseases and of brain working to imagine that gross post-mortem changes are needed, to explain all cases of insanity. It is a travesty of the word " scientific " to exclude from its all-embracing range any possible aspects of the study of mental diseases, or to claim that a microscopic and morbid anatomy view is the only or the chief " scientific " mode of studying the subject. Especially is this the case when we consider our present methods and instruments for accurately investigating mind and brain and their co-relations. Can any reasonable man expect a full explanation of subtile mental, affective, and moral changes, from health to exaltation, from exaltation to depression, then to health again, this alternation going on for years with no permanent damage to mental functions, in gross cellular or vascular changes ? As regards the pathological appearances found after death in cases of prolonged alternating insanity, I found in all of them more or less brain atrophy, especially afl'ecting the convolutions, in all of them thickening of the 250 STATES OF MENTAL ALTERNATION. membranes, in many of them thickening of the skull cap. One case who had been for twenty-five years ill, showed an amount of deposit of bone on the inner table of the skull I have never seen exceeded (see Plate A'^I.). In most of them there was vascular disease, and in one or two cases local dis- integrations from embolisms and other causes of blood- starvation. In short, I found the common pathological appearances in cases of chronic insanity, but with no special pathology whatever. No doubt such a deposit as that figured in Plate VI. is secondary and partly compensatory for the brain atrophy, but, like many of the changes of structure in the bones and membranes, the vessels and lymphatics, the neuroglia, and the epithelium of the brain in chronic insanity, it is very instructive in the light it sheds on the pathology of the disease. If the intensity of the morbid action was so great even in the bones, as to cause such secondary changes, how great must it have been in the convolutions, its primary seat ! That skull cap is a vivid object lesson, which rightly interpreted, enables us better to realise the dynamic, trophic, and vascular conditions within the skull during life, at the times when the brain cells are in a state of maniacal exaltation. LECTUEE VI. STATES OF FIXED AND LIMITED DELIJSTOIT (MONOMAKIA, MONO-PSYCHOSIS, PARANOIA). " Delusion," popular and medical use of — Delusion from want of judg- ment in idiots and imbeciles — Religious Delusions, visions, voices, Lyperfcsthesia of special sense centres — Delusions from ignorance and superstition — False sense impressions transmitted to brain — Sleep and Dreaming and Nightmare — Definition of "Insane De- lusion " — Fixity or not of Delusion important — No pure Monomania — Delusional states commonly associated with some enfeeblement (Dementia) — Types most Common: Of Pride ; of Unseen Agency ; of Suspicion ; two last sometimes associated with first ; "megalo- mania" — Infinite variety of Delusions and subjects of Delusion — JfoMOOTaiim usually incurable — How it arises : 1. Out of temperament and disposition ; 2. After acute mania and melancholia ; 3. From brain poisoning by alcohol, or after traumatic injury ; 4. From perverted or misinterpreted sensations — Legal importance of De- lusion ; importance for Diagnosis and signing Certificates of Insanity; " harmless " and "dangerous" delusions. Treatment: Change ; distract mind by new ideas, new pleasures, new work ; correction of any bodily disorder, or any cause of irritation ; an asylum. Frevention : Counteract temperament and morbid dis- position by reason and good principles and habits ; suitable choice of occupation ; temperance in all things ; cheerful family life ; work body rather than brain. Paranoia: German origin of name — Want of clear definition — Variety of forms — Hereditary — Slow evolution — Abnormal reactions — Dangers — Social effects. Sane "Delusion." — The study of tliis form of mental aber- ration should, like that of every other form, be begun from a physiological point of view. There are all sorts of false sense impressions and false intellectual beliefs which are consistent with sanity and due to physiological laws. When a light is '2o'2 STATES OF FIXED AND LIMITED DELUSION. rapidly intermittent and appears to the eye to be continuous, when the sensation of the toes and their movements are felt in an amputated stump, and when one is deceived by the quick movements of a juggler, we have sense delusions produced. When through brain fatigue, brain poisoning, or disturbance of the circulation, objects are seen double; or when the old impressions on the perceptive centres of the brain are projected and appear to be seen as real objects, the true nature of which can be ascertained by the judging faculty, we have then real hallucinations, but not insane hallucinations. The whole mental life of a child in its very early years, before its senses are trained or its judging power developed, is one series of delusions. The superstitions of the ignorant are delusions, but they result from lack of training and want of development of the judging power, not from a diseased perversion of it. When, on the 2Sth February 1896, I saw a great part of the population of a Nile village turning out one night, and with frantic gesticulations, great shouting, and firing of guns, trying to frighten away a beast which they believed to be devouring the moon during an eclipse, it was an instance of a delusion of ignorance. I have heard a perfectly sane but ignorant woman in Cumberland say that every time she had sat by the bedside of a dying person, she had heard the " Death Clock " in the wall, and whenever she heard that, she knew the patient was going to die, and that as to this she had never been deceived. You meet with people who believe that certain things are going to happen on utterly absurd grounds, and so labour under delusions in a popular sense. Dreaming and nightmare give you the best idea of an insane delusion, and are the nearest physiological counterparts of it. A sufficient amount of fatigue and exhaustion from want of sleep will produce a condition in almost any brain that is closely allied to that of the monomaniac. Such "delusions" have little relationship practically to "insane delusions," however much they may resemble them in certain respects, or however much they may be psycho- logically allied to them. The delusions that are really half- STATES OF FIXED AND LIMITED DELUSION. 253 way house between those I have referred to and the true insane delusions, are the false beliefs of imbeciles, and the temporary delusions of persons whose emotions have been strongly roused by religioiis services or contemplation, so that they see visions or hear voices. The imbecile has deficient judging power from want of brain development, and often has, in addition, morbid energising of his convolutions. His delusions have often to be treated as insane delusions, as when he imagines he is married to a woman and wants to act on his belief, or when he thinks his neighbour's property is his own, and proceeds to use it. To us, as practitioners of medicine, the " insane delusion " is the one that affects the conduct or life, provided it results from a morbid condition of brain, either through mental deficiency or disease. The education, age, class, and even race, in some degree determine whether any given false belief is an insane delusion or not. The whole subject of false sense perceptions, sane hallucinations, unreason- ing " instincts " about things, is most interesting both from the physiological and medico-psychological side. Definiiion. — An " insane delusion " may therefore be defined to be "a belief in something that would be incredible to people of the same class, education, or race as the person who expresses it, the belief persisting in spite of proof to the contrary, this resulting from diseased working of the brain convolutions," Illustrative Cases. — There was once an old gentleman, D. L., a patient in Morningside Asylum, who in his manners and conduct was all that was gentlemanly, in his emotional nature was benevolent to a high degree, and in his dress and deport- ment exhibited no peculiarity whatever, but who calmly asserted that he was many thousand years old ; that he had known Noah rather intimately, and found him a most sociable man, but " a little too fond of his tOddy " ; that he once went out snipe-shooting with King David, who was a crack shot ; and one day gave St Paul a lift in his gig on the Peebles road. I once had a patient, D. M,, at the Carlisle iisylum, who was acute intellectually and morally irreproachable, but 254 STATES OF FIXED AND LIMITED DELUSIOIT. who, ever after a liemiplegic attack, believed that twice two was not four, but four and a quarter, and who spent his whole time not devoted to keeping the Asylum accounts — which he did accurately on the " old system " in deference to the steward's " prejudices " — to making elaborate calculations by his own mode of arithmetic as to the distances of the stars, a new system of logarithms, constructing new quadrants, &c. His manuscripts, which filled two large chests at his death, he solemnly left by will to the University of Oxford. In both these cases there was no trace of the morbid mental depression or exaltation that I have described. The delusions, which were perfectly fixed and unchanging from year to year during the lifetime of the patients, really constituted the insanity. They were examples, therefore, of delusional insanity or monomania. There are very few, if any, examples of a pure monomania — that is, of a person who has one single delusion and that alone. The ordinary form of this type of mental disturbance is for the delusions of the patient to refer to one particular subject or set of subjects, or for him to be morbid in a particular direction of intellect or feeling, while he is sound in most directions. The chief directions such delusions take are of unreal greatness, unseen and impossible agencies, unfounded suspicions and fears, constituting the three varieties of monomania : — a. Monomania of grandeur or pride. h. Monomania of unseen agency. c. Monomania of suspicion. Monomania of Grandeur or Pride. The Rightful King of England. — Here is a pauper patient, D. N"., who believes himself to be the rightful king of England. He looks sane, and is perfectly quiet and self-possessed in manner. He is a well-developed man, far above the average of his class in general looks and in facial expression. He told us his story with perfect calmness and coherence, rather apologetically, and saying he knew we would probably not believe him if he said he was heir to the throne. Then when he came to tell STATES OF FIXED AND LIMITED DELTTSION. 2oO about Ms betrotlial at tliirteen to Queen Victoria — I have hail a score of patients who were to have been married to Her Majesty — and Prince Albert's adroitly slipping in, he got on to ground purely imaginary and delusional. The whole story was a queer mixture of wholly imaginary premisses and much sound but also much unsound conclusions from them. Reasoning of the Insane. — Insane people generally do not reason rightly from wrong premisses, as Locke said, but some of them do. The simply delusional and the melancholic cases are usually the classes who approach nearest to this descrip- tion. It is most difficult, if you beUeved his case is incurable, to pick a flaw in the reasoning of a melancholic who says, " I am miserable and incurably ill, and shall get worse, and lose what reason I have got. I believe all such people are better out of the way. I have all my life believed this, therefore I mean to put an end to myself as soon as possible." One premiss is correct, and the other was held by him. to be so when he was quite sane, and is held by many sane people. But in the case of the monomaniac, one of his premisses-is indubitably wrong in the estimation of all sane people, but you cannot convince him of this. If twice two had made four and a quarter, as D. M. said it did, then he was quite right to have devoted every spare moment of his life to the demonstration that the world had fallen into a serious error, and to working out a new system of astronomy and logarithms on a correct basis. D. N., the king, is an excellent black- smith, and we get him to work at his trade in our shop. Nowadays we do not allow our monomaniacs or insane people generally to dress themselves or to look like what they believe themselves to be, as they did of old. The antipathy to individualism which affects society in every direction is strong in asylums for the insane. We now discourage those outward manifestations of insane delusions that used to give a lunatic asylum its most striking ■ character. The monarchs crowned with straw, the duchesses in gaudy spangles, the field-marshals with grotesque mihtary uniforms, that could be seen in any 256 STATES OF FIXED AND LIMITED DELUSION, asylums of old, you will not now see when you go througli our wards. If the man with the millions of money, who is the rightful heir to the throne, affixes the top of a soda-water bottle to the front of his cap aa a faint symbol of his position, it is at once unfastened. If the princess, who is the greatest beauty in Europe, bedecks herself too conspicuously with bits of coloured glass and in conspicuous ribbons, they are quietly removed at night. The insane man, like his sane brother, in most cases soon adapts himself to his circumstances, and submits to rule and public opinion. Half the discipline of asylums is directed against insane appearances, habits, and ways. By suggestion those would daily strengthen delusions and would confirm evil habits if uncorrected. The last of the great characters of the older period of this Asylum, D. 0., lived on into the present regime, and was allowed to wear the insignia of his rank, but I have allowed no successor to arise. He was the " King of kings," and wore a most elaborate crown of many colours, each part of which had a symbolic meaning. He was so picturesque a character about the place, and was so striking a clinical illustration of monomania of grandeur, and withal so harmless and useful in the garden, that I never ordered him to be discrowned. He had certain visions from heaven which ho reduced to concrete forms in drawings and polished stones, and his relations with Queen Victoria were most intimate. One " cloud of the Lord " which he once saw on the top of St John's Church, had taken most vivid hold on his imagination, for ho cut likenesses of it on the bark of almost every large tree in the Asylum grounds, where they will remain for perhaps hundreds of years. The tendency to symbolism and morbid outward decoration is much stronger in the Celtic races than in the Teutonic, and in the female than in the male sex. In the Highland asylums it is almost impossible to make the patients abandon their conceits in dress. Such changes have their drawbacks, for no Dean Ramsay of the future will be able to compile for us such delightful stories of our fools, and our writers and artists will STATES OF FIXED AND LIMITED DELUSION. 257 have" to look out for less striking environments for their mad- men than fools' caps and gewgaws, or chains and iilth. Hallucinations of the senses are very common in this whole class, and also delusions as to the identity of the persons around them. I have a gentleman patient who, whenever he goes into Edinburgh, meets the late Emperor of the French, or the late Prince Consort, So marked is this tendency in some cases that it might be called a special form of mono- mania, that, namely, of mistaken identity. It is well illustrated in this letter of D. 0. A. : — " JIy Dear Mama, — I have been long in answering your last kind letter, but the real reason is that I have been always so scarce of news to give you that I could never make up my mind to sit down and write ; indeed, I cannot say that I have anything to say at present. I was out on Saturday seeing Signer Bosco's magical entertainment in the Masonic Hall. I think I will just tell you all my ideas about the people here, as I do not think that they are fancies of my own. Old Captain G. , surgeon of Uncle T.'s dragoon regiment, is here ; he calls himself Dr S., but I don't mind that. " Sir J. H. is here too, calling himself J. S. ' With frisking airs Miss pussy tries the power of she's gooseberry eyes to win the heart of every swain.' He is attendant on a Mr Y. , whom I have no reason to doubt now is a brother of the operatic singer that the Duke of Cambridge shot in the theatre at Yienna. I am positive that I saw Sir A. in the Meadows without his case of false teeth. Emperor Yea of China is here too, calls himself Mr B. ; he is kept by a son of Lord C. Peter D. is head gardener here ; he, his wife and family live at the lodge at the gate on the road out to Comiston. S. D. is here on the ground ilat ; I think, when I recollect right, you put that idea into my head out at P. He is attended by Malcolm, a son of Abraham Lincoln's. He writes squibs in the papers about the ' Solo ' royal family. He gets the papers printed over at the asylum press for my use, but I never read them. Maggie F.'s brother is also one of the attendants here. Bell, the brother of the Private Bell of the 5th D. G. , is here acting as general scogey. He is the man that J. bought "Wasp from. The matron of the East House here is a sister of my attendant's ; they are both childien of Lord C. , and their mother is the cook to the East House. Abraham Lincoln's wife is here, kept by Miss D. Wilkes Booth and Miss Reynolds, Gregory, Mag Wallace and old Armstrong son is head attendant of the male wing, East House. ' ' Kind love to you all, and I remain, my dear edie, " Your most afi'ec. son, D. 0. A." K 258 STATES OF FIXED AND LIMITED DELUSION. " Am I in a trance again when I say that you really cooked and eat the meat which came oft' my head ? " But to return to D. N., who may be taken as a typical case of monomania of grandeur. His mind is not only affected by the delusion that he is king, but it is affected by a tendency to unreal elevation in all directions, and it is also now some- what enfeebled, as is commonly the case after many years of such a state. He often writes me long rambling letters, pro- posing various impracticable modes of managing the Asylum, and he is the greatest fault-finder in it. Then affectively he is different from a sane man, showing small love for his wife or children, and he takes morbid dislikes to people without real cause. He once went down to Leith to see liis family, and went to all the houses of a certain street which he imagined belonged to him, and gave the inhabitants due notice to quit at the next term ! He is, of course, very inconsistent to work as a blacksmith, he being a king ; but the conduct of by far the majority of the insane is quite inconsistent with their beliefs ; and then if he did not work, he would get no tobacco or beer to lunch, arguments that even royalty can appreciate. Sometimes the kings and cases of monomania of grandeur will not occupy themselves in common occupations. I have a " prophet of the Lord," D. 0. B., a joiner, who by no means at our disposal can be got to work at his trade. He says the Lord has set him a new work, and he must follow it. He sees visions from God all the time, which he puts down on paper, green and blue angels, sapphire prophets, &c. He will go to no amusements, nor to church. I have another man, D. 0. C, with almost precisely the same delusions — viz., that he is a " Man of God " — who is a capital worker in the garden, and enjoys a dance or a concert immensely. The mental disease in D. N. first appeared thirty-four years ago as an attack of melancholia, from which he recovered in four weeks, and the present attack began twenty-nine years ago, also with an attack of melancholia, which, as it passed away, left him in his present condition. STATES OF FIXED AND LIMITED DELUSION. 259 There is a strong heredity to insanity in his family, his brother having been a melancholic and committed suicide ; and his eldest daughter, D. 0. D., has been a patient here since she was twenty-two, being now a case also of monomania of grandeur, and believing herself to be a princess ; her insanity beginning with melancholia. She is like her father in face and complexion, but was begotten when he was sane, when therefore his disease was in him a mere potentiality. But this is often seen. That law of neurotic heredity, through which in each successive generation the neurosis appears at an earlier age than in the preceding one, was exemplified in this case, for the father was thirty-three when he first became in- sane, the brother, who committed suicide, thirty-two, while the daughter was only twenty-two. The tendency towards early developmental dementia that is usually seen in such strongly hereditary cases if they do not recover, is shown here, for along with her delusional condition she is also much more mentally enfeebled than her father, not being able to employ herself, not taking interest in anything, and having little mental vigour or spontaneity. A Distinguished Assemhlage. — In addition to the cases I have mentioned, I am able to present to you some of the most remarkable personages that have ever lived. Here is Jesus Christ, and here are the Prophet Elias, the Emperor of the Universe, the Universal Empress, the Empress of Turkey, the only daughter of God Almighty, Queen Elizabeth, four kings of England, one king of Scotland, the Duke of Kil- marnock, the inventor of perpetual motion, a man who has discovered the "new elixir of life" that can cure delusions, twelve persons to whom this establishment and all that it contains belongs, a lady who daily and nightly has delightful conversations with the Prince of Wales and the rest of the Eoyal family, a man who is to renovate humanity, and cure all our existing ills by means of a scheme he has in his head. The gentleman who has discovered the " new elixir of life '' wrote out an advertisement setting forth its infaUible virtues 260 STATES OF PIXED AND LIMITED DELUSION. that would have done credit to the most successful patent medicine proprietor. He used to make it up in the Asylum, and wanted much to try it on the patients, but none of them believed in him or would take his nostrum. But he was allowed to go out for a walk into town occasionally, being a harmless man, and I found that he iised to take a few of his bottles with him, and sometimes sold them at five shillings a piece — this monomaniac — to sane citizens of Edinburgh ! Those all are calm and cheerful people, some of them bearing themselves in their deportment and manner as become such distinguished personages, though a few do not exhibit any indications of their greatness in appearance or gait, and all are absolutely unmoved by the most conclusive argument or evidence that their ideas are wrong and unfounded. They all looked on me as the fool to be pitied or contemned, who could not see their greatness. They were all in good bodily health, and all looked as if they would live as long as any of us. Physiological Foundation of Monomania. — In considering the origin of this form of mental aberration, we see that all this imaginary grandeur and power has a physiological foun- dation in the brain- working of every man. The wildest of those beliefs are not half as extravagant as the day-dreams, imaginations, fancies, castles built in the air, and longings of nearly every man and woman. And in comparison to the imaginings or even the beliefs of a child, they are tame. Com- pared with the dreams of most men, they are very reasonable indeed. It is easy to conceive how the brain of a man with an heredity to insanity, of unstable constitution, of a proud imaginative disposition, would, when it became dis- ordered in working from any cause, readUy play its owner the trick of making him believe his day-dreams and longings to be realities. Once impair the judging power that enables us to compare and estimate facts, and we should all be kings or very great men at once. Sometimes the monomania of grandeur is combined with STATES OF FIXED AND LIMITED DELUSION. 261 that of suspicion and persecution — the megalomania of the French. Monomania of Unseen Agency. — Another marked type of delusional insanity is that of unseen agency. Such patients believe that they are electrified, that they are mesmerised, that noxious gases are blown into their bedrooms, that people speak to them and call them bad names through walls, by telephones, and out of the ground, that spirits and devils haunt them, that persons come to them at night and break their bones or ravish them, that persons read their thoughts, or have power over them to act on their thoughts. Most of those delusions imply a sense of ill-being on the part of the patient, or pain or discomfort, the origin of which they misinterpret. I had a woman who for long believed the devil was inside her. At the point where she said he was, I discovered a cancerous tumour, of which she died in a few months. This was merely assigning an insane and impossible cause for a real pain which she felt. Such cases are common. One of the most typical examples of delusions of being affected by electricity — and this and mesmerism are the two most common of all unseen agencies of which the insane com- plain — was that of a woman, D. 0. E., who at sixty-four became possessed with the delusion that people were electri- fying her at night. This idea came on gradually, with a little depression at first, until it made her life an evident burden to her, unfitted her for all work, and she accused her neighbours of " working the electricity " on her when she was sent to the Asylum. We found she had had heart disease, accompanied evidently by angina. The pain of this she attributed to people electrifying her. This continued, and got worse, till her death of the heart disease. Living a solitary life tends to bring out such delusional conditions. I have a case now with " a big serpent inside," in whom the delusion originates in angina. It is more common to have delusions, and not to be able to trace out such obvious causes as those two cases. All constitutional diseases, such as cancer, tuberculosis, rheumatism, alcoholism, 262 STATES OF FIXED AND LIMITED DELUSION. and especially syphilis, which cause brain ansemia, and local disturbances and pains, may, in a person whose brain is pre- disposed to mental disturbance, cause delusions of unseen agency. Dr Hugh G. Stewart long ago described certain syphilitic cases who imagined that noxious gases were blown into their rooms at night, or driven into their nostrils. To prevent this they stopped the keyholes of their doors at night, plugged their nostrils and ears, or wrapped their heads up. I have met with many such patients. It is evident that there is a general sense of organic discomfort in such men, which is misinterpreted into those delusions. Frequently the chronic irritation of the drunkard's stomach is attributed by him to living animals inside, or to poison. I once had a patient, D.P., who had been a great drunkard, and had had many attacks of acute alcoholism, who said he had mice inside him, gnawing and running about. He was gradually cured or recovered in about two years, under a teetotal regimen, bismuth, easily digested food, and fresh air. I give here the letter of a syphilitic case, D. Q. : "Forced dreaming, forced vomiting from the stomach, forced glut vomiting from the throat, cold shivering by the forced thinking, sweat- ing done in the same way, pains in the stomach any way they think. I think it is time that this way of punishing should be stopped, and let me know if there is anything going to be done for my benefit ; and I want to see about bad usage. I think it was time it was stopped. I would thank you to let me know the real truth. — I am," &c. This man was an old soldier, and had on admission all the appearance of the syphilitic cachexia. He used to talk con- stantly about his delusions, and was rather dangerous, but now, after five years, he never mentions them except he is spoken to about them, and in fact scarcely speaks at all. His bodily health is much improved, and he works in the garden every day. The following letter was written to me by a man, D. E. who was very dangerous indeed from his delusions, often threatening to kill me, and he afterwards said, often seriously deliberating whether he would do so or not : STATES OF FIXED AND LIMITED DELUSION. 263 "1st April 1868. " Mil Ct-ousTON, — I now take the opportunity of writing you these few lines to let you know that I am quite well in health, but you have punished me sore, and I do not know what it is for. A week or two after I came here you let me alone, and then you started and did wrong with me, and all your attendants had some stuff to stifle me with. I think it is a disgraceful affair, and John very nearly choked me. Some, too, at the table, for I think you have them put on to do so, and in the bedroom there is Adam , for I have catched him, and told him about it. On the 18th of February you crushed my breast, and on the 20th you crushed my left side in. I thought you had done for me, and on the 21st February you crushed the right side in. And the curious conversations you have been making with me at nights. It's a shame and a disgrace. You ought not to try to kill me altogether. I have stood bad treatment that would have killed ten men, and you ought to put a stop to it, for I have done no wrong," &c. Find out a Bodily Cause for Delusion. — This man, D. R., eeemed in perfect bodily health, and I could not discover any peripheral causes for the painful sensations he probably had, and which he so misinterpreted. But in every case I advise you to examine carefully into the condition and working of all the great organs and functions, the history of the patient, to find out whether there has been syphilis or rheumatism, or other constitutional disorder. Try, in fact, to discover a bodily basis for the delusions. Such delusions of unseen agency are often associated with hallucinations of hearing. Patients fancy that people whisper through floors and down chimneys. One patient I had was tormented by people speaking down her chimney, another was constantly annoyed by people talking to him through telephones, and a man who had been a heavy drinker, and had acute alcoholism several times, said he was constantly subjected to a process which he called " ric-me-tic." That persons read their thoughts and influence their thoughts are very current delusions. Patients almost always complain most of vmseen agencies at night, just as they have hallucinations most at nights when, there being no conflicting real impressions on the senses, the brain is most anaemic, and is acting at its lowest point, the season, in fact, of fears and superstitions. Macbeth during the 264 STATES OF riXED AND LIMITED DELUSION. day was a man not "taint with fear," but at night " mine eyes are made the fools o' the other senses." "How is't with me when every noise appals me ? " It is very common for women to have the delusion that they are made insensible and ravished at nights. One can, of course, more readily understand the explanation of such delusions than of others. I am told it is very common, indeed, for criminals under- going solitary confinement in penal servitude to have delusions that they are worked on by electric batteries. Their weak degenerate brains, natural suspicions, ignorance, and the occa- sional use of the electric battery to detect imposture among them, seem to account for this. I once had such a man sent from Broadmoor Criminal Asylum to the Carlisle Asylum at the expiry of his sentence, a strong, bad-looking, dangerous follow, whom we regarded as the worst man in the place. After a few months he escaped, and after being in hiding among his friends for a short time, began to work, and has remained an industrious, self-supporting member of society ever since, and that after having been for years regarded as a most dangerous criminal lunatic. No doubt, having first to secure his safety from recapture, and then to earn his own living, and being away from those whom he would consider his natural enemies, his mind would be distracted from his delusion, and it would cease to have its former power over him to influence his conduct. Pleasant Delusions. — In some few cases delusions of unseen agency are pleasant to the patient, or at all events are not complained of. Some of the sexual cases are of this character. Such was the case in the man D. S., who wrote me this letter : " Record of Miracles. — The Reverend ■ • came to see me, and his countenance changed to that of my deceased uncle • My length while in bed was increased to about seven feet, and then made norma]. When in bed a very pretty coloured landscape, including cottage and woman at her washin" tub, appeared on the wall. The picture could not have been pro- duced by the aid of the camera. P. Smith, casting a wry look at STATES OF FIXED AND LIMITED DELUSION. 265 me, jumped from the floor to a height of a foot, then passed through a framed picture without injury thereto, and through a solid 14-inch stone wall, then came throvigh the water-closet door to meet me. While peering in at the laundry windows a number of the girls' clothes flew off them while at their washing tubs, and after about half a minute's nakedness their clothes came back to them, and they were properly fastened without their aid. Near Myreside Cottage, James S., astride a thin wire fence, was seen speeding along for about 100 yards, the wooden posts forming no impediment to his ' wiremanship,' " &c. I have under my care at present a gentleman, D. T., who believes he is under the power of "an automaton,'' who con- trols him, makes him scream out, talk nonsense, break dishes, &c. He is a quiet and most courteous gentleman, who, after having done one of those things, will reply, if asked why he behaved so, in a peculiarly measured calm manner — "The automaton made me do it. I did not wish to do anything of the sort." He will say sometimes, still most calmly, "Will you write to the commissioners to remove the automaton ] I beg to renew my request of the 14th July." Monomania of Suspicion. — The third great class of delusional cases are those of suspicion. Along with the second variety it constitutes the "monomania of persecution" of some authors. This kind of delusional condition is essentially the same as the last, only it is not so great a departure from soundness of mind. Patients who labour under this form of mental disease do not attribute their annoyances to unnatural, unseen, or impossible means, but to the malevolence of real persons who plot against them, have evil designs on them, poison their food, annoy them, persecute them, prove unfaithful to their marriage vows, &c. We all know that the natural development of suspicion is very various in diflTerent people. Many people are of a suspicious temperament from the beginning, others are made suspicious by real experiences in life or by ill-health. We know that the weak are always suspicious throughout the whole of the animal 266 STATES OF FIXED AND LIMITED DELUSION. kingdom. It is the same with the liuman brain — an element of morbid suspicion exists at the beginning of nearly all cases of melancholia. Nothing is more common than for such persons to imagine that people are looking at them, watching them, and following them about. I look on this as mental evidence of an ill-nourished or anaemic brain. But in the class of persons of whom I am to speak, it is a chronic mani- festation of a disordered brain. As we shall see when I come to talk of phthisical insanity, morbid suspicion is the most constant sign of the brain malnutrition that goes with a com- bination of tuberculosis and insanity. "Joe the Tinsmith" working off a Delusion. — D. T. A. is full of suspicions, thinking that every one about annoys him on purpose. If another patient coughs, it is to annoy him ; if one spits, it is to insult him ; if one sings, the words refer to him. His career is instructive. He was a soldier, and lived hard, had an attack of acute mania, and when the exaltation and excitement passed oif, he was left in his present condition, and remained so all his life. For the first thirteen years he was regarded as a dangerous man, and it was feared to put any sort of tool or instrument into his hand, for he was the hero of many fights — in fact, fought or wanted to fight someone every day. But as he was a tinsmith originally, and I found him one day in a better humour than usual, I sent him to the tinsmith shop of the Asylum, not without fears that he might murder someone. He had just before written this letter: — "I write to you to let you know that I am much abused here by villains. I will be clear of the band of villains they have upon me. Be so good as come before they kill me. I am not able to stand death here. They have poisoned me many a time. I will not stand the bloody abuse that they are giving me. A fellow they call Hamilton (a fellow-patient who talked to himself) is abusing me most awfully," &c. With much tobacco and a little beer, of which he was very fond, and many promises that all the " villainy " would be ended if he would work well and not fight, we set him to STATES OF FIXED AND LIMITED DELUSION. 267 work. He took to it at once, worked as if his life depended on it, hammered away at tin and copper plates, making them into utensils, and evidently found much satisfaction in the outlet that unlimited hammering and much noise gave him for his muscular energy and irritated feelings. He clearly treated the tin plates as if they wore the " villains " that had been annoying him. The great difficulty was to provide him work enough, he got through it so quickly. From that day to his death, for fourteen years, " Joe the tinsmith " was one of the most useful members of our community. If he had a fight, it was usually on Sunday. He retained the delusions of suspicion, but they were not all-powerful in his mind as at first, and his countenance was less expressive of fierce passion. He got to believe that he had some friends, and it mollified him. He died of cancer in the stomach, which had caused many small secondary deposits in the brain. But apart from this there was marked disease in the brain cortex, with hyper- trophy of the spider cells and pigmentary and granular degen- erations of the nerve cells. Patients in this condition of morbid suspicion often attach delusional importance to simple acts, every movement of persons near them having to them a hidden meaning. I had a clergyman once, D. T. B., under my care, who fancied that a conspiracy had been got up against him to put him out of every curacy he had held, and to prevent him getting a living, that the bishop had been concerned in this, and of course magistrates and authorities had refused him redress. Here is part of a letter of his : — " My dear Dr Clouston, I have oftener than once heard of your welfare, which I hope will go on prosperously, so long as you are the true and faithful servant of God, though no further, as I told you. My state of outrage and wrong you know well or better than I do, for all to me is a complete mystery beyond what I do really know and have been compelled to feel. In places of this kind there is so much ' pantomime,' so I pay no attention to such nonsense. I have received no redress or improvement whatever ! ! "What part 268 STATES OF FIXED AND LIMITED DELUSION. you have taken in the wrong I am suffering you Inimo. There are and have been several nice vacancies, one of which will suit me, though any part of England, so as to be far off the atmosphere of asylums will suit me. I am in constant expectation of 'freedom,' ' compensation,' and a ' benpflce ' of my own. I have merit and purity enough for a bishop," — and so on for many pages of complaint and morbid suspicion. By the way, you will notice that ho underlines much of his letter. The late Sir Robert Christison once said to me that he could usually tell a man who laboured under insane delu- sions by the way he unnecessarily underlined his letters. Insane Jealousy. — The most painful of all the cases of delu- sions of suspicion are those where a husband becomes insanely jealous of his wife, or the -wiie, of her husband, and is sus- picious of conjugal fidelity without reason. After the full de- velopment of such a case it is easy to sec that such suspicions are insane, by the exaggerated way they are put, and by tho utter want of evidence ; but at the beginning they are most difficult and unpleasant. I have now a lady in the Asylum, D. T. C, quiet in manner, ladyhke, and almost rational, who showed her insanity first by going to her clergyman and making a confidential report to him that her husband had given her syphilis, and ho was accordingly at once summoned for ecclesiastical censure by the kirk-session of his church. Being a sensitive, nervous man, this had an extraordinary effect on him. From being fond of his wife he suddenly conceived a hatred of her, believing that it was a deliberate plot to ruin him. Though other symptoms of insanity de- veloped themselves in her, he never to his dying day could be made to believe that the syphilis delusion was any symptom of insanity on her part, but looked on it as simply wickedness. In her case the nature of her delusion seemed to be determined by the fact that she had a chronic uterine tumour, the uneasy sensations connected with which seemed to have suggested it. I was once sent for in great haste, as a gentleman, D. T. D., was said to be killing his wife. I found a STATES OF FIXED AND LIMITED DELUSION. 269 most respectable man, of first-rate business capacity, wlio had made a large fortune, and was still doing business, and wlio was reputed by the world at large to be perfectly sane, making the most, outrageous allegations about his wife, and saying she had been unfaithful to him. I soon found that those accusations were of necessity insane delusions. He had seen her wink to scavengers as she passed them. He had met her just parted from a labouring man, with whom she had had connexion under a wall, &c. I have now in the Asylum two quiet, rational-looking men, whose chief delusion is that their wives, both women of undoiibted good character, have been unfaithful to them. Keep them off that and they are rational. On that subject they are utterly delusional and insane. They, like most such cases, are incurable. The true physiological psychology of the 'married life has yet to be written. The unworthy travesty of it which Tolstoi presents in the Kreutzer Sonata is a brute, not a human psychology. As an example of a perverted sensation or a local pain causing a delusion, I had once a gentleman patient, D. T. E., with disease of the rectum, who maintained that people came at night and committed sodomy. It is not uncommon to find women of middle life with the combined delusions that certain men want to marry them, but that other people are preventing this. Clergymen are the most frequent objects of this very undesirable fancy. I have met with at least a dozen cases in all ranks of life of this kind. The subjects of it are usually not marriageable nor attractive-looking persons. I will show you a one-legged dressmaker of 40, D. T. P., with certainly no personal charms, who went to her clergyman and asked him to " proclaim " her and Mr in church. On inquiry, he found the gentleman to be proclaimed had never spoken to her. He sat opposite her in church, and she said he looked at her in such a significant way that she knew he wanted their banns proclaimed. D. T. !F. said it was all owing to a scheming neighbour that she was not married to Mr . 270 STATES OF FIXED AND LIMITED DELUSION. A morbid feeling of fear is often associated with that of suspicion, especially in the cases that have arisen out of melan- cholia. I have a patient who is afraid, if I take out my hand- kerchief, that it means something evil towards herself, who is constantly saying— "Now, doctor, I know you are going to do something to me ; what is it to be 1 " It is common for patients with monomania of suspicion to conceal their delusions, except to intimate friends or near rela- tions, for a long time, even for years, and when asked about them to deny that they believe them. We once had a gentle- man in Morningside, D. T. G., who was full of morbid suspicions, behaving that some of the people about him were other persons altogether, and that he was at times in danger of his hfe from poison. Yet for many years he never told those things to any person but one fellow-patient. Unlike the majority of such cases, he was to most persons a pleasant man ; his social instincts were strong, he was fairly happy, going all about the country on fishing excursions, and enjoying a joke and good story immensely. Before his death, when his brain disease had advanced, he was not so reticent about his delusions. I have now two patients, D. T. H. and D. T. I., who on their first admissions I had to discharge because they denied their delusions so strenuously. In fact, D. T. H. was twice discharged for that reason. Yet they both laboured under insane suspicions, that the people in their houses and the streets annoyed them, and wanted to kill them. When- ever D. T. H. got a glass of whisky these delusions at once came out. On one occasion the second medical certificate for his admission could not be got, and he was tried before the Sheriif for threatening language. I had to say that I believed him to be insane, but that I had no proofs of it from himself. That was deemed sufficient, and he was committed to the Asylum. I have another patient who has been four times in an asylum, and while there has never uttered one insane suspicion, though full of such about his wife, and really dangerous to her. STATES OF FIXED AND LIMITED DELUSION. 271 Lisane Silence. — There are cases of monomania not to be classified under those three headings. I have, for instance, a man in the Asylum, D. K. T., who for twenty-seven years has never spoken a word, but who I may say in most other respects behaves sanely, showing no symptoms of morbid pride or suspicion. He is about the best joiner we have. "We know he has a delusion which prevents him speaking, but what it is we can't find out. If he wants instructions about his work he writes, but nothing will induce him to write why he won't speak. He has never been heard to make any laryngeal noise except once, when a fellow-patient scattered some tacks round his bed, and on stepping on "the business end" of one of those he cried " Oh ! " There are certain patients, too, who simply express delusions as to the identity of those about them, without any suspicious, fearful, or persecuted feeling (see D. 0. A.'s letter, p. 257). There is indeed a great variety in the symptoms of those who labour under delusional insanity. Proportion of Cases of Monomania. — At the close of the year 1881 there were 822 patients of all classes in the Eoyal Edinburgh Asylum, and of these 87 were cases of delusional insanity, viz., 35 of grandeur, 14 of unseen agency, and 38 of suspicion. Of the 87, 48 were men out of the 421 male patients, so that the proportion in the two sexes did not differ much. There were more cases of monomania of pride and grandeur among the women than among the men — 20 to 15, while of suspicion there were 25 among the men to only 13 among the women. I found one marked phenomenon in the natural history of delusional insanity. Out of 120 patients of the higher classes socially, all with educated brains, and many of them of old families, there were 23 cases of mono- mania, or about one-fifth of the whole, while among the 554 pauper patients there were only 44 cases of this variety of mental disease, or only one-twelfth of the whole. The 158 private patients of lower social class were intermediate, and had 20 cases of monomania, or over one-seventh. It would 272 STATES OF FIXED AND LIMITED DELUSION. seem, therefore, that delusional insanity is most apt to occur in trains of the highest education. Diagnosis of Monomania. — I had a woman sent into the ■Asylum lately, who told me she was the mother of God. We had no history of the case at all. There was no general exal- tation, no excitement, and no depression apparent. Was not that a case of delusional insanity ? Not in a correct use of the term, for the woman gradually passed into an attack of simple mania, ceasing to express this particular delusion after a few days. Therefore you must always take into account the fixed- ness of the delusion or the delusional state, and the time the patient has suffered from it. Many maniacal and melancholic patients hegin by expressing a single delusion, or exhibiting a single delusional state, as the commencement of their general disease. I have met with plenty of cases, too, where, from the very sub-acuteness of the mania or the melancholia, the symp- toms of general exaltation or depression were not very evident, and a delusion stood out as apparently the disease, and yet the patient soon recovered. And as patients are recovering from mania and melancholia they often exhibit delusional conditions for a long time after the general exaltation or depression has passed off. I had a patient who had an attack of acute mania lasting for three months, and after that, though quiet, industrious, and rational on most subjects, he believed his food was poisoned for twelve months. He then gradually ceased to believe his food was being poisoned, but he believed that it had been poisoned before for twelve months longer. I classify such a case as one of acute mania, not of monomania of suspicion. A recovered patient's belief in the reality of his former delusions is not at all uncommon. A man says : "No one annoys me now, but I was subjected to persecution at home, and when first I came into the Asylum." I should not keep a man in an asylum, or count him a monomaniac, or even necessarily reckon him as legally insane, merely because he believed in the reality of his former delusions, if he hafl ceased to believe in their present existence, any more than I STATES OF FIXED AND LIMITED DELUSION. 273 should count a man. insane who could not get rid of the impression that the events of a dream had really taken place. The two chief things to be kept in mind in the diagnosis of monomania are : — 1st, not to call any disease by that name that has not existed unaltered for at least twelve months ; and 2nd, when there exists along with the delusional condition any general brain exaltation or excitement, or any general depres. sion, not to call it by that name till those have passed off. Origin of Monomania. — The question has been keenly dis- cussed whether morbid emotion or faulty cognition initiates monomania. It is one impossible of determination. I believe the affective state is always disturbed in the disease, and com- monly it is more disturbed at the beginning. I do not believe the false beliefs always arise out of the disturbed emotions, how- ever. Looked at from the brain point of view, it arises in at least four different ways in different cases. 1st, It is a gradual evolution out of a natural disposition, a proud man becoming insanely and delusionally proud, a naturally suspicious man passing the sane borderland with his suspicions. From going over our cases I find about one-fourth of them arose in this way. It is the most common origin of the disease. There is usually a hereditary predisposition to insanity in those patients. The disposition may in fact be regarded as one effect of the nervous diathesis out of which the mental disease springs. 2nd, It remains as a permanent brain result and damage after attacks of mania and melancholia, especially the former, from which the patients recover up to a certain point but no further. This is the origin of about one-sixth of the cases. 3rd, It arises from alcohoHc and syphilitic poisoning of the brain and body, from traumatic injuries of the brain, or sunstroke, or from gross lesions, such as embolic softenings. This seems to me to be its origin in about one-fifth of the cases. Such have usually the delusional insanity of suspicion or unseen agency. They are the most dangerous class of monomaniacs on the whole. 4th, Most of the remainder, comprising over one- third of the cases, seemed to me to arise either out of perverted S 274 STATES OF FIXED AND LIMITED DELUSION. organic sensations caused by constitutional diseases cliarac- torised by lack of trophic power and brain anoemia, notably tuberculosis, or out of perverted sensations from local diseases misinterpreted by tlie brain, as in the woman with cancer of stomach. Any man with an amcmio ill-nourished brain is apt to be morbidly suspicious.' Legal Importance of Inmne Deludonx. — Delusions are often of small clinical import, but they are always of the highest value as a test of insanity from the lawyer's point of view. Therefore I advise you to bring them in always, if they exist, in signing certificates of insanity, in medico-legal documents, and in giving evidence before courts of justice, iktt you must remember there are harmless and dangerous delusions ; and if a delusion is obviously harmless, and does not bulk largely in the patient's life or greatly aiTect his conduct, the law scarcely recognises it as unsoundness of mind at all. It is quite impossible to distinguish scientifically between some vain or proud men, who dress and behave in an absurd manner, but do nothing needing interference with their liberty, and the man who thinks himself the son of George the Fourth, claims property that does not belong to him, and is therefore shut up in an asylum. There are plenty of persons doing their work in the world well, and yet they labour under monomania of pride or suspicion in a mild form. The now famous case of Mr Wyld, who held an important Government office, and did his work well all his life, and yet liad laboured under the delusion of grandeur that he was a son of George the Fourth and left all his money to the town of Brighton because that monarch had been fond of that place, is one in point. Ho was held to be sane in everything he did but his will-making. I am constantly consulted by their friends about the insane delusions of persons who do not show them to anybody but ' This form of insanity has been treated of by recent French authors, notably Magnan, with extreme care. Dr John Waopherson in this country has studied it most exhaustively. Though I by no means concur in all the French views about it, they are worthy of careful study. STATES OF FIXED AND LIMITED DELUSION. 275 their near relations, and continue to do their work and occupy responsible positions. I now know in Scotland lawyers, doctors, clergymen, business men, and workmen, who labour under undoubted delusional insanity, and yet do their work about as well as if they had been quite sane, though they are not such pleasant people to have to do with, especially to their relatives, as they would have been if really sound in mind. Treatment of Delusional Insanity. — At the beginning, when there is a chance of the delusions not being quite fixed, there are two indications for treatment. The first is change of scene, circumstances, company, and occupation, which can best be got by travelling about. The mind may be sometimes diverted from morbid tendencies in that way. And, while this is being done, the second indication should be carried out, wliich is to correct and cure bodily disorders, to treat con- stitutional diseases like tuberculosis and syphilis and anaemia by suitable means, and to remove every bodily cause of con- volutional disturbance, to withdraw objects of suspicion, and to bring up to the highest possible mark the nervous and bodily tone. By this means there is no doubt that some cases, especially those characterised by morbid suspicion, can be cured, even after they have existed for years. I have even seen a marked case of monomania of grandeur get better. A man who for more than a year fancied himself the Duke of Kilmarnock got quite well, through improvement in his bodily health and working in the Asylum garden. Especially the alcoholic and syphilitic cases are hopeful at first. Potassium iodide acts like a charm in both kinds of cases at times. But for the confirmed monomaniacs of all sorts, who will insist on carrying out their ideas, an asylum is the only possible place of care. Dr Charles H. Skae cured a case of monomania of suspicion, caused through an injury to his head, by trephining. Prognosis.— The prospect of recovery is certainly very bad in cases of delusional insanity that have lasted for over a year, but one is surprised sometimes by occasional recoveries after many years. There is a tendency to mental enfeeblement as 276 STATES OF FIXED AXD LIMITED DELUSION. time goes on. Some cases end in complete dementia after a few years, and in most the intensity of the conviction of the delusion, and the aggressiveness with which it is put for- ward, tend to diminish as time goes on. Many monomaniacs live long, but the cases of morbid suspicion mostly die of phthisis. Prophylaxis. — I think something can be done, in those who are predisposed towards delusional insanity by their nervous diathesis and hereditary predisposition to the neuroses or to consumption, or to both, towards counteracting the morbid disposition. While the reasoning power still holds its sway it may be used in deliberate attempts to reason a man out of hin morbid tendencies. I think I have seen a man in this way, and by not allowing himself to dwell on morbid thoughts and feelings, keep in check a morbid disposition. Good principles and good habits of life help greatly in the same direction. Occupation may be helpful, too, in counteracting it. I have often seen monomania of suspicion arise out of a suspicious reserved temperament in young men through the thoughtless and cruel small persecutions and annoyances of fellow-clerks and fellow-workmen. It is from this exciting cause chiefly that hunchbacks and deformed persons are so often suspicious, irritable, and misanthropic, the predisposing cause, no doubt, being their developmental neurotic weakness. Human nature is not tender or considerate towards such weaknesses. I have seen a proud disposition become a monomania of pride through the injudicious pamperings and foolish adulation of female relations, and the encouragement of such a person in occupations and schemes beyond his capacity or means. No doubt temperate and systematic habits in all things are very prophylactic for the kind of brains I am now describing. I think I have seen cheerful family life cure a commencing delusion of suspicion. Association with thoir fellow-men is good for all persons predisposed in this way, provided they can get suitable company to associate with. To be suitable, it needs often to bo opposite and complemental. In all STATES OF FIXED AND LIMITED DELUSION. 277 persons predisposed to delusional insanity the social instincts are apt to be rudimentary and need development. In some of those who show their morbid tendencies at an early period of life, they can be prevented, the brain being still plastic. PAEANOIA. There has been of late years in Germany a decided tendency to discard the conditions of fixed and limited delu- sion, such as I have described, as a distinct form of mental disease, and to substitute for Monomania the term Paranoia, not as covering the same ground, but as including most cases of monomania, and some others that would have come under impulsive insanity, or under mild dementia, or even under simple mania. It is exceedingly difficult to define paranoia as the term is used in Germany, and now largely also in America. As yet it is clear that different authors understand by it different things, but taking the sense of the majority of them, I think the following may be accepted as a short description of the condition. It always occurs in persons in whose brains there is the potentiality of mental or nervous disease through hereditary predisposition to the psychoses or the neuroses. It is, in fact, a strongly hereditary insanity. It evolves slowly without an acute first stage. It consists, in fact, of a slowly developed change from the normal mental state of the individual, and most commonly in the direction of elevated ideas and exaggerated self-importance. Sometimes the change is towards morbid suspicion and sensitiveness, this often going with the elevated ideas. Sometimes the sexual instincts are changed or perverted, constituting the " sexual paranoiac " who has attracted such an amount of morbid attention in Germany. The conduct is always afi^ected, but not necessarily at first taking the form of actually insane action. Queernesses, oddities, impracticability, insensibility to the motives which ordinarily influence humanity — o 278 STATES OF FIXED AND LIMITED DELUSION. abnormal mental roacUon, in fact. The reasoning power cannot correct obviously mistaken conclusions, and cannot be trusted in regard to any subject. The hereditary social instincts and the gregariousness which seem to bo the chi(^f factor of the solidarity of human society are weakened, and gradually become perverted. Hereditary morality, probably the strongest ethical force, is weak in its power over conduct, or assumes perverted and diseased shapes. The instincts, appetites, and propensities are disturbed or perverted. The affective nature is always changed. No paranoiac loves his wife, or his brethren, or his friends in the right and normal way. His affectiveness takes strange and often a-social forms, so that instead of holding together and upholding the family and the state, it is disruptive in its effects. The moral sanctions and the affective drawings of the paranoiac do not tend towards social cohesion, but destruction. The man of the "insane diathesis," as described by Maudsley, is a para- noiac in its early stage; later on he develops delusions, but not always fixed or organised dohisions. He often commits crime, thinking it a virtue, as Guitcau did when he murdered President Garfield who had done him no harm whatever. Still later the paranoiac often sinks into mental (infooblement, not of the complete kind, but often enough he livt^s out his life without thus mentally dying. King Louis 11. of ]5avariii,' was a typical case of paranoia, all the symptoms of the disease being developed in exaggerated forms through his autocratic; position and command of money, and brought out vividly through the "fierce light that beats upon a throne." In him there appeared to have been sexual perversion of the most abominable description. This unsavoury subject and all that relates to the pathological manifestations of the generative nisus have recently been very fully — far too fully, I take leavo to say — treated by Krafft-Ebing and Schrenck-Notzing in Germany. In this country we rarely see such cases as are ' See Dr Ireland's study of him in liia delightful series of Studies in rsychuluiiy and llislory — "Through the Ivory (!ato." STATES OF FIXED AND LIMITED DELUSION. 279 described in such repulsive detail by those two authors, and I think it is better we should not look too closely for them. The whole subject of paranoia is allied to the "degeneracy" and the "hysteria" which Max Nordau so vividly describes as influencing our present-day i literature and art. ^ Degeneration, by Max Nordau. LECTUKE VII. STATES OF MENTAL ENFEEBLEMENT {DEMENTIA, AMENTIA, PSYGHOPARESIS, CONGENITAL IMBECILITY, IDIOCY). Physiological weakness of mind ; Cliildhood and Dotage —Weakness of mind in ordinary bodily diseases from Starvation, Exhaustion, ex- treme mental efFort and tension, or emotional shocks — Delinition of true Dementia ; symptoms negative— Enfeeblement general, but not uniform, of all the faculties and mental powers — Originating mental power first and most markedly alfooted — No line of demar- cation between Sane and Insane weakness of mind. Varieties — (a) Secondary [Terminal] Dementia: The most common, important, and characteristic Dementia of all ; The natural termination of all Insanities, if recovery or death do not occur ; acute Insanities tend most towards it, especially acutely maniacal states — S. Dementia. Pathologically considered weakened trophic and functional state of a delicate structure (originally unstable), commonly following morbid over-action — A typical case ; clinical features ; heredity ; acute mania ; non-recovery ; changes in expression of face, of tastes, habits, volition, judgment ; moral faculties ; affective nature ; memory ; silliness ; a mental death before the rest of the body dies— Re-education of brain ; limits ; bodily health often good; long life — [Varielies) Things lending to Demciiiia ; (1) Occur- rence of primary attack during adolescence ; (2) long duration of attack ; (3) acuteness ; (4) many previous attacks ; (5) heredity very strong. If 1, 2, and .5 are all present, risk very great, Treat- ment — Dementia in rare cases comes on gradually without acute insanity or other known exciting cause. Milder forms of mental weakness, mental "twists," and changes, often follow attacks of insanity and apparent recovery— Temporary states resembling De- mentia and Stupor that are recovered from after acute attacks of mania— (6) Primary Dementia: Congenital Imbecility, Idiocy, Amentia, Cretinism. Ireland's classification— Genetous Idiocy Eclamjisio I., Epileptic I., Paralytic I., Inflammatory I., Traumatic I., Microcephalic I., Hydrocephalic I., Idiocy by Deprivation, STATES OF MENTAL ENFEEBLEMENT. 281 Cretinism— (c) Senile Dementia : Kinship of this to Secondary Dementia. Special Characteristics : Irritabil ity ; loss of memory ; sometimes follows Senile Mania and Senile MelancJiolia — {d) Organic Dementia : Results from Softenings, Apoplexies, Tumours, and such gross Brain lesions — (e) Alcoholic Dementia : The judging faculties, the emotions, the volition, but especially the memory, weakened by continuous alcoholic poisoning, commonly with irritability. We iise the term " mental enf eeblement," not in its wide and popular sense, meaning any mental weakness or disease what- ever, but in a special and scientific sense. It may be defined as "a general weakening of the mental power, comprising usually a lack of reasoning capacity, a diminution of feeling, a lessened volitional and inhibitory power, a failure of memory, and a want of attention, interest, and curiosity in a person who had those mental qualities and has lost them, or has come to the age to have them and they have not been developed." There are two great physiological periods of mental enfeeblement, viz., in childhood and old age. Consider the condition of a child of two as to reasoning power. There are many words indicating a lack of mental power that have two meanings, a pleasant or an unpleasant one, according as they are used in reference to a child whose mindlessness is physiological or to a man in whom it is morbid. Wliat more charming than "prattle," " artlessness," "childishness," " innocence," as applied to a child 1 But, said of a man, they mean "chatter," "silliness," "lack of sense," or "a want." If the brain development is arrested before birth or in child- hood we have congenital imbecility and idiocy — amentia. Dotage must be reckoned as natural at the end of life. It is not actually the same as senile dementia, but there is no scientific difference. Mental enfeeblement, both in judgment, feeling, memory, and volition, frequently occurs in and after bodily diseases, especially after fevers. It always occurs in the process of death by starvation. It frequently is seen after the exhaustion of long journeys, great exertions, severe campaigns, and great mental tension, strains, or efforts, such as business crises, sieges, &c. It sometimes occurs after 282 STATES OF MENTAL ENFEEBLEMENT. sudden or great emotional shocks, such as loss of children. Now, in all these cases the actual psychological condition may be the very same as in patients labouring under mental disease proper, or technical insanity. Yet we do not practically reckon them in that category except they are unusually severe or very lasting. The student of brain function and medical psychology, as well as the practical physician, finds a study and comparison of those conditions of mental enfeeblement most profitable. Degrees of Enfeeblement. — The conditions of mental enfeeble- ment that are ordinarily reckoned among mental diseases may exist in every possible degree, from the merest dulling of the keen edge of certain mental and moral faculties up to complete loss of intelligence, feeling, and memory. One man may be just so much altered that his friends say — " He is not the same man he once was," and another may not be able to comprehend or answer the simplest questions or to recollect his own name. A clever man may be left in such a condition that in his slight dementia ho is more intelligent than another stupid man. A man may, while he is not energising mentally, seem as other men are, or as he once was, but, when he comes to think, or act, or work, it is seen that he cannot do so as before. In most cases all the mental faculties are enfeebled together, either equally, or one suffering more and another less. In a few cases some mental faculties are left almost intact, while others are almost destroyed. I have a patient now whoso brain was once a very energetic and subtle one and his memory extraordinarily retentive, who talks quite rationally on all kinds of subjects if they are suggested to him or if you "draw him out," and who argues most correctly, but who never originates anything is utterly helpless in action, and who cannot tell you the day of the week or what he had for breakfast ; this condition being the result — a common one — of many years of alcoholic excess. The originating power of mind, spontaneity of thought and feeling, active vigour of will, that highest quality of all, are always diminished or lost in dementia. I know a STATES OF MEXTAL ENFEEBLEJIENT. 283 man who when well always impressed those with whom he came in contact as being a leader of men, and who now, after an attack of mania, has lost the power of producing that impression. As one of his friends said to me — "I was always afraid of Mr , and never could be famihar with him. Ifow that's gone." Pathologically and psychologically the mental state of such a man is the same in kind, if not in de- gree, as the absolute dement of asylums. Yet, of course, the degree makes a great difference from a legal and social point of view. One man's mind may be slightly weakened and yet he may enjoy his personal freedom, and another man who is a little more affected has to be deprived of this ; but there is no line of demarcation, and no test to distinguish between technical sanity and technical insanity in dementia. It must be remembered that in all insanity there is an element — often a strong one — of mental enfeeblement pure and simple. Most cases of exaltation have enfeeblement of judging power as well as of feeling. Many cases of melan- cholia are enfeebled as well as depressed. It is the prevaUing morbid condition that determines the name we give the disease. A typical case of complete dementia is one affected as tliitf young man, E. A., w. As he came into the room his walk was hesitating, almost shuffling, and you see his bodily attitude is one of diminished muscular and nervous vigour. He stoops, his face is vacant-looking, he has no curiosity as to where he is coming, or as to what I am saying about him ; when I ask him his name he teUs it, but cannot tell the day, or month, or year. In asking him questions, I have to adopt means, by speaking loud and sharply, or by patting his arm, to rouse his attention to listen to me. His mental operations are slow as well as weak, for it takes his brain long apparently to take up impressions from the senses, and still longer to evolve the outward process of speech in response, his mental reaction- time being, in fact, very much prolonged. When I ask him, " "Where were you born?" he says, after a minute, " Oh yes, I 284 STATES OF MENTAL ENFEEBLEMENT. think so." When I ask him "Who is that?" pointing to a student, "That's my Uncle John." "What place is this you are living in?" "I don't know." "Did you ever ask any one what place it was?" "Yes." "Are you sure?" "No." "How long have you been here ? " " This morning." (He has been here six years.) He cannot reason, he has almost no affections, caring for no one, showing no pleasure in seeing his relations. He has no wishes, hopes, or fears, and little memory ; ambition, joy, and sorrow are dead to him. He does not resist anything, and has no choice as between any two things. He has no fineness of feeling, no "tastes." His habits would become dirty and degraded if not looked after. Looked at from the purely bodily point of view, he has no keen appetite at all, even for food, for he has been several times forgotten in the garden over meal times, and hunger did not bring him to dinner. He has no proper sexual appetite, though he masturbates in an automatic way. His temperature is about a degree and a half below the normal, his circulation poor, his hands blue and cold in chilly weather, his muscles flabby, his common sensibility much diminished, for you see pricking with a pin does not rouse him much. Ilis digestion and the action of the bowels are good and regular, and the sleep power of his brain is perfect, in fact he would sleep too long if allowed to. There is a good deal of flabby fat on his body. Sores are slow in healing, and when he catches cold he scarcely ever coughs, though there may be much bronchial catarrh. The reflex action of the cord is diminished, though the tendon reflex is normal. Last of all, that power of action and power of co-ordination of those marvellously innervated strands of muscles in the face that give " expression " to the face seem to be utterly dulled and diminished, and the eyes are also expressionless. It is clear that all the highest qualities of his brain are gone, and that even the lower qualities are much enfeebled. He is now demented ; but ho was once an intelligent educated man, who had an attack of acute mania, and was left, after that had passed away, as you see him. STATES OF MENTAL ENFEEBLEMENT. 285 There are five chief kinds of dementia : — 1. Secondary {Ordinary or Sequential or Terminal) Dementia, following mania and melancholia or other insanity. 2. Primary Enfeehlement {Congenital Imbecility, Idiocy, Amentia, Cretinism), the result of arrested brain development, or of brain disease in early life. 3. Senile Dementia. 4. Organic Dementia, the result of gross organic brain disease. 5. Alcoholic or Drug Dementia, following the long continued excessive use of alcohol, or of neurotic drugs such as opium, cocaine, chloral, &c. As the last three varieties will be de- scribed under the headings of the senile, paralytic, and alcoholic insanities, I shall not further refer to them here. I have purposely omitted a variety which you will find in all the text-books — "Acute" or "Primary" Dementia — because I think this is a misnomer, and leads to much con- fusion, besides being an unscientific nosology. I prefer to classify " Primary Dementia " under Stupor. As every variety of real dementia is incurable, and as the medical profession outside of public institutions has little to do with its treatment, I shall devote little time to it. Secondary Dementia. — This always follows, and is in a way "the result of " more acute mental disease, such as mania and melancholia, and therefore may be called sequential. It is the most characteristic, and the most interesting to the psychiatrist of all the forms of mental enfeehlement, so that when you hear of a person labouring under dementia it is usually this that is meant. It is dementia par excellence, therefore. It is the goal of nearly all iasanities that are not recovered from. When any condition of morbid mental exaltation, especially acute mania, has existed for a long- time, we find that the over- action usually causes a tendency to mental weakness as the exaltation passes away, and this in some cases is left as a per^ manent brain condition. This is dementia. The same tend- 286 STATES OF MENTAL ENFEEBLEMEXT. ency is seen, but to a less degroe, as the result of a prolonged condition of mental depression. This is the termination we most of all dread in acute insanity. All mental diseases when long continued tend towards dementia. AVhen the matter is looked at pathogenetically it might be thus stated. For the production of most cases of mental disease we need a morbid neurotic heredity, or prolonged causes of irritation or exhaustion. Then comes an exciting cause of disturbance from without or from within, mental or bodily, strong enough to convert this tendency, this potentiality into an actual disease; or this occurs in the ordinary course of the development, evolution, or dissolution of a liereditarily weak lirain, and a severe out- burst of abnormal action occurs in the, brain convolutions. The chief symptoms of this are the maniacal exaltation or the melancholic depression. The abnormal action means abnormal nutrition as well as abnormal energising. This abnormal nutrition tends injuriously to affect tlie minute and delicate neurine structure, the capillaries, tlie lymphatics and the packing tissue of the grey matter of the, convolutions. It even affects, as we have seen, the structure of the surround- ings of the brain, — the pia mater, the Inrge vessels, the arachnoid, the cerebro-spinal fluid, the epithelium, the dura mater, and the calvarium. "When this storm of morbid action at last passes ofl' or exhausts itself, the neurons in some cases have become so damaged that they are no longer fit to become the vehicles of normal mentalisation — their nutritive, their storage of energy, their receptive, their constructive, and their productive power being impaired, nic.fcabolism, anaboliam, and katabolism being all abnormal in them. Dr Macphail has shown that the constitution ^ of the blood is altered in dementia. The mental result of all this is enfecblement or dementia. Somewhat analogous damage to function occurs in coarser forms in all the coarser tissues and organs, e.g. the permanent damage to locomotion that results from long- continued rheumatic inflammation of a joint, to digestion from ^Jour. Mcnt. Sci., Oct. 1884. STATES OF MENTAL ENFEEBLEMENT. 287 prolonged over-stimulation of the stomach, to sight from the intense lights of the desert or the Alps, to hearing from the continuous clang in an iron sliiphuilding yard. You must always remember, however, that from the very beginning there was probably a tendency through a bad heredity towards that weakening of the mental functions of the brain which we call dementia, towards mental death in fact; and there are many cases where the previous excitement was so slight or so short that we must conclude that the essential nature of the mental disease was the tendency to dementia from the beginning. And it is useful also to keep in mind that there are brains of such quality that they may have repeated attacks of acute excitement yet never sink into enfeeWement. The follmoing is another typical case of secondary demetitia : — E. B., a handsome, well-developed, intelligent, well-educated young woman, whose mother was insane, her sister a woman that "no one could live with," and a brother a confirmed drunkard, had, at the age of twenty- four, a cross in a love affair. At first she was depressed in spirits for a few months, then she took to a morbid eccentric religionism, and in six months became acutely maniacal. She remained so for a year. At the end of that time her whole appearance and expression of face were so different from the attractive girl she had been that her friends scarcely recognised her to be the same person. Her face, that " mirror of the soul," expressed no doubt the fancies and the passions that were evolved in her morbid brain, but there was also a vacancy and a physiological degra- dation very manifest. About that time she began to sleep better, then to eat better, then to talk and scream less, then to be able to sit still longer and control herself more. This process of gradual quiescence went on for six months, with occasional spurts of exaltation and short relapses into active mania. By that time she was getting fat, sluggish, devoid of interest in anything, and with no emotion. She did not ask for those who had been dearest to her, or exhibit any pleasure when they came to see her. She often laughed, and talked '288 STATES OF MENTAL ENFEEBLEMENT. to herself. Her speech and conduct were best described as very " silly." Her memory seemed gone. All that education had done for her brain seemed to have disappeared, or could only be brought out in disjointed incoherent scraps. The nameless charms of dress and manner and behaviour of a bright young lady had absolutely disappeared. She was slovenly and not over cleanly, showed few likes or dislikes, and no will of her own. Her face was vacant, her eyes e.xpressionless, her motions slow and wanting in purpose and vigour, and her nutrition flabby. She slept well, she ate very well but with little choice of foods, hor digestion was good, her bowels regular, and her menstruation, whiuh had ceased during the whole of the maniacal jjoriod, became regular. She is in fact dead to mental life in any proper sense, and so has remained now for many years, and so will remain till she dies of some disease that will not necessarily be a brain disease at all. Her chances of life are probably below those of a sane person at her age, but she may live long. These are the cases that form the bulk of the old inmates of asylums, and about whom their friends say they seem to outlive all their sane relations and friends, because they are free from the worries and cares of life, and live a regulated existence under medical rule. In certain things E. B. did improve after the first two years. Her brain was subjected to a re-education of a simple kind, but its capacity for this was limited. It had no power of acquiring any sort of high attainment in anything. She was taught to dress herself more neatly, to do a little simple work, to observe certain hours for meals, &c. Curiously enough certain mechanical achievements in which she had been well educated, so that they had become the automatic property of the motor brain centres, came back to her easily, and were well done. Such were certain kinds of ladies' work and sewing. It was found she could play some of her old tunes on the piano, but the music was mechanical. All the life and soul was out of it. She could not be taught the simplest of STATES OF MENTAL ENFEEBLEMENT. 289 new tunes, no new stitcliing, no new dance steps. Every now and again she has a slight return of the maniacal exaltation, beginning usually at a menstrual period, and at the very beginning of one of these she will look and act more like her sane self than at any other time. She is placed under the control of social inferiors, and she does not resist. She lives in the Asylum, and she does not ask why. She has no money, and she does not seek it. She forms no attachment, and she associates with strangers without feeling it. Varieties. — This is the type of all the cases of secondary dementia in its causes and symptoms. But there is, of course, great variety in the details of the clinical pictures. Attacks of melancholia may be followed by dementia, but this is not nearly so common as in the case of mania, except in certain senile cases. Nothing more conclusively shows that conditions of depression are essentially less profound departures from mental heath than conditions of exaltation, than the lesser tendency to dementia after the former. "When it does occur it is a less complete dementia than occurs after mania, and is nearly always tinged with a melancholic cast. Out of 100 cases of dementia taken at random, whose histories I know, only 20 followed melancholia. All sorts of partial dementia occur. I have many patients in the Asylum who look like other people, who converse with you rationally when you talk with them, and have no delusion, but they have no initiative, no origi- nating power, no active desires, no power of self-guidance or resistive capacity. I sent such a man out of the Asylum lately, and he just sat down at home, would not work, would scarcely get out of bed, cared nothing for cleanliness and the decencies of life, and only earned ten shillings the six months he was out. Some persons in this state do some work in the world outside under suitable, interested, and kindly guidance. Sometimes a man is left after a maniacal attack mentally twisted, or has a curious mixture of enfeeblement and obstinacy. I know a gentleman who once had an attack of mania, and who now shows a mild dementia chiefly in either defying or being un- T '290 STATES OF MENTAL ENFEEBLEMENT. conscious of the conventionalities of life. He goes about the streets often in a dressing-gown and slippers, he pays no defer- ence whatever to ladies, he eats at irregular hours, is "never to he depended upon " in anything, and yet he manages his affairs and seems happy in a way. In some cases a man shows mild dementia by slight degradations in his habits and feelings. I know such a man who is simply not so sensitive as he once was, not so particular in small things, is content with worse- fitting clothes, and is not so neat and clean in his ways. I know another case where it shows itself by what his friends call excessive laziness. He will not walk or work, or do any- thing, in fact, but sit in the house and smoke. I know many cases where it shows itself in deficient inhibitory power over the appetites, the patients taking to drinking and sexual im- morality. Indeed one might say that the " moral faculties " — if by these are meant the combined feeling of repugnance to what is wrong and the power to avoid it— are the first to be affected in dementia. Such high moral attributes being the last to appear in the evolution of man, are, as Dr Savage rightly puts it, the first to disappear in certain morbid mental states. In other cases the patients simply sink into a lower social stratum, and evidently are more happy there than in their own. Such cases are commonly reckoned as being examples of mere eccentricity, but they are scientifically cases of partial or limited enfeeblement of mind. Things that are of the greatest [importance in relation to secondary dementia. — 1. The period of life during which the primary attack of mania or melancholia occurs is, in my opinion, of primary im- portance. Much more than half of all the terminal dementia follows the insanity of adolescence. 2. The risk of dementia is in certain cases in direct ratio to the length of the maniacal exaltation. This does not quite apply to melancholic depression, the existence of which for long periods is not so damaging to convolution function. Beyond a doubt there are some cases that become demented STATES OF JfENTAL ENFEEBLEilENT. 291 after only a few weeks of maniacal excitement, when in fact it is clear that the tendency to it was present from tJie beginning, and. when it was an inevitable doom of their brains. These are the brains which seem to have innate energising power in them to last only for so many years, and then they fail and die as to their higher mental functions. Of course, it may be asked. How do we know that this is not the case in all those that become demented, without reference to the preceding mania at all? May not the mania simply be one incident on the road to mindlessness, and not the cause of the latter at all? I am convinced this is so in many cases, but the facts of a great number of cases make one conclude that a maniacal attack does tend to damage the brain convolu- tions, and that the longer it lasts the more likely is that damage to be permanent. There are exceptional cases, how- ever, that are maniacal for years and yet recover. 3. The character of the primary attack influences the tendency to dementia as well as its duration. The more acute the attack the greater tendency there is to subsequent mental enfeeblement. But to this rule there are many exceptions. I have now a case, quite demented, where the primary maniacal attack was very mild, — only amounting to simple mania, and that lasting but for a month or so. Then enfeeble- ment showed itself, and slowly progressed, till in four years there was deep dementia. I have even seen a few cases where a mental enfeeblement began ab initio without mania, without melancholia, without gross organic disease or epilepsy or alcoholism. Such cases are very rare indeed, however, but of profound interest. We can usually get evidence of some symptoms of mania or melanchoUa if we have the means of ascertaining correctly the patient's state. The habit of masturbation may cause dementia as a primary mental disease in young people with a strong neurotic heredity, with- out preliminary mania, and the continuous abuse of alcohol or nervine stimulants or sedatives may have the same effect. 4. The number of previous attacks is no doubt of much 292 STATES OF MENTAL ENFEEBLEMENT. importance in the preliminary history of dementia, except in the case of those typical examples of alternating insanity called foKe cirr.ulaire which I have described. The case of D. B. (p. 229), whose brain had over two hundred attacks of acute maniacal excitement in forty years, and yet did not become wholly demented, was a most striking example of the recuperative power of the brain cortex. Speaking generally, the tendency to dementia increases in each successive attack. The relapsing tendency of adolescent insanity is to my mind an illustration of the two inherent tendencies in such brains, — the one to mental recovery and life, the other to mental death. And we notice that the sooner the relapsing tendency stops the more likely is the former result to occur. 1 1 often happens that after a first attack of insanity certain mental peculiarities are left, seen it may be only by the patient's near relations and intimate friends. He is not " quite the same man." Each succeeding attack that he has leaves him with more marked peculiarities or weaknesses, until the final irre- parable breakdown of dementia is reached. You will con- stantly be asked your opinion of a man who has once boon insane, to hold appointments, to accept trusts, to contract marriage, &c. One must frequently give a guarded answer, and this not only after a personal examination, but after minute inquiry from disinterested friends who have seen most of him. I find it often more difficult to pronounce a man sane than to pronounce him insane. There is no doubt that a man may fully and perfectly recover from attacks of insanity. They may leave nut a trace behind them in any shape or form. I could point to hundreds of men and women who have becu insane, and who now do their work as well as ever they did. It is a grave injustice to regard all men who have been insane as tainted and unfit to hold appointments of trust, though this is unfortunately a common prejudice. There is a risk, no doubt, but it would be indeed a terrible thing if mental diseases were regarded as necessarily implying an incurable mental deficiency or a relapse some day. STATES OF MENTAL ENFEEBLEMENT. 293 5. The next element that affects the occurrence of dementia, and that we have to take into account, is the heredity of the patient. The common opinion undoubtedly is, both among the profession and general public, that a strong family pre- disposition to insanity means a bad chance of recovery in any particular attack, — in other words, a tendency to dementia. Now this is not true as a matter of fact. Strongly hereditary cases are the most curable of all, biit they are most liable to recur ; though many of them are undoubtedly incurable from the beginning. A strong and direct heredity implies four things — (a) instability of brain, (5) liability to attacks at early ages, (c) liability to a recurrence after cure, and (d) typical dementia in many of the cases after one or more attacks especially in the adolescent cases. 6. There is a state of mental weakness, that frequently follows sharp attacks of mania and melancholia, which closely resembles dementia, and yet is quite curable. It is in reality a mild form of "secondary stupor," and I shall treat it under that heading. It is analogous to the stage of temporary exhaustion and reaction that follows many acute diseases. It is the period of functional rest but trophic activity, during which, through the vis Tnedieatrix natures, organs that have been diseased heal, tissues whose nutrition has been disturbed eliminate morbid elements and become normal, and functions that have been altered or suspended resume- slowly their activity. This period is of the highest importance for treat- ment. Treatment of Dementia. — Kegulated activity, nutritives, tonics, sometimes stimulants, and counter-irritants are indi- cated in the early stage. It is the time for the use of the stimulating nerve tonics and vaso-motor stimulants, such as strychnine, quinine, iron, phosphorus, the phosphates and hypophosphites, shower baths, friction to skin, the interrupted and continued currents, Turkish baths followed by brisk shampooing, and blisters to the back of the head. I have a man who had become dull, stupid, and lethargic after an 29-i STATES OF MENTAL ENFEEBLEMENT. attack of acute mania, "wakened up" visibly under such treatment. I had a young woman who had ceased to speak, rouse up and begin talking and working immediately after a bhster had been applied to the back of her head. I had a man who roused up, not only in mind but in muscular activity and in vaso-motor force, his hands getting warm instead of blue, under the use of Parrish's synip. This was stopped in a fortnight and he at once fell back. It was re- newed and he picked up, and again stopped and he fell back. It was given continuously for three months till he recovered completely. The use of thyroid extract, given in large doses, as recommended by Dr Lewis Bruce, is of extraordinary efficacy in some cases for preventing the occurrence of deraentia. I now am never satisfied that all has been done in any case threatened with dementia till a course of thyroid has been tried. When dementia is confirmed, a regulated physiological life, control, order, system, cleanliness, exercise, suitable employments and amusements, tend to prevent further deterioration. Mental and moral stimuli, careful mental nursing and rousing interest in work, &c., all come in as efiectual treatment. After a very careful study of dementia in all its relations, I have come to the following conclusions : ^ — • 1. Normal brain cortex differs enormously in different individuals in its inherent qualities and potentialities, these differences being, as far as our present knowledge goes, " functional." 2. The strongest clinical and psychological connection of every form of mental disease is the tendency to end in dementia. 3. Dementia being a virtual death of the higher mental powers, all insanities, therefore, may in the end mean mind death and social death. 4. Dements constitute two-thirds of our insane population. 5. Forty out of every hundred of all new cases of asylum ' " Secondary Dementia," Jour. Ment. Sci., Oct. 1888. STATES OF MENTAL ENFEEBLEMENT. 295' insanity soon pass into secondary dementia pure and simple, or mixed up with maniacal or delusional conditions. 6. The functional change that takes place in the brain cortex in secondary dementia is primarily and chiefly con- fined to the mind tissue, and is, in fact, a unique disease in nature with no strict pathological analogies. 7. The problem of what secondary dementia means and liow it can be averted is the cardinal problem of psychiatry. 8. Mental disease might even be defined as " a tendency to dementia." 9. The constant association with dements alone tends to lower the mental tone of the sane by the well-known law of the action of mind on mind. 10. Secondary dementia has as yet no sufficient patho- logical explanation, but recent researches point to cortical cell degeneration, chromatolysis, and atrophy of dendrites with a great diminution in the number of cortical neurons (Plates XV. fig. 10, and XVI. to XIX). 11. It may be looked on as a reversion of type, as a premature functional death of the mind tissue, or as a beneficial result of the laws that bring a bad stock to an end. 12. Eeal secondary dementia may be so closely imitated by secondary stupor that only time and the effects of treat- ment can distinguish them. We may look on the primary maniacal attack as threatened dementia, and the secondary stupor as being that threat partly carried into execution. 13. We have no reason to think that a brain which has a perfectly sound heredity can by any series of bad con- ditions be made to pass into typical secondary dementia. 14. The impressions through the senses from the outer world do not stimulate normally the mental cortex of a dement, though if the stimulant is very strong a certain response is obtained. 15. Dementia cannot be looked on as entirely caused by the damage done to the mind tissue through the primary acute disturbance, for it sometimes occurs without an acute 296 STATES OF MENTAL ENFEEBLEMENT. primary stage, and its occurrence bears no definite relationship to tlie intensity or the duration of the primary attacks. 16. Most of the cases of chronic and delusional mania have also some amount of dementia supperadded. 17. The pathological appearances, naked eye and micro- scopic, found in the hrain cortex in long-continued cases of dementia are capable of possible explanation on the theory of the degeneration and atrophy of long disused tissue ; but more probably they are the advanced stage of the pathological condition, which is the real cause of the dementia, but which in its early stage we cannot as yet recognise. 18. No merely vascular theory of dementia is tenable. 19. Typical secondary dementia always has a neurotic heredity, and its genesis can often be traced through the stages of mental hyper-activity, hyper-sesthesia, diminished inhibition, instability, melancholia, mania," and alternation in different generations, or in members of the same ' generation affected in different degrees. 20. Pure and uncomplicated secondary dementia does not readily supervene on the insanities that occur after full development and before the period of decadence, such as puerperal and lactational insanities, or those resulting from overwork or emotional causes at that age. 21. Melancholic and alternating insanities, delusional and inhibitory insanities are not the preliminary stages of secondary dementia nearly so frequently as maniacal attacks. 22. Most of the pure and typical cases of secondary dementia will be found to have originated in the develop- mental — pubescent and adolescent — insanities. 23. Masturbation may be an element in the production of secondary dementia in some cases, but it is not a necessary or a constant cause. 24. Idiocy and congenital imbecility represent nature's mental failures during brain growth, while secondary dementia is the typical failure during development of brain function after full brain weight has been attained. STATES OF MENTAL ENFEEBLEMENT. 297 25. Pure secondary adolescent dementia means tliat the organism has failed in its most highly organised structure and in its most important function just at the point before full reproductive perfection should have naturally been reached. 26. Undue and unphysiological stimulus through a forcing- house mode of education during adolescence ■without regard to the hereditary capacity and weaknesses of the organism may tend towards dementia. 27. The constant changes in each generation of modern civilised life in the adaptation of the human organism to its environments and the special efforts thus rendered necessary by the struggle for existence tend towards dementia through the strain they put on the mind tissue — the most delicate of all organised tissues — in hereditarily predisposed subjects. 28. Adolescent insanity ending in secondary dementia may be regarded as the most " typical " form of mental disease. 29. Dementia would have seemed, but is not, a more natural sequence, of the insanities of decadence — climacteric and senile — than of any others, for in them it would be a mere anticipation of the reproductive and mental death that has physiologically begun. 30. The lower animals, while subject to attacks analogous to melancholia and mania, are not subject to any state corre- sponding to secondary dementia before the senile period. 31. By prophylaxis in some cases, and by right treatment of the primary attack in others, dementia may be averted, but in many cases it is inevitable through the bad heredity of the individual. Primary Enfeellement {Idiocy, Congenital Imhecility, Amen- tia). — I do not propose to say much about primary mental enfeeblement, but rather to glance at a few of the most typical varieties. Ireland's ^ definition is that "idiocy is mental deficiency or extreme stupidity, depending upon mal- nutrition or disease of the nervous centres occurring either 1 The Mental Affections of Children, Idiocy, Imlecilily, and Insanity, ty W. "W. Ireland, M.D., 1898. 298 STATES 01? MENTAL ENFEEBLEMENT. before birth or before the evolution of the mental faculties in childbood." "Imbecility is generally used to denote a less decided degree of mental incapacity." In short, idiocy and imbecility are conditions of mental enfeeblement resulting from arrested brain development before birth or in very early childhood. The mental faculties were never there, their organ being unfit to manifest them. In dementia, as we have seen, they were destroyed or enfeebled in a previously normal individual. It is well to bear in mind certain things in regard to idiocy. 1. That there are great varieties of the condition, both as to symptoms, causes, treatment, educability, and prognosis. 2. That the mental deficiency is always accompanied by bodily weakness of some sort, — trophic, resistive, and motor, — which can often be treated with good effect by the ordinary resources of our profession. This is woU proved by this fact, that two- thirds of the cases die of tuberculous affections. 3. That by heredity and pathological connection it is apt to be associated with scrofula, tuberculosis, drunkenness, insanity, and crime. 4. That the main instruments of treatment must be a general bodily and mental education of a special kind, adapted to the physiological educability and potentialities of the individual brain under treatment, with often special conditions of diet, clothing, control, and modes of hfe. This can usually be best attained in a special institution. Congenital Imbecility. — This may exist in every degree, from the smallest amount of mental weakness down to idiocy. Here is a fairly common case: — E. C, now 25, of a family in which both drunkenness and insanity had occurred. When a child he was well developed, and apparently like other children, till he was about three or four years of age, when it was noticed that he was not so bright, not so imitative, and not so observant as a child at that age should be. Speech was long in coming and difficult to learn. As he grew older he could learn almost nothing at school; his school-fellows annoyed him, and he showed un- STATES OF MENTAL EXFEEBLEMENT. 299 governable passion and violence. The faculty of inhibition is almost always weak in imbeciles, but they are not all passionate or ungovernable. At puberty he got much more difficult to manage at home, and all his weaknesses and peculiarities were thus more observable. Unfortunately he was not sent to a special institution or home for the training of imbeciles. He could then have been taught much more than he now knows. In fact, I see no reason why he should not have learned some trade or mechanical work, and done it in a sort of way. He got so irritable, and, when in a passion, so violent, that he had to be sent here about' twenty-nine years ago. He has settled down into the life and routine of the place, is cleanly, tidy, and orderly in his habits, industrious in simple matters, such as bed-making, floor-washing, but is still very passionate and impulsive. He is happy and contented, and has no unfulfilled ambitions nor longings to satisfy. Look at him. He is fairly developed, but his hard palate is narrow and V-shaped (see Plate XI.). At ten yards' distance you would say he was an ordinary-looking young man. Wlien you observe him closely you see there is a weakness in his expression of face, a lack of mind in his eye, and a sort of shuffle in his walk, whUe all his movements lack purpose and conciseness. When he smiles he looks silly, and his speech is rather defective. Tou see at once there is no force in him of any sort, motor or mental. When further tested, his memory is seen to be defective, he cannot tell you how much four added to four and two off is. He can write, but like a schoolboy. You see that he is unfit to guide himself, to manage his affairs, to earn unaided his livelihood, or to resist any sort of temptation put in his way. He is in good bodily health, eats and sleeps well, enjoys simple pleasures like danc- ing, concerts, and jugglers' entertainments, and may live long. E. C. is a good type of the most common form of con- genital imbecile. There are others where one has much more difficulty in determining whether they shall enjoy civil rights and liberty, be allowed to marry, &c., being very 300 STATES OF MENTAL ENFEEBLEMENT, near the minimum legally sane line. Such persons often become the dupes of designing people, cannot resist tempta- tion or control natural desires, and so are the worst kind of dipsomaniacs. Some imbeciles show special talent in certain directions, — some in music, some in drawing, some in imita- tion, some in a kind of constructiveness ; some, who are of the criminal class, are bad and depraved from the beginning — are born imbecile criminals. As to treatment, the great things are, carefully to develop the body, to keep it always fat, not to give much animal food or stimulating diet, especially at puberty, "to train in good habits — bodily, mental, and moral, — to make their lives systematic and orderly, to avoid occasions of ill-temper, to punish justly, usually by deprivation of indulgences, to send to institutions for training and not to ordinary lunatic asylums till this is unavoidable. We find all sorts of bodily malformations, asymmetries, dwarfishness, and ugliness among congenital imbeciles, these all being developmental.' Congenital imbeciles may have attacks of maniacal excite- ment or melancholic depression — in fact, are subject to them. They may become impulsive, dangerous, and even homicidal ; they may, after an attack, have, secondary stupor, or may become demented as compared with their primitive condition. They are often terrible masturbators. Idiocy. — I find the most useful classification of idiocy is that of Dr Ireland, viz.: — 1, Genetous; 2, eclampsic ; 3, epileptic ; 4, paralytic ; 5, inflammatory ; 6, traumatic ; 7, microcephalic ; 8, hydrocephalic ; 9, by deprivation of the senses; and 10, cretinism. GeMetouH idiocy in that varicfy that begins hf/ore birth. E. D. is a very unfavourable case. She is now twenty-six, and never showed any mental potentiality at all from the beginning. She showed no affection, no clinging to any one in particular, not even hke that of a dog to those who fed her and were kind to her. She has never had any ' Fu!c Author's Neuroses of Development, STATES OF MENTAL ENFEEBLEMENT. 301 understanding of anything, never could speak, always grunted in that animal-like way you hear, never showed curiosity, imitativeness, nor power of attention. You see her body is squat and ugly, her temperature low, her palate deformed, high, and V-shaped, and her teeth irregular and few in number. She has from childhood beaten her head with her hands, as you see her now doing, just as the gorillas beat their breasts in the African woods. Her face is utterly unhuman, hence such cases have been called theroid or beast- like. The evolutionists would find many proofs of reversion to conditions common in the lower animals in her. When you place a tumbler of water on the floor before her, you see she kneels down and laps it with her tongue. She has not a rudimentary sense of decency or sexual propriety. Such a case is beyond the reach of teaching or training of any sort. Ifothing can be done but to feed and clothe her and keep her clean. The next case of E. E. is a much more hopeful subject. H'e too is a genetous idiot, and is small, ill-developed, rather deformed, bandy-legged, cold, feeble in muscle and trophic power, but he in a way understands some things you say to him, is always smiling, is gentle, has been taught to be cleanly and almost tidy. He has no sexual feehngs, cannot read nor write nor count, and will probably die of consumption. There is a distinct and interesting variety of genetous idiots called "Kalmuck," having oblique eyes, small round heads, no occipital protuberances, and large deeply scored tongues. The genetous variety forms the largest class of idiots, varies greatly in the mental capacity present, and many of them can be trained in training schools, and made more human and comfortable. The eclampsic idiots are those whose brains have been injured and their development afterwards retarded by convulsions at dentition. They are an unfavourable class as regards training. The damage done to the brain and its envelopes is usually demonstrable after death. 302 .STATES OF MENTAL ENPEEBLEMENT. I produce before you a whole series of epileptic idiots. Their characteristics are — 1st, that they vary in mental condition very much according to whether they are taking fits or not at the time; and, 2nd, that the effect of the constant recurrence of the epileptic seizures is such on the brain that it tends to lose the effects of training and to deteriorate. Take this example of E. P., now 16, who has taken fits since, he was a year old. At times he is gentle and teachable, and works in the garden, and enjoys life ; then he will have a few epileptic fits, and he will be stupid, dirty in his habits, and will forget all his training. After that he will be for a day or two irritable, violent, impulsive, and even dangerous. He articulates in a childish way. He is getting worse, and will no doubt die some day in a fit or after a series of fits. I have seen the steady use of the bromide of potassium very useful in such cases, lessening the number of the fits and their severity, diminishing the irritability, and improving the nutrition. We have one boy here who is quite another being for the past four years under 20-grain doses three times a day. The paralytic form of idiocy is represented by the case of E. G., who was normal in body and mind till he was four years of age. He then had an apoplectic attack, and his left hand, arm, leg, and left side of his face and head have been partially paralysed, ill-developed, and the limbs shrunken, con- tracted, and useless ever since. He takes sporadic epileptic attacks. He tries to articulate, but you cannot make out what he says; he is restless, irritable, not very educable, weak, and cold. Such cases, looked at from the motor point of view by the general physicians, constitute one variety of essential paralysis of infancy. The degree to which the paralysis and the mental affection are found in different cases varies from sanity to idiocy, from the slightest weakness to complete paralysis, shrivelling, and contortion of the limbs. The pathology of those cases is very interesting. Often the STATES OF MENTAL ENFEBBLEMENT. 303 convolutions in the affected liemispliere are found undevel- oped, damaged, or atrophied, the lower ganglia and centres undeveloped, and one-half of the spinal cord, as well as the motor nerves from it to the affected side, atrophied or not developed. In some cases we find the bones of the cranium enormously thickened compensatorily on the aff'ected side (as we found in E. G.'s case when he died). I have never been able to understand why cerebral apoplexies occur in infancy. I am inclined to think that they are often, not effusions of blood, primarily at least, but vaso-motor spasms with subse- quent dilatations affecting certain of the cerebral vessels, and resulting in trophic damage to the parts of the brain affected. "We may have, however, apoplexies in childhood and succeed- ing paresis without marked mental defect. Inflammatory idiocy results from the inflammations and sloughings that affect the throat and ears in scarlet fever, spreading inwards and damaging the brain. Certain portions of the organ are sometimes found to be hypertrophic in those cases. It is a very unfavourable variety. Traumatic idiocy is much like the inflammatory, or some- times like the paralytic form, and results from falls and blows on the head. The microcephalic is a very interesting variety of idiocy. On the whole, the heads of idiots are smaller than those of sane persons, but there are many exceptions to this rule, and, as a matter of fact, the average sizes of the heads of idiots are as large as the minimum sizes of perfectly sane persons. Ireland says : — " The size of the head gives no estimate of the compara- tive intelhgence of the (idiotic) children." There is, however, a certain minimum size below which a head is incompatible with average intelligence. I believe a circumference of below 18 inches means idiocy. Very typical microcephalics are rare, but, when seen, they make a strong impression. With their bird-like profiles they look so impish and unearthly. They are usually active, alert, mischievous, imitative, intractable. I have no really good specimen, but E. H., with a head 304 STATES OF MENTAL ENFEEBLEMENT. of 18 inches in circumference, a small face, a small but perfectly well-formed body, an active, imitative way, and a restless manner, gives an idea of one. Her only deformity is a cleft and acutely arched deformed palate. She just looks like a little dried-up woman, with small features and a singular expression of face, and she smiles as if a baby was imitating the features of an old woman. Microcephalics should always be sent to training-schools. They are often educable up to a certain point, and if not educated and employed, they are often little demons. Their muscular activity, therefore, must be provided with outlets. Hydrocephalic idiocy is very common, but I need hardly say to you that hydrocephalus, with even enormous enlarge- ment and great deformity of the head, is perfectly compatible with sanity and mental capacity. It usually has a dwarfing and often a deforming effect on the body. A small head is no proof that there has not been hydrocephalus. E. I., is a good example of a hydrocephalic idiot. She is now ten, and is slow in her movements, very gentle and patient ; sometimes cries and moans, as if she had an organic sensation of discomfort in her head. Her head is globular, the fontanelles raised, the temples projected. She looks unhealthy, has scrofulous glands and a feeble constitution. Her temper is good. She is educable, and worth educating. I am going to have her sent from this to an imbecile training institution. Drs Batty Take and Campbell Clark have de- scribed very fully the condition of the brain in certain cases of hydrocephahc idiocy. The former found enormous hyper- trophy of the neurogha, and the latter found a floating lobe or portion of brain unattached to any other nerve tissue, which could never therefore have exercised nerve functions, yet it had nerve cells and fibres in a primitive form. Idiocy, real or apparent, may occur by deprivation of the senses only. The famous case of Laura Bridgman, who was bhnd, deaf, and dumb, and with an indistinct sense of smell, but with common sensation through which Dr Howe educated STATES OF MENTAL ENFEEBLEMENT. 305 lier brain, developed intelligence and emotion, and raised lier from a condition of absolute want of intelligence to one of great mental capacity, is and will always be the classical case of apparent idiocy by deprivation. She diiFered essentially from most other forms and cases of idiocy in having a brain well developed and apparently normal in all respects, except that its inlets and outlets were obstructed. Ordinary deaf- mutism is closely allied to idiocy, and is one of the hereditary neuroses. Insanity is very much more common among deaf- mutes than among the general population. To me it seems a physiological sin that marriages between such persons should be legal, though apparently healthy progeny often results. But we know that each one of these must carry potential neuroses to future generations. Cretinism is an endemic disease occurring in connection with goitre in some valleys of mountain chains, such as the Alps, Cordilleras, and Himalayas, and is very seldom found here, so I need say nothing about it. It is very interesting from an etiological and pathological point of view, and has quite a literature of its own on the Continent. LECTUEE VIII. STATES OF MENTAL STUPOE ("ACUTE DE- MENTIA," "PRIMARY DEMENTIA," "DE- MENTIA ATTONITA," PSYCHO COMA). A distinct variety of mental disease — Definition : Lethargy ; stupor ; impressions on senses produce no effect ; attention gone ; desire and emotion absent ; stupor from the physiological point of view ; re- ceptivity and irritability of brain gone ; higher reflex functions suspended ; even reflex functions of cord lessened ; hunger and thirst not felt ; reproductive instincts not absent, but they assume de- praved automatic forms — Age commonly between 20 and 30 ; men- tal condition may be unconscious, conscious, or half conscious ; mus- cular system may be passive, cataleptic, or resistive — Mclancholio Stupor {Melancholia Attonita, Milandwlis avec Stupeur) : An intense melancholia, with delusions that "paralyse" the mind; memory, consciousness, and attention not gone ; sensibility not gone; prognosis; 54 per cent, recover — Anergic Stupor ("Acute Dementia," " Primary Dementia," " Dementia attonita ") : A real stupor ; sensibility, memory, attention, resistance gone ; feeble circulation ; vasomotor paralysis ; relationship of stupor to trance, hypnotism, and catalepsy. Pathology — Treatment : Vaso-motor stimulants ; continued current ; strychnine ; iron ; ergot ; warmth ; rubbing ; shower baths. Moral treatment unavailing at first. Causation : 1. Sexual ; 2. Emotional shock ; 3. Acute disease ; 4. Alcoholism ; 5. A stage of other mental diseases ; 6. Senility — Secondary Stupor : Transitory ; sequential, usually following sharp attacks of acute mania ; curable. You will not find stupor put among tlie ordinary symptomato- logical varieties of mental diseases, along with mania, melan- cholia, &c. This I think is a mistake. The only objections to its being so placed are two, — that it is not commonly a primary disease, and that the word stupor does not imply to the lay or even to the medical mind any necessary mental disease at all, STATES OF MENTAL STUPOR. 307 as they understand it. But these ohjeotions should not prevent us using the word to express in a correct scientific sense a morbid mental condition, which is different psychologically and clinically from all other morbid mental conditions which, while it lasts, demands different treatment from them in many cases, and has a different course and termination. Stupor, used in this strict medico-psychological sense, may he thus defined : — " A morbid condition in which there is mental and nervous lethargy and torpor, in which impressions on the senses pro- duce little or no outward present effect, in which the faculty of attention is or seems paralysed, in which there is no sign of originating mental power, in which the higher reflex functions of the brain are paralysed, and in which the voluntary motions are almost suspended for want of convolutional stimulus, but where the patients usually retain the power of standing, walk- ing, masticating, and swallowing." The condition of stupor may be the expression of an ex- hausted, lowered, and devitalised brain. A typical case of this condition stands for hours where he is placed, in the same attitude; when spoken to he takes no notice; he shows no active desires, passions, or affections ; he does not speak nor move, nor show any interest in anything. His expression of face is vacuous ; his vaso-motor power is much below normal, so that his extremities look blue and are cold ; he does not obey the calls of nature, nor take any notice of them at all. Loud sounds make no impression ; pleasant or terrible sights that would in others produce motion and emotion fail to do so. A woman once committed suicide by hanging herself in a dormitory in Morningside in the presence of another patient in a condition of stupor, who took no notice whatever of this frightful sight. Looking at the condition of stupor from the point of view of the physiology of the brain, we see that its power of receiving impressions from without is in abeyance, and its higher reflex functions suspended. The mental and motor irritation of a full bladder or loaded rectum is not felt by the higher brain centres.; 308 STATES OF MENTAL STUPOE. and when, througli the action of the lower centres, evacua- tions take place, there is either no consciousness of them, or, if there is, it does not result in the volition that pre- pares suitably for them, or in the vexation that would be felt in health if they took place over the body. Even the ordinary skin and spinal reflexes are much diminished or abolished. The appetites for food and drink are par- alysed, or, if felt, are not followed by any exertion to , satisfy them. Age, and Relationship to Reproduction, Hysteria, Mastur- bation, ^c, — Most of the typical cases of stupor occur in the actively reproductive period of life. The majority of them, in fact, are under 30. Dr Hack Tuke^ found that 27 was the average age in 20 cases. In my experience all the very typical cases are nearer 20 than 30. A striking exception, and the only material exception, to the passivity or suspension of brain function in stupor, is the gratification of the reproductive instinct in a low automatic form, the inhibitory centres being dormant. In the majority of the cases the commencement of the disease had been connected with or accompanied by a sexual excitation in some form or other. Many of thom had indulged badly in masturbation and had exhausted the brain energy thereby — had "stupefied" themselves in fact by this. Most of them indulged in this habit long after they had entered into a condition of mental stupor, doing it automatically rather than volitionally, and many of them have sexual delusions at the expiry of the attack. Many of the girls had been hysterical, and showed during their disease marked hysterical symptoms. The aspect, expression of eyes, and behaviour before the other sex, while consciousness existed, were markedly erotic, this being so in some of the cases even after speech and all outward mental manifestations had ceased. Many of them had cataleptic, trance, and hystero-epileptic symptoms, all these afi'ections being commonly connected with the function of reproduction ^ International Medical Congress, 1S81, Transactions, vol. iii. p. 638. STATES OF MENTAL STUPOR. 309 its disorders, or its perversions. The direct connection of stupor in most cases with the reproductive and sexual functions has not been sufficiently considered hitherto. Those functions are the dominant vital activities from adolescence to 35 in many persons of the neurotic diathesis. If the inherent brain stability is hereditarily weak, with the inhibitory power poorly developed, and if under those cir- cumstances there is intense sexual excitability or a constant sexual drain through masturbation or excessive sexual inter- course, then is stupor, in some form or degree, the natural expression of the exhaustion of the higher nerve force that follows. We shall see examples to prove this presently. When I thus bring out strongly the connection of stupor with the reproductive function, it must be remembered that I am referring particularly to that form which is attended by unconsciousness, though this may have a distinctly melan- cholic stage or tinge throughout — mental depression, too, being a symptom of brain exhaustion — and it must be kept in mind that there are individual cases of stupor of the melancholic type at all ages and resulting from other causes, such as mental or nervous shocks, frights, losses, or bodily diseases, which have no reproductive or sexual complication at all. Muscular Conditions. — -The voluntary motor system is found to be in three conditions in different cases or in different stages of the same case, viz., (1) passive, unresistive, and having no tendency to keep fixed positions ; (2) cataleptic, with decided tendencies to keep fixed attitudes and positions, but with no resistance to external force used in changing the " waxy " muscvTlar conditions ; (3) resistive, showing a more or less strong resistance to external efforts to change the position. The first is commonly found in the anergic form of stupor, especially when it is caused by a previous acute attack or by masturbation; the second also in some of the anergic re- productive cases ; and the last in the melancholic form alone. Varieties. — Loohed at from the purely mental point of view, conditions of stupor are divisible into three varieties, viz., the '310 STATES OF MENTAL STUPOK. unconscious — tlie anergic, — where consciousness and memory are gone; the conscious — the melancholic, — where they are both present, and where there is a deep emotional depression with delusion present, these facts being ascertained and tested afterwards by the patient's own account ; and the hdlf- conscious, or confused, where there is some consciousness, but by no means a keen or a correct subjective realisation of events, and where the recollection of them afterwards is con- fused or delusional. Some cases pass through all these con- ditions in different stages. Conditions of mental stupor have excited much interest, and have an extensive literature, especially in Trance. Dr Hayes N"ewington, when assistant physician in Morningside in 1874, studied them carefully, and wrote a capital description ^ of them, with which I in the main agree ; indeed, all must agree with him, for he sticks closely to clinical fact. He gave us the admirable word " anergic " to describe the passive, unconscious, non- depressed cases. This should take the place of the older term "acute" or "primary" dementia, still commonly applied to such cases, which should be discontinued, for it is confusing and incorrect. If you take a typical case of either the melancholic or the anergic varieties, each undoubtedly corresponds to his descriptions ; but an extended clinical experience has shown me that the same case may begin by being in the condition of melancholic and conscious stupor, and may end by passing into the anergic and unconscious variety. Then I find that by far the larger number of the cases that were anergic during the greater part of their course had a short melancholic stage to begin with. As for stupor being a primary affection, I call to mind very few cases where it was entirely so. Insanity seldom begins with stupor. There is a stage of mental depression or of mania, — very short, it may be, but still present. The stupor may be the disease for all practical and clinical purposes, but preceded by an initiatory stage of another condition. The cases which ' Journal of Mental iScwnce, October 1874. STATES OF ilENTAL STUPOR. 311 •we shall see, or to which I shall refer, will illustrate those various points of causation and symptoms. The test clinical division of stupor would be, I think, into the following kinds; which, in the order of their frequency or importance, are : — a. Melancholic stupor. b. Anergic stupor. c. Secondary stupor (transitory after acute mental disease). d. General paralytic stupor. e. Epileptic stupor. Melancholic Stupor is the most frequent form. It is the melancholia attonita, or the melancholie avec sfupeur, of the authors. As I have said, it is, either throughout its whole course or at some part of it, the conscious and delusional form or the half-conscious looked at from the mental point of view, the resistive looked at from the muscular aspect, and the less paralytic looked at from the vaso-mo'tor point of view. Some authors write as if there was always one overmastering delusion of a terrible kind, — the patient fancying himself dead, or that he is too wicked to hold intercourse with his fellow-men, or that if he speaks he will be killed, &c., which, as it were, fiUs the whole mental vision and leaves no room for any other manifestation of mind, paralysing speech, and active volition of any kind. I do not think this a true view to take. There may or there may not be such a delusion, but by itself a delusion never causes stupor. There must be something more than this. There is always, in addition, a distinct morbid con- dition of the brain affecting its reflex action, its trophic and vaso-motor state, its receptive power in all directions, and most especially its active ideo-motor functions. None of these things are the necessary concomitants of merely delusional conditions. I look on the delusion as one symptom only, and not the cause of the melancholic stupor. Melancholic cases are sometimes suddenly impulsive at one period of the 312 STATES OF MENTAL STUPOR. disease, and it is -well to remember that during convalescence they may be suicidally impulsive. Gusts of motor energy seem suddenly to be evolved in the brain, and in fact I look on those as being correlative and complementary to stuporose conditions. I have seen epileptiform fits occur occasionally in such cases, but much more frequently a condition merely simulating epilepsy or apoplexy, the patient being conscious and having a real control over the muscular movements. Whenever you see a melancholic patient said to be "in a fit," always think of this condition. It is not uncommon. In some instances this state occurs as the acme of an ordinary case of delusional or excited melanchoha, being a short incident in the case. In other instances, though preceded by depression of mind, the stupor is the chief part of the disease. In some instances the stupor remains characteris- tically melancholic all through — being conscious, resistive, and unaccompanied by much vaso-motor paralysis. In other instances it passes into anergic stupor, — the patient becoming unconscious, unresistive, and with marked vaso-motor and trophic paresis. Some cases of melanchoUc stupor assume melancholic attitudes. Here is a young woman who lies flat on the ground, with her face on the floor, and she resists being placed on a chair. Here is a young man who is bent down till he almost crouches. Here is another who puts his fingers to his ears and keeps them there. The folloioing are three cases of melancholic stupor, the fird two {E. M. and E. N.) being patients of tlie ordinary type, and the third {E. 0.) being a very extraordinary case in if/t severity, duration, and the length of time he was artificially fed, and in its termination in recovery in these circumstances : — E. M., set. 21, a well-educated, bright, clever, and industri- ous youth of sanguine temperament. No nervous heredity admitted. Habits temperate and correct. The cause of the attack was overstudy when he was rapidly developing in body, and had not attained manhood. His brain was ex- hausted by the body growth, development, want of sleep, and STATES OF MENTAL STUPOE. 313 continuous mental eflbrt. His first symptoms began eighteen months ago, and were mental depression, sleeplessness, and pain in the head. He got worse in mind and body, and soon became suicidal — attempting to take away his life. He became suspicious, too, his affection for his relations diminish- ing, and he was fickle. He then got so much better through rest and change that he resumed his work and studies. "When he relapsed, a few weeks before admission, he became again very suicidal — asking for poison, and wanting to drown himself. His motive for suicide was that people were going to kill him. On admission he was much depressed, though he could pick himself up and smile in a forced way. He was very fearful, imagining that he had done some great crime, and that he was to be tried and would be hanged. He was thin, his muscles flabby, his pulse 60 and weak, bowels consti- pated. Temperature — 97"2° in the morning, 96'4° at night. TS'eight, 9 st. 10 lbs. He was unsettled and restless at night as well as being sleepless. His appetite was poor. He was evidently all the time looking for the means of suicide, so he was carefully watched night and day. He got more confused and more obstinate, until in a fortnight after his admission he was in a state of complete stupor ; his countenance wore a heavy, semi-vacuous, depressed expression ; he would not answer questions nor take notice of anything; was utterly careless of his dress and person, letting his motions pass where he stood. The skin had a warm, clammy feel, except at the extremities, which were blue and cold. He had a few lucid intervals of a few minutes each, when he would as it were wake up and ask where ho was. The treatment from the beginning consisted of his being compelled to take an enor- mous quantity of milk and eggs in liquid custards, flavoured with nutmeg, and with half a glass of sherry in each. He took usually in the day 12 eggs and 6 pints of milk, and began to gain in weight after the first fortnight. He had quinine and strychnine in moderate doses, and cod-liver oil emulsion, containing hypophosphite of lime and pepsine. He 314 STATES OF MENTAL STUPOB. was walked in the open air a great deal. His skin was well rubbed with rougb towels night and morning, and occasionally he had the continued current up to fifteen cells. He steadily- gained in weight. After three months' treatment he began to speak, and wrote the following letter to his mother : — " My mother, please let me go home. I don't know where I am. I feel very ill. "Would you let me go home." In a few days he wrote to her to send him some money to pay for his main- tenance here, saying that he thought about £3000 would do, that he was a nuisance to those around him, and asking what great crime he had committed, and requesting that he might be punished adequately. In another month the confusion of mind was passing away ; in a month from that he was prac- tically well in reasoning power, in feeling, memory, and in bodily health, and was over 11 stone in weight, having gained 18 lbs. He was bright, intelligent, hvely, and a great favourite. He said he remembered in a confused way the events that occurred during his period of stupor, that he had the, delusion all the time he had committed a crime, and was to be punished, and could not pay for the food given to him. When discharged, six months after admission, I never was more satisfied in any case that a complete recovery had been made. I always like to see a patient get fat on recovery from any form of insanity. This was a very typical case of melancholic stupor, and would be called by most authors one of " primary dementia," showing well how the stupor was the acme of the brain condition, which showed itself first as melancholia, how there was a melancholic tinge through the stupor, and a distinct melancholic delusion. But I conceive it would be a mistake to describe the stupor as being caused by this profound delusion. As a matter of fact, in this, as in all such cases, the intensity of realisation of the delusion, and the capacity to feel keenly, were blunted by the condition of stupor. The stupor I look on as a brain condition distinct from that of acutely felt depression in melancholia, in which delusions are STATES OF MENTAL STUPOK. 315 vivid and the misery acute. The condition of the mental portion of the convolutions in stupor is probably analogous to the stupidity of a nervous child when terrified or bullied. The folloioing icas a case of melancholic stupor of short dura- tion, and loith a complete recovery : — E. N., set. 35. Temperament melancholic. Habits intem- perate ; a prostitute. Heredity — mother intemperate, and subject to periodic attacks of melancholia. Her illness began by melancholic depressions and delusions, but she soon became excited, noisy, and tried to commit suicide. She had no great overmastering melancholic delusion to account for the stupor into which she soon passed after admission, which was complete, with all the characters of melancholic stupor, being muscularly resistive with no cataleptic tendency, with refusal of food, and expression of face depressed. She would not walk nor move, and had to be kept in bed. She remained in that state for about six weeks. It was evidently the acme of the attack of melancholia, and she shortly got better and made a good recovery in six months. She said that the period of stupor was a blank to her, and she remembers nothing that took place then. The folloioing was an extraordinary case of prolonged melancholic delusional stupor, lasting three years, and requiring artificial feeding all that time, loith final recovery. F. 0., aet. 31. Admitted 26th January 1876. Disposition retiring. Strumous diathesis. Habits unsocial, and almost too industrious and sedentary. Excessive masturbation. Father intemperate ; mother died of consumption. Had one slight attack of mental disease — melancholia — three years ago, from which he quite recovered in a few months. First symp- toms of mental disease were slight depression and foolish fancies. Along with these there were sleeplessness, pains in head, loss of nutrition, and great coldness of extremities. Sometimes he could not be kept warm by any means used. Was not dirty, destructive, nor obscene, nor violent. Those symptoms showed themselves fifteen months ago. As he got 316 STATES OF MENTAL STUPOR. worse lie opened a vein and lost some blood, and on several other occasions lie seemed to have tried to choke himself with a scarf. He was at times noisy and incoherent, and sleepless. He had changing delusions, e.g., that his brain was compressed by an evil spirit. On admission he was depressed and hypochondriacal, fancy- ing that he was dangerously ill, that he had been a great sinner and very licentious, that he suffered shame more than all mankind, and that his body had been tampered with when he had attempted suicide. Along with the depression there was much mental enfeehlement, facility, childishness, and impairment of memory, with rambling and incoherence. He had delusions about his sexual organs. He was anaemic, flabby, thin, and we thought that there was slight comparative duhiess at apex of right lung, with rough breathing sounds. Temperature, 98 'i". Height, 5 feet 6 J inches. Weight, 8 st. 13 lbs. He remained very much in this mildly melancholic condition for three months. He constantly wanted quack medicines, had a poor appetite, and used to twist and wriggle his body about in obedience to delusions. He then had an attack of deeper depression, with more confirmed delusions, intense insane obstinacy, impulsive violence, shouting at times and twisting his body about, as if there were beasts crawling on him. After this he refused food entirely in May, and was fed with the stomach-pump on May 7, 1876, resisting strongly. He took his food on the 17th, but again needed to be fed on the 18th, and for several weeks afterwards. Then for several months he took his food himself, his mental condition other- wise remaining much as before, and his delusions being very pronounced. But in May 1877 he again began to refuse food, and from that time till April 30, 1880 — a period of over two years and eleven months — he took no food, and required to be fed twice a day with the stomach-pump. But this was not the most extraordinary part of this case. In the course of a month after his being fed, he had passed STATES OF MENTAL STUPOR. 317 into a condition of absolute stupor, lying motionless, insensible to pain, unable to stand, his urino and fseces dribbling away, his circulation feeble, offering no resistance to anything done to him, and taking no notice apparently of anything. Nothing could rouse him, nothing could stir him, nothing could excite any mental or bodily reply or response, except that he shut his eyes tightly when the eyeballs were touched, and there was slisht motion of the legs when the soles of his feet were tickled. But this last reflex power disappeared in October 1878. Much difficulty was experienced in keeping him warm, but an old and most affectionate maiden aunt, who came to see him almost daily, contrived the most wonderful woollen foot coverings and body rugs. He was dressed in the morning, carried down to a sofa, and his penis inserted into an indiarubber bottle. There he lay all day, never moving, never resisting anything done to him. He seemed the most complete case of "acute dementia " or anergic stupor I ever saw, except for two things : these were, a certain expression in his face, which was never so absolutely blank as it is in that condition, and his not being able to stand nor move, which seldom occurs. There was none of the resistance nor muscular rigidity of typical melancholic stupor. As regards treatment, he was fed in the morning with a liquid mess, consisting of a pound of beef done to a liquid form in a large mortar, with potatoes and vegetables similarly pounded down, the whole being made liquid enough to pass readily through a stomach-pump tube, with beef-tea and a quarter of a pound of sugar. In the evening he had a custard with three eggs and a quarter of a pound of sugar. His bowels kept regular. He had at various times quinine, strychnine, phosphorus, ergot, cod-liver oil, the hypophosphites of lime and iron, and the continued current up to twenty cells of a Hawksley's battery, used once a day for months together, through his brain and spinal cord. No good seemed to be done, yet he was a case about whom we never quite lost hope. His nutrition kept fair, and he did not lose weight. At last, in June 1879, he was observed by his attendant to 318 STATES OF MENTAL STUPOE. turn over on the sofa. Then reflex action on tickling of the soles] returned, and his countenance began to acquire more expression. The continued current was being used at this time, but I am very doubtful if it had anything to do with his improvement. In February 1880 his glottis became more sensitive, so that the passage of the tube caused coughing, and he raised himself up after feeding once. One day he seized the tube and remained rigid and cataleptic for a few minutes. On April 30, 1880, he spoke for the first time, and at feeding time said he was tired of custards, and wanted some tea, took a moderate tea and supper, and a good breakfast. He had never lost weight during all the time of his artificial feeding. He took no food on May 1st, but on May 2nd asked Dr Clark, who was about to feed him, if it was the custom to keep sane men in the Asylum, and on being told that it was not much like a sane man to refuse food, he replied, " Then if I take my food will that prove my sanity 1 " " Yes." " Then give it me at once." He took it there and then, and never missed a meal afterwards. He was weak, and his appetite was feeble at first, but he soon began to walk, then to go out, and he got stronger, and heavier by nearly a stone than he was on admission. When asked about his stupor, he always gave some sexual reason, such as that it was " gonorrhoea " or " emissions " that had been the cause of it. He asserted that he had been conscious aU the time, and made some statements which proved that there had been some consciousness, reason- ing power, and memory. He described how a sphygmograph was used on his radial artery, he told the names of assistant physicians who had been in charge of him during his stupor, and he " asked pardon for my conduct." His memory was not quite clear, however ; he could not tell much about what happened, nor the year he entered the Asylum. His memory of events before his illness was good, and he showed much curiosity as to what had been going on in the rehgious world. He was hypochondriacal, notional, and somewhat weak-minded and was discharged relieved on June 21, 1880. He has im- STATES OF MENTAL STUPOR 319 proved still further at liome, liis old maiden aunt thinking him as well as ever he was in his life, and considering him a most intelligent and exemplary youth. She takes almost the entire credit of his resurrection, a distinction which I am much in- clined to award her, for she kept him warm, she kept up the interest of every one in his case by daily visits, and she never despaired of his recovery. Relation to Trance. — This was essentially a case of melan- cholic stupor {melancholia attonita, pyschoeoma, melancholie avec stupeur), with many of the features of "anergic stupor.'' In fact, after the symptoms attained their greatest intensity, when there was no apparent consciousness, no attention, no muscular resistance, no voluntary motion, no spinal reflex function, when the body temperature was very low, the capillary circulation in the extremities was very weak, the urine and faeces passing involuntarily and at all times, I con- sidered the case as one of anergic stupor (acute dementia), that had arisen at first out of a melancholic condition, and used to speak of it as such, a fact of which the patient reminded rue after his recovery. I certainly did not think there was consciousness, or attention, or memory really present, as the patient's recollections afterwards proved them to have been to some extent. In old times the case would have been called one of trance, and there were many of the features of what is now described in the books by that name. Stupor is one of those conditions that seem to take hold of the popular imagination, cases being reported in the newspapers, becoming the subject of works of fiction,^ and exciting interest in all sorts of ways. The wonder is that more hysterical young women don't fall into it. The way in which it is sometimes mis- managed is a disgrace to our knowledge of mental diseases. Stupor is frequent in hysteria. I think it probable that most cases of trance, if examined by an alienist, would be placed under melancholic or anergic stupor. It will be noted how well the digestive and trophic functions of the body were per- ^ Tlie story of Called Back is well wortli reading. 320 STATES OF MENTAL STUPOR. formed when there was no voluntary muscular action whatever. The great length of time during which the symptoms lasted, and the final recovery, so far as the stupor was concerned, are very marked features of the case, if they are not unprece- dented. The following loas a strildng case of stupor {melancliolic) fol- lowing a mental shoeJf : — E. 0. A,, ast. 55, of a melancholic temperament, and steady and industrious habits, through which he had made and saved £6000. There was no known neurotic heredity. He was a shareholder in the City of Glasgow Bank, and the failure of that ill-fated concern, and the loss of all his money, seemed to " take the spirit out of Mm " completely. He became sleepless, nervous, and much depressed. He lost weight — from 14 stone to 10 stone 4 lbs. He first spoke constantly about his being victimised and cheated, and then expressed delusions that he was in debt, and that he must go to the police office and give himself up. His delusions next referred to his body — no doubt his organic sensations, as he got thin, weak, dyspeptic, and costive, were those of discomfort — and he said that his inside was burnt up. On his admission to the Asylum, six months after the beginning of his disease, he was with difficulty got to speak, to answer questions, or to take food, and he slept badly. He would appear as if he were about to speak or answer a question, but the volition power to articulate seemed to fail him, and he could say nothing. His next delusion was natural enough, the wish being father to the thought. He fancied he was dead, and he would say — " I am dead : put me in my grave." Then for two months his stupor was complete, with no outward expression of mentalisation at all. But the expression of face was melancholic as well as stupid, and there was muscular resistance. He lay in bed all day. All this time he was getting weaker. No tonics excited his appetite, no stimulant — and he got brandy in large quantities— roused him, and his food did not nourish him. The news of his favourite daughter's STATES OF MENTAL STUPOR. 321 death, did not affect him. I have no doubt he had the dekision he was dead. He got thinner and weaker, and gangrene of his heel appeared, then hypostatic pneumonia, and, lastly, gangrene of the lungs, of which he died eight months after admission. In the last month of his life, and especially when his temperature rose to 102'5° from the lung disease, he would answer questions at times, and once or twice spoke sensibly, asking what sort of night he had had, but generally he wanted to be put into his grave and "buried." At the post-mortem examination we found considerable atrophy of the convolutions, and congestion of the brain substance. ISo dramatist ever drew a more vivid picture of adversity overwhelming a man, striking him dumb, crushing the whole vitality of mind and body out of him, and killing him outright. This was clearly an instance of " the power of the mind over the body," even to the extent of putting an end to life. Anergic Stupor {Acute Dementia). — This may be a primary disease commencing without any melancholic or maniacal stage, though I have scarcely ever met with a case in which I could not discover at least a trace of these conditions at the beginning of the attack. Its symptoms are complete uncon- sciousness, and of course no memory of events that occurred during its persistence ; no delusions ; no muscular resistance, but in some cases a static or cataleptic muscular condition ; a loss of facial expression ; a marked vaso-motor paresis, so that the extremities are blue and cold ; a lowering of the trophic energy, so that sores are apt to form and even gangrene may occur j the reflex functions of the cord being markedly diminished, and the higher reflex functions of the brain almost in abeyance. The following case, E. P., was one of anergic stupor, occur- ring in a girl of eighteen, who had had two slight attacks of melancholia on previous occasions. One grandfather had been melanchohc with delusions, but not in an asylum ; father had several epileptic attacks, and had been very " excitable " after X 322 STATES OF MENTAL STUPOE. eacli; sister became "dazed" after, and in consequence of, motlier's death, and died of phthisis in four months ; and a brother was eccentric and foolish. Masturbation suspected. The attack began by a short maniacal stage, with much incoherence,— " laughing in a childish way." This passed into a condition of stupor in two months, during the con- tinuance of which she never spoke, and stood in one position, or sat where she was placed. She swallowed liquid food when put into her mouth, but showed no desire for anything nor interest in anything. Loud noises did not startle her. She did not obey the calls of nature. She was cold, her feet blue and swollen, her pulse weak and quick, and the reflex function of the spinal cord abolished. There was no muscular resistance and no catalepsy. After about a month she seemed, under the use of stimulants, nerve tonics, and blisters to the occiput, to improve somewhat, but she soon fell back again, and remained ill for over a year. Menstruation, which had been absent for the first six months, returned, and she seemed to be none the better for it. As she began to improve she sot a little obstinate and even violent, and her brain was for a time in the repeating state one sees sometimes in certain cases of mental disease ; when asked a question she would repeat the words said, or part of them, like a parrot, as the reply. After she began to improve she rapidly got well, having been previously fattened with milk diet, and she has remained quite well now for eleven years. The folloioing zoas a case with catalejptic symptoms who died. E. Q., set. 27, admitted 2nd April 1881. Disposition bright and cheerful. Habits steady and industrious. First attack. No hereditary predisposition. Cause, anxiety in regard to an operation for removal of mammary tumour which she had to undergo. Duration about five weeks. Became gradually depressed, lost appetite, fell oflf in flesh, slept badly. Ultimately became quite stupid, was unfit for her work, took no interest in her children, would stand in one position for an hour or two continuously, and was very restless at night. STATES OF MENTAL STUPOK. 323 On admission she was in a state of stupor, paying no atten- tion to questions addressed to her or to anything occurring near her, would not utter a word, stood in a listless and stupid attitude, obeyed no orders, refused food, did not attend to the calls of nature. She was in very poor condition and weak general health. She was xinresistive, cold, and her extremities blue, and her face expressed vacancy, not melancholy. She remained in this state with the addition of a degree of catalepsy for about a year. To have custards, plenty of extra milk, porter, and cod-liver oil emulsion, and friction to skin, with extra warm clothing. The mental faculties seem blunted or dead ; she is utterly careless and apathetic ; she is slovenly and dirty, requiring to be washed, dressed, and attended to in every respect ; she never volunteers a remark, and indeed never utters a single expression, except while being bathed or dressed, when she sometimes gives vent to expressions of disapprobation and disgust. Her general look is one of utter stupidity and degra- dation, the features being coarse and blurred, the saliva dribbling from the mouth ; but frequently, without apparent external cause, the face assumes various exaggerated expres- sions of disgust, amusement, and eroticism, while at times she has muffled outbursts of chuckling laughter. In the twelve months she improved in many respects, but she then died of diarrhoea. The following is a complicated case of stupor, catalepsy loitli epileptiform convulsions , temporary partial recovery, de- mentia : — ■ E. S., set. 17, admitted to Eoyal Edinburgh Asylum, 2nd May 1874. Disposition quiet and dull ; habits steady ; family history not ascertained ; assigned cause a severe blow on the back of the head three years before admission, since which he has been duller and more stupid. The injury seems to have been chiefly spinal. After it he gradually lost complete con- trol over the movements of his head — it " came forward " — then he ceased to be able to stretch his arms forwards and 324 STATES OF MENTAL STUPOK. back, but he still could write. Was sick, and sometimes vomited. Could not walk far nor run at all without being very tired. Had pain in his head. About three weeks ago showed mental symptoms, viz., religious anxiety, delusions that his food and medicine were poisoned, shouting, violence, and dirty habits. It appears that an epileptiform fit im- mediately preceded those symptoms. Took another fit sixteen days before admission, springing right up from his bed. Convulsions lasted three-quarters of an hour. During the fit the lip and tongue were bitten. He was then for five hours in "a trance." His head had been shaved and blistered. Had six or seven fits subsequent to this, and before admission. On admission he was in a state of stupor with no mentalisa- tion apparent, insensitive to pain, and spinal reflex action abolished. Pulse 130, weak; temperature 97-8°; was very weak ; urine and faeces passed in bed. He remained in this stupor, but sometimes cried and moaned, and took many epileptiform fits for the first ten days. He then showed the true cataleptic symptoms, his body assuming any position it was placed in for any length of time. He took no notice of anything, and would not answer questions. One evening the attendant got him up, put the chamber-pot in his hands under his penis, went away, and forgot all about it, and he was found in the same position in the middle of the night by the night attendant. He remained cataleptic and uncon- scious for eight days, when he had a feverish attack with diar- rhoea, temperature being 103°. While this lasted he could be roused to answer questions in monosyllables, and appeared to be more conscious and intelligent. After the fever subsided he agaiu became completely cataleptic. There collected and ran out of his mouth a fcetid greenish fluid somewhat purulent in character. Sometimes he had to be fed with the stomach- pump. The food always had to be made liquid. During all the time, up tiU August 10th, he had muscular twitchings of the extremities, and occasionally a regular epileptic STATES OF MENTAL STUPOR. 325 fit. Pulse then 60, weak and irregular; temperature, 98-9°. During September he began to move slowly by volition in a snail-like way, without speech or expression in his face. When up, and told sharply to get into bed, he would move slowly and manage to go there in half an hour or so. Bowels very costive. When much roused, on September 17th, he got up and walked along the corridor. There were no fits after the 18tli September. He steadily improved after this, still being slow and stupid, afiectively religious, going to church, and saying very long prayers before going to bed. In October he was able to dress, undress, go out to do a little garden work, but was stolid, slightly enfeebled in mind, reserved, wanting in curiosity and interest, and as if he had some latent morbid fancies. On 8th November 1875, he was discharged as "recovered," being coherent and intelligent, but there was present some of the general listless mental state referred to. He did very well at home for a time, but a process of gradual mental enfeeblement seems to have come on, with irascibility and sometimes violence, so that, on 4th June 1878, he was re- admitted to the Asylum in a state of ordinary secondary dementia. He stUl remains there. He has never had any recurrence of the epileptiform fits. There are two additional facts which one may assume, though they do not appear in this record. The first is that there must have been a strong heredity to insanity. The second is that the lad practised masturbation to excess. He says he has no recollection of what occurred during his period of stupor. That I believe. I look on such a case as being partly caused by adolescence, complicated by masturba- tion and by traumatism, all of which were concerned in the causation of the epileptiform attacks and the condition of stupor. Secondary Stupor. — All acute forms of mental disease are liable to be followed, after the acute symptoms have passed 326 STATES OF MENTAL STUPOR. oflp, by a condition of mental torpor and a kind of mental enfeeblement. But this differs from tlie true secondary dementia. There is in it to a large extent the mental characters which I have described as being those of stupor, and, above all, it is curable. The patients are inattentive, confused, lethargic, and torpid. The brain reflexes are dulled. The energising of the convolutions is slow and confused. All the higher reasoning and affective powers are in abeyance for the time being. It is a time of exceeding importance for treatment, which should be supporting, tonic, nutritive, and stimulating, though not too exciting. !N"erve stimulants and counter-irritation to the head are often of service. It is a time for moral and mental treatment, for mental stimula- tion of the higher centres by amusements and congenial work. The fact that this state is of frequent occurrence should make us guarded in our prognosis, and never come hastily to the conclusion that incurable secondary dementia is present. 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 itseK 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 exalta- tion had acted as strongly as the physical exhaustion. E. P. (p. 321) and E. S. (p. 323) were examples. 2. The hysterical condition. 3. Mental and moral shocks (E. 0. A., p. 320), and over- work during adolescence (E. M., p. 312). L The brain exhaustion caused by acute mental diseases, more especially acute mania. STATES OF MENTAL STUPOR. 327 5. stupor often occurs as an incident or stage in other mental diseases, notably, as we have seen, in general paralysis and epilepsy. 6. An alcoholic stupor may be caused by excessive drinking, and is "thus one form of alcoholic insanity (E. N., p. 315). Such a condition is usually transitory, but not always. 7. Stupor is frequently one of the stages of alternating in- sanity 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 had once under my care an old gentleman of 84, who, when his periods of exaltation were un- usually long, would afterwards become torpid, never speak nor take any notice of anything, would not even stand, but must be kept in bed, would scarcely swallow, and this would some- times continue for four or five weeks (and see case T>. E., p. 232). When younger he never had such attacks. He has laboured under irregularly alternating insanity for thirty years. 8. Adolescence alone, as in the case of E. P. (p. 321). 9. Senility. In the extremest form of senile insanity the mental faculties sometimes disappear so entirely as to con- stitute stupor. 10. It is sometimes the chief mental symptom of brain atrophy. Some of these causes may, of course, co-exist, and they are all apt to be aggravated by the existence of a strong hereditary predisposition to insanity. 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 50 per cent, of the cases recover. Pathology. — There is undoubted vaso-motor paresis along with diminution or even abohtion of many of the cerebral reflexes. A case of deep stupor exhibits the nearest approach we yet know to a complete temporary suspension of all the 328 STATES OF MENTAL STUPOR. higher cerebral centres. Dr Wiglesworty has carefully in- vestigated the condition of the cortex in certain very deep and fatal cases of stupor with motor symptoms. He describes and figures globose, granular, and pigmented cells, some with the beginning of vacuolation of nuclei. The following are his general conclusions: — "That from the ill-defined assemblage of cases commonly called ' Melancholia,' ' Melancholia Attonita,' and ' Acute Dementia,' a group has to be distinguished which constitutes a definite clinical and pathological entity. That tliis group is clinically characterised by the association of more or less of self-absorption passing into vacuity, with a definite affection of the muscular system, to wit, muscular tremors and muscular rigidity. That the pathological basis of the same is a primary inflammatory affection of nerve cells, best marked in the so-called ' motor cells,' and possibly originating in these, but showing a decided tendency to spread beyond their area.'' Treatment of Stupor. — All forms require 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, digitalis, warmth, the continued current, exercise, friction, alcoholic stimulants, rousing moral treatment, occupation, distraction of mind, are the general indi- cations. In the relation of the clinical histories of the cases described, the details of treatment have been sufficiently spoken of. ' Journal of Mental Science, Got. 1883. LECTUEE IX. STATES OF DEFECTIVE INHIBITION {PSYCHO^ KIFESIA; HYPERKINESIA; INHIBITORY INSANITY; IMPULSIVE INSANITY; INSANE IMPULSE; VOLITIONAL INSANITY; UN- CONTROLLABLE IMPULSE; INSANITY WITH- OUT DELUSION, EXALTATION, DEPRESSION, OR ENFEEBLEMENT) ; THE INSANE DIA- THESIS. Self-control in the popular sense — Sane self-control is not perfect ; variation in amount of, in different persons, ages, and conditions of society ; laws, natural and human, should teach it — Physiological view of inhibition in a child ; its absence at first ; its gradual growth with brain development ; degrees of inhibition and of account- ability ; conscience as a physiological brain quality ; children of criminals and of the insane; organic lawlessness — Self-control affected in all insanities ; want of inhibitory power and morbid impulse as an insanity ; without other morbid mental symptoms — Uncontrollable motor impulses ; coughing , sudden acts of defence and offence ; exhaustion lessens controlling power ; meaning of irritability ; existence of obscure tendencies to kill, destroy, &c., in mankind — Doctrine of inhibitory centres of motion, nutrition, and mental action ; Laycock's doctrine of reflex function of brain ; illus- trated by maternal instinct in cats — Illustrations and cases of impulsive but reasoning insanity ; epileptiform character in some cases ; hereditary connection with epilepsy ; impulsive acts by sug- gestion ; brain acting automatically, just as muscles do during sleep, in coughing, speaking, &c.' — Action from impulse, either by loss of controlling power, or by an excessive production of energy that must find an outlet somewhere — Conscious and unconscious impulsive action ; medico-legal importance and diflSculty of uncontrollable action from impulse — Defective inhibition may affect every kind of action, every kiud of affective state, and every propensity and instinct ; degree of strength ; may result in no action, but merely a 530 STATES OF DEFECTIVE INHIBITION'. desire to act. Etiology : Heredity ; sunstroke ; elFeets of alcohol on brain and offspring ; injuries to brain ; congenital defects ; want of or bad early training; "moral idiocy"; "instinctive juvenile mania " ; visceral derangement and reflex irritation ; first symptoms of mania or other insanity. Prognosis: Depends on causes; some of the worst and most hopeless cases of insanity as well as the most dangerous and troublesome of this class, and some of the slightest. I'reatment : Protective to self and others ; change of scene, and removal from association of morbid ideas ; Medical, by improving health, strengthening nervous tone, removing visceral or other irritation, the bromides and sedatives ; regimen, brain rest and muscular exertion, nutritive non-stimulating diet, no alcohol ; educative in young psychokinetics. Vakibties — (a) General Impulsiveness {Psyekokinesia) : Lack of control or impulse in all directions ; to kill, towards suicide, to break and destroy, to sexual acts, &c. (6) Epileptiform Impulse : Impulsiveness the mental characteristic of epileptics ; "mental explosion " ; masked epilepsy. (c) Animal and Organic Impulse : Perverted sexual impulses, taking forms of impulsive masturbation, sodomy, incest, rape on children, beastiality ; perversion of other appetites, propensities, and instincts, e.g., urine drinking, eating stones, rags, nails; infinite variety of such impulses, {d) Homicidal Impulse : Medico-Legal importance ; examples ; letterof medical man suffering from this, &c. (e) Suicidal Impulse : Conscious or unconscious ; with or without depression of mind ; by suggestion ; instinct of love of life perverted ; most com- mon of all impulses. (J) Destructive Impulse : Takes the form of breaking, tearing, smashing, &o., with no other tendency ; the glass smasher, (g) Dipsomania : Importance ; causation, neurotic or drunken heredity, excess in drinking, injuries to head, losses of blood and bodily weakness, bad hygienic conditions and emploj'- ments, slight mental weakness combined with neurotic diathesis, senility, first stage of maniacal conditions, special functional condi- tions, e.g., menstruation, pregnancy, &o. Symptoms ; craving for alcohol and all stimulants, lying, general demoralisation, falling in social scale, loss of all self-respect, cringing, self-indulgence, irresolu- tion, loss of affection. Treatment ; abstinence, isolation, work, healthy food, regimen, and conditions of life. Prognosis : bad in most cases, (h) Kleptomania: Rare in uncomplicated form, but this impulse very common in many forms of insanity, especially in General Paralysis, and less so in Mania and Congenital Imbecility, (i) Pyromania : Rare in uncomplicated form, (j) Moral Insanity : Congenital absence of sense of right and wrong, and incapacity for moral education. As a matter of fact, we find persons with no moral sense, no remorse, no love of the good, but a love of and impulse to do every evil thing. Conscientiousness hereditary. STATES OF DEFECTIVE INHIBITION. 331 Self -Control — Jlental Inhihition. — 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 in- hibitory 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 tempta- tion 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. 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, from no fault of his own his brain is weak, and no sense of right and wrong has been implanted in him, yet in spite of all this he is held as fully responsible by the law and is punished in the same degree as the strongest, best taught, and most favourably 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. Human 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 332 STATES OF DEFECTIVE INHIBITION. first of tliese is in regard to children, and tlie second is in regard to persons whose mental power has heen affected by disease or want of brain development. Degrees of Control— 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 exist- ent as mental inhibition— no desire nor 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 kiUing 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, by admitting no responsibility for crime, and exempting entirely from punishment, if committed before the age of seven, and by taking each case between seven and fourteen into special consideration as to whether there was responsibility or not. 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 con- trolling 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 some of those whose ancestors for several generations have been criminals, insane, or drunkards. Then, again, in other persons, the sense of right and wrong is STATES OF DEFECTIVE INHIBITION. 333 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 anaesthetic, in others hyperaesthetic, just as sensation may be. Notoriously it is a bad thing to force any sense or mental faculty into too great activity tUl its brain substratum is suificiently developed. I have known many children whose anxious parents had made them morally hypersesthetic at early ages through an ethical forcing-house 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 question as to whether he should eat it or not ; who would suff'er acute misery, cry 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 copy at once our ethics nor our power of controlling our actions. It seems to take many generations to re-develop an atrophied conscience. Professor Benedikt of Vienna showed, at the International Medical Congress of 1881 in London, a number of brains of habitual criminals which he afiirmed 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 general 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 334 STATES OF DEFECTIVE INHIBITION. 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 its various forms, and in different individuals labouring 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, hke 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 self-control in his patients when they are ill, apart from technical insanity. He knows that the thing called "irritability" usually 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 always 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 STATES OF DEFECTIVE INHIBITIOX. 335 in tlie shape of ex.citemenb or depression, insane delusion or incoh.erence of speech, before they are wilhng to put forward the plea of diseased want of self-control in mitiga- tion 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 melancholies 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 incohe- rence 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. Inhibition, Motor and Mental. — Consider first the variety of simple motor impulses or acts that are physiologically uncon- trollable, or partly so, such as coughing, vomiting, &c. Next, look at a more complicated act, that will be recognised 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 a man, and he will either perform 336 STATES OF DEFECTIVE INHIBITIOX. 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 ? " Irritability " is one manifestation of this. Many persons have so small a stock of reserve brain power — that most valuable of all brain quahties — that it is soon used up, and they then lose their power of self-control. They are angels or demons just as they are fresh or tired. The 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 completely 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 destructive- ness, 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 pro- genitors, 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. STATES OF DEFECTIVE INHIBITION. 337 The doctrine of nervous inhibition and of inliibitory centres has done very much to definitise our notions in regard to the mental working of the brain. There is, of course, no positive proof of mental inhibitory centres, but there is mental in- hibition, 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 patency of the capillaries and arterioles, and that the latter was dependent on two sets of nerves and two sets of centres, one to open and the other to shut those vessels, such physiological facts were at once correlated with the facts observed in conditions of mental excitation and depression, mental quickening and slowing, emotional supersensitiveness and torpor, and the conclusion was arrived at that in the higher department there must be a somewhat similar apparatus for regulating the exer- cise of the mental functions of the brain, and that disorders of these would probably make all the difference between sanity and insanity, between self-control and insane impulse. That there was a physiological analogy between the jactitation of the hmbs of a man with chorea, who tries to control these motions but is not able to do so, and the insane impulses to murder, suicide, and violence which the patients are aware of, deplore, and fruitlessly try to resist but are unable to do so, seemed very evident. In the one case, a controlling centre or centres of motion are not doing their work, either from absolute loss of their own internal power of governance or from an excess of energy generated in the lower motor centres of the choreic limbs ; in the other, the controlling centres of mentalisation and feeling are not doing their work for the same reasons. We know that there are controlling centres of many of the lower reflex functions, and there can be no doubt that they exist also to control the great reflex functions of the cerebrum, which were so clearly expounded by Laycock. That doctrine has done much to make us understand better Y 338 STATES OF DEFECTIVE INHIBITION. the mental functions of the brain and their derangements. Let us glance at an example. The maternal instinct of care and affection for offspring is a mental function of brain common to man with the lower animals, and ranks next to the love of life and the desire. to reproduce the species in importance, while it equals these in conscious intensity for the time it is in operation. Its periods of activity are, of course, intimately connected with the activity of the reproductive organs. The objects of the instinct need not necessarily be the animal's own offspring. Cats will suckle and take tender care of young rabbits when their maternal instinct is in full activity after parturition and when the mammse are function- ally active. There is a nervous influence sent up from these organs to some portion of the brain, rousing it into activity, and so developing the feeling for young, and the unceasing innumerable acts of care, defence, playing with, and protection, which for the time dominate the whole mental life and out- ward actions of the animal. Artificial irritation of the mammee without previous parturition will sometimes develop this instinct. In the case of the cat suckUng the young rabbits, it entirely inhibits the opposite instinct to kill and eat them. In conditions of disease the maternal instinct may be completely perverted in its exercise, so that animals some- times eat and destroy their young. Now, the same thing happens in the human species. In the insanity which occurs after childbirth one of the most common symptoms is either an entire inhibition of the maternal instinct, so that " a woman forgets her sucking child," or an entire perversion of it, so that she wants to destroy her own offspring. Forms of Impulse. — The physiological word " inhibition " can therefore be used synonymously with the psychological and ethical expression " self-control," or with the " will " when exercised in certain directions. It is the characteristic of most forms of mental disease for self-control to be lost, but this loss is usually part of a general mental affection with melancholic, maniacal, demented, or delusional symptoms as STATES OF DEFECTIVE INHIBITION. 33^ the cliicf manifestations of tlie disease. The cases, not so numerous, where the loss of the power of inhibition is tlie chief and by far tlie most marked symptom, we are now to consider and study. I shall call this form "inhibitory insanity." Some of these cases have uncontrollable impulses to violence and destructiveness, others to homicide, others to suicide prompted by no depressed feelings or delusions, others to acts of sexual gratification (satyriasis, nymphomania, erotomania, bestiality), others to drinking too much alcohol (dipsomania), others towards setting things on fire (pyromania), others to stealing (kleptomania), and others towards immoralities of all sorts (moral insanity). The impulsive tendencies and morbid de- sires are innumerable in kind. Many of these varieties of insanity have been distinguished by distinct names : to dig up and eat dead bodies (necrophilism), to wander from home and throw off the restraints of society (planomania), to act like a wild beast (lycanthropia), &c. Action from impulse in all these directions may take place from a loss of controlling power in the higher regions of the brain, or from an over-develop- ment of energy in certain portions of the brain, which the normal power of inhibition cannot control. The driver may be so weak that he cannot control well-broken horses, or the horses may be so hard-mouthed that no driver can pull them up. Both conditions may arise from purely cerebral disorder, or from cerebral excitation or paralysis caused by eccentric agency in the organs — it may be reflex, in short. The former of these may be without consciousness at all, the ego, the will, the man being non-existent for the time. The most perfect examples of this are murders done during somnambulism or epileptic unconsciousness, or acts done in the hypnotic state. There is no conscious desire to attain the object at all in such cases. In other cases there are consciousness and memory present, but no power of restraining action. The simplest example of this is where an imbecile or a dement, seeing some- thing glittering, appropriates it to himself, or when he commits indecent sexual acts. Through disease a previously sane and .340 STATES OF DEFECTIVE INHIBITION. vigorous-minded person may get into this state. The motives that would lead persons in health not to do such acts do not operate in such persons. I have known a man steal who said he had no intense longing for the article he appropriated at all, at least consciously, but his will was in abeyance, and he could not resist the ordinary desire of possession common to all human nature. I have known a married man with opportunity of sexual intercourse indulge in masturbation, his reason tell- ing him the act was wrong, and his feehng causing disgust and regret, yet he could not resist this simple but unnatural mode of sexual excitation. Volition and resistive power were paralysed. {' The second class of impulsive acts, where we seem to have normal volitional power, but the impulses so morbid and so strong that they cannot be resisted, is often seen by the physician in the early stages of mental disease, before its symptoms have fully developed. Its existence may be ridiculed by journalists, aud the dangers of admitting its existence may be painted in dark colours by lawyers, but that it exists as a fact in the history of human nature no one can doubt who has actually seen the terror and agony of a mother conscious of an impulse to destroy her child, and striving against it with vehement resolution. A lady came to me lately to consult me, and this was part of her conversation: — "Thoughts of putting myself away co.me suddenly into my mind when I am working and quite cheerful. Oh ! my God ! if I could get these thoughts out of my head what would I not give? I could and do scream for rehef sometimes. Oh, me ! it's hoi'rible ! It comes on me that some day I will take away my life or that of my children. I had this idea before I was married at times. My mother had it. It comes on mo in one instant, and some day I will not be able to resist it. It seems now as if there was a galvanic battery up from your floor up to my brain that makes my head feel queer and tingling. Filthy words and bad thoughts shoot into my mind, too, in the same way." And she threw herself on her knees in an agony of STATES OF DEFECTIVK INHIBITION. 341 distress, beseeching God and me to deliver lier from these homicidal and suicidal impulses. Yet a minute before she had been cheerful and laughing, and a few minutes after she was the same. This condition passed into an ordinary attack of melancholia, from which she recovered in due time. No doubt the theory of uncontrollable impulse is liable to abuse, and to be applied wliere it does not exist ; but one might as well assume that there is no real epilepsy because malingerers and hysterical girls simulate fits, or that there is no such con- dition as hypnotism because rogues, fools, and quacks dabble in deceit and call it mesmerism. Etiology. — The states of defective inhibition and impulse may be momentary in duration, or may be constant. They may be slight in form, or most intense. Their etiology is as varied as their duration. As a general rule they are met with either in those hereditarily predisposed to the neuroses, or in those whose normal brain functions have been impaired by over-indulgence in alcohol or nervous stimuli on the part of themselves or their parents. In some few cases a merely defective training of the brain in youth seems to end in morbid hyperkinesia. No doubt, if we could devise a perfect mode of teaching self-control to the J'oimg brain, it would be an educational discovery, the most valuable yet made by humanity. The great crises of life sometimes set up this condition — puberty, adolescence, the climacteric period, and senility. In many cases there have been congenital or early defects of brain development, causing volitional and moral imbecility, or what Morel called instinctive juvenile mania. Visceral derangements and reflex irritations are the causes in many cases. Who does not feel his volition or self-control sympathise with the state of his digestion ? I know a young woman who, during menstruation, which was with her dif- ficult and painful, did all sorts of impulsive acts — eat dirt, hurt herself, and pinch children, — while she was at other times amiable, and did none of these things. There is no doubt that the organic instinct of reproduction sometimes becomes 342 STATES OF DEFECTIVE INHIBITION. transmuted morbidly into instinctive impulses to kill, steal, &c. Varieties.— 1 shall confine my observations to the commoner and more typical varieties of morbid impulse, and they are the following : — a. General Impulsiveness. h. Epileptiform Bnpulse. c. Anivial and Organic Impulse. d. Homicidal Impulse. e. Suicidal Impulse. f. Destructive Imjndse. g. Dipsomania, h. Kleptomania, i. Pyromania. j. Moral Insanity. General psychoJcinesia, or impulsiveness in all directions, is well illustrated in the following case, who was a patient of mine in Morningside : — E. T., set. i7, of a very neurotic heredity, a brother being insane and epileptic, and a sister insane. In addition to this, she has had twenty years of sorrow and domestic worry, with a drunken husband who could not provide for her, and through the loss of several of her children. She has had ten children and nine or ten miscarriages. The children whom she lost all died of convulsions or hydrocephalus. The exciting cause of her illness was an abortion at two months. She was very impulsive on admission in all ways. She tore her clothes, she tried to jump out of windows, she refused food at times when she did not get what she wanted, she would do any mischief that was in her power. Between those acts she was rational in speech and conduct, aflfectionate, and agreeable. She would be dancing, lively, and chatty in the drawing-room, apparently one of the happiest women there, and, seeing an open window, she would suddenly change in expression of face and eyes, would step towards it, and try to throw herself over. When asked about it she would say STATES OF DEFECTIVE INHIBITION. 343 slie coiild not help it. She was always most impulsive at the menstrual periods, and at these times frequently had retention of urine, needing the catheter — this she had been subject to occasionally during her married life. The bromides, fattening non-stimulating foods, fresh air, baths and constant super- vision, discipline, and occupation were all tried, with a gradual good effect. The impulses became less intense, and her self- control more, as her bodily condition improved. She was subject to sudden feehngs of what she described as " unutter- able dread and woe," coming like a flash over her, and passing away as quickly. Unfortunately, at first we gave her chloral and hyoscyamus at night, which I found was a mistake. She became very dependent on these things for sleep. She did much better when they were stopped. Now I never give chloral for long where there is impulsiveness. I believe that its effect is to lessen the inhibitory mental power of the brain. In about three years she had improved considerably, and was removed to another asylum, and ultimately, after ten years, made a good recovery. It must be remembered that all these impulses, obstinacies, violences, destructivenesses, and suicidal attempts were contrary to the whole habits of the life of this lady till she was 47 ; that they then lasted more or less for nine years ; and that between those acts of impulsiveness she was one of the most agreeable and sensible persons I ever saw, and was clever, witty, and often hilarious. Tlie next case ipos a very striking one, and loas well described by one of the former assistant physicians here, Mr James Mac- laren} I look on it as being generally impulsive and to some extent mentally epileptiform in character. " Late one night a lady, whom we shall know as E. U., was brought to the Royal Edinburgh Asylum, labouring under great excitement, and bleeding from wounds in her mouth caused by her attempts to swallow pieces of the glass of a cab window which she had broken. Her insanity was very early seen to bo of a kind in which the leading features were ' Medical Times and Gazette, January 8, 1876. 344 STATES OF DEFECTIVE INHIBITION. impulsive acts of a sudden and a most dangerous character to herself and to others. She is not an epileptic ; she has no definite delusions or hallucinations. In her the paroxysm of violence has the following characters: — It is periodic; it is accompanied by always partial, frequently total unconscious- ness, and consequently followed by a similar state of forget- f ulness of her acts ; it is preceded by a sharp pain in the head, and followed by a dull pain in the head, dizziness, and con- fusion of ideas. There exist also certain neuroses, but these will be detailed in the course of the history of her case, which it will be well now to enter on. "She is forty-three years of age, the fifth child of a family of fourteen. Her parents are both of a neurotic type ; her father is almost totally deaf, and a brother of his died insane. Her mother dwells on the borderland of insanity; she was always a person of very peculiar disposition, suspicious, unreasonable, and of an exceedingly high-strung and nervous temperament. This was her condition previous to marriage. Its cares and troubles, and particularly the mental and physical wear and tear involved in the bearing and nursing of fourteen children, told badly on her. Her confinements were severe, and after them she was subject to alarminf floodings; at her menstrual periods, too, the haemorrhage was always excessive. That all this told on her severely was noticed by her friends in her increasing debility, nervousness, eccentricity, and irritability as she advanced in years, and, to any one who could read the lesson, was confirmed by what seems to me a very curious fact. She had, as I have said, fourteen children. The first four of these were fairly healthy, and are still living ; then came the subject of the present note, regarding whose mental and physical health we shall presently hear ; and after her came nine children, all of whom are now dead. The elder ones lived longest, and then, as the mother grew in years, and the strain on her became greater, the duration of the life of her ofi'spring shortened. It is true that none of them died directly from brain disease; still it STATES OF DEFECTIVE INHIBITION. 345 does not seem too much to assume, ■vvitli tlie liistory I have described, that the parents were at first able to procreate healthy offspring, that this began to fail with E. TJ., and that after her the strain became greater and greater, and so they produced children only in the poorest degree endowed with the power of living. The inverse ratio between the age of the parents and the duration of life in the offspring seems too marked and definite to be due to accident or chance. So, then, in this neurotic couple we have them in their early married life transmitting to their children health, later on insanity, and ultimately a tendency to early death. "And here, forestalling its position in the history of her case, comes in another step in the descent and progressive degeneration. E. U. has become pregnant several times ; one child is alive, one lived a few months, all the rest were born prematurely. The child which is alive is, as regards his mind at present, precocious and talented, writes letters in a style beyond his years, reads books on natural science, and is fond of sketching and painting, and thought exceed- ingly gifted by his friends. He was stunted in body, weak and miserable when young, and often barely kept alive by constant and most careful nursing, but developed into a strong-looking lad. " I have now to speak of the personal history and charac- teristics of the unfortunate lady who is the subject of this sketch. As I have said, she was the fifth child of her parents. In her early years she was only noted for everything that was good and amiable. In this I am not taking the words of possibly too partial friends, but of others who knew her more or less intimately ; and one and all bear testimony to the fact that, as regards the possession of many good qualities, she was far above the average. Kind and loving, very gentle and quiet, but apt to become emotional on trifling provocation ; devoted as far as her strength permitted to all good works, generous even to a fault, and earnest in season and out of season to do her duty, — such is the account of her in her early 346 STATES OF DEFECTIVE IXHIBITION. days. From her earliest years religion was part of her daily life, not engrafted on to her other duties, but forming the moving principle of all she did. She belonged to a devout family and an earnest sect ; and so, by education as well as temperament, was thoroughly and entirely devoted to sacred thoughts and duties, and was noted among her friends for the emotional fervour and power of her prayers. In ability, too, she was above the average — clever, studious, and painstaking. " At the age of twenty-three she married her present husband— a gentleman in every way calculated to make her happy. It was long before he noticed anything particularly strange in her manner or conduct. ■ Certain shght peculiarities, a morbid sensitiveness as to possible wrong-doing, occasionally excessive emotionalism; and once or twice, when in circum- stances calculated to excite or distress her (such as being in the company of uncongenial people or those of a higher social rank), a tendency to become rambling and incoherent, — these were, as far as he can remember, the only facts that called for notice or excited alarm. Still they were of the slightest. " Some years after she was married, and ten years ago, the boy already mentioned was born, but previous to that, and since, she had several times aborted. On each occasion her bodily weakness from excessive flooding was great, and her men- tal distress at the unfortunate issue very painful. Two years ago she again became pregnant, and, greatly to her joy, was delivered of an apparently healthy boy, and for a little while the caring for it seemed to restore the balance of her mind. However, it was only spared to her for a few months, and its death and the final and marked access of her insanity followed each other. During her pregnancy, and for some months before, the little abnormalities I have mentioned were beginning to be more and more marked. Her reli- gious feelings became of the most exalted character, and her emotionalism excessive. On one occasion while walking with her husband in a frequented place, she knelt down STATES OF DEFECTIVE INHIBITION. 347 and prayed for strength to bear her coming trial ; and her benevolence and generosity, always prominent features in her character, became almost unbounded and frequently quite unreasonable. AVhen the baby came, her attention was taken up with it, to the exclusion of everything and every one else. Then it was taken away, and from that time is dated the marked unmistakable arrival of the insanity. General excitement, an altogether morbid and excessive fear regarding her religious state and future salvation, and an ex- cessive sensitiveness as to the possibility of ever having in any way wronged any one with whom she might have had deal- ings, were the early symptoms she displayed. Then sudden and unaccountable outbreaks of dangerous violence, attempts at self-destruction occasionally, and most destructive ten- dencies in every respect, rendered her removal to an asylum imperative. She was accordingly taken to a private estab- lishment, where she remained for a few months, gradually getting worse and worse. During this time a hsematoma of the left ear developed itself, and ran the usual course, leading to the shrivelled and characteristic insane ear. " First, as to her appearance — she is slight and almost undersized, a very gentle- looking lady, with a pale, pretty face, light hair, and blue eyes, a singularly kind, pleasant, winning manner, and a soft, quiet voice. Second, as to her mental state — free from excitement, she is what she has already been described as, thoroughly devout and good. Her memory and judgment a,re in all but one respect correct. Thoughts of her husband and child, bitter regret at her separation from them and at her sad calamity, a constant and prevailing desire to do what is right, and an excessive and morbid sensitiveness lest her slightest word, or look, or action may be in any way wrong. That is the bright side of the picture of a singularly pure but sadly imperfect nature. Now for the reverse. " It is difficult in a pen-and-ink sketch to give an idea of the intense impulsiveness of her acts. She will sit reading her Bible or some good book, or talking in her quiet, gentle 348 STATES OF DEFECTIVE INHIBITION. way to her attendant, when suddenly, without a moment's warning, the hook is flung through the nearest window, or at whatever is breakahle at hand, then she makes a rush to run her head into the fire, or turns on her attendant, tears her clothes, or tries to strangle her. All this withoiit speaking a word, except perhaps an occasional muttered text of Scrip- ture ; but beyond that, she keeps quite silent, and struggles on quietly but fiercely, till either exhausted, or restored by some apparent process of awakening to her former condition. Excitement, of course, there is in plenty, but it is very difierent from that associated with more ordinary forms of mania. There is no noise or shouting ; her eyes are fixed and suffused, her face flushed, and her teeth clenched, and every muscle is on the strain ; but the whole time she is perfectly quiet, and struggles on with a fixed determined purpose expressed in her whole manner, but without wasting a word. There is hardly a method of attempting violence that the mind could conceive that she has not had recourse to. At one time, but only for a few weeks, her acts took the form of exposure of her person, and in this, too, suddenness was the marked feature. I have seen her weeping bitterly at the sadness of her lot, and praying for some help, and while the words were still on her lips, throw herself on the ground, and pull up her dress. Once or twice about this time there was a slight increase of her general excitement, and she laughed and talked more than usual ; but as a rule the exposure was something altogether different from the ordinary suggestive act of an erotic female. This tendency to exposure, however, did not last long, and has not returned. "i^Qw, as to the nature of her paroxysms. Though not very definite, there is no doubt that there is a certain amount of periodicity in them. It is not hard and fast, but her attendants notice that she has, as they put it, a good day and a bad one, or two good days and two bad ones. Then — and this seems to me a very important point in her history there is, as a rule, entire unconsciousness and forgetfulness of what passed during an attack. I have often taken her carefully ■ STATES OF DEFECTIVE INHIBITION. 349 over tlie events of a day in wliioli one had occurred, and invariably found her correct and precise in every detail till we reached the onset of the seizure. Then all was a blank, and she only remembered that she seemed to faint, and then found herself lying on a sofa with an aching head, and con- fused and stupid. Occasionally, and if her seizure has not been very severe, she has some slight recollection of her act and of the impulse which led to it, and the latter is always a feeling of imperative necessity that it is her duty to do as she has done ; but in by far the greater number of her attacks un- consciousness during and after was the rule. " There are a few physical phenomena connected with her case that I will now mention. The insane ear has already been recorded. Her tongue is tremulous, and points markedly to the right side. After an attack she has a slight stutter and thickness of speech. The right pupil is more dilated than the left. During a paroxysm both pupils dilate and contract con- stantly and independently of each other, so that sometimes one and sometimes the other is the more dilated. Her hair is exceedingly dry ; her temperature is normal, with a steady increase of two points in the evening over the morning figure. Her menstruation has not returned since her last child was born. Her sensibility is at all times dulled ; during an attack it is greatly impaired. The reflex action of the cord is much dulled. "What is the nature of her insanity? Her attacks, read alone, seem only to want one factor — epilepsy — to make all complete. This, though, is wanting ; she is not epileptic now, and has never been so. " It is a strange condition of dual consciousness. Whether she remembers in each pamxysm what happened in the last I cannot say, but I think she does, and it is certain that she follows out trains of thoughts in successive attacks of which she has no consciousness during a remission. Por instance, of late, as soon as a seizure comes on her, she makes particular efforts to get at one special picture in the room. When the attack has passed, this picture awakens no feelings in her at all, 350 STATES OF DEFECTIVE INHIBITION. and slie has no recollection of anything particular connected with it ; but as soon as the excitement returns, her attention fixes on it at once." In the course of three years she gradually became less dangerous and the impulsive attacks less intense, -while her mind became more enfeebled. She got so much better that she was taken home under the charge of a nurse, seemed to be almost demented, and quite incurable. The impulsiveness seemed to have disappeared, but after nine years she suddenly committed suicide. Ejpileptiform Impulse. — Epilepsy, as we shall see in the psychosis commonly associated with it (epileptic insanity), tends remarkably towards impulsive acts, which will be considered under that form of insanity. By epileptiform impulse I mean those sudden impulsive acts, attended by unconsciousness, which are exactly the same in character as those we are familiar with in epileptics, and yet the patients are not subject to ordinary epilepsy. Some of the acts of the last case, E. U., were clearly of this character. I have now a patient who brought on his disease by over-drinking, and who on one occasion leaped through a window on the third story when quite sober, and did not know anything about it afterwards. On another occasion, in passing the corner of a building in the Asylum, he ran violently against it with his head, causing a wound five inches long, and very nearly breaking his skull-cap. He is not a regular epileptic, but he once took a convulsive epileptiform attack. His case is incurable, he is now getting partially demented, and his impulsiveness is passing off. The regular use of the bromide of potassium seemed to diminish the impulsive tendency. Animal and Organic /jjipwZse.— Under this term I include all the uncontrollable impulses towards sexual intercourse, mastur- bation, sodomy, rape on children, bestiality, &c. The per- verted instincts, appetites, and feelings shown in urine drinking, eating stones, rags, clay, nails, , D., a woman of 36, who paxnoA gnulunily into an attach of quiet non-delusional general paralysis (ftcr a small punctured wound in the top of her head penetrating for about an inch into tlie brain. A pitchfork had fallen accidentally on the top of "•er head as she was loading a cart of wheat. After death '^me whole of tlie convolutions round the wound were found specially affected, though the cortex in most parts of the vortex and sides of the brain were affected as well. Symptomatological Varieties.— Hhavo are many cases of paralysis where the course, and oven the nature, of thi^ symptoms vary, within limits, exceedingly from the typical symptoms and the typical course. They constitute sympto- matological varieties of the disease. The most common aiul the most marked of these is the nan- delusional variety, as seen in the following case, where there was no excitement, no delusions of grandeur and no congestive attacks, but GENERAL TAEALYSIS. 393 simply a gradual mental enfeeblement beginning witli the volitional power, and a gradual paresis beginning ■with muscular weakness and fibrillar tremblings in the facial muscles and tongue, this gradually passing into complete inco- ordination. G. C, set. 50. A quiet-living man, who had married about three years before he became ailected in mind, first showed mental defect by irresolution, want of keen interest in any- thing, forgetfulness, and the want of a realising sense of the necessity for his working in order to live. Soon he got a little irritable when pressed to work. Then his mind showed clear signs of enfeeblement and facility. He would believe silly stories, he could not carry on a connected conversation, he had few likes or dislikes. I saw him at this stage, and found his speech thick, his lips showing, as he began to speak, that fatal quiver that to a practised eye almost marks the disease from all others. His walk, too, was not firm, and in turning round sharply he did so uncertainly, and he could not walk along a chalk line on the floor or stand steadily on one leg. He gradually got more enfeebled and frail in mind, his speech became less articulate and his walk more paretic. Nearly all his symptoms were negative. He had a gentle kleptomania. He would pick up and fill his pockets with stray pocket-handkerchiefs, aprons, and rags in a sort of automatic way, not in the least caring or objecting wheoj they were taken from him. He died in six years of pure exhaustion, absolutely paralysed, never having made a sound that could be called articulate for a year, or voluntarily moved a voluntary muscle during that time, lying on a water-bed, and leading a merely vegetative hfe. Such cases are apt to live a long time. They have not commonly lived dissi- pated lives, and they are usually of a calm phlegmatic temperament. Nearly one-third of all the cases of the disease that I have seen were of this character, and neaiiy all the older medical officers of asylums say that this type is increasing, while tlie classical grandiose type is diminishing in 394 GENERAL PARALYSIS. frequency. This type is very common in the female sex ; in fact, the majority of the female cases conform to it more or less. It is also the common type of the disease in those parts of the country where the people live unexciting lives. Standing at the opposite point from this quiet form of the disease are the two varieties of which I shall now give examples. The first is the spedalhj convulsive form, as exhibited in the following two cases : — G. E., £et. about 40. A man who had been of an excitable disposition, and had led a dissipated life in regard to drink and women ; of a fiery temper ; who had suffered from syphilis ; whose whole life had been a whirl of mental excite- ment, lie had complained for some time of very severe head- aches, had been off his sleep, had been unusually irritable and not fit to do a day's business. , One day ho suddenly fell down in a fit, and remained in general and severe convulsions with complete unconsciousness for about two hours, and died in them. After death I found all the pathological signs of general paralysis : especially the adherence of the pia mater to the con- volutions of the vertex in patches was very marked. There was no local disease in the membranes or vessels that has been recognised as syphilitic, and he had not been drinking heavily before his death. My conclusion was that it was a case of general paralysis with a strongly convulsive tendency, this killing the patient before the usual symptoms had time to develop. I do not know whether I should or not have been able to diagnose the case had I seen him before the convulsive attack, or whether there were any motor symptoms present before it occurred. But, it may be said — Is it possible for a man to have marked disease of the brain affecting the convolutions of the vertex without mental or motor symptoms 1 My experience of the cases of general paralysis, who died as G. E. did early in the first stage, would lead me to the conclusion that the recognisable pathological lesions of the convolutions precede the marked mental symptoms. They usually need to develop in some in- GENERAL PARALYSIS. 395 tensity, and to infoTve a certain number or kind of convolutions, before mental or motor symptoms become very manifest. I had a general paralytic in the Asylum, G. A., who took an epileptiform convulsion every day for months. The tempera- ture rises often before, and always after, an epileptiform con- vulsion or a merely congestive attack in these cases. I had another patient who had many epileptic-looking fits for a year, and was treated for epilepsy by eminent physicians during that time, before the usual mental and motor signs of general paralysis appeared. The convulsive tendency is best treated by the steady use of the bromides, which, however, always aggravate the inco- ordination. During a congestive attack with convulsions they can be stopped by large doses of chloral, or by putting the patient under chloroform ; but I doubt whether consciousness is sooner regained thereby, or if life is prolonged. The next marked departure from the normal type of general paralysis, such as I have described it, is where the first stage consists of a maniacal exaltation alone, loitliout any motor sign that one can recognise, for months, and even years. I have had several cases now who had what appeared to be attacks of ordi- nary acute mania, and to all appearance had recovered, who had even second attacks and recovered, and then developed the motor symptoms of general paralysis. The following is one of them : — • G. G., set. 36, an Irishman born— Irishmen often enough suffer from general paralysis here, if they do not at home — drunken and hard working ; married. Had an attack of "acute mania" in 1876, and was sent to the Asylum, and " recovered " in five weeks. No motor signs nor evidences of general paralysis were noted by me or anyone else then. In 1878 he had another attack, and this time some suspicion of the disease was excited, but no diagnosis made. He was again discharged recovered, and it was only on his third admission, three years after his first, that the disease was manifest. He died of it in three years after his last admission. 396 GENEEAT. rAEALYRIfi. In such a case as that of G. G. T have no doviht whatever that the first attack in 1876 was really a part of the general paralysis, but at that time the disease waw probably super- ficial in the anterior cortex ami confined to a limited area, and did not involve to any extent the motor ccntrcsH in the convolutions, causing, no doubt, much congestion and much vascular overactivity in the cortex, but not inco-ordination of motion. The first attacks were brain-storms that passed away, so far as tlu! active congestion and the vascular disturbance wore concerned, leaving the incipient organic eonvolutional change there, but quiescent. I have also no doubt — in fact, ] obtained clear evidences of it from liis wife— that intel- lectually he was weakened after the first attack of "acute mania" in 1870. Such cases enable one to understand the "recoveries" and "cures" of general paralysis, not one of which, I believe, was <'.ver real or lasting, if tlic diagnosis has been correct. Do not diagnoHefrow, menial m/rri'/ilomn (dune.- It is common to have in the beginning of the first stage very acutely maniacal mental symptoms, and no apparent motor signs discovered — and general paralysis should never be diagnosed from mental symptoms alone. But there is no doubt that the mania of general paralysis is the most intense — not to be incoherently delirious, — the most unreasoning, and the most exhausting we ever see; and to tin; experienced eye it has a certain character of its own in most cases which suggests the disease. In certain cases we have a combination of the nrm-ddudonal very uncommon for a man irlio f^unc/-;' from general jiaraJijfi^ to have hcen insans hfore, but I have met with a few examples. One, G. H. A., had an attack of mania in youth, recovered, kept well, and did his ordinary business for twenty years, and at the age of fortj'-four became a general paralytic. "We meet with certain long-lircd cases that do not die at the normal time, hut live on for periods up to thirty years. Tlie foUowing is tite most marked case of this kind on record : — G. J., fet. 35, admitted to the Eoyal Edinburgh Asylum IStli Xovember 1S60. Had led a somewhat rough life, and nine months before had an ''epileptic fit." Xo heredity to insanity, but he had a very eccentric, somewhat silly sister. The attack had been preceded by a melancholic condition, and he had refused his food. His articulation was slurred, his pupils unequal, his walk slow and unsteady. He was unhesitatingly diagnosed as a general paralytic. Ai'rer nine months he was taken out of the Asylum by his relatives, but had to be sent back again in eighteen months, having been, while outside, totally unable to do anything for his own livelihood, and having got gradually worse in mind and body. "VThen admitted in 1SG3 he was "stout, stupid, and silent," had the '"peculiar expression of face of general paralysis well marked, as well as its walk." Some days he was " quite well and happy." In a few months he wa5 "uproariously happy," with the most exaggerated notions about his riches, strength, height, beauty, ito. He is 40 feet high, is God, is married to the Queen, is the strongest man in the world, and has a "damnable heap of money." AU Leith Docks belonged to him, and most of the ships there. In December 1S63 he had a series of epileptiform fits, which were ushered in by a regular con- gestive attack. He became very weak, and could with difficulty articulate or make his water. He got over this condition in a few weeks, and became facile and contented. 398 GENEHAL PARALYSIS. An assistant physician of tho Asylum recorded, in the Case- Book in 1864, — "Is a magnificent specimen of a general paralytic." In June 1864 he had a congestive attack, succeeded by epileptiform fits, being maniacal and restless afterwards. In August 1864 he had another congestive attack, and one in January 1865, and got so frail in March that he had to be kept in bed. In March he had another congestive attack. He had no congestive or epileptiform attack again till December 1880. During all these years the symptoms remained the same, but the disease did not advance much till after the epileptiform attack in 1880. The period of general convulsion was short, only a few minutes, but ho was confused and stupid afterwards for four hours, and was then excited and noisy. The paresis in- creased after this, and the general strength failed much. In February 1881 ho had another severe attack of general convulsions, with several hours of unconsciousness following them, the temperature rising to 102 '4° in three hours, and then falling to normal in two hours after that. Ho had two such attacks in April of that year. After the lust tho left side was found weaker than tho right, and he was shaken generally. During tho summer he could not walk far witli- out becoming paralysed in his legs; he had incontinence of urine, his speech was thicker and less articulate, and mentally he was more facile and stupid. In 1887, twenty-eight years after the commencement of his illness, his condition was as follows: — Facial expression vacant; pupils both contracted, but partially sensitive to light, the left being slightly the larger, outlines not regularly circular; tongue tremulous, and its muscles inco-ordinated over surface ; articulation aflfected just like that of a typical general paralytic in end of second stage of the disease, difficult words being worse pronounced, and the ends of sentences worse than their beginning; walk uncertain, dragging, strad- dling; sensibility diminished, can smell pepper, but cannot be made to sneeze ; spinal reflexes very acute, patellar tendon GEXEKAL PAKALYSIS. 399 reflex quite absent. Often has retention of urine. Can- not walk well ; turns round with difficulty ; cannot stand on one leg; whole nutrition flabby j mentally in a facile, morbidly contented, exalted state. In 1889 he had an attack of unconsciousness, with a period of mental confusion afterwards. He retained his grandiose delusions, his irritability, and his kleptomaniacal tendencies. His articulation got more and more slurred, but had not then in any marked degree the shakiness and quavering of the typical general paralytic. In 1890 he became almost inarticu- late ; witliin eight days of his death he collected in his pockets leaves, flowers, dirty paper, rags, old iron, stones, broken plaster, and wood. He became feverish four days before his death, which took place on the 29tli July 1891, over thirty years since the commencement of his disease. The following ^pathological repoH of his case is by Dr Middlemass : — " Tlie skull-cap showed slight general thickening, especially of the inner table, but the bone was soft rather than dense. The dura mater was adherent to it over a small area in the region of the frontal eminences, and the whole membrane was thickened and rougher than normal. On its inner .surface there was marked 'rusty staining,' but no membrane. The cerebro-spinal fluid was much increased both in the sub-dural and, to a greater degree, in the suh-arachnoid spaces. The pia-arachuoid was considerably thickened, and presented a milky appearance, but it was nowhere adherent to the grey matter of the cortex. There was very marked atrophy of the convolutions, especially of the frontal region. Instead of their usual rounded appearance, they were wedge-shaped, but flattened on the top, some even had a slight depression running along the outer surface. The sulci were wide and gaping, and the ventricles considerably dilated. There were numerous small granulations on the ependyma of the ventricles. The pia mater of the cerebellum was not apparently thickened nor adherent to the grey matter. 400 GENEEAL PARALYSIS. " MicroHcojiic Ajjpeiii-iiiKXK. — As regards tho microsoopic ap- pearances of fresh sections of the cortex, those seen in one from the anterior part of the frontal region may be described first. The pia mater was considerably tliickcucd, and in tho cortical layer immediately subjacent to it there wr.vo numerous spider cells. These for the most part were small, not well stained, and nearly all exhiljited signs of fatty degeneration. Tho vessels were prominent, partly from an increase of tho adventitial nuclei, partly also from a deeper than usual stain- ing of tlie matuiial formiiif,' their walls. In tho docper ami larger vessels there was a slight deposit of pigment iiud fatty particles in the perivascular spaces. The ncrvo-cella of tho second and third layers showed evidences of marked granular and slight pigmentary degeneration, the protoplasm being irregularly stained and many of the processes gone. In many of the nuclei there were one or two small futty globules, and in a few vacuolation oven had occurred. The large pyramidal cells of tho fourth layer showed decided pigmentary degener- ation, and in many there were fatty granules. Tlie colls of the remaining layers were not so much degenerated. In this region, however, there was an increase in the nuclei of tho neuroglia colls, and a dense fibrillation of tho neuroglia, duo to tho delicate processes of very numerous spider cells. These were small, and stained slightly. Many woro fatty, and most of them show(Ml signs of degeneration or feeble vitality. "Sections from Broca's convolution indicated a greater degree of thickening of the pia, an increased number of spider colls subjacent to it, and more pronounc(!d degenera- tion of the nerve cells. "In the ascending frontal convolution the thickening of tho pia mater was slight, but the cellular degeneration was still marked. "In sections from the sensory regions tho pial thickening was not apprccia,ble, the nerve cells of the two deepest layers were only shghtly degenerated, and the spider cells in this level almost absent." GENERAL PARALYSIS. 401 So far as I am aware, no case with every mental and bodily symptom of general paralj'sis, and diagnosed by many com- petent and experienced specialists to be such, ever lived so long as thirty years. Dr Blandford ^ relates such a case who lived twenty-seven years. I have known many cases that lived over ten years ; and, if ten years, why not thirty ? Xature goes far in her exceptions to most pathological '"rules" on a few rare occasions. It may be said — "Was not this a case of alcoholic or syphiUtic brain damage to the mental and motor constituents of the cortex that was not really progres- sive, wliich merely caused brain atrophy, and that the patient died of old age ! If that is so, we are landed in the awkward dilemma that we may have every symptom of general paralysis during life, and every pathological change in the brain after death, except adhesion of the pia mater to the convolutions, and yet not the disease itself, because the patient lived beyond the hitherto recorded time. As our knowledge of the disease has advanced, we have seen that it is found at early ages and at late ages. I cannot see any valid reason why hitherto un- precedented duration should upset the conclusion founded on clinical and pathological evidence. The non-adherence of the pia opens out very interesting pathological questions in regard to the disease. Had it so adhered in the early stages of the disease, but, through cortical shrinkage, absorption of pathological products, and fatty de- generation of spider cells during the long course of the case, had the adherence disappeared, leaving the other pathological changes stiU present ? I beheve this to have been the case. It is consistent with the experience of other oases, and with the known laws of the absorption of pathological products ; and Bevan Lewis ^ thinks there is imdoubtei evidence that this process of disappearance of pial adhesions takes place. Instead of the exalted condition of mind, or the merely en- feebled and facile one, we have a few cases — from 3 to 4 per ' Insamty and its Treatmciit, 3rd ed., p. 299. - Op. cU., p. iSS. 402 GENERAL PARALYSIS. cent, in my experience — with melancliolic symptoms. My belief and experience is that in almost all these there is some organic visceral disease or disturbance which transmits to the convolutions sensations that are disagreeable and depressing. On examination of our pathological register, I found that nearly all the cases that had tubercular disease had been melancholic. I had a man, G. K., who had the fixed melancholic delusion that a man was inside him who annoyed him constantly, and tliis made him depressed. After death we found a tubercular disease of the intestines. I have a most instructive case now showing the influence of visceral disease on the mental condition of a general paralytic, G. L., a cabman, who thought on admission he had £.30,000, and got £1000 from Queen Victoria for driving her along Princes Street. Suddenly one day he became melancholic, saying he was a beggar, and crying bitterly. We examined his chest and found he had bronchitis. The reflex action was so dulled, as in most cases of the disease, that he had no cough, felt no pain, and made no complaint. As his bronchitis improved, his mental elevation and delusions of grandeur returned. He had a relapse, and the melancholic state at once came back. For a week or so he was elevated one day and depressed the next. At last the bronchitis was recovered from, and ho is the happy imaginary possessor of his thousands. Whenever I see a general paralytic dull now, I always search for an organic visceral cause, and usually find it. I had one case of the disease, G. M., that herjan with aphasia, and was treated for several months for this. As he began to speak the peculiar articulation was noticed, and he died in about two years. In his case, the motor reflex ex- citability of the brain and cord was greater than I ever saw in any case whatever. A very slight tap on the toe would set up a convulsion first in that leg, and then in the next ; a slight pufl" suddenly into his face would make him jump off his seat with his whole body. I have many times seen general paralytics aphasic after congestive attacks. In such GEXEEAL PAKALYSIS. 403 cases, and in all cases where the speech was specially affected during the disease, I have always found after death that the third frontal convolution of the lef t_ side and the region of the brain round it had the pia mater especially adherent to the cortex. I have lately seen several cases of what I have called "developmental general paraJysisJ'^ The disease is very rare hefore the age of twenty-five, but a few cases had been re- ported — one by myself in 1S77 — at ages from twelve to twenty. Two such cases were placed under my care in 1890, in both of whom the first symptoms of this disease had shown themselves at fifteen, and in both followed a typical course till they died, the one at the age of seventeen and the other at twenty. Both were girls who had never menstruated, and were undeveloped and girlish in form and appearance. Both had a neurotic heredity, and both had hereditary syphihs. The pathological appearances — naked eye and microscopic — - found in the brains of both were typical, and taken along with the symptoms during Ufe left no doubt whatever &s to the nature of the disease. ^Slj conclusion is that the disease may occur as one of the great and varied groups of the neuroses of development in subjects with a strong neurotic heredity. Tlie special senses are always more or less affected sooner or later, but commonly later. Many cases cannot distinguish between substances having different tastes when the disease is advanced. Some become blind, some are deaf, and many lose the sense of smell. This is caused, I believe, by a primary degeneration in the cortical centres of special sense, and a secondary degeneration in the nerves of special sense and their terminal nerve apparatus. These latter can be demonstrated in many cases, the optic nerves in some being like grey fibrous cords. The eye symptoms generally are most important in this disease. They are chiefly oculo- motor, but the expression of the eye is entirely changed, there being an expression difficult to describe which is very pathognomonic of the disease. The patient lacks vivacity 1 Tlie author's Xeuros^ of Development. 404 GENERAL PARALYSIS. of look, and the cornea is dull and lifeless, in this respect' being entirely different from acute mania. The changes in the pupils are marked in most_ cases. There is commonly contraction, sometimes up to pin-point condition, in the first stage. This sometimes lasts all through the disease. There is in by far the majority of cases inequality of the pupils, one of which does not react either to light or to accommodation so ■well as the other. In many cases there is dilatation, and this is the more common condition in the second stage and in the quiet gradual class of cases. Then the outhne of the pupil is com- monly irregular in contour from irregular motor innervation. Bevan Lewis points out the delayed reaction-time in the disease. This together with the dulled reflexes is, in my opinion, the reason why so large a proportion of the cases of broken ribs in asylums are general paralytics. When the chest is struck or the weight of another patient or an atten- dant is thrown on it, the laryngeal muscles do not act in time to close the chest and make it resistive, through its being filled with air that cannot be driven out. I have only seen one patient in whom long-continued ordinary insanity became changed into general paralysis. It was a case of dementia of twelve years' standing. It was an exception that proves the rule that general paralysis and ordinary insanity have little in common pathologically. The conditions that are most apt to he misfaJcen for general paralysis are alcoholism, syphiHtic insanity, paralytic insanity, certain cases of epileptic insanity, certain cases of brain tumour, acute mania with ambitious delusions, choreic insanity, some senile conditions, some traumatic cases, and some cases of imbecility with stuttering speech. It is quite impossible to diagnose correctly at once some cases of alco- holism from general paralysis. We must wait in such cases. Never diagnose general paralysis till you are sure. I have met with two cases of traumatism where the symptoms were chiefly those of general paralysis, but the cases lived on and died of diseases not cerebral. GEXEKAL PARALYSIS. 405 Incepiion. — General paralysis does not common!}- begin by a sudden appearance of any of those motor or marked mental symptoms. If a correct history of the patient's mental state for two or three years before the "insanity" openly showed itself can be obtained, we will usually find premonitory symp- toms in the shape of sensory neuroses, diminished energy, changed disposition, lack of enjoyment of life, depression, or some other mental change indicating weakened nervous ener- gising. In many cases I think the middle-aged general paralytic is suEFering for the sins of his youth. Causation. — There are two causes that, singly or combined, above all others, cause the disease, viz., sesual excess, espe- cially if indulged in at or after middle life, and alcoholic intemperance, especially if impure and bad drinks are used. If hard work, muscular or mental, with a stimulating diet of flesh, are combined with these, then we have an additional liability. .Some recent continental authors assign syphilis as the real cause of the disease, and Dr Drummond of Xewcastle homologates this view.^ I cannot agree with it because I have had many cases in which the existence of personal syphilis was excluded by every sort of reliable evidence. But mental shocks and strains of all sorts will of themselves cause the disease. There is a certain temperament that predisposes to it — the intensely sanguine. Dr G. E. Wilson contends that there is a " diathesis of general paralysis," and adduces very many pertinent facts in favour of this view. " General intelUgence," "ambition and energy, sociability and a large capacity for enjoyment, a firm belief in oneself, and a prefer- ence for handsome women,'' are the gooi and sane character- istics of this diathesis, while a lack of tbe higher control, tendencies to excess, especially sexual excess, selfishness, vanity and restlessness, are its weak p Dints.' This accentu- ates the above causes of brain irritation and exhaustion. 1 Srit. M&i. Jour., Sth August 1S93. -Jour. Men. Si-i., Jan. 1S92, '■ The Diathesis of General Paralysis," by G. K. VUson, M.B. 406 GENEUAL PARALYSIS. Hereditary predisposition to insanity or to the neuroses is less common in this disease than in the ordinary forms of insanity. But lately I had a general paralytic patient, and Dr Savage had his twin brother/ there being a strong family history of insanity, both men being of the same temperament and dis- position, viz., sanguine and keen, both being of very active habits, both indulging to great excess in wine and women, both following a similar occupation, an exciting one, and both being affected by the disease within a year of one another. Such a clinical history has never been put on record before, and it shows conclusively that heredity may predispose to the ■disease. The idea is gaining ground, however, that heredity, either mental or neurotic, has more to do with the develop- ment of the disease than was formerly supposed. Age. — The common age for the occurrence of the disease is between 25 and 50. The chart in Plate V. shows its pre- valence in 104 cases admitted to this Asylum as compared ■with mania and melancholia, and the ages at which it occurred. The greatest number of cases occurred between 40 and 45 years. But there are a few exceptional patients. I have referred to the "developmental" cases (p. 403), and I have lately had a case beginning at 66 years of age, the diagnosis being confirmed hy post-mortem examination. Pathological Apjiaarances in the Brain in General Paralysis. —At this point I think it is bettor to supplement the clinical history of the disease by describing very shortly the patho- logical appearances met with in the brain. It is a subject of supreme importance and interest not only for the psychiatric department of medicine, but for every branch. When we know fully the pathology of this disease and that of epilepsy, we shall be very near the solution of the chief problems of mental disease and of many social facts now very obscure. The encasings and supports of the brain are all found to bo affected, and the longer the patient has lived the more marked are the changes met with. The bone of the calvarium is ' Jour. Mcnt. Science, vol. xxxiv. p. 65, GEXEKAL P.iEALYSIS. 407 denser and harder, in many cases the diploc being obliterated and in many others there is a distinct layering and deposit of new bone on the inside of the inner table of the skull-cap, this being usually confined to the frontal and parietal bones. The dura mater is thickened, adheres more or less morbidly, and frequently leaves shreds attached to the bone. In many cases I have seen spicida of bone gio-wing in at the junction of the falx, ■which is always much thickened. When the dura mater is reflected, the most characteristic morbid appearances of the disease are seen. I have endeavoured to depict some of them, as seen in a very advanced case, in Plate I. (see Frontispiece). In a number of the cases we find, under the dm'a mater, and attached to it, lying between it and the arachnoid, a new substance of a morbid and peculiar kind, commonly called a false membrane. It varies in consistence frsm a hard fibrous texture to a jelly, in colour from a dull greyish- white to that of blood clot, in thickness from a film to a quarter of an inch, in extent from a small patch or two to a covering of both hemispheres above and below. It is usually thickest over the vertex. In some cases it looks hke a clot, in others like an extra layer of dura mater, but it can always be easily scraped away. "When it is removed from the dura mater that membrane is commonly not congested nor inflamed look- ing. It always contains new blood-vessels, and nearly always blood-corpuscles or blood-colouring matter. Drs Middlemass and Eobertson ^ have devoted much attention to the investiga- tion of this condition. They conclude that it is not inflamma- tory and not hsemorrhagic in the ordinary sense, but that for its formation we must previously have "a hyaline degeneration of the vessels and their perivascular canals which leads to the obUteration of both. While the vessels are undergoing" tliis morbid change small haemorrhages frequently occur from them. Their obhteration is followed by the formation of new capil- laries which are, doubtless, required to maintain the nutrition 1 Edin. -ifcrf. Jour., February 1895. 40S CEXERAL PARALYSIS. of the fibrous tissue. From these new vessels, the formation of which is necessarily accompanied by the development of a certain amount of granulation tissue, further minute ha3mor- rhages occur. The extravasated blood becomes the basis of more granulation tissue. These changes are at first subendothelial, but the extending granulation tissue soon breaks its way through this barrier, and a membrane becomes developed." But I must refer to the full and elaborate description by those gentlemen. This is the so-called parln/iiirniiii/it/.K iHviiiorrhwjira interna of the Germans, a ridiculous and misleading name, for it is not the result of inflammation at all. The formation of the substance is, to my mind, full of interest and instructivo- ness. Its formation implies, I believe, a very great intensity of morbid action in the convolutions, vascular disease, and above all, great and sudden changes in the blood-pressure within the cranium. Under the membrane if present, and under the dura mater if not present, we see in very well marked advanced cases the appearance presented in Plate I. h. on the anterior lobe. The arachnoid is immensely thickened, and either mottled with white spots or striated along the sulci with white fibrous- looking bands.' Under it there is what looks ■ like a dull opaque jelly, through which the convolutions dimly appear, and under which great tortuous congested veins meander, some of these being, perhaps, if the case has died during or after a congestive attack, obstructed by little white masses of hard uvir-mortem clot. But this is not really a jelly, for if the arachnoid is pricked it nearly all oozes out as a dirty opaque fluid, that amounts to from 2 to 10 ounces in quantity. This is, in my opinion, a compensatory fluid, filling up the space left vacant by the atrophy of the convolutions and brain generally. It does not nearly represent the whole ' For a full and aocuvato deaoviption of tlio pathological process that takes place in the pia-aracliiioid in such cases I must ruler to Drs Middloraass and Kobortaon's original investigations as described in the Edin. Med. Jour, for April and May 1895, GEXERAL PARALYSIS. 409 of the brain atrophy, for we have, in addition, enlarged ven- tricles and dilated perivascular spaces, which often contain 6 ounces more of fluid. But the advocates of the theory that this disease is an inflammation in its essence, look on tliis fluid as an inflammatory product, and consider that its presence causes pressure within the cranium, and this again causes irritative maniacal symptoms, and ultimately atrophy of the convolutions. To relieve this hypothetical pressure Drs Clay Shaw and Batty Tuke have trephined the skulls of patients labouring under the disease, and opened the dural space. After the fluid has drained off, the pia mater and the convolutions are better seen. Both are strikingly abnormal. The pia mater is thickened, vascular, and tough to an enor- mous extent. The convolutions are atrophied, especially over the vertex of the anterior and middle lobes and in some locaUsed places elsewhere, and generally tend to be wedge- shaped, and lie loosely together. "When the pia mater is re- moved from the convolutions — do this in every case of mental disease you examine, — it is found to adhere to and raise up portions of the outer layer of the grey substance on the ridges of the convolutions — seldom in the sulci — which stick to the pia mater, are removed with it, and appear as irregular patches over the membrane that has been detached from the brain (see lower part of Plate I.). The convolutions from which those patches have been removed look eroded, like the surface of a cheese where a mouse has been (see middle portion of Plate). Xow, this adhesion of the pia mater to the con- volutions is a very morbid phenomenon. It has never been found to any extent in any patient whose mind was sound and strong before death. It is, in different cases, confined to a few convolutions, or general over aU the brain. It is by far most frequently confined to the vertex and to the anterior and middle lobes, to the convolutions of the hemispheres lying in contact with each other above, below, and in front of the anterior part of the corpus callosum, and to the gyri round the olfactory bulbs at the base. Its greatest intensity 410 GENERAL PAEALYSIS. is evidently difTeront in difTeront omkch, so tliat it affocta different areas. This corresponds to tlio clinical fact lliat in one general paralytic tlir speech will be found most iilfected, in another the writing, in anothur the walking, and in another the trophic jiowcir. I have, seen two cases in which gangrene of tho limbs occurred from puro trophic nerve failure. The two homispherc^H usually adhere anteriorly, and in the attempt to separate them some of the Hiili.stiinco of the convolutions will be torn away. In some cases wo find this adhesion of the pia mat demarcation botwoon tlioso two. Aloiij:; tins lino the brain tissue sooms softor and more pultaccous. There is uo real solorosis, though, on the wliolo, tlio outor layer of the gvoy substance may bo slightly hanier in to\turo than normal. In some oasos, howovor, it is distinctly softer. The whole groy matter is thiunor, especially in the cases that have lasted long. The white substauoo is often very congostoil, especially in irregular patches (as seei\ in Plate YV,), its perivascular pieces are always enlarged, and the small vessels tough and their coats thickened. On opening into the ventricles they are nearly always found enlarged, but the most strihing peculiarity is, that their normally delicate epithelial linings are toughened and roughened in au extraordinary degree. Their surfaces look in the less marked cases like frosted glass, in the more marked cases they are granular, and even minutely nodular, feeling rough to the touclu They arc leathery, too, when torn. This condition is usually most marked in the floor of the fourth ventricle, and the covering of the calamus scriptorius is always a greyish, gelatinous-looking, but really tough meni- Inanc. The microscopic examination of a section of such a granulation at once shows what has taken place (see Plate II. lig. S). The single normal layer of delicate epitheh'um has become enormously hypertrophicd, and in addition, the neuroglia nnderneath it, and for a short distance down into ihe nerve libres, or cells, has become hypertrophicd in limited areas, throwing itself up in masses, thus constituting the bulk of the granulations. Miciv^^rtipii- Apjwai'attrrf: — The microscopic appearances in the brain in general paralysis have been the subject of the most careful examination by some of the best modem histol- ogists. Meyncrt, "Mendel. V. Guddcn, Yoisin, and many others abroad, and I'atry Tuke and Miokle in this country, have all greatly advanced our knowledge ; but it was not until Bev;ui Lewis devised his method of examining and staining fresli sections of brain that tlie morbid clianges could 412 GENERAL PARALYSIS. be followed in each constituent tissue of tlio diseased cortex and through the various stages of the disease. In the chapter on the " Pathological Anatomy of General Paralysis," in his Text-Book of Mental Diseases, we, for the first time, have opened out to us the main facts on which a pathology of the disease can be based. Most of Lewis' facts are indisputable and of supreme importance. His interpretation of some of them admits, perhaps, of difference of opinion, at all events on some points. I shall first shortly summarise Lewis' facts, almost all of which I may say we have been able to confirm in the patho- logical laboratory of the Royal Edinburgh Asylum through Dps Middlemass and Robertson, the pathologists here, using Lewis' methods. During the first stage of the disease, in acute cases, there is groat " turgescence of the vessels of the pia," and "great distension and engorgement of the cortical arterioles." "The perivascular lymph channels are the site of a nuclear pro- liferation and segmentation of protoplasm, often so enormous as to entirely conceal the inclosed vessel from view." Lewis has thrown an entirely new light on the lymphatic system of the cortex, both in its histological, physiological, and pathological aspects. In the first stage of the disease, which he calls that of "inflammatory engorgement," he says little about the condition of the nerve-cells, which after all constitute the tissue for which everything else in the cortex exists. Next, there is a " notable increase in the nucleated protoplasmic cells of the adventitia of the vessels of the pia, together with a general though slight proliferation of the most superficial flask-shaped cells of the peripheral zone of the cortex and thn vessels of the intima pia resting upon it." From these cells of the pia long delicate processes are sent out extending deeply into this layer. Next, there is " a very free exudation into the meshes of the pia." The vessels lose tlieir support through atrophy of the cortex, and there is in consequence a "strong tendency to hEemorrhagic transudation or to actual rupture and haemorrhage." GEXKKAl PAKALYSIS. 413 The second stago is characterised by a further enormous production of protoplasmic masses on tJie walls of the lymph channels in the perivascular canals within the substance of the cortex, by a granular change in the nerve- cells, which is succeeded by a fuscous degeneration and breaking down into granular debris. Then comes the most striking of all the marked changes. The ultimate cells of the lymph con- nective system which have direct connection with the walls of the capillaries and minute vessels by means of fine pro- cesses, become enormously enlarged and developed. Instead of being fine spider-like cells (^Deiter's cells) they become the "phagocytes" or scavengers of the tissue, because the usual lymph chaiiiids have become blocked up, and they enlarge accordingly both in cell and cell process until in a section tliey seem to be the dominating element of the cortex (see Plate YIII. fig. 1 a.a.). '' Occasionally several of these active elements are seen completely covering a large nerve-cell which is in an advanced stage of decay," removing its disintegrating substance filled with its molectilar debris, " They are usually noted in great abundance in the deeper half of the peripheral or outermost layer of the cortex." The medullated nerve-fibres of the cortex are found to be undergoing absorption as well as tJie cells, as had been previously clearly described and figured by Tuczek. lu the third stage these proUferated spider-ceUs throw out innumerable fine processes that form a fibrillar meshwork, and the nerve-cells further degenerate and atrophy. In fact a sclerosis and general atrophy take place.'- Lewis' explanation of those morbid changes in tire cortex is that we have a true inflammatory process arising first in the vascular tissues of the pia, through which the blood- vessels are damaged, the lymph channels are obstructed, ■* Bcitrilge ::ur Fath. Anaiamie u. :nir Patholom'c tic Pcmentia Faralytica. " The appeai-ances of the diseased cells and vessels will be seen in Plates XIII., XIV., and XV. 414 GISNERAL PAHALY8IS. all the tissues undergo mcclianical and vital cliuiig(!S, Urn nerve-cells sud'oring in nutrition through thoHu cliangos in the vessels whicli bring tljcrn piibulum, and in thii lymphatics that remove the products of metabolism in thoir texturo. He contends against Miorzojewski's view that the morbid process in the ficlls is " inflammatory in its intrinsic natuni." lie "wholly fails to rccogrjiHc an inflammatory condition in the cells themselves, but huoh tho ovidenco of a true degeneration due to acute nutritional anomalicH," and ho "fails to obHcrve any notable difrercnce betwocri tho changes through which these cells pass, and those of the cortex in senile atrophy, except in the greater tendency to a tnie steatosis in tho latter state." It in always an inviilioim thing, that should never be lightly done, to put a dill'erent interpre- tation on the facts discovered by a eomjietfuit and acute investigator. But the physiology and the pathology of the brain cortex is as yet so backward that it cannot injure the ultimate truth to put forward a did'erent cxidanation of Lewis' facts. My view is that general jiaralysis is not essentially an inflammation of the jiia, extending to the cortex, through which the brain cells are secondarily disturbed and ultimately killed, but that it is a special and distinctive disease of tho mind cortex primarily, the ccIIh of which take on a morbid nutrition and energising, and sricondarily cause the vascular and lymphatic changes. My reasons for this view are the following, which, it must be understood, are put as succinctly as jiossible. 1. The chief causes of the discane are nervous and mental, so far as we can assign them, f;.(/., sexual excfjss, alcoholic poisoning, bodily and mental strain and exhaustion, &c. 2. The course of the disease is tliat of a typical rjerve degeneration in the highest and dominating centre of all, it is steadily j/rogrcHKive, and affects all the lower and subsidiary centres in a steadily progrcHsive way, the eonl, the retina, the peripheral nerves, the sympathetic ganglia, and the whole tiophic system. GEXEEAL PARALYSIS. 415 3. At the beginning of many other nervous degenerations and dissolutions there is a preliminary stage of irritation and quasi-inflammatory symptoms, e.g., locomotor ataxia ; and even senility often has such a stage. 4. The occasional high temperature in the first stage of general paralysis can be explained by its being a maniacal temperature, and is often equalled in uncomplicated acute mania. It seldom — apart from congestive attacks — rises to a true inflammatory temperature. 5. The vascular congestion and subsequent lymphatic changes can be satisfactorily explained through the vaso-motor and trophic centres in the cortex being affected. The cortex is now generally recognised to regulate its own blood-supply through the vasomotor centres which exist throughout its substance. It is well known that mental exertion, mental irritation and excitement determine blood to the cortex. Xo one thinks of such congestions as being inflammation. 6. The morbid process never, in any one case, goes on to form ordinary inflammatory products such as pus. 7. There are many cases of the disease — one-third— in which there is no first stage of mental excitement or ir- ritability, or high temperature, or headache, or any symptom pointing even to congestion of the membranes or cortex. The clinical aspect of such cases is that of a slowly advancing loss of function of the cortex. 8. Looking to the history of the examination of the brain cortex, it seems a far more reasonable assumption that by our present methods of examination we are not yet able to demon- strate the changes in the cells in the earhest stages of the disease, while the changes in the coarser tissues, such as the blood-vessels and lymphatic system, being far easier seen, seem to be the first pathological changes, when in reality they are secondary and resultant. 9. Every individual pathological change described by Bevan Lewis can be seen in other varieties of brain disease, e.g., brain syphilis, softenings, alcoholic damage, senile changes. 416 GENEEAL PARALYSIS, traumatic injuries, yet these are admittedly distinct from general paralysis in their nature and course. 10. If it was an inflammation there would surely ho some exceptional cases that would recover. Its universal incura- bility agrees with the theory of its being a specific degenera- tion or disease of the special cortical tissues, that is, the vehicle of mind, which brings mind into relationship with motion, but does not agree with tho inflammatory theory. 11. The universal vascular and trophic changes throughout the course of both carotids, as evidenced by the liability to liaematoma, by the "false membranes," by the nutritive changes in the ear cartilages, the skull hones, in the dura, in the epithelial linings of the brain, are best explained by a morbid action of the vaso-motor centres in the corlox which control both carotids rather tljan by a local inflammatory action arising in the pia. 12. This is not a question of terms merely. The advocates of the view that the disease is in its CKsence a degeneration of the highest cortical centre admit that the lymphatic and vascular changes are indistinguishable from inflammation in the appearances seen, but contend that these are secondary and non-essential. The advocates of the inflammatory theory admit the degeneration and atrophy of the nerve-cells of the <;ortex, but contend that those are secondary. Tho degeneration theory is based on the whole etiological, clinical, and patho- logical history of the disease ; the inflammatory theory is Ijased almost exclusively on visible pathological changes in the vascular and lymphatic elements of the cortex. There is no nervous tissue that is not found diseased and degenerate in advanced cases of the dLscaHe, — tho cord, the retina, the peripheral nerves, the sympathetic ganglia, &c. Dr Greenlees has shown that hypertrophy of the heart is frequent in this diseaHo, no doubt caused by the disturbed innervation of tho organ and the blood-vessels. As I first demonstrated many years ago, the liones are friable, and altered in texture and composition from the same cause. GEXEEAL PARALYSIS. 417 Xafure and Causes of the DL^ease. — "Wliat, then, is general paralj-sis t There are few diseases whose essential nature we as yet know. But we know that the special trophic energy and inherent physiological qualities of different tissues become perverted in special waj's, so that most tissues have their own special types of disease. There can be no doubt that the grey substance of the convolutions of the brain of man is the high- est in quality and function of any organic product yet known in nature. That substance reaches its highest development in the male sex between adolescence and middle life. Its uses are called forth in the highest degree in the European races who live in towns. Its physiological abuses by alcohohc and other poisoning, by over-strain, through violent energising stimulated by continuous strong mental and other stimuli up to the point of exhaustion, are also most common under those circumstances. Its cortex is most delicately constituted, has far more blood, more fine fibres and more minute cells than any other portion of the brain, and, on the whole, may be regarded as the most important factor in mentalisation, being in fact the mind tissue. Immediately underlying the smaller cells in the convolutions, in certain parts of the brain, we have what are probably the motor cells. This outer rind of grey matter, to which trend fibrils from every neuron, is precisely that affected first in general paralysis. The proof goes to show that all the other nervous degenerations which finally affect the whole nervous system are subsequent and sequential. Granted a progressive and incurable disease of this mind tissue, towards which the whole of the rest of the nervous system tends and in which it ends, which controls and regulates it all, and which is its crown and highest development, being in fact the highest and dominating centre of the organism, it is quite espKcable that all the rest of the nervous system should de- generate in structure and function, and in fact die slowly and progressively. It is a quality of nerve tissue to degenerate in the Hues of physiological activity, and in this disease we have a good illustration of the law. It is the great descending de- 2d 418 GENERAL PARALYSIS* generation. General paralysis is in fact a special and absol- utely distinctive disease of the cortex, and peculiar to it. In many other diseases we have adhesion of the pia mater to the convolutions, but in none the element of certain pro- gression of neurine degeneration. It is essentially a death of that tissue. I look on it as being equivalent to a prematuro and sudden senile condition, senility being the slow physiolo- gical process of ending, general paralysis the quick pathological one. The causes of it are causes that have exhausted trophic energy by over-stimulation. Its first stage is accompanied by undoubted morbid vaso-motor dilatation, so that all the tissues enveloping the brain, and holding its elements together, receive an abnormal supply of blood, and thereby acquire tissue hyper- trophy — the bones of the skull-cap, the membranes, the neu- roglia, the lymphatics, the epithelium, and the vessels. Just as the tissue degenerations, especially the brain degenerations of old age, cannot be arrested, and arc necessarily progressive, so is general paralysis. Those high nerve cells have lost their once inherent power of self-restoration, and so they degenerate and atrophy. The diseased process is peculiar because the tissue in which it originates is peculiar. It is admitted by those who put down the disease to syphilis, that it is a lesion entirely difl'erent from any other syphilitic lesion, except it is conceded that locomotor ataxia is sypliilitic in origin. Anti-syphihtic treatment admittedly has no curative affect on it. Treatment of General Parali/sis. — The disease being as yet incurable, treatment can only be directed towards relief of symptoms. But considering that in the early stage of many cases it is impossible to make the diagnosis certainly as between this disease and brain syphilis or alcoholism, I would in all such cases give large doses of the iodide of potassium with about J.j grain of bichloride of mercury, with blisters or other counter-irritation to the scalp, keeping the patients on the medicine for six weeks or so. I have now met with many cases who had almost all the early symptoms of the disease a,t;iin in each section. Proliably these Jiad contained some morbid jiroduct, such as iu;i-wm of granular matter, which had fallen out, or been disnolved by the tur- pentine and spirit in the process of prcjiaration. 1 could scarcely have believe'], had I not seen thi^ ease, that convolu- tional brain tinsue, grey or white, could have been jireHxcd out through holes in the, dura mater and yet have ri;tained any normal structure at all. Sl'didicH of J'andyUo In/ardbj . — In the nine years, 1874- 82, we have hafl, out of our .'514.0 admissions to the Jloyal Asylum, Edinburgh, 91 cases diagno.^ed as pandytic insanit.y. That is nearly '■'> per cent. Of those '.)[ cuhch, 17, or almost 19 per cent., recovered mentally. 'J'his was one of the results of 8tati«tical inquiry into sjiecial forms of insanity that siir- pric/jd me. llad I been asked before, J should have said that PARALYTIC INSANITY. 433 it was quite a rare thing for a case of paralytic insanity to recover. But this shows that when a gross lesion of the brain first occurs, it often sets up a convolutional storm of mania or melancholia, which is temporary and curable. The immediate mental effect is of the nature of a reflex irritation, with tem- porary vascular congestion, which subsides like any other maniacal or melancholic attack. Ten cases were discharged more or less improved, in addition to the seventeen recoveries. Forty-six of the patients have died up to this time, in thirty- six of whom. jpo,-i|ii('iilr IIH (ivi>i'. Tlio iimjdii'iy of I.I111 |iii,l-iiin1,H ({iiniiiil (^iiiiHidin'itlily in wiiiglil. wldlo l.lm doHiw w(!ni uiidnr lin ^,'riunH Mircn l;lnioH a diiy. Their itt^Kii')/"!." wolgld, wan K™"lcr iil. I,liii oiid of IIki IJdrl.y iiiKllt. wkhIch Ukui It luid Iikiki In liDKin witli, tlKiiijrli II, licfriin lo fall al'l.cr .'lli grain dimivn liad linen reniilKiil. Tho |iii,t,innl,n' uvonigo teni|iend.Mi'e lull HoninwlKil. nnUI l.hey ^nl, hi CO-grain (liweH tlil'icd a day. 'I'lio pnlHii gnulually fell almnl Hevon lioatH lip io 40 grniii dniiiM. Al'Irer that it rime, \nii, net. up id iU tiniial Hl.anilanI wilJionl. inedlenin. None of Uie paLieirU Bnirered in tllull' goneral heallJi evr.epi, live. All llio otliuru vveje Imnellieil in Home way. 'I'llO ill ellnrtH |ir(«liM!ed liy Uie ineilieino In tlioHe (Ive ivir.es were f(ir|inr nf iidnd and boily, ilniwHiiiOHH, iiiei'ea,Hii cd' l.eni|ieivil.ni'e, loHH id' weif;ld., loHH of a|ipi'lil,ii, iind in lliiee ol'thcin uliyjil ilnnMe |ini>iMniuiia, TIlO oaHiiH niiiHt Iji'iinlitod liy Uie driijr werii very variniiH an l.n l.lin oauBOfi, iiiiikIht, and eliaiaeter iiftlKi lil,H, age, and In every ntlier renpeel,. On tho wlinle, the cam'H who l^nolc iikihI, III.h lienelil.ed niiiHl.. 'I'lie caHiia in whom the niedieine had ill edi'i'dii Imd all tall< liiorn Uian "lie I'd, jierweelt, linl, Heemed in have nnthilig elnu in ennimnn. Tho diniiiiiitiiin of the lilH and all lliu ntlier ^^imd elfeetii nf llio rnodioino rnaelied Uieir inaxliniiin In ii,dulU at 111) (.niiin doHOH llireo tlinim a day, wllile ill eU'euta were inaidfeHled when ilfi grain dimeti Uiiee linietl u day were rniielied. 'i'liere tieemed In he nn Herinimly ill ell'eeU prndueed In twenty of the caHOH by CO-grain douos of the nuidleliio thrlee u day oonliniied fur ten weel(!(. When the niedieine wan entirely diHenntlniied fnr a innntli in all the oa»o«, tho average nninherof IUh inereaeeil In live of the oawm heiielited to or hoyond their original nmnlier. In thirteen oamiK tlioy remained e,on- sidorably 1oh8. Tho ttvorago nuniher during that time waH a little more than one-half the nnnibor of (ItH taken liefore the niedieine wa« given, and tlm grealenl, nnnjherof (il.H oecnrred in tho HeeomI wdok after the medhdne wan dhi (Mnitinned. TKAUMATIC INSANITY. 459 TEAUMATIC INSANITY. Definition — Sunstroke — Symptoms — Motor symptoms, two kinds — Case of Traumatic Insanitj', cured by Trephining — Traumatism acting as exciting cause of ordinary insanity — Prevalence. A few cases of mental disease are caused by blows on the bead, falls, and otber traumatic injuries to tlie brain. Sun- stroke also causes insanity, and the general mental symptoms of traumatism and sunstroke are apt to be alike. No doubt sunstroke gets the credit of far more insanity than it pro- duces. Few Eritons become insane in hot climates in whom that cause is not assigned. My experience is that traumatic insanity is to be found in two forms. The first form is the more characteristic type of the disease. It is accompanied by motor symptoms, in the shape of speech difficulties, slight hemiplegia, general muscular weakness, or convulsions. Usually in such oases there are, in addition, sensory symptoms, such as cephalalgia, vertigo, hallucinations, a feeling of con- fusion and incapacity for exertion of any kind, mental or bodily. The mental symptoms are usually a form of melan- cholia at first, tending in time towards an irritable and some- times impulsive and dangerous dementia or delusional insanity. In my experience such cases are all absolutely intolerant of alcoholic stimulants, a very little of which will always make them maniacal, and often very dangerous and even homicidal. Many of them have a craving for stimulants, too, which they indulge, and which aggravates all their symptoms. It is surprising what a number of the traumatic cases are com- plicated with alcohol, in having been addicted to drink before these accidents, or taking to it after. Over one-half of my cases were so complicated. In either case, whether a drunkard falls and injures his brain and becomes insane, or whether a man takes to drink and becomes insane after an injury, the alcohol aggravates the mental symptoms, and 460 TRAUMATIC INSANITY. tonds more strongly towards incurability than mere uncom- Ijlicated traumatism. Motor SymplomB. — A few cascH Lonome ordinary epil'iptics. I have two epileptics in the Royiil Asylum now who have large depressed fractures, and T Lave boctj several more on the ]iod-morl.r:m table. In one th(;re had been a fracture above the ear, where the bone, membrancH, and lirain all adhered by an old inflammation. I have seen three patii:nts now, in whom the motor symptoms were so exactly those of ;.;(;iieral paralysis that I diagnosed them as such, but they turned out to be non- progressive, though not curable paralytic cases; and now, after over ten years, they are alive, and no worse than at first. One man, H. H., fell off a ladiler, and fractured the base of his skull, was unconscious for long, and nr:erned afterwards to become a true general paralytic from tliis cause, but his symp- toms did not progress. Another, If. f,, a drunkard, received an injury to his head, was unconscious, and Kcf^med to become mentally and bodily a typical genr^ral paralytic, but the motor symptoms never progressed. As I mentioned, traiirnatism is one of the rare causes of true general paralysis. 1 had one such case that was caused by a railway collision, but then the man, after the accident, attem filed to study and enter a pro- fession with a weakened brain and an impaired memory. Within three years he became a general paralytic, and died of the disease. Usually the motor symptonw of traumatic insanity are non- progressive, or very slowly so. lint they do not always rnaTii- fest thercHelves at once after the injury. I had one jjatient, JI. L., who was not msxde uneoriHcious at all by the blow of a jiieee of wood falling on his head, but who gradually in three months got weaker on one side, as well as being rmiscularly weak all over, and alwo mentally irnjiairfjd in memory, energy, and volitional power. lie was also very irritable. Certain very interesting caHcs have been reeorded of insanity directly following fractures of tlie skull, with consequent ]lT^.Vr sure on the brain, which were cured by trephining or raising TKAUMATIC IXSANITY. 461 the depressed bone. One of the most striking of these was published by Dr Charles H. Skae.^ It was that of a miner who received a depressed fracture of the skull about three inches above the left extremity of the left eyelid, was un- conscious for four days afterwards, then went to work, but within a fortnight exhibited a change of disposition and habit. Instead of being a sociable, merry, good-natured man, fond of his wife and children, he became at first irritable, moody, unsocial, and suspicious, then excited and dangerous, and then acutely maniacal. He was sent to the Ayr Asylum, and two months after admission, during which time he had not im- proved, an operation was performed by Dr Clarke "Wilson, by which the depressed portion of bone was removed. A gradual improvement in mind took place week by week after this, until in a short time he was as sociable, lively, and cheerful as ever, and has continued so ever since. Such cases are very suggestive of thought and inquiry as to the possible reflex and direct irritations that may be the causes of mental disease in many cases, and they clearly show that the general dynamical brain disturbance that we call insanity may sometimes originate in special points of local brain irritation. The condition of the urine as to sugar and albumen should be carefully tested in all traumatic cases. Where sugar exists there is room for grave suspicion of mischief to the pons near the floor of the fourth ventricle, though this can scarcely be diagnosed with certainty in this way. Some cases of idiocy result from injury to the brain by the forceps during delivery, and I have two now in the Eoyal Asylum resulting from falls on the head in early childhood. The other and less distinct class of traumatic cases are those in whom an injury to the brain acts as an exciting cause of an ordinary attack of insanity in a person predisposed to the disease — in fact where traumatism acts like a moral shock. ' Journal of Mental Science, vol. xix. p. 552. 462 TRAUMATIC INSANITY. As tlie result of a bout of drinking or some sucli disturbing cause of brain action after traumatism, I Jjave seen attacks of mania and melancholia in patientn, from whicli ihcy recovered perfectly; and, on the other hand, 1 have now umlor my care several cases of ordinary dementia, and one of chronic mania, and one of delusional insanity, all incurable, and originating in traumatism, but without any motor or 8(;nsory signs, and without progression of symptoms. 1 orir^e saw a young man, H. M., of 19, who had an attack of ordinary acute mania just after being in a railway accident, and presumably caused by it, but by which he had not been made unconscious, or even stunned. / jMve now a Traumaiin ('.(m; of waicvUd 'irudancjudia, ]r. M. A., wt. 46, TfiHulUng dirar.Uy from an injurn iolm liMid through apier/i of done faUimj on it from a Unvjld of \0 fcM, and titen hi» falLiwj 20 fvi on th/i liw.k of hin licad, off Urn naif - fold on which ha viaa worlcing, r/ulj.ing I.Iia Klein over IJia oixiput, hut wiUli/:r injury cMuning prolongfid wai'/nwrAouawMH. 'J'liis occurred three months ago, and ever since he has bccrj able to do no work, has suffered from a dull feeling in his head and much pain in his back. Ifis mental condition became gradually depressed. His attention was concentrated on his ailments, until he was quite melancholic, lie became suicidal, fancied he passed only blood from his bowels, which was a delusion, and that his food did him no good, he being fairly nourished. There were no motor signs, and his temj;erature was normal, the reflexes being also normal, but he did not sleep. He gradually improved under treatment, until lie became well in mind and body and able for his work. In the case of insanity coming on after railway accidents, or of mental symptoms short of "technical insanity" ajipearing or being simulated, we need to be very careful indeed in our conclusions as to causation. P^specially if the mental symptoms are chiefly subjective, we must remember there is a motive to exaggerate them till the damages are paid by the company. L' maU'.nvi of Tra/umatic IvMinily. — We liava ha, 25,, 30 ,, ,, 20 ,, ,, 30 „ 35 „ „ 9 „ „ 35 „ 40 „ „ 12 „ J'UERPBEAL INSANITY. '557 •cisely ascertained, but in nearly all these it was within the first fortnight. Of the remaining forty-two cases the disease began within the first week in twenty-one, and in eleven more within the second week, so that we may say that in 80 .per cent, of the cases it began within the first fortnight. If that period is passed it is clear that the chief risk is over in a woman in childbed, the first week being by far the most liable to its invasion. At least half the cases occur then. Only one case of the sixty occurred after the twenty-eighth day. Character very Acute. — The next point is very important clinically. Of the sixty cases no less than forty-three were very acute in character and symptoms, while seventeen only were mild and without acute symptoms. Twenty -nine of the .forty-three acute cases were generally maniacal in character, .and fourteen generally melancholic with motor excitement, some of each of these classes changing from one state to the -other at times. In the mild cases the prevailing character was mental depression, fourteen of the seventeen being so. In at least eighteen of the acutely maniacal eases, the mania amounted to absolute delirium, with no power of attention and no coherence of speech whatever. I know of no clinical form of insanity that would yield so large a proportion of very acute cases. Puerperal insanity may therefore be regarded as the most acute of all forms. Temperature. — The temperature of all cases on and after admission was taken.^ It is very instructive to look at the column of highest temperatures in each case. Of the sixty there were thirty-four cases under 99°, and therefore they cannot be said to be much above the average temperature of ordinary health, or at all events of the average I From 96° to 97° in 3 cases. From 101° to 102° in 3 cases, „ 97°,, 98° „ 10 „ „ 102° „ 103° „ 4 „ ,, 98°,, 99° „ 21 „ „ 103° „ 104° „ 3 „ „ 99°,, 100° „ 12 „ „ 104°,, 105° „ 1 „ „ 100° „ 101°,, 2 „ „ 105°,, 106° „ 1 „ 558 .PUERPERAL INSANITY, temperature of the insane. But twenty-six cases, or 43 pet cent, of the whole, were over this, and of these fourteen cases, or 23 per cent, of the whole, were over 100°. No other form of insanity shows this alarming result, for a temperature over 100° I look on with alarm in any form of mental disease. The most serious part of it is, as we shall see, that all the deaths occurred in the cases with a temperature over 100°. Yet to show that a high temperature, though alarming, is not necessarily prognostic of death, I find that of the five cases where it was over 103° three made excellent recoveries. I lately saw a case in private practice who recovered, and whose temperature had heen over 105°. The causes of the high temperature differed in different cases. The chief causes were — (1) simple acute hrain excitement ; (2) inflammation of the womh and surroundings, in some cases septic, in others simple ; (3) meningeal inflammation ; (4) incidental causes, such as malaria, mammary abscess, &c. Appetite. — The most common and one of the most im- portant of all the symptoms present was the refusal of food — paralysis of appetite. In thirty cases, or 50 per cent., this was present. It could not he overcome but by the use of the stomach-pump or nose-tube in about ten cases. In a puerperal case refusing food I now use forcible feeding at once if food cannot be given in any other way. In no other kind of mental disease has the doctor's instructions to the nurse to be, " give much food and give it often." I am quite sure that many of the puerperal cases not septicsemic that die at home or in asylums die from want of early feeding. I give stimulants, too, in larger quantities with the food than in any other kind of insanity. I have seen the greatest and most evident good results from large doses of quinine as an antipyretic. In the case to which I have alluded, where the temperature was over 105°, every 10-grain dose of quinine was followed regularly by a fall of from 2° to 4° of temperature. Individual Symptoms. — There were many other symptoms, mental and bodily, very common [besides a high temperature. PUERPERAL INSANITY, 559 Tenderness on pressure over the region of the womb was common, and whenever it is present, as well as in most other cases, I am in the habit of ordering carbolised warm water vaginal injections and slightly counter-irritating poultices over the abdomen, with, sometimes, blistering over the pubis. Local abscesses in the ankles, fingers, wrists, and body occurred in some cases. Muscular jactitation and subsultus occurred in some of the worst cases, but were not always followed by collapse. (Edema and albuminuria were present in two cases, and convulsions in one. Of the mental symptoms, one of the most important, from its great frequency, was the suicidal impulse. It was present in twenty-iive cases, or 40 per cent, of the whole. It was present in an impulsive form in many of the maniacal as well as some of the melancholic cases. 1^0 medical man, therefore, in treating a case of puerperal insanity, but should keep in mind that the patient may attempt suicide, and he should warn the nurses and attendants of this. The presence of hallucinations of the senses, especially of hearing, I was surprised to find so common. It occurred in at least one-third of the cases, and was often very per- sistent, as hallucinations of hearing are apt to be, after the other symptoms were passing off. But this did not indicate incurability, as is the case so often in chronic auditory hallu- cinations of alcoholic origin. The patients in many cases passed from the acute stage into one of stupor, and in some this existed from the begin- ning. At one part or other of the case stupor was present in at least fifteen cases, or 25 per cent. It was connected, I fear, in some of them with the habit of masturbation, to which some puerperal cases are very subject. Neither the stupor nor the masturbation indicate incurability. One case in which both were the most prominent symptoms recovered. Curahility. — The last and most important point brought out in this study of these sixty puerperal mental cases is the great curabihty of the disease. Thirty-three cases were discharged 560 PUERPERAL INSANITY. recovered, and seventeen were discharged much improved. Of the latter the prospects of complete recovery were very good. I actually knew they did complete their recovery in twelve cases. That is, forty-five cases out of the sixty recovered, which amounts to a recovery rate of 75 per cent. Most of the recoveries took place quickly. In three months from the beginning of the attack over one-half of the cases were well, and in six months 90 per cent, of those who recovered were well. But to prevent anything like loss of hope, I mention that one of the melancholic cases with stupor recovered after the disease had existed for four years. No recoveries from mental disease are generally better or more satisfactory than those from puerperal insanity. In some cases recovery was very rapid indeed after it began. In the cases where stupor existed, or supervened on acute insanity, the occurrence of menstruation seemed often to act as the exciting cause of recovery. I myself believe that this was mostly a coincidence, or rather I should put it that sanity was the mental, and menstruation a chief bodily symptom of the restoration of brain and body to their normal working. It is the proper mode of treatment, however, whenever a puerperal case gets strong in body and the weight becomes normal, to use every means to restore menstruation if it has not returned. Warm baths at night, mild shower baths in the morning, hip baths with mustard, aloes and iron pills, and borax at the time menstruation is expected, are all use- ful in addition to the general tonic and fresh air treatment. Menstruation returning before the general strength is im- proved is usually a bad thing, for it is apt to be attended with increased mental excitement, and is apt to become menorrhagic. Looking at curability of the cases according to their characters of acuteness or mildness, and of mental exaltation or depression, I find that the forty-three acute cases recovered in the proportion of 81 per cent., and the seventeen mild cases in the proportion of only 62 per cent. But then it must be PUEKPEEAL INSANITY. 561 kept in mind that the mild cases were longer in being sent into the Asylum, and, of the total number of mild puerperal cases occurring, the most intractable and prolonged would be the only ones sent into the Asylum ; the rest would recover at home. Of the exalted and depressed cases — mania and melancholia — an almost equal proportion, that is 75 per cent., of each recovered. Mortality. — Five of the sixty cases died, four of them within a month of the onset of the disease, and one within two months. This is a mortality of 8'3 per cent, of the cases. !N"o cases are more difficult to get post-mortem examinations in than puerperal cases, and they were performed in only three of the five cases. The cause of death in one was found to be phthisis pulmonalis, under which the patient had laboured for long before her confinement, and which as usual advanced rapidly after parturition ; in another it was septicsemia ; and in the third simple maniacal exhaustion, without symptoms of septicaemia. There is no doubt, however, that the chief cause of death in puerperal cases that have been properly fed is septicaemia. They are, in fact, cases of combined puerperal fever and puerperal mania, the mania having more of the character of delirium than of ordinary insanity. It is curious that there was no history of preliminary chill in the septicaemia cases. As I said, I do not like the temperature to run up much above 100° in puerperal cases. Of the fourteen cases in which this took place, five died, or 35 per cent. I still less like to see muscular subsultus with a restless moving of the hands and twitching of the facial muscles. There may be septicaemia in a puerperal case with purulent peritonitis, metritis, and phlebitis, and yet the patient never complains of any local pain, and even on pressure there may be no uterine or peri- toneal tenderness. Many of the cases with the worst symp- toms, bodily and mental, made good recoveries.^ ' These statistics may te usefully compared with and supplemented by Sir 3. Batty Tuke's statistics, obtained from an analysis of cases in 2n 562' LACTATIONAL INSANITY. LACTATIONAL INSANITY. Mostly an anaemic insanity ; occurs over six weeks after confinement, or after prolonged lactation ; risk greatest after several children ; usually mental symptoms Melancholia at some period ; some cases Mania ; premonitory symptoms usually present ; headaches ; tinnitus aurium ; flashes of light ; irritability ; precordial anxiety— Forma 4 per cent, of insanity in females ; rare among richer classes — Prognosis ; Good ; 77 per cent, recover ; duration, longer than Puerperal lnsB.nity— Treatment : Stop nursing ; tonic and support- ing. The poor are more liable to insanity while nursing children than the rich, both being equally subject to puerperal insanity. This is as might be expected. If the wife of a labourer has had ten children and nursed them all, if she has during all the years those ten pregnancies and childbirths and nursings have been going on had to work hard, if she has had to struggle with poverty and insufficient necessaries of life in addition to this continuous reproductive struggle and family worries, if in addition to all this she has inherited a tendency to mental disease, no physiologist, or physician can wonder if she should become insane during the tenth nursing. Indeed, the wonder is that any organism could possibly have survived in body or brain such a terrible strain and output of energy in all directions. Such a woman often enough becomes insane during a nursing long before the tenth. An organic sense of duty and a stern physiological necessity among poor women compel them to nurse their offspring. What else can they do ? It is well for the offspring, but the neurotic mother often enough dies, or is upset in body or brain in the attempt. Symptoms. — A typical case of lactational insanity is one this Asylum, in the Edinburgh Medica,lJimrnal for May 1865 ; and with those of Dr Campbell Clark's papers in the Lancet, vol. ii., 1883, and in the Jour, of Menial Science, July 1887 ; with those of Dr M. Macleod's paper in the Brit. Med. Jour, for August 7, 1886 ; and with those of Dr Wiglesworth's paper in the Liverpool Medico- Chirurg. Jour., 1886, which all contain important additions to our knowledge of the subject. XACTATIONAL INSANITY. 563 Occurring in the case of a poor woman who has had several children, and has mused the last for several months, who has got pale and thin in the process, and has become subject to headaches, noises in her ears, giddiness, flashes of light before her eyes, lassitude and nervous irritability, in fact to the usual symptoms of general bloodlessness and brain aucemia. She then gets depressed in mind, her sleep leaves her, her self- control is lost, and she becomes either lethargic and stupid or suicidal, with delusions that her husband and neighbours are against her, thereby, poor woman, merely misinterpreting her sensations of mental pain and distress. She had little organic strength for her pregnancy, still less for her delivery, and it has quite broken down in her nursing. To such a woman the organic delight of suckling her infant, for which the maternal nature craves and is satisfied by the process, becomes an irrita- tion, an excitement, and an exhaustion. But such a typical case, if taken in time, and if nursing is stopped and rest is given, with good nourishing food, malt liquors, iron, cod-liver oil, and fresh air, at once begins to amend, sleeps, acquires self-control, ceases to imagine things that have no objective existence, puts on flesh, begins to employ herself, gets cheerful, and is quite well and strong in three months, her blood con- taining many more blood corpuscles than it had when treat- ment was begun, and the re-nourished brain resuming all its normal functions in a normal way. But cases of lactational insanity vary greatly in form, degree of mental disturbance, and duration of attack. It must be admitted that they do not follow this one type. They are nearly all melancholic at some period of the attack. They nearly all sufi'er from pre- monitory neuroses of sensation in the shape of headaches, lassitude, neuralgia, feelings of sinking at pit of stomach, or some of the other signs of ansemia and ill-nourishment. They are a very curable class if put under proper treatment in proper time. Tlie following case is an almost typical one, except that the first part of the asylum stage of it was more acute than usual : — 564 .LACTATIONAL INSANITY. K. J., set. 40, tlie wife of a plumber who earned when in full work 28s. a week, has had seven children in sixteen years, and nursed each about fifteen months. There is no known heredity to insanity. She nursed the last child for twelve months, and of course had to do her family duties meanwhile. Her first symptoms were great depression and want of energy. She would sit for hours doing nothing, saying nothing, and taking no notice of anything. Her brain seemed to have been exhausted in its power to energise mentally. Then she began to be restless and sleepless, and her head felt sore and queer. Soon she became delusional, fancying she saw friends in the street who were in the colonies. She was sent at first to the Eoyal Infirmary, but proving unmanageable there she was sent here. On admission she was markedly depressed, and the mental working of her brain was enfeebled in such a way that she would begin a sentence in answer to a question, and would stop in the middle, her volitional power having run short apparently. She rambled in speech and mistook the identity of persons round her. She had the delusion that she was to be burned at the stake. She was thin, pale, muscularly feeble, lacking in energy, with blunted sensibility. Her special senses were also impaired, pulse small and weak, temperature 98 "8°. After admission she was sleepless, rest- less, and acutely excited for a week. Then she became more quiet, with short intervals of almost sanity, but with impulsive action. Sitting quietly sewing in a room with others, she would suddenly drop on her knees and pray aloud. Was put on extra diet, with porter and quinine and iron. She always got worse and more delusional in the evening, this fact probably indicating that by that time her brain power was getting exhausted. But she steadily picked up in flesh and strength, mental and bodily, and in ten months was discharged almost recovered, having gained 24 lbs. in weight, and looking fresh and healthy. What will happen if she has more children, and nurses each of them fifteen months, can easily be con- jectured. I have met with many cases who were sober LACTATIONAL INSANITY. 565 ■women when in good health, taking to drink when the de- pression first came on. Treatment. — The treatment of lactational insanity is simple and physiological. Stop the nursing, give nourishment in abundance with some malt liquor, change the scene, free the patient from family cares for a time, give quinine, iron, cod- liver oil, and tonics generally. The suicidal tendency must be thought of and guarded against if present, as it is in a very large proportion of the cases. Statistics. — A survey of my nine years' clinical experience in the Eoyal Edinburgh Asylum, 1874-82, in regard to lacta- tional insanity is instructive. AVe have had altogether fifty- two cases that I classified as lactational. But some of these were old cases of the disease transferred from other asylums, or readmitted, and these I shall take no notice of. Their study would lead to no good clinical results, and would merely tend to confusion. Forty of the cases were admitted labouring under recent lactational insanity, and of these only I shall speak. Character, — As classified on admission, twenty-one of these were cases of mania and nineteen of them of melancholia. Only about half of these twenty-one cases of mania had mental exaltation as their predominant feature throughout their whole course, the others beginning with marked melancholic symptoms or ending with them. But the fact that half the cases were maniacal during their most acute period shows that the insanity of lactation is by no means exclusively a melancholic form of mental disease. It shows that bodily and nervous exhaustion and malnutrition, though their first mental symptoms may be mental depression, yet tend in a large number of cases towards morbid mental exaltation with excitement, in the long-run, mania being in fact another and a further stage of the convolutional brain disturbance. When classified according to the acuteness or mildness of their symptoms, independently of psychical exaltation or depression, I find there were twenty-two acute cases and eighteen mild 566 LACTATIONAL INSANITY. ones, tlie majority (eighteen) of tlie acute cases being maniacal, and a majority (thirteen) of the mild cases being melancholic. Time of Occurrence. — As regards the months of nursing in which the disease occurred, my records do not state this point in seventeen, but of the remaining no less than ten occurred within the first three months, seven in the next three, four in the next three, and only two in the last three months. I confess I was surprised at this. It is a different result from that arrived at by Batty Tuke from an examination into the statistics of fifty-four cases of the insanity of lactation that had been in this Asylum previous to May 1865. Only two of his cases occurred within the third month, and only eight within the first six months of nursing, while twenty-one cases,, or 51 per cent, of those in whom the period was recorded, occurred after the ninth month of nursing, my percentage for the same period being nine. My statistics distinctly point to the causation of this form of mental disease being in many cases due to the dis- turbance of the puerperal period aggravated by the reflex excitation of the brain through the physiological act of suckling the infants, Tuke's statistics clearly point to a pre- ponderating causation by the exhaustion of mere long- continued nursing. Both causes operate, I have no doubt, but why they should have operated so differently in the cases in the same asylum at different periods I am unable to explain. My records were so deficient in regard to which nursing the disease occurred in as to be worthless. They merely show that lactational insanity may occur after the first child or the seventh. The suicidal impulse is common, seven- teen of the forty having had it in greater or less intensity. Temperature. — The temperature shows a very marked difference from the puerperal form of insanity.' A glance at ' From 96° to ■ 97° in 1 case. „ 97° „ 98° „ 6 „ ,, 98° ,, 99° ,, 20 „ „ 99° „ 100°,, 8 ,, From 100° to 101° in 3 oases. ,, 101° „ 102° „ ,, „ 102° „ 103°,, 1 ,, „ 103° ,, 104°,, 1 „ LACTATIONAL INSANITY. 567 the highest temperature shows that only about one-third of the cases (thirteen) were over the normal standard, and of these the great majority (eight) were only between 99° and 100°. Three were between. 100° and 101°, leaving only two that were over that, in one of whom it was caused by an inflamed breast. The temperature record shows clearly the milder type of lactational insanity as compared with the puerperal form. The thermometer, though the readings seldom reach very high in uncomplicated mental disease, I look on as being simply invaluable as showing the intensity of the brain action. Its readings upwards, from normal to 102° or 103°, are usually in the exact ratio to the intensity of the mental disease. Only, it must be remembered that half a degree in the estimation of the intensity of brain overaction is equivalent to two degrees in the measurement of febrile disturbance. I attach especial importance to the readings of the thermometer in all acute mental dLseases, and have used it in every case under my care in the Carlisle ^ and Eoyal Edinburgh Asylums since the year 1866. Heredity. — Heredity to insanity was known to be present in fifteen of the cases ; but then in. twelve of the forty no re- liable information on this point could be got. And as proxi- mate causes, mental and normal disturbances occurred in nine of the cases. Curahility. — Let us look now at the results of treatment, the most interesting of all questions to the physician, and still more so to the relatives of the patients. Thirty-one of the forty cases recovered, and three more were removed from the Asylum uncured but improving. This is 77^ per cent, of actual recoveries, and a still higher figure of potential restora- tions to mental health. The lactational cases recovered in slightly larger numbers therefore than the puerperal cases, and only one case of the forty died. I find that the maniacal and the melancholic, the acute and the mild cases recovered ^ Seeauthor's paper, "Observations on the Temperature of the Body in the Insane," Journal of Mental Science, April 1868, 568 LACTATIONAL INSANITY. in somewhat equal proportions.' The six who did not get better, but are still under treatment, were three of them patients who had repeated attacks of insanity before, the other three looking phthisical. The lactational cases did not recover as soon as the puerperal.^ Only sixteen recovered within three months, but twenty-five, or 62 per cent, of all ^he cases, and 80 per cent, of the recoveries, recovered within six months, and all of them within eighteen months. And they made good and lasting recoveries, few of them relapsing. Eecovery in all the patients was accompanied by a great in- crease in body-weight, in strength, in appetite, and in fatness. In some menstruation continued during the disease, and in its earlier stages produced excitement and exhaustion of strength. It was often menorrhagio in such cases. The function, when absent, usually returned of itself without any special treat- ment, as the nutrition improved. Effect of Patient's Circumstances. — One instructive fact I came across in relation to this disease. Out of 166 admissions of ladies to our higher-class departments there were only two lactational cases, while there were among them nearly the usual proportion of puerperal cases. Out of 1383 pauper and poorer private female patients, there were thirty -eight lacta- tional cases. In short, the puerperal cases were sent for hospital treatment in as great a proportion among the rich as the poor, while the lactational cases were only sent in half that proportion. This points clearly to the greater mildness of type of the latter, and the possibility of treating it at home, if not to the greater infrequency of the disease ^ Of the twenty-one cases of mania fifteen recovered ; of the nineteen eases of melancholia sixteen recovered; of the twenty-two acute oases fifteen recovered ; and of the eighteen mild oases sixteen recovered. Within 1 month 6 cases recovered. Within 7 months 1 case recovered ,. 2 , > 6 „ „ 8 J) 1 )i ,, 3 , . 4 ,, ,, 9 J) 2 J) „ 4 , , 2 „ 11 »» 1 M „ 5 , 1 6 „ 18 f } 1 ,, 6 , . 1 1. THE INSANITY OF PEEGXAXCY. 569 among the well-fed classes, who have servants to work for them, nurses to attend their children, and doctors to tell them when to stop nursing in time. Probably the custom among the poor of nursing each child a long time in order to delay the conception of the next has something to do with the greater prevalence of this form of mental disease among them. THE INSANITY OF PREGNANCY. Eare ; 1 per cent, of insanity among women ; occurs most frequently in women advanced in life when pregnant ; usually melancholic ; suicidal tendency in half the cases ; connection of the insanity with the morbid cravings, &c. , of pregnancy ; a few cases of stupor ; a few of dipsomania — Most cases recover at childbirth ; 60 per cent. ; a few rapidly become demented. Tlie Psycliology of Pregnancy. — Eew women carry a child without being influenced mentally thereby in some way or other. The psychology of pregnancy has yet to be written in a scientific way. There are innumerable facts on record, but they are scattered and undigested. Without going into the domain of mental disease in any technical sense, we find examples of partial mental exaltation, mental depression, mental enfeeblement, mental paralysis, and mental perversion. No doubt the alterations are chiefly in the affective faculties, but the reasoning power, the moral sense, the volitional power, the imagination, and even the memory, are often enough affected in pregnant women. As a part of the nervous dis- turbances, the bodily appetites become changed, the physio- logical functions altered, and the nutrition of organs profoundly affected. In this state many women have endless caprices, unfounded dislikes and likings, cravings for foods and drinks never before desired, unnatural desires for indigestible things, causeless weeping and laughing, stealing and lying, morbid thirst and hunger, an activity of digestion never before known, pigmentation of the skin, alteration of the expression of the 570 THE INSANITY OF PREGNANCY. face, of the tones of the voice, and. of the power of muscular co-ordination. It is scarcely surprising that every function of the great central nervous system should be thus affected in many cases, for, physiologically, pregnancy means a dynamical change for the time being in the direction of some of the great currents of energy, and a change, amongst others, in the quality of the blood. Psychologically it is the fulfilling of the second strongest organic necessity of life — to reproduce the species. All the changes, mental and bodily, that I have referred to, and far more than these, should be taken into account in studying the question of how pregnancy produces those great psychical disturbances that we call insanity in brains predisposed there- to. A considerable number of women are mentally unsound during pregnancy, if judged by an ideal standard of volitional power, while very few indeed pass the conventional line that divides sanity from insanity. Nature seems to care for pregnant women physiologically in all directions, and does so in the case of the mental functions of the brain convolu- tions. Those may be, and are often, slightly affected in preg- nancy, but are seldom quite upset. It is a very rare form, as an insanity, as we shall see from the statistics. In fact, there is no period in the life of a woman after the age of 25 when she is less liable to actual insanity than during her pregnancies: But there is an infrequent type of case exactly the contrary of this rule, where a woman cannot become pregnant without becoming insane. I have such a patient now, K. K., who has been five times pregnant and five times insane, each time during pregnancy. This, no doubt, is iixe clearest indication nature could give that such a woman should never become pregnant. I had one patient, K. L., who had six different attacks of insanity — two of pregnancy, two puerperal, and two of lactation — and she made perfect recoveries from them all, though in each she was most determinedly suicidal and homicidal, strangling and killing her first child, and attempting at least six different times to take away her own life. Yet for the last eleven years she has kept quite well, and done her work at home. THE INSANITY OF PREGNANCY. 571 She had one or two other children without heing affected in mind more than by a little depression. Symptoms. — The typical mental disturbance of pregnancy of the mild kind not requiring asylum treatment, and often not incapacitating a woman from doing her duties, consists of a mental depression, or mental apathy not amounting to stupor, with a loss of interest in things, a loss of conscious affection for husband and sometimes for children, a slight weariness of life, a fear of something going to happen, and a general loss of courage and a disincHnation for social intercourse. These symptoms do not usually come on before the third month of pregnancy, and much more frequently they do not come on till after the sixth month. Sometimes they only last for a part of the period of pregnancy and then pass off. More tisually they do not disappear till after delivery. They either do so then or become aggravated into a more acute puerperal psychosis. There is another distinct type of case where during the first pregnancy insanity comes on, becomes acute, and ends in dementia soon. This is perhaps one of nature's ways of ending a bad stock ; just as I look on the insanity of adoles- cence to be, and on sterility to be in some cases, and on sexual antipathy to be, and on absence of the social instincts to be. There are psychological bachelors and old maids, born so, whom no social cultivation or opportunity can make other- wise, and these will be found to occur usually in families with a heredity to insanity. The following case pi'esents the most common type that family doctors have to do loith : — K. M., a married woman, set. 34, with an insane heredity, who had had five children comfort- ably, came to me saying she was dull and jniserable, and could not do her work nor take an interest in anything. ' It seemed as if she did not care for her husband, nor to do her household duties, and she said she was afraid of herself, meaning that she might commit suicide. She was stout, strong, and well nourished, and looked the picture of good health. She slept well, ate well, and all her bodily funptions 5V2 THE INSANITY OF PKEGNANCY. were normal. Slie was in the sixth month of pregnancy, and the mental change had come on a month before. I advised that she should have a female friend with her and should go on doing her work, should walk much in the fresh air, and wait patiently for her confinement. After the eighth month she felt much better, and after confinement every trace of her mental depression left her. , The following loas a very acute ease of tJie insanity of preg- nancy : — K. N., set. 32, pregnant of an illegitimate child, became at the sixth month dull and apathetic, then within a month incoherent, talkative, and almost delirious. She would moan at times as if in pain ; would say, poor soul, " I am in a fearful state; never was in such a state as this." She had hallucinations of sight, seeing elephants all of a green colour before her. She was very weak on admission, could not walk well without assistance, her tongue and mouth tended to be dry, she had pain in her abdomen, her ankles were swollen, her pulse was 136 and weak, and her temperature 100'4°. She continued restless, depressed, excited, and sleepless, and eight days after admission was delivered of a healthy male child. Her mental state improved much thereafter for a week, when she had a relapse. In fact, the puerperal state caused an excess of puerperal insanity, but in four weeks after the birth of the child the excitement had passed off, the delusions only remaining. In another week the delusions too had left her, and in two months she was discharged strong in body and well in mind. The next is a more characteristic case, K. 0., aet. 30, a married woman with a hereditary history of insanity, and pregnant with her first child, became insane six weeks before its birth; a fear came over her first, and she said, "I must die, I must die." An inflammation in one lung had reduced her strength, and she had been sleepless for two weeks, soporifics having no effect. She was suicidal, and tried to jump out of a window. Her friends properly kept her at home, nursing and looking after her as best they could till THE INSANITY OF PREGNANCY. 573 the child was born. She then got much worse mentally, and remained maniacal for two months. Then she became apathetic, confused, and childish, with occasional impulsive spurts of maniacal excitement. This state lasted for a month, then she began to improve, and was well in six weeks, her attack having lasted altogether five months. The bromides and iron were used largely in the acute stage of her disease, strychnine in the apathetic stage, and extra food and fresh air and good nursing throughout. There was a very decided tendency to stupor during some part of this case. Statistics. — The cases of the insanity of pregnancy of such an acute type as to need asylum treatment are rare, and by no means of a uniform type. I have had only fifteen such in the past nine years sent to the Eoyal Edinburgh Asylum. Nine of these were maniacal and six melancholic ; nine of an acute type, and six were mild in their symptoms ; seven of them were suicidal, some being desperately so. This is an enormous proportion of suicidal cases for any clinical variety of insanity. In half of those with a history there was heredity to insanity, mostly strong and direct heredity. Curability. — Of the fifteen cases only nine recovered, or 60 per cent, of the whole, this form of mental disease in its worst forms being thus more incurable than the insanities of childbed or nursing. The time of recovery in relation- ship to confinement was various. In only two cases of the nine who recovered was the termination of pregnancy attended with speedy and marked mental recovery. In four cases con- finement distinctly aggravated the previously existing mental disease. In three of these, in fact, the symptoms had not been so bad before confinement as to need asylum treatment at all. The puerperal state seemed to bring the insanity of pregnancy to a climax in. those cases. In three cases of the nine who recovered they got better, and were discharged from the Asylum recovered before they were confined. The whole nine had recovered in six months. Three cases were transferred to other asylums, within four months after 674 THE INSANITY OF PREGNANCY. admission, in an improved condition, and of these one might possibly have got better ultimately, and one was taken home before recovery and did get quite well. This would bring Up the recovery rate to 7.3 per cent. Two died, one of uraemic poisonings this probably having been the real cause of her insanity — seven days after admission, and another of general tuberculosis in ten months. First Pregnancies. — Women are more liable to become in- sane during the first than subsequent pregnancies, for seven of the fifteen cases were first pregnancies ; and the fact that five of the fifteen were illegitimate children shows that moral causes tend to bring on the disease. Onset. — The coming on of the disease was gradual in most of the cases, and it began in all hut two with depression of mind or apathy and stupor. The affection towards their husbands became perverted in nearly all the married cases. The psychology of the affection between husband and wife, and the way it is influenced by sexual intercourse, by preg- nancies, by the children or the absence of children, by neurotic constitution of brain, by the climacteric, and by old age, will be an intensely interesting and important study when written from the physiological point of view. Many strange chapters on this subject could family doctors write. I have not had a single case of the insanity of pregnancy in a rich patient sent here. This is natural and proper, for if any kind of mental disease should be kept out of asylums without sacrificing hfe or recovery it is this. It would be a terrible fate, as things go in this world, to be born in a lunatic asylum, in addition to being the child of an insane mother. The asylum cases can scarcely be taken as the real type of the insanity of pregnancy, they being by far the worst, no doubt. Treatment. — The treatment of the insanity of pregnancy is in no way special. The women are not usually run down. The temperature in only four of my cases — one being the ursemic case — was above 99°. Fresh air, exercise, watching, nursing, employment, cheerful society, change, freedom from THE mSAHITT OF PREGNANCY. 575 too much work and worry, and suitable food, are about all we can do. Slight sedatives may be required as placebos, but in as small doses and as seldom as possible. The blood of an insane mother needs not to be mixed with morphia or chloral to make it bad for her unborn progeny. The tendency to suicide must be especially kept in mind. One of my cases had a secondary syphilitic eruption, and needed treatment for that, and in two more I suspected syphilis, both children being prematurely dead-born. I think that abortion should be re- sorted to if marked insanity comes on in the early stage of pregnancy. It can now be almost safely carried out. In the later months, too, premature labour should, I think, be in- duced. Of course, such measures should only be resorted to after consultation, and with the written consent of the husband or nearest relatives. Frequency. — Together, the insanities of childbed, nursing, and pregnancy have constituted over 9 per cent, of all the female cases in the Eoyal Edinburgh Asylum for the past nine years (1874-82), there being 141 cases out of 1549 admissions (including readmissions). There was 5 per cent, of the puerperal form, 4 per cent, of the lactational, and 1 per cent, of the insanity of pregnancy. As we admit all classes of society, this may be taken to represent the real effect of child-beating in the production of insanity, at least in this part of the country. In Cumberland and Westmore- land, for the ten years (1863-72) during which I was in charge of the Carlisle Asylum (for the poorer classes only), there were 75 cases out of 431 female patients in all, or 17-4 per cent. This enormous difference of nearly twice the proportion is made up entirely of the excess of puerperal cases, there having been 51 of these, or 11-8 per cent, of the whole of the female insane of those two counties. That is more than twice the Edinburgh proportion. Such great differences in the local distribution of the different forms of insanity form an interesting problem in medico-psychology that needs yet to be worked out as to its causes. LECTUEE XVI. THE INSANITIES OF PUBERTY AND ADOLES- CENCE {THE DEVELOPMENTAL INSANITIES). EDormous differences in the physiological activities of the brain at different periods — Type of mental derangement much influenced by the special physiological activity or decadence of the period — The developmental insanities and those of decadence — Insanity of Puberty: Hare; only two oases in Eoyal Edinburgh Asylum at ages of 14 and 15 out of 1800 oases, and only 22 at 16 and 17 ; always hereditary ; acute ; remittent ; not dangerous to life ; maniacal ; theories and practices of education at puberty — Prognosis : Good — • Treatment: Tonics; fresh air; baths; milk and farinaceous diet; cod-liver oil ; bromide of potassium ; no opium or chloral — Insanity of Adolescence : Meaning of Adolescence — Physiological and psycho- logical characteristics ; momentous period ; far more so than puberty — Novelists the best students and describers of the mental character- istics of adolescence ; Gwendolen Harleth {Daniel Deronda) — Eela- tionship of adolescence to emotion, sense of duty, capacity for work, sentiment, religious sense, courtship, engagements to marry, sexual intercourse — Of 1800 cases, 230 uncomplicated between 14 and 25 ; of these 49 occurred at the ages of 18, 19, and 20, while 167 occurred from 21 to 25 — Mental Symptotns : 78 per cent, exaltation ; only 22 per cent, depression ; mania, acute, remittent, relapsing in 66 per cent.; hereditary predisposition very common (45 per cent, ascer- tained, far more than that in reality) ; morbid ideas, emotions, speech, and conduct tinctured by erotic, sexual, or adolescent characteristics — Prognosis : Good ; 66 per cent, recover ; relapses often occur in after life ; remainder mostly become demented and live long, bodily health often being good — Mm-talily Small : only 1-8 percent, died — Treatment: Same as for insanity of puberty Signs and Accompaniments of Recovery: Perfect development of form and mammas ; growth of beard and sexual hair ; change of voice ; psychologically and physiologically they emerge from attack men and women. THE INSANITIES OF PUBERTY AND ADOLESCENCE. 577 Psycliology of Development. — When one considers the enormous differences in the physiological life and prevailing brain activity of the same human heing at the different periods of life, it does not seem wonderful that each period has its own type of psychological disturbances, just as it has its special kinds of ordinary disease. Indeed, it would be very wonderful if the brain of a child, whose chief characteristics are active growth, intense inquisitiveness in all directions, great sensitive- ness to impressions, which succeed each other rapidly, and, whether they are painful or pleasurable, leave only slight lasting traces, if this organ manifested quite the same dis- turbances when its mental functions become deranged as the brain of an old man, whose chief characteristics are retro- gression in all its activities, and insensitiveness to ordinary impressions. The essential qualities of the two organs are in many respects different ; their prevailing receptive, dynamical, and trophic activities are dissimilar. Then what a change in the mental activity of the brain does the period of puberty cause ! Looking at the matter from the combined point of view of physiologists and psychologists, we must connect the new development of the affective faculties, the new ideas, the new interests in life, the new desires and organic cravings, the new delight in a certain sort of poetry and romance, with a new evolution of function in certain parts of the brain that had lain dormant before. This awakening into intense activity of such vast tracts of encephalic tissue, though provided for in the evolution of the organ, does not take place without risk of disturbance to its mental functions, especially where there is an inherited predisposition in that direction. And if this predisposition is thus developed into actual derangement of function, it happens, as might have been surely predicted, that the type of derangement is much influenced by the great function of the reproduction of the species then arising de novo. To form a right conception of the kinds of mental disease that occur at the various important periods of life it is essential that we consider them 2 578 THE INSANITIES OF PUBERTY AND ADOLESCENCE. in connection with the normal changes that take place in the organism at those periods, with the normal modifications in the mental energy at those periods, and with the changes that take place in the brain texture and mode of action, so far as we know them. In short, we must take a physiological view of mental disease. The Period of Puberty or Pubescence. — The period of ■puberty is the next great physiological era in the life of man after that of birth. Before that occurs the whole trophic and mental energy has been occupied in acquisition alone. The brain has been growing in bulk, rather than developing in higher function. There has been no production. Before that time there has been a general psychical likeness between individuals of the same and of opposite sexes which then rapidly disappears. Individualities of all kinds spring iip far more decidedly at that time in those of the same sex ; while, dividing the sexes at this time, there arise most striking psychical differences that far exceed the bodily contrasts. Up to that time the mental development of each sex has been very much in the same direction ; after puberty that development takes place in the man far more in tlie direction of energising and cognition, in the woman in the direction of emotion and the protective instincts. But these changes do not ordinarily take place all at once in the human species, any more than a full capacity for reproduction takes place in either sex immediately the testes assume their function, or menstruation and ovulation are set up. It Jiakes several years for the full development of the size and form of the body that is normal and typical for each sex, and it takes still longer for the complete evolution of the masculine and feminhie psychical characteristics. It is not at the time of the first appearance of the reproductive function that there' is the chief peril to the healthy mental balance, but it is the after years of gradual coming to maturity that are often full of danger to the mental health of both sexes. It cannot be otherwise. The hereditary influences THE INSANITIES OF PUBERTY AND ADOLESCENCE. 579 and tendencies that all the former generations have trans- mitted, to a man come then most fully into play. And when we consider for a moment that it is not only his father's and his mother's own inherited tendencies that may come to him, but some of their acquired peculiarities as well, and not only so, but the inherited and acquired peculiarities of his four grandparents, and his eight great-grandparents, not to go any further back, how great a risk does every man and woman run of suffering for the sins of their fathers ! Maudsley speaks of a man's yielding to the tyranny of his organisation. We might go further, and say he may fall a victim to his grandfather's excesses. Most fortunately for the race, there are other influences obviating such effects of heredity. One is that the tendency towards reproducing the normal and healthy type is generally stronger, if the conditions are favourable, than towards the abnormal. If the conditions of life are favourable, mere tendencies never develop, and potentialities never become actualities. The other is, that when the tendency to abnormality is strong, the victim of it often is idiotic or sexually unattractive, dies before the age of reproduction, or he is incapable of procreation. Now, the insanity of puberty is always a strongly hereditary insanity; it, in fact, never occurs except where there is a family tendency towards mental defect or towards some other of the neuroses. Its immediate cause may be some irregularity in the coming on of the reproductive or menstrual function ; its real and predisposing cause is heredity, having for its subject this higher physiological law, that the repro- duction of the species tends to stop when the inherited tendency to brain disease acquires a certain strength in any individual. I Unphysiological Education. — I cannot help here adverting to some absurd and unphysiological theories of education which are common, and which we as medical men should combat with all our might. The theory of any education worth the name should be to bring the whole organism to 580 THE INSANITIES OF PUBERTY AND ADOLESCENCE. such, perfection as it is capable of, and to train the brain power in accordance with its capacity, most carefully avoiding any overstraining of weak points — and an apparently strong point in the brain capacity of a young child may in reality be its weakest point in after life. I have known a child with an extraordinary memory at eight who at fifteen could scarcely remember anything at all. Then, as the age of puberty approaches, one would imagine, to hear some scholastic doctrinaires talk, that it was the right thing to set ourselves by every means to assimilate the mental faculties and acquire- ments of the two sexes, to fight against nature's laws as hard as possible, and to turn out psychically hermaphrodite specimens of humanity by making our young men and women ahke in all respects, — to make our girls pundits and our young men mere examination-passers. If there is anything which a careful study of the higher laws of physiology in regard to brain development and heredity is fitted to teach us, it is this, that the forcing-house treatment of the intellectual and receptive parts of the brain, if it is carried to such an extent as to stunt the trophic centres and the centres of organic appetite and muscular motion, is an unmixed evil to the individual, and still more so to the race. There is no time nor place of organic repentance provided by nature for some of the sins of the schoolmaster. Some educationalists go on the theory that there is an un- limited capacity in every individual brain for education to any extent in any direction you like, and that after you have strained the power of the mental medium to its utmost, there is plenty of energy left for growth, nutrition, and reproduc- tion. Nothing is more certain than that every brain has at starting just a certain potentiality of education in any one direction and of power generally, and that it is far better not to exhaust that potentiality, and that if too great calls are made in any one direction it will withdraw energy from some other portions of the organ. These persons forget that the brain, though it has multiform functions, yet has a solidarity THE INSANITIES OF PUBERTY AND ADOLESCENCE. 581 and interdependence through which no portion of it can he injured or exhausted without in some way interfering with the functions of the other portions. To expect that any one man could have the biceps of a blacksmith, the reasoning powers of a Darwin, the poetic feeling of a Tennyson, the procreative power of a Solomon, and the longevity of a Parr, is simply to expect a physiological miracle. "Man cannot add a cubic to his stature." The blacksmith's arm will not grow larger by twenty years of daily exercise after it has once attained a certain size. The possible extent of development of every brain and of every function in any one brain is just as much confined by limitations as the size of the blacksmith's arm, and physiology teaches us that no organ or function should be worked even up to its full limit of power. Ifo prudent engineer sets his safety-valve just at the point above which the boiler will burst, and no good architect puts weight on his beam just up to the calculation above which it will break. Nature generally provides infinitely more reserve power than the most cautious engineer or architect. She scatters seeds in millions for hundreds to grow, and she is prodigal of material and strength in the heart and arteries beyond what is needed to force the blood-current along; therefore no function of .the brain should be strained up to its full capacity except in extreme emergencies. Especially do these principles apply if we have transmitted weaknesses in ^ny function or part of the organ ; and what child is born in a civilised country without inherited brain weaknesses of some sort or in some degree ? These principles also apply, I believe, most strongly to the whole reproductive functions of the body and its centres in the brain, both in the male and the female. Especially are they apphcable in the case of the female organism, on which the chief strain of reproducing the species rests. The risks to the mental functions of the brain from the exhausting calls of menstruation, maternity, and lactation, from the nervous reflex influences of ovulation, conception, and parturition, are 582 THE IXSANITIES OF PUBEKXY AND ADOLESCENCE. often enormous' if there is much original predisposition to derangement, and the normally profound influences on all the brain functions of the great eras of puberty and the climac- teric period are too apt, in these circumstances, to upset the brain stability. Beyond all doubt, boarding-school education has not as yet been always conducted on physiological principles, and is responsible for much nervous and mental derangement, as well as for difficult maternity ; but if the education of civilised young women should become what some educationalists would wish to make it, all the brain energy would be used up in cramming a knowledge of the sciences, and there would be none left at all for trophic and repro- ductive purposes. In fact, for the continuance of the race there would be needed an incursion into lands where educa- tional theories were unknown, and where another rape of the Sabines was possible. American physicians used to tell us that there were some schools in Boston that turned out young ladies so highly educated that every particle of their spare fat was consumed by the brain-cells that subserve the functions of cognition and memory. If these young women did marry, they seldom had more than one or two children, and only puny creatures at that, whom they could not nurse, and who either died in youth or grew up to be feeble-minded folk. Their mothers had not only used up for another purpose their own reproductive energy, but also inost of that which they should have transmitted to their children, nature, no doubt, making provision for the transmission of the unused-up energy of one generation on to the next, on the principle of the conservation of force. As physicians — the priests of the body and the guardians of the physical and mental qualities of the race — we are, beyond all doubt, bound to oppose strenuously any and every kind and mode of education that in any way lessens the capability of women for healthy maternity, and the reproduction of future generations strong mentally and physically. Why should we spoil a good mother by making an ordinary grammarian? The relation of the THE INSANITIES OF PUBERTY AND ADOLESCENCE. 583' psycHcal and emotional development to the generative function is full of interest and importance to us as physiologists, and few- men have been long in practice before such questions obtrude themselves as very practical ones indeed. The first hysterical girl a man has to treat in a good family, where he does not want to lose the case or the family practice, may test severely his knowledge of the reflex relationship of the function of reproduction with the sensory, motor, and mental functions of the brain. It is a mere cloak for ignorance, and an excuse for not thinking, to call certain abnormal phenomena " hysterical," and imagine that explains them. It does not require much consideration to see that at the period of puberty in both sexes, but especially in the female, the direct connec- tion of certain physiological functions and processes with certain mental facts influences the whole life of the individual. If that connection is in any way abnormal, we have great strains on the mental functions of the brain, and sometimes actual derangement. Oar high civilisation and refinement, no doubt, add to the risks by increasing the strain. The psychological analysis of what female modesty is, by a physi- ologist, reveals the transformation and apotheosis in the higher regions of the brain of reflex reproductive impressions into a high moral quaUty, not only beautiful, but absolutely essential to social life. How can a physician understand the true import of the obtrusive and grotesque modesty of a hysterical patient except he takes this into account? The intense and complete outward repression and inhibition of certain physiological cravings required by our morals and our civilisation causes, no doubt, a dangerous strain on the brain functions, and a reaction in other directions, where there are hereditary neurotic weaknesses. Statistics. — Puberty is the first really dangerous period in the life of both sexes as regards the occurrence of insanity ; but it is not nearly so dangerous as the period of adolescence, a few years afterwards, when the body, as well aj; the functions of reproduction, have more fully developed. . There are a i&yr, 584 THE INSANITIES OF PUBERTY AXD ADOLESCENCE. cases of insanity in childhood, but very few. They consist of either short attacks of delirium or short melancholic attacks. Delirium is the typical psychosis of childhood. Child melan- choly is a very striking abnormality when first seen, being so contrary to the normal mental state of the period. I have seen a child of six wailing and weeping, with groundless fears and suspicions and much obstinacy, for two days. There is always a strong morbid heredity in such cases. The nutritive energy of the brain is so great in youth, its recuperative power so vigorous, and its capacity for rest in sleep so wonderful, that its mental functions are not often upset at this period, and when upset, they soon are set right again. To bring out this fact statistics are useful. In Scotland at the present time nearly one-half the population are under the age of 20 ; while in the Royal Edinburgh Asylum we have, out of a total of 730 patients, only ten under that age. The contrast between 50 per cent, and 1'5 per cent, in the sane and insane popula- tions is a very marked one. But, to show how different is the state of matters in the older periods of life, let us com- pare the number of persons over 60 in Scotland and in the Asylum. In the general population there are just about 8 per cent, over that age, while in the Asylum, out of the 730, there are no less than 126, or 17 per cent. Or, to bring out the facts differently, it is found that the number of people so insane as to require to be in asylums is about one in 600 of the population. Now, at this rate our 730 inmates represent an ordinary population of 438,000. One-half of these, or 219,000 persons, are 20 years of age or under, and they have only supplied ten of our lunatics, insanity occurring in them at the rate of only one in 21,900, while the remaining half of the general population, that over 20, had produced 720 lunatics, or one in 304, that is, in seventy times the propor- tion of those under 20 years of age. After the age of 20 there is no such enormous disproportion at other ages in the produc- tion of lunacy. It is undoubtedly most frequent between the ages of 3-5 and 55. Speaking generally, therefore, insanity in THE INSANITIES OF PUBERTY AND ADOLESCEXCE. 585 its worst forms is not a disease of youth or puberty, but of middle and advanced life. Slight attacks of nervous and mental derangement, however, that do not require asylum treatment, are by no means uncommon in those predisposed to the neuroses at the earlier ages, especially in the female sex ; and if the general health and strength and nutrition are poor, puberty is liable to cause neurotic symptoms in those cases. Such symptoms, if there is an inherited predisposition to insanity, should by no means be despised. They may develop into actual insanity at a later period. For the pro- duction of decided insanity requiring asylum treatment at the age of puberty we must, as I said, have a strong neurotic pre- disposition, as well as the advent of the reproductive era and the changes it brings along with it. I have scarcely ever met with a case without this. Tlie Developmental Neuroses. — Other affections of the nervous centres are very apt to appear at this period of life, notably the two great derangements of the motor centres, epilepsy and chorea. In fact, the insanities of puberty and adolescence are merely two of a great number of develop- mental neuroses, some of which come on before seven years of age, during the growth period of the brain, such as convul- sions, squint, stammering, night terrors, infantile paralysis, tubercular meningitis, ^hydrocephalus, rickets, and some varieties of idiocy and imbecUity. The next series of this group are first met with chiefly in that period when brain growth is not so acute, but when muscular motion becomes fully co-ordinated with emotion — the pre-pubescent period — that is, from seven to fourteen. The neuroses of this period are chiefly chorea, somnambulism, asthma, megrim, some eye defects, and some amount of epilepsy. The third period, that of puberty and adolescence — from fourteen to twenty-five — bears the neurotic fruits of epilepsy, hysteria, adolescent insanity, instinctive immorality, arrested body growth (dwarfishness), ugliness, joint disease, ingrowing nail, acne, and many skin diseases, many forms of im- 586 THE INSANITIES OF PUBERTY AND ADOLESCENCE; paired vision, barrenness, and perhaps plitliisis and acute tlieumatism.i The Hard Palate in Adolescent Insanity. — While investi- gating the physical characters of the preceding neuroses of development, I discovered a curious line of connection between congenital insanity — idiocy and iinbecility — and adolescent insanity. It had long been known that a high-arched saddle or V-shaped palate was very common among idiots. I found that the palate inight be classified into three varieties, viz., the typical, the , neurotic, and the deformed (see Plates XI. and XII.). The examination of large numbers of various classes gave the following results : ^ — Frequency of the Three Types of Palate in various Classes of Persons examined. No. 1. No. 2. No. 3. Number The Different Classes. Typical Neurotic Deformed of Persons Balate. Palate. Palate. examined. Per cent. Per cent. The general population, . 40-5 40-5 19 604 Criminals (the degenerate), 22 43 35 286 The insane (acquired insanity), 23 44 33 761 Epileptics 20 43 37 . 44 Adolescent insanity. 12 33 55 171 Idiots and imbeciles (congeni- \ tal insanity), . . . / 11 28 61 169 Adolescent insanity is thus seen to have 55 per cent, of the cases with deformed palate, thus approaching the 61 per cent, among the idiots. No doubt the degree of deformity among the latter class was greater on the average than among the former, but individual cases were frequent where the degree was quite as extreme in the one as in the other. The general ^ The Neuroses of Development, by the author. ^ A careful Study of Palatal Deformities will be found in Journal of Mental Science for January 1897, by Dr Walter Canning. , THE INSANITIES OF PUBEKTY AND ADOLESCENCE. 587 characters of adolescent deformed palate are seen in Plate XIII., the figures of which show vertical transverse and vertical antero-posterior sections, taken from the typical adolescent cases now in the Asylum, 'by Dr G. E. Wilson. The motor centres are, no doubt, more unstable and easily upset in their working in youth than either the mental, sensory, or tropluc centres. The insanity of puberty in both sexes is characterised especially by motor restlessness. Such patients never sit down by night or day, and never cease moving. There is noisy and violent action, sometimes irregular movements, or, in the few melancholic forms and melanchohc stages of the maniacal cases, cataleptic rigidity. The mental symptoms consist most frequently of a kind of incoherent delirium rather than any fixed delusional state. In boys the beginning of an attack is frequently ushered in by a disturb- ance in the eraotional condition, — dislikes to parents or brothers or sisters expressed in a violent, open way ; there is irrational disHke to, and avoidance of, the opposite sex. The manner of a grown-up man is assumed, and an offensive " forwardness " of air and demeanour. This soon passes into maniacal delirium, which, however, is not apt to last long. It alternates with periods of sanity, and even with short stages of depression. The following is a very characteristic case of the early insanity of puberty. I have seen others presenting the same peculiar symptoms : — K. P., aet. Hi, of an active and cheerful disposition, and a bright boy at school. His parents were poor, and he waa brought up in a poor part of the town. His mother had an attack of puerperal insanity — mania^after the birth of a child born before K. P., and another attack of ordinary acute delirious mania after he had been sent to the Asylum, from both of which she recovered, but she died melancholic. He has an elder brother who, at the age of 19, had an attack of adolescent insanity — mania — and became demented, a sister has since become insane, and another sister was devoid of any moral 088 THE INSANITIES OF PUBERTY AND ADOLESCENCE. feeling or self-control. There was no exciting cause of the toy's illness. He caught a feverish cold, and then became exalted in mind, singing continuously, clinging to his mother, saying he was going to heaven. This continued all day, but at night he slept twelve hours, and he took his food as usual. When sent to the Asylum there was a very peculiar mixture of mental exaltation and depression present. He went on all the time singing joyful hymns to lively tunes, but in a voice as if crying. He would not answer questions nor take any notice of anything about him, and could not be made to attend to anything any more than if he had been in a condition of trance. His whole condition was one of almost mental autom- atism, and as he sang he vould rock himself, and keep time rhythmically with his hands and body. If any one put their arms round him he would cuddle up to them, and in a child's whining voice sing, " Tak me to ma mammy. Oh my bonny mammy, my bonny mammy; come to me, mammy. Have mercy on me," &c., over and over again, in a rhythmical way ; and if his eyes were shut and covered up he would go right off to sleep. The moment he awoke the singing would begin. If he were much interfered with he would shout and resist in a sort of unconscious way. He was poorly nourished and weak in body. He was sent out in the open air much, and was ordered a large quantity of milk and cod-liver oil emulsion. In about seven days the state of delirium passed off, and he got quite well mentally. His father took him home in three weeks, but he got into precisely the same state again on finding his mother insane at home and unable to speak to bim. His mother was taken to the Asylum, and he took the delusion that his father, too, was dead and gone. In about a fortnight he passed out of the delirium, and became quite cheerful and active. Just four weeks and two days after his second ad- mission he complained first of toothache, and then almost immediately became very excited, and said he could not see, sobbed, shouted, and was with difficulty restrained from throwing himself about. The symptoms were more those of THE IXSAXITIES OF PUBERTY AXD ADOLESCENCE. 589 ordinary acute mania, but with some of the former delusions, automatism, and facility for sleeping. This attack lasted for a few days only. He then remained well for exactly four months, and then had another attack, preceded by dilatation of the pupils and dimness of vision. The attack lasted for three days. He then got well again, but in another month to a day he got excited and emotional again. Though his face looked sad, and his voice was that of weeping, he never shed tears. This was the fifth attack he had ; after that he kept well, was sent home, and kept well for over three years, when he took another attack, and now has become demented. The chief features of this case were — (1) the suddenness of the coming on of the mental attacks, without external . cause j (2) the curious automatic delirious character of them, the mixture of exalted feeling with depression, and the impossibility of rousing his attention to anything outside of him ; (3) the way in which he went off to sleep when his eyes were closed and an arm was put round him, in both these respects resembling the hypnotic state; (4) the repeti- tion of the attacks in irregular monthly periods; (5) his complete recovery from the first attack. I look on such a case as an example of the evolution of a new function, that of generation, upsetting the convolutional working of a brain strongly predisposed by heredity to in- sanity. The physiological problem solving in the brain at this time seemed to be — Shall the organism have power to reproduce itself 1 or shall it die in its highest function — men- taHsation — in the process of the evolution of the power to reproduce? His elder brother had been attacked with insanity, not at puberty, but during adolescence, at the age of 19. He had at first exhibited a good many cataleptic symptoms, a motor automatic condition, just as K. P. had many mental automatic symptoms. In each case the "higher centre " of volition was powerless. The treatment I look on as an attempt so to strengthen the vital forces and the nutrition of the organism that it 590 THE INSANITIES OF PUBERTY AND ADOLESCENCE. shall pass safely through the whole period of the evolution of the new function. K. P.'s case was no doubt in the very earliest stage of puherty, and, indeed, in some of its mental characters partook of some of the characteristics of the delirium of childhood. Adolescence. Its Psychology. — The mental disturbance characteristic of this period is closely allied to that which occurs at puberty. It occurs later, between the ages of 18 ^nd 25, notably between 20 and 25, when the function of reproduction is attaining its full development and the body is arriving at its full growth. That there is such an era in life physiologically, is sufS.ciently proved by the existence in all languages of a word to signify the same thing as our " adolescence." I cannot hope to change the accepted meaning of the present nomenclature, but I would, if I could, distinguish between puberty and adolescence in this way — I should restrict puberty, as is now done when the term is used in a •scientific and physiological sense, to the initial development of the function of reproduction, to its first appearance as an energy of the organism; while I should use adolescence to denote the whole period of twelve years from the first appear- ance up to the full perfection of the reproductive energy, when the bones are finally consolidated, and the full growth of the beard and the sexual hair takes place, and there occurs the perfect assumption of the manly form in the male sex, and the full development of the adipose tissue and the mamma gives the female form its perfect grace of contour. Dr Matthews Duncan has proved statistically that in the female sex "the climax of initial fecundity," which may be taken as proof of full development, " is about the age &f twenty-five years." ' This may be assumed to be the case for both sexes. Looked at from a psychological point of view, it can scarcely be denied by any one that the later years of 1 FKundily, Fertility, and Sterility, 2nd ed., p. 33. THE INSANITIES 0¥ PUBERTY AND ADOLESCENCE. 591 adolescence are far more important than the first. For years after puberty, boys and girls are still boys and girls in mind, but as a physiological fact the female sex attains its full bodily development first. At twenty-one the great majority of that sex have attained good physiological development, and Duncan's statistics show that their initial fecundity is then almost at its climax. But this is not so in the male sex. The growth of the beard and the form of the body do not reach full development in that sex on an average till the age of twenty-five. Mentally the difference is still more marked. The subtle but profound mental influences of adolescence have usually reached their full maturity in women three or four years before men.^ A careful study of human nature will soon show any observer that the period of adolescence in this sense is a most momentous one. The mental change that takes place from eighteen to twenty-five is incomparably more important, and I think more interesting psychologically too, than that which occurs between fourteen and eighteen. The psycho- logical change at puberty is, no doubt, great from childhood ; but it is inchoate and nascent ; it wants precision and con- scious power : its emotionalism is spasmodic and childish ; its sentiment wants tenderness, and its ambitions and longings are allied to castle-building in the air. At the latter period of adolescence in the male sex life first begins to look serious, both from the emotional side and in action. It is then only that childish things are put away, For the first time literature in any correct sense is appreciated. Poetry, not even understood before, now be- comes a passion, at least certain kinds of poetry. K'ot that the highest kind of literature is reached. No adolescent ever really appreciated, or even thoroughly liked, Shakespeare. That is reserved for full manhood. The kind of novel that is •enjoyed is always a good test of the mental and emotional 1 See Sdinburgh Medical Jov,rnal, July 1879, " The Study of Mental Diseases," by- the author. 592 THE INSANITIES OF PUBERTY AND ADOLESCENCE. development. The boy enjoys Ballantyne and Marryat; at puberty the adolescent takes to Scott and Dickens; while only the man enjoys and understands Shakespeare, George Eliot, and Thackeray. Go into a university and watch the demeanour of the first and fourth year's man, if any one has any doubt as to the immeasurable distance between puberty and late adolescence. There seems to be a great gulf fixed between them. The fourth year's man treats his junior not as a mere junior, but as of a different and inferior species. He never speaks to him if he can help it ; he would no more room with him than he would with a baby in arms. Watch the two in the presence of the opposite sex. Their behaviour is quite different. In the one case you see mere shyness, that breaks out into rollicking fun the moment a real acquaint- ance is formed ; in the other there is real sexual egoism, that most painful pleasure that consists of the half-conscious feeling that each person of one sex is an object of the most intense interest to each person of the opposite sex of the same age. The real events and possibilities of the future are reflected in vague and dreamlike emotions and longings, that have much bliss in them, but not a little, too, of seriousness and difficulty. The adolescent feels instinctively that he has now*entered a new country, the face of which lie does not know, but yet that is full of possibility of good and happiness for him. He has a craving, too, for action of some sort — not merely the football action of the boy, but something of more serious import. Longfellow's youth, that vaguely cried " Excelsior," was evidently at this stage of life. His reason- ing faculty first gets full back-bone at this period. His emotional nature acquires for the first time a leaning towards the other sex that quite swallows up the former emotions. It is not yet fully under his control, or definite in its aims. His sense of the seriousness and responsibility of life may be said to awake then for the first time in a real sense. The first sense of right and wrong and of duty becomes then more active instead of passive. He has yearnings after the THE INSANITIES OF PUBERTY AND ADOLESCENCE. 593 good, and is capable of an intense liatred and scorn of evil which he could not have experienced before. Adolescence in the Woman. — But it is in the female sex that the period of adolescence has attracted most attention, especially among those psychological students and deHneators of character, the novelists of the day. As physicians, we know that it is only then that hysteria, migraine, and the graver functional and reflex neuroses arise. As men of the world, we know that the love-making, the flirting, the engage- ments to marry, and the broken hearts of the adolescents are not really very serious affairs. The cataclysms of life do not happen then. We know that no artist ever painted, or no sculptor ever modelled, a Venus who was not near the end of adolescence. A very fine and most interesting study of adolescence in the female sex is, in my opinion, to be found in the Gwendolen Harleth of George Eliot's novel of Daniel D&ronda. This authoress was by far the most acute and subtle psychologist of her time, and certainly the character I have mentioned is well worthy of study by all physicians who look on mind as being in their field of study or sphere of action. Prom the time when, at the gaming- table, Gwendolen caught Deronda's eye, and was tota^y swayed in feeling and action by the presence of a person of the other sex whom she had never seen before ; playing, not because she liked it or wished to win, but because he was looking on, all through the story till her marriage, there is a perfect picture of female adolescence. The subjective egoism tending towards objective dualism, the resolute action from instinct, and the setting at defiance of calculation and reason, the want of any definite desire to marry, while all her con- duct tended to promote proposals, the selfishness as regards her relations, even her mother, and the intense craving to be admired, are all true to nature. Witness her state of mind when Grandcourt first appeared : — " Hence Gwendolen had been all ear to Lord Brakenshaw's mode of accounting for Grandcourt's non-appearance ; and wlien he did arrive 2p 694 THE INSANITIES OF PUBERTY AND ADOLESCENCE, no consciousness was more awake to the fact than hers, although she steadily avoided looking towards any point where he was likely to he. There should be no slightest shifting of angles to betray that it was of any consequence to her whether the much-talked-of Mr Mallinger Grand- court presented himself or not. And all the while the certainty that he was there made a distinct thread in her consciousness." Again : — • " Gwendolen knew certain differences in the characters with which he was concerned as birds know climate and weather." The sentimentality of this period of life is well illustrated when Gwendolen says : — " 'I never saw a married woman who had her own way.' 'What should you like to do ? ' said Alex, quite guilelessly, and in real anxiety. [He was an adolescent just entering on the period. ] ' Oh, I don't know ! Go to the North Pole, or ride steeplechases, or go to be a queen in the ball, like Lady Hester Stanhope,' said Gwendolen, flightily. 'You don't mean you would never be married ? ' ' No, I didn't say that. Only, when I married, I should not do as other women do.' " The inchoate religious sentiment, as a psychological faculty contending with the egoism, is thus brought out : — "What she unwillingly recognised, and would have been glad for others to be unaware of, was that liability of hers to fits of spiritual dread. . . . She was ashamed and frightened as at what might happen again, in remembering her tremor on suddenly finding herself alone. . . . .Solitude in any wide scene impressed her with an undefined feeling of immeasurable existence aloof from her, in the midst of which she was helplessly incapable of asserting herself. With human ears and eyes about her she had always hitherto recovered her confidence, and felt the possibility of winning empire." The selfishness and craving for notice is thus hit off : — " ' I like to diSer from everybody. I think it is stujiid to agree.' " "Her thoughts never dwelt on marriage as the fulfilment of her ambition. . . . Her observation of matrimony had induced her to think it rather a dreary state, in which a woman could not do as she liked, had more children than were desirable, was consequently dull, and became irrevocably immersed in humdrum. Of course marriage was social promotion. She could not look forward to a single life. . . . She meant to do what was pleasant to herself in a, striking manner ; or rather, whatever she could do so as to strike others with admiration, and get in that way a more ardent sense of living, seemed pleasant to her fancy. " THE INSANITIES OF PUBERTY AND ADOLESCENCE. 595 But extracts merely spoil the whole picture, which is one that is in perfect accord with the facts of nature, drawn by a consummate artist. It seems like passing from the poetry of science to Dryas- dust's details, to descend from George Eliot's word-pictures to the details of physiological fact and speculation that underlie all this charming maiden's mental constitution. I think most medical men of extensive observation would agree with me, that the incompleteness of those mental tokens of merely developing womanhood and manhood during the period of adolescence do indicate that the conditions under which the reproduction of the species takes place should be deferred till adolescence has passed. The love-making of adolescence is not the serious matter it should be, as Gwendolen's history well shows ; and therefore, the full physiological and psycho- logical conditions for dualism not being there, it should not be encouraged. All serious love-making, engagements to marry, too free intercourse with the other sex, too much dancing, too much going into society, merely tend to force on the full development, like young plants in a hot-house, with the result that the flowers and fruit have a tinge of artificialness, do not last, do not stand the same tear and wear. A young man who marries before his beard is fully grown breaks a law of nature and sins against posterity. A girl who gets engaged while in Gwendolen's state of mind is not likely to derive aU the happiness in marriage of which she is capable. It follows, therefore, and most members of our profession would, I think, agree with me, that sexual intercourse should never be indulged in till after adolescence. The period of adolescence is very liable to those psycho- logical cataclysms in weak brains, attacks of mania, which have a special relationship to the function of reproduction. Especially it seems to me that the periodicity and remission of the nisus generativus in both sexes, and the menstrual periodicity which accompanies it in women, are reflected in a 596 THE INSANITIES OF PUBERTY AND ADOLESCENCE. corresponding periodicity and tendency to remission in the insanity that occurs during adolescence. Insanity in Adolescence. — Passing now from the physio- logical and psychological characteristics of adolescence to the forms of mental disease that prevail then, the following was a very severe case of the insanity of adolescence terminating in recovery : — K. Q., set. 23, a student, who worked hard, who had a neurotic heredity, his mother having had puerperal mania after the birth of almost every child and been latterly epileptic, his father having been nervous, two sisters and one brother having attacks of mania subsequently to his own attack. His life had been sedentary, and his bodily health and nutrition had run down. He had been given to the habit of masturbation. He had been working extra hard to pass an examination, when suddenly, without any other exciting cause, he became morbidly exalted, lost his power of sleep, got restless, talkative, violent, and unmanageable at home. Within four days he had to be sent to the Asylum. He then laboured under acute, almost delirious, mania. He was exalted, giving incoherent descriptions of metaphysical speculations and mental problems. There was a great deal of the sexual element running through his incoherence and his speculations. His temperature was 100'1°; his pulse 84, weak; his weight 11 st. 12 lbs. He was kept outside nearly all day in charge of two good attendants, though most violent ; he was compelled to take four custards a day, each containing four eggs and a pint and a half of milk, in addition to any ordinary food he could be got to take. He was treated with warm baths at night, with cold to his head, and large doses of bromide and iodide of potassium combined while the temperature was high. He slept little, and in spite of the enormous quantity of nourishment taken he fell off in flesh and strength. Contrary to my usual custom in adoles- cent cases, I added a considerable quantity of port wine to his diet, as he looked at times so exhausted. In the first six weeks of his stay in the Asylum he lost 28 lbs. in weight. THE INSANITIES OF PUBERTY AND ADOLESCENCE. 597 All kinds of sedatiyes were tried temporarily in vain. I thought he was going to die of exhaustion. He had a slight beginning of a hasmatoma, which was blistered, and so stopped. The excitement became paroxysmal and reciwrent in its intensity, though he was never free from it. After about two months the intensity of the maniacal condition began to abate, and he passed into what is to me a most anxious stage in these cases. His expression of face became en- feebled looking, his habits dirty, he masturbated badly, and his whole mental state suggested secondary dementia rather than either mania or recovery. One cannot pay sufficient attention to the treatment of such symptoms in that stage. The nourishment was made a little more stimulating by strong soups, in addition to the milk and eggs. He got fresh vege- tables, cod-liver oil with the hypophosphites, and strychnine and iron. He was narrowly watched and well nursed, and much moral treatment adopted to rouse and interest him. It seemed to be in truth a toss-up between recovery and dementia, between mental life and mental death. Fortunately the recuperative power of his brain and constitution pre- vailed, he slowly picked up flesh, and his beard and whiskers began to sprout, — I have much faith in adolescent recoveries when the beard grows coincidently with recovery, — and his weight increased fast and steadily, until in six months from the commencement of his illness he was quite well in mind, and strong and stout in body, weighing 13 st. His was one of only about ten patients that I have seen where even partial recovery took place after a haematoma had formed, or even been threatened in any degree. Unfortunately, after living in the country for a time he came back to a city hfe, could not get work, had domestic trials, and became insane again in eighteen months — this time the symptoms being melan- cholic ; but from this he also recovered, kept well for a time, then had another attack of mania, which ended in secondary dementia. Lives that looked full of promise are sometimes blasted on 598 THE INSANITIES OF PUBERTY AND ADOLESCENCE. the threshold of what seem most brilliant careers, as in the following case of K. E., set. 20. Heredity very neurotic, mother being very nervous, aunt insane, and father drunken. He had been a most brilliant and successful student, and he had poetic gifts that made his friends look forward to his future with much enthusiasm. His illness came on when he was reading hard, sleeping little, supporting himself by teach- ing, and also perhaps further exhausting his energy by illicit sexual indulgence. Without any proximate cause he became much exalted in mind and much excited, sleepless, and fell off his food. The common remedy of enormous doses of morphia was resorted to, which caused sleep, but he was no better for it, and after it would take no food whatever. When he came to the Asylum he was quite incoherent, raving about religion and women. His tongue and lips were dry ; his temperature 99° ; pulse 144, small and thready ; and his general strength small, though his maniacal muscular energy was great. I could get him to take no food, so at once fed him with the stomach-pump. He had to be put in the padded room at night on account of his delirious violence, but was taken out each day into the fresh air by three good attendants. He began to take his food after a few days, but remained acutely excited for a fortnight. Then there was a remission, but the mania came on again, as indeed it did all through his case, by spurts. In about three months he began to be more coherent, and wrote some poetry. As it illustrates the common mixture of religious and sexual emotion in this and most of those cases very graphically, I quote some of it here : — A SOLEMN ANTHEM IN CELEBRATION OF THE NEW JERUSALEM. 0, Eosaly, my warm and panting girl, Just image to yourself the gates of pearl ! The angels sitting in illustrious row, Kissing their hands to the Holy Ghost below That glorious unimagined mystery, The very hot and lovely Trinity, THE IXS.iXITIES OF PUBERTY AND ADOLESCENCE. 599 Afar they see the lake of crystal shine, FilM with the juice of maidens' paps divine They hear the sappy sound of neighbouring love And kisses, sacred as the brooding dove. They look unto the Gi-eat "White Throne and laugh. Christ plies the A'irgin with luxurious chaff ; Jehovah fiiels the Queen of Sheba's beauty. And refers to the loveliness of Duty. The Devil reads the Sermon on the Mount, And adds a little on his own account. And so they sing their wicked songs together, AVhile God in anger frowns upon the weather. His bodily health and strength gradually improved, his beard and whiskers sprouted in great luxuriance, but his mental power did not return. He continued to write poetry, but it got more and more incoherent. He called himself at times "Jesus Christ, Prince Algernon Swinburne,'' though tliis was scarcely a fixed delusion. He had been an intense admirer and great reader of Swinburne's poems, and, as in the specimen given above, all his insane poems were influenced by the rhythm and perhaps by the early ideas of that poet. The treatment adopted was the same as in the pre'vious case, but to no avail as regards his recovery. The change to another asylum was tried, but did not rouse him. He sunk into dementia in about two years. The following patient was not a head worker : — K. S., xt. 21. A quiet, steady, and intelligent fisherman; stout, ruddy, and strong in body. He came of one of the families of the fishing village of Xewhaven that must have had some verj- unstable ment;il stock introduced into them many genera- tions since, and that have intermarried for many years, and in many of which now there is an enormous amount of in- sanity or epilepsy. I know one such family of which twelve members out of four generations have been iu the Asylum, brothers and sisters and cousins, some of them maniacal, some melancholic, some epileptic, some idiotic, and many of them dying of phthisis. In four-fifths of them those neuroses appeared first during adolescence, this being most marked in 600 THE INSANITIES OF PUBEKTY AND ADOLESCENCE. the younger generations. If any proof were needed of the supreme importance of hereditary influences in the production of mental diseases and epilepsy, and the small influence of healthy conditions of life in counteracting these hereditary influences in many instances, I would point to the village of Newhaven. The people are well-fed fisher folks. They are rohust and handsome. Most of the " bonny fishwives " that are so picturesque an element in the street scenes and street sounds of Edinburgh belong to this village. The life they lead is a natural outdoor one, and yet insanity is more common among them than in any community of a similar size I know. That fact, along with others, notoriously the frequency of insanity among the old families of the Society of Friends, the most self-controlled and virtuous of all religious sects, is a complete answer to those who say that mental diseases are mostly due to drink and vice and the manifestly bad and unnatural conditions of modern town life. But to return to K. S. He at first behaved as if something was " preying on his mind," and when questioned could only assign as a cause a common dispute in a boat. This was no doubt the melan- cholic prelude to the attack. Then he became elevated, and then maniacal and violent. This lasted for about a week, and then he appeared to get well. In a few weeks he again became maniacal, and was sent to the Asylum. His bodily health seemed absolutely perfect in all respects. He was a fine, fresh, ruddy young son of the sea. He was set to hard work in the garden, and in ten days became rational and quiet, and kept well for three years. I noticed that during the three months he was in the Asylum his beard and whiskers, which were nascent on admission, grew out full and strong, so that, though he came in smooth-faced, he left a bearded man. He had a subsequent attack of a similar kind in three years, from which he also recovered, and the last I saw of him was when he came to tell me he was going to get married. No doubt he will have a numerous neurotic and insane pro- geny, for he looked in glorious bodily health and vigour. THE IXSAXITIES OF PUBERTY A\D ADOLESCEXCE. 601 This was a case in ■wliicli there seemed absolutely no exciting cause whatever for the attack hut the completion of the period of adolescence. The last case I shall refer to is one where recovery did not take place, but dementia resulted. K. V., set. 16. Has an aunt a patient in the Asylum. Had been a month ill before admission. He was excited, noisy, shouting, and dancing about. That was in 1878. For four years he was subject to attacks of acute maniacal excitement at intervals of a few months. In the first year they were very acute. This is a general rule. ^Ij experience is that the first attack or the second is apt to be the worst. In K. V.'s case the attacks got less acute after the first year, but in the intervals between the attacks he was less sane. A clouding process over his mind went on, each attack leaving him rather more enfeebled than the last. But he was once so well that he was tried at home for a short time. He gradually sank into secondary dementia, with rare and occasional spurts of restlessness and mild maniacal excitement at irregular intervals — a type of the healthy chronic lunatic that forms half the population of most asylums, and he is likely to live for many years. He can work in the garden, can answer simple questions, sleeps well, is not uncleanly in his habits, mingles in the Asylum amusements, but all his " higher nature " is gone. He cares little for his relations. His joys and sorrows are very mild. He has no interest in life, no ambition, no great sense of right or wrong, no volition in any higher sense, and no religious instinct. Treatment of the Insanity of Adolescence. — The treatment I have lately adopted for such cases is founded on physio- logical considerations. The normal completion of the period of adolescence is in both sexes accompanied by a consider- able deposit of adipose tissue, by an overplus of strength and activity, and by a state of general good nourishment of the body. To attain to this normal condition of body should undotibtedly be our aim in treating all cases of mental disease 602 THE INSANITIES OF PUBERTY AND ADOLESCENCE.' at this period. It always seemed to me that there' were two things that constantly worked the other way, and that I had to contend against in their treatment. These were the general brain excitability, and the morbid strength, and often perversion, of the generative nisus with the inhibitory power over it gone. The one tended to mania, sleeplessness, purpose- less motor action, thinness, and exhaustion; the other to erotic trains of thought, sexual excitement, and masturbation. I found that inaction, reading, indoor life and amusements increased the one, while novel-reading, solitariness, and long hours in bed aggravated the other, while animal food and alcoholic stimulants gave increased strength to both morbid tendencies. I therefore put my patients to active exercise in the open air for as many hours a day as possible, walking, digging in the garden, wheeling barrows ; I give them shower baths in the morning when the weather is suitable and they are strong enough, and I encourage active muscular exercise in every way. Athletic games of all sorts in the open air are certainly good as far as they go. I place great reliance on the diet. Milk in large quantity, and as often in the day as possible, bread, porridge, and broth are the staple articles of food for such patients here. My friend Dr Keith, of this city, was the first to direct my attention to the advantage of a light farinaceous and milk diet in another class of cases, and my experience is strongly in favour of his views. The patients may have some fish, or fowl, or eggs, but in reality milk is the most important means of treatment. I seldom give such cases alcoholic stimulants. I give to all such patients who can take and assimilate it easily an emulsion of cod-liver oil, hypophosphite of lime, and pepsine, made and flavoured in such a way that it resembles cream or extract of malt. I find very few indeed who cannot take this. Beyond this, an occasional bitter tonic, with sometimes a chalybeate or some of the new compound syrups of the phosphates, are about all the medicines I give. The effect of this diet, regimen, and treatment is very marked in the majority of cases. No doubt THE INSANITIES OF PUBEETY AND ADOLESCENCE. 603 during tlie first part of the attack patients may lose weight "while the excitement is in its most acute stage ; but they soon begin to gaia weight, and my prognosis is always favourable when I find a patient beginning to gain weight within a reasonable time, say six months or so. I have had patients who, in spite of very sharp excitement indeed and much sleeplessness, gained weight under this treatment. It seems to me that the process of fattening such a patient, and the conditions under which it takes place, are antagonistic to the disease and its results. I have known the stopping of the cod-liver oil to be followed at once by a loss or diminished gain in weight, and its resumption to be followed by the former rate of increase. If a young man or woman suffering under the insanity of adolescence is found to gain one or two pounds a week within the first three months, I look on him as pretty safe. It is common to gain a stone in a month. I have now pursued this plan of treatment long enough to yield results that can be relied on, and I believe that more of my patients recover than before I adopted it. They recover sooner, and their recoveries are more reliable and permanent. Even in the case of those who sink into dementia, I think they do so more quietly and with less of the element of chronic mania than under a flesh diet. It is, I think, certain that the habit of masturbation, which is so frequent and so deleterious in such cases, is less practised by patients on this diet, and, when practised, is less damaging to brain function, and takes less hold on them. Prophylaxis. — Lastly, in connection with this subject, I would say a word about prophylaxis in children with a strong neurotic inheritance. My experience is that the children who have the most neurotic temperament and diathesis, and who show the greatest tendencies to instabihty of brain, are as a rule flesh-eaters, having a craving for animal food too often and in too great quantities. I have found also a large propor- tion of the adolescent insane had been flesh-eaters, consuming and having a craving for much animal food. It is in such boys 604 THE INSANITIES OF PUBERTY AND ADOLESCENCE. that the habit of masttirbation is most apt to be acquired, and, when acquired, produces such a fascination and a crav- ing that it may ruin the bodily and mental powers. I have seen a change of diet to milk, fish, and farinaceous food produce a marked improvement in regard to the nervous irritability of such children. And in such children I thoroughly agree with Dr Keith, who in Edinburgh for many years has preached an anti-flesh crusade in the bringing up of children up to eight or ten years of age. I believe that by a proper diet and regimen, along with other means, we can fight against and counteract inherited neurotic tendencies in children, and tide them safely over the periods of puberty and adolescence. Statidics. — The following is a statistical and clinical inquiry into the subject of the insanity of adolescence. For this inquiry I took for the period of five years and a quarter (from 1874 till the end of the first quarter of 1879) all the cases that were admitted into the Eoyal Edinburgh Asylum. They amounted to 1796 — 917 men and 879 women. Of these, 320 were between the ages of 14 and 2.5, viz., 195 males and 125 females. Now, if my object had merely been to arrange those 320 patients each in a classification of symptoms, it would have been simple enough : so many with exaltation under "Mania," so many with depression under " Melancholia," &c. That was done, but a great deal more information must be expiscated about each case if we are to arrange them in clinical or physiological groups, and especially if we are to have any light thrown on the question — "Did adolescence influence the mental symptoms present in those cases ? " We must ask and answer the following inquiries : — " In how many cases did the disease exist before the age of 14, or was of a kind with which adolescence could have nothing to do ? " I found I had to deduct 90 such cases, or about one-third of the 320, those having been mentally defective or epileptic from birth, or at very early ages, or laboured under organic disease, or in THE INSANITIES OF PUBEKTY AND ADOLESCENCE. 605 whom tlie disease came on in nursing or childbirth, leaving -30 in whom it was possible for pubei'ty or adolescence to cause or influence the disease. The next inquiry naturally was — " If 230 occurred in the twelve years between the ages of 1-4 and 25, is that proportion greater or less than is found in the same number of years at other ages? " I find it to be far more than between 2 and 14, but less (10 per cent.) than between 30 and 40. At this par- ticular age, either from adolescence or some other cause, it is clear that there arises a liability to insanity which did not before exist, but which does not cease when adolescence is past. The next query was tliis : — " Taking this long period of twelve years, is there any special liability during any of the years of that time'/" "Does it arise at puberty, or towards the completion of the period of adolescence 1" A glance at the numbers who became insane in each of the twelve years shows that the first two, that is the 14th and 15th, were especially exempt, only producing one case each; and the next two, the 16th and 17th, also very few (22). Xow, the fact that there only occurred in those four years of life 24 cases out of about ISOO in all (230 of them being adolescents and healthy up to that period), does show clearly that the first onset of the reproductive function is not a dangerous one as regards liability to insanity, however liable it may be to chorea, epilepsy, and other neuroses of development. The next three years — the ISth, 19th, and 20th — were still low, producing only 49 cases, or an average of 16 in each year. In those three years, while puberty has occurred in nearly every individual of both sexes, yet adolescence has been completed in very few of them. It was in the next five years, from the 21st to the 25th, that the vast majority of the cases occurred, viz., 157 of the 230, or an average of 31 in each year as compared with an average of 8 for each of the first five years. At 14 and 15 the liability to insanity was practically nil, from 21 to 25 it was 606 THE INSANITIES 01? PUBERTY AND ADOLESCENCE. very great. In fact, a comparison with the liabihty at other ages during the past five years in the admissions to the Asylum shows that there is no period of life where uncom- plicated insanity occurs more frequently than during the completion of the physiological era of adolescence, from 21 to 25 (see Plate V.). It must be kept in mind that I am not now speaking of the numbers becoming insane in pro- portion to the number of the general population alive at any particular period. Those statistics are confirmed in the main by those of Lewis.^ Comparing the two sexes, the pro- portion of females is smaller in the adolescent period than at later periods of life. Si/mptoms. — Having elucidated those pointH, we come to the question as to what mental symptoms these adolescents suffered from, and if those symptoms were in any way peculiar? While investigating this, I found the complica- tions of marriage, child-bearing, and lactation in the females so common after the age of 21, that it was difficult to com- pare them with the males. I therefore made 21 tlie limit of age for them. This reduced their numbers to 40, making, with the 140 males, 180. The first fact of importance is, that there were only 40 cases where the symptoms present were classed as states of mental depression, while the rest were cases of exaltation. Now, the significance of this proportion is only seen by com- parison. During those five years there were admitted nearly two cases of uncomplicated mania to one of melancholia (849 to 439), whereas among the adolescents it was 3^ to 1 (140 to 40).2 And if we compare them with those at more advanced ages, e.g., women at the climacteric period, the proportion of mania to melancholia is then reversed, there being one case of the former to 1 1 of the latter. ' Text-Booh of Mental DiseascK, by W. Bevan Lewis, p. 384. ' During the past seven years, 1890-97, tho number of melancholies have been about equal to the oases of mania. This I attribute to the effects of the influenza on the brain constitution of the community. THE IXSANITIES OF PUBERTY AND ADOLESCENCE. 607 The proportion of states of exaltation of mind or mania, therefore, is much greater as compared with those of melan- choHa among the adolescent insane than among the insane at all ages, this excess being still more marked when compared with the cases of mental disease occurring at the climacteric period of life. A Bclapg^uKj Mania. — The next inquiry was — "What was the character of the mania?" I found it had several well- marked characteristics. It was, in the first place, often of a very acute, though seldom of a delirious type ; in the second place, it was mostly of short duration, the patients getting soon apparently quite well; in the third place, the patients were subject to constant relapses. Out of the 180 cases, 118, or 66 per cent., had such intermissions of insanity with sub- sequent relapses. This tendency to short sharp attacks, with intermissions of more perfect sanity than occur in most other kinds of mental disease, with relapses occurring one, two, three, four, and five times, and even more frequently, before recovery or dementia finally takes place, may be taken to be especially characteristic of this insanity of adolescence. In many of them, as the maniacal attacks passed ofi', there was a slight tendency to melancholia. This was noticed in 62 cases. In a few cases headaches came on and evidently took the place of the psychoses. This relapsing character, with the tendency towards depression, brings adolescent insanity into relationship with folie circulaire. The real cause of the remissional character of both is no doubt the periodicity of the generative power and desire. Heredity. — Another weU-marked characteristic was this, that a hereditary predisposition to mental disease, or at least to some of the graver neuroses, was on careful investigation found to be present in 65 per cent, of the adolescent insane. It is very difficult to get family histories of insanity in most cases, and you may often multiply by two those you get, if you want an approach to the truth, at all events if you take in the graver neuroses. Our proportion of hereditary predis- 608 THE INSANITIES OF PUBERTY AND ADOLESCENCE. position in the Asylum, as recorded in our Case-Books, is only 23 per cent., as compared with 45 per cent, among the adoles- cents, in whose cases no special pains had been taken to ascer- tain family histories. I observed a still more striking fact in regard to the heredity of the insanity of adolescents. I happened to have a personal knowledge of the history of the cases or of the families in fifteen of the cases, and in twelve of these, or 80 per cent., there was a hereditary predisposition to the neuroses. It is a common enough fact to have the children of a neurotic couple, one or both being highly intel- lectual, sensitive, artistic, and religious, but wanting, it may be, in stability, or common sense, or self-control, yet with no insanity nor epilepsy — it is common to find one or more of the children of such a couple subject to adolescent insanity; instinctive immorality or hysteria. The insanity of adoles- cence is therefore predisposed to, in most cases by a nervous heredity, being in fact the most hereditary of all forms of mental disease. Sexual Tincture. — Another marked character of the mania was that the ideas, emotions, speech, and conduct were all strongly tinctured by the normal mental characteristics of adolescence in an exaggerated or morbid way. That perversion of the sexual act, the habit of masturbation, was very common, probably existing in over 50 per cent, of the cases, aggravating the symptoms and diminishing the chances of recovery. In the females hysterical symptoms were common, such as mock modesty, simulated pains, and a desire to attract attention. In the males heroic notions, an imitation of manly airs and manners, an obtrusive pugnaoiousness, and sometimes a morbid sentimentaUty were present. In almost all the cases the physical appearance of the males was boyish when the attack commenced ; and most of the females were girlish rather than womanly in contour. Remits of Treatment. — As regards the results of treatment in those cases, 93 were discharged recovered, or 51 per cent. ; but then 40 were removed home or to other institutions re- THE INSANITIES OF PUBERTY AND ADOLESCENCE. 609 lieved, many of whom would liave been likely to recover ultimately. I only know of 26 of the 180 ^^•ho became incurable. Insanity occurring at the adolescent period is therefore a very cvirable disorder as compared with many other forms, though not so curable as some forms, e.//., puerperal insanity. Just before recovery, in almost all the cases which did get well, signs of physiological manhood appeared, the beard growing, the form expanding, the weight increasing. ^Vhenever I see those signs, accompanied by mental improvement, I am inclined to give a favourable prognosis. The mortality was very low, only three of the 180 cases having died. Adolescent Psi/clioses not amountimj to Insamfi/. — There are a series of lesser mental and moral changes and perversities short of technical insanity that are liable to occur in adoles- cents of both sexes who have hereditary weakness, often more difiicult to treat, frequently as distressing and always more obscure, but all due to the same hereditary and pathological causes and of the same essential nature as insanity. They consist in some cases of stupidity and lethargy, or in an a-social development when all the social instincts should be most keen, or in causeless aversions to father, mother, or other near rela- tions, with intolerance of control and utter disregard of parental feelings — all the time, perhaps, getting on well with strangers who don't live with the patient. Or we have a general incom- patibility of temper, the patient losing situations, quarrelling with friends, and making enemies everywhere. Or it takes the form of visionary scheming, or of frothy religionism, or of sudden immoralities contrary to the tenor of the past life. Or new and causeless immoralities show themselves — such as stealing, violence, or murder. It is a striking fact that one- half of all first convictions are in the cases of offenders under the age of 25. There seems to be an adolescent form of criminahty as well as of insanity. Or perverted sexual and reproductive ideas and acts show themselves. Sometimes the neurotic adolescent shows a simple diminution of the volitional 2q 010 THE INSANITIES OK I'UBERTY AND AD0W5SCEN0E. power, showing fickleness, irresolution, morbid "laziness," and paralysis of volition.' I lately saw a young gentleman of ■ 20 who said "something camo ou " him that prevented him using his muscles, so that, e.ij., in the midst of his breakfast ho could not raise the spoon to his mouth. I was once consulted about the case of a lady who, up to the age of 14 or 15, had been as other children, but who, since that time, has been the despair of innumerable governesses and teachers, and thn family skeleton at home. Clever intellectually, especially in defending her perverted conduct and in making preparations to shook lier parents, not given to gross immorality, yet sho seemed to e.xhaust all the arts by which disobedience, lying, and outrageous unconventionalities of all sorts could break lier , parents' hearts. She only showed affection or consideration towards strangers, animals, and oddities, and sho only professed sympathy with the low, bad, and unfortunate. Kospoctability was an unpardonable offence to her. Yet she would pass muster among strangers for a month at a time as a clover, interesting, and original girl. She ultimately married one of lier father's labourers and became a frugal farmer's wife, " dropping " all her former acquaintances. LECTUEE XVII. THE INSANITIES OF DECADENCE. CLIMACTERIC INSANITY. The climacteric ; physiological and psychological characteristics of period ; melancholic symptoms in 64 per cent, of the cases, and maniacal symptoms in 36 per cent. — Mental Siimptoms in a typical case ; loss of keen interest in life ; fits of depression ; capacity for work diminished ; irritability ; suspicion ; scn^c of fear and iinpcndini/ danger; change of connubial affection; suicidal longings; vague melancholic delusions — Bodily Symptoms : Sensory neuroses ; ver- tigo ; pains ; sensations of heat ; vaso-motor neuroses, flushings, A:o. — Motor Syinploms : Restlessness — 228 climacteric cases out of total of 3145, or 7'2 per cent. — Frognosis : Fair ; 53 per cent, of uncomplicated cases recover — Treatment : Change of scene ; travel ; change of air and of diet ; iron and quinine ; sea-bathing ; fresh air ; fattening diet ; the bromides. As unstable brains are apt in certain cases to be upset in their mental functions by the slow development of the reproductive power and the onset of the sexual function at the periods of puberty and adolescence, so they are apt to suffer as those great powers of the organism pass away at the climacteric period. An animal has functionally and physiologically three distinct periods of existence — (1) when its life is dependent on that of its mother before birth; (2) when it lives independently, but cannot reproduce itself before puberty and after the climacteric; and (3) when it both lives and can reproduce. The mental function is non- existent in the first period, more or less imperfect in the second, and fully developed in an ideal sense only in the third. There are some animals low in the scale in whom 612 CLIMACTERIC INSANITY. the reproductive act is always followed by death. At the period of the climacteric there is unquestionably a mental change in both sexes. The sexual desire, after a short period of irritable aggravation perhaps, invariably weakens in its intensity or ceases altogether, and with it the affectiveness changes in its object and greatest intensity from the mate to the progeny, losing its imaginative force, its fire, and its impulsiveness. Poetry and love tales then cease to have the power " to set the brain on fire." Action of all kinds ceases to be so pleasurable for its own sake as it has been before. Much of " the go " is out of the person. The instinctive feeling of difl'erence of sex, and all that it implies, which has been all-pervading before, now lessens visibly. The subtile interest of the society of the other sex is less electric and overmastering. Along with these affective changes there are bodily changes too. The form alters, especially in women, and the expression of face changes, the ovaries shrivel, Peyer's patches les.sen in bulk, and the spleen and lymphatic glands harden. The blood-forming and the blood-using processes slacken in speed, and the trophic energy in all the tissues is less intense in action. " liife becomes slower," in fact, mentally and physically. And as a result of this, after the climacteric lias been safely passed, the organism is less liable to many diseases than it has been before. The real climacteric in both .sexes is never a definite fixed time, but usually extends over a year, or two, or throe, or even more. The mere cessation of the function of men- struation in women does not necessarily fix definitely the mental and nutritional changes that mark the period. I have known a woman of 50 who had gone tlirough the mental changes of the climacteric, in facial expression and in form was post-climacteric, who had no sexual desire, yet was menstruating regularly ; and, on the other hand, I have known many women of the same age, in whom menstruation had ceased from 40 to 46, who were yet quite shapely, amorous, and mentally youthful. So the mental disease that CUMACTEEIC IXSAMTY. 613 accompanies the climacteric neetl not be quite coincident with the menopause, but may occur some time before or some time after that event. As a matter of fact, tlie ordmary sensory nervous symptoms tliat are connected with the cHmacteric in women, viz., giddiness, flushings, flashes of light, uneasy organic sensations, &c., usually precede the actual cessation of the menses rather than accompany it. -1 Typical Case. — A typical case of climacteric insanity begins by a loss of energising power, bodily and mental, of which the patient is rather supersensitively conscious. Her courage is less ; little things come to have the power of annoying her that she would have thought nothing of before. Groundless fears, which at first she knows to be groundless, haunt her at times. And at this stage the sleep is apt to be dreamy and broken, the appetite for food is less intense, and the bowels costive. There is apt to be some falling-off in the bloom of the complexion and in looks generally. The skin often gets muddy, and more pigmented than usual. It is a trouble for her to go into company or to move about in public, and yet she has little restful feeling and no con- tentment or organic happiness. At the menstrual times all these things are much woree, and there is apt to be real depression of mind, weeping, with irritability of temper and sleeplessness. I have never yet met with a climacteric case in this early stage wlio did not feel much better in the open air than in the house. That is an indication of treatment and of prevention of further symptoms that I never fail to find useful. I have seen iron at this stage, too, do very much good ; in fact, sometimes it seemed to act as a specific. But those mental symptoms do not constitute insanity, though tliey have a close kinship to it. The next stage consists of more real and continuous depres- sion. The morbid fears and fancies assume a more intense character, though they are often indefinite. The patient is quite sure some evil thing is going to happen to her, though she cannot tell what it is to be. The self-control is often lost. 614 CLIMACTERIC INSANITY. but much more frequently the patient is terrified that it is going to be lost. There are vague impulses towards suicide, sometimes towards hurting husband and children, and the existence of those add to the terror and intensify the depres- sion. Such things are thought by the patient to be "so wrong," and she blames herself for tliem. A conscious loss of affection, or rather a loss of the pleasufable feeling that conscious affection for husband and cliildren gives, is a cause of the greatest distress. There is often a sort of organic repugnance to the husband and to his attentions. By this time all the usual sensory accompaniments of the climacteric have disappeared, or rather they have been transformed into the mental neurosis I am describing. There are no headache.^, nor giddiness, nor flushings. But the trophic neuroses become aggravated all the time. The thinness, the flabbiness of muscle, the pigmentation of skin, get worse. There arc fre- quently skin irritations, and the patient picks and scratches her skin. The bowels are costive, the appetite is gone, the sleep absent, and the capacity for work greatly lessened. In the worst cases suicidal feelings are strong and attempts frequent, but they are rather apt to be feeble. The very loss of courage and vigour of will operate against any effectual attempts at suicide, however much tVie wish may be there. Hallucinations of hearing are frequent. This condition may pass into acute excited melancholia and exhaustion, and death ensue, or it may become a sort of chronic shy uselessness, or " paralysis of energy," or it may gradually pass away under proper treatment and conditions of life, and the woman be- come strong, cheerful, well-nourished, and useful, sometimes more " healthy '' in a certain sense than ever before. Tlie following is a case of climacteric insanily, of elwrt dura- tion but very acute form, and with an dement full knowledge of all the facts, and strict impartiality. 6. Giving evidence as to civil capa- city ; management of property, making wills, contracting marriage, &c. ; great caution here ; get facts on both sides of the question ; don't promise to give evidence till you have got all the facts —Mode of life ; "habit aiidrepute ;" eccentricity ; youthful extravagances ; wide views of the law on this matter ; Scotch jirovision of Curator Bonis without deprivation of personal liberty— Will-makiny : (a) Is he free from influence of drink or drugs ? (ft) does he understand the nature of the act he is doing, and the effect of the document ? (c) can he state his reasons for making a will ? (d) is the disposition of the property a natural one, andifnot, why? (e) is it not influenced by insane delusion or insane state of mind? (/) is there no facility with undue influence being exerted 1 {g) can he tell twice over the disposi- tion he wishes to make ? (h) can he tell his relations and their claims on him 1 (t) can he tell the amount of his property ? (J) is there any brain disease or aphasia ? don't let a good motive sanction a bad will. 7. Delecting Feigned Insanity : No general rule ; are the symptoms those of any known type of insanity ? is there any motive ? — Watch the patient when he thinks he is unobserved ; commonly overdoes his part ; power of endurance ; sleep ; sensibility ; sudden shocks, shower bath, electric battery, &c. ; hysteria ; effect of drugs ; Diffi- culty of the question. Was Hamlet mad ? Self-accusations of really insane jjeople. 8. Giving confidential family advice as to such matters as engagements to marry, education, choice of jirofession, sudden change of conduct and morals, &c. ; Dreadful effect of help- ing to increase the neuroses, the insanity, and the idiocy in the world ; on the other hand, Maudsley's ojiinion as to genius resulting from neurotic marriages ; Special mode of education sometimes needed for neurotic children. The medical profession has grave medico-legal responsibilities thrown on it by the provisions of many of the forty enact- ments that stand on the Statute Book relating to the insane. In addition to their statutory duties, judges, lawyers, and administrators of the law constantly call in medical men to DUTIES OF MEDICAL MEN' IX MEXTAL DISEASES. 671 help tliem in the solution of questions that they only can solve. There are few things about which the British public is more sensitive than those relating to the liberty of the subject, to civil capacity, and to the control of property. In addition to these responsibilities, there are most delicate duties of a purely medical and medico-social kind thrown on our profession by the exigencies of practice, and the impossi- bility of finding elsewhere so quahfied and wise an adviser as the family doctor. There is no doubt that all those duties should be done with much care, and after searching inquiry into facts, and a grave consideration of the whole effects of any opinion expressed or of any act done. A special know- ledge of the subject, experience, sound judgment, conscien- tiousness, and caution, are all qualities requisite in deahng medico-legally with the insane. The chief medico-legal and medico-social duties of medical men in relation to mental diseases may be thus classified : — 1. Taking file responsibility invoiced in treating cases at Jwme, placing tliem under the care of attendants, advising that they should be put under a certain degree of control, and pre- vented from transacting business. This in doubtful cases and in the early stages of the disease, is often a very serious thing to do. The patient may not know he is ill, says in fact he is quite well, resents as an insult and a degradation being put under control, and threatens all who have to do with it with the most dire consequences. The only sound and safe rule for the doctor is to make it clear that he only advises, and does not take any legal responsibility whatever for the steps by which a patient is controlled. Let that fall on a relation who has the legal right or moral duty to take measures for the safety of the patient, and on no account be assumed by the doctor, to whom the law gives no authority whatever but to grant certificates. If the patient is removed to lodgings to be under treatment, the relatives must authorise this step. It need not be the nearest relative. It is often desirable to have family councils under those circumstances. Especially when hus- 672 DUTIES OF MEDICAL MEN IN MENTAL DIHEA8ES. hands or wives arc mentally affected, " both sides of the house " Khould, if possible, be taken into consultation. But as regards the doctor the rule is clear. Let him advise but not act. I have even in some rare cases refused to take the responsibihty of regular attendance and treatment, without first getting a letter of protection from legal risk. The attendants in charge are the servants of the relatives, and under their orders technically and legally, however much in fact they may be under the doctor's deputed authority. Ill England a patient can be treated at hi.s own home or anywhere else, if not "for profit," without certificates of lunacy, as long as his friends desire, and so long as he is not badly treated, which last procedure sulijecl.a those responsible for it to very heavy punishment. In Scotland a patient can be treated, with a view to cure, anywhere out of an asylum for six months without formal certificates, if a medical opinion to that effect and intimation is sent to the Commissioners in Lunacy. This is a most valuable and common-sense provision. The time might very well have been extended to twelve months. If treated at home or anywhere else " without profit," and his treatment implies control over his actions, his case must be intimated to the Commissioners at the end of twelve months. 2. TJie mod common of all Lli/; medim-lr'gal duUes ihrovn on medical men is that of dgnincj the daiutory mediral aerliji- cates for placing patient H in amjlumn or under earn in private homes. Tliis is done for the proper treatment of the patient, and often for his safety as well as for the safety of the public. The form of certificate is fixed by statutr;, and no other form will do. The form is praetically the same in i^ngland, Scot- land, and Ireland, though the mode of placing a patient in the asylum is different in the three countries. In j':rigland a private patient can be placed in an asylum only on the "order" of a magistrate after the two medical certificates and a petition from a relative have been obtained; in Scotland the sheriff must sign the "order," after having seen the DUTIES OF MEDICAL MEN IN MENTAL DISEASES, bib petition, statement, and medical certificates. Pauper patients are placed in asylums in England and Ireland on the order of a magistrate, who must see the patient, and on one medical certificate; while in Scotland pauper patients are placed in asylums in the same way as private patients, that is, on a petition and statement by the inspector of poor, two certifi- cates, and a sheriff's order. As to the grounds on which a British subject can be legally deprived of his liberty on account of insanity, the common law of England only recognised as a sufficient cause danger to the patient or the public, and a recent decision seems to imply that some Judges still hold that to be the law. But by the imiversal practice of the country, sanctioned by the Com- missioners in Lunacy, the recent statutory law is taken as superseding or supplementing the common law ; and the former, without defining insanity, or prescribing any specific grounds on which a patient may be detained as a lunatic, clearly enacts that " care and treatment " are the chief objects of his detention, and liis being dangerous is nowhere made a sine qua non. This being so, the first thing a medical man with an insane patient who needs care and treatment in an asylum, or to be boarded with a private family, has to do, is to make up his own mind in regard to the definite grounds on which the steps are to be taken. Having done so, his next business is to convince the patient's responsible relatives of the necessity for certification. In doing this it is far better not to press them too strongly at first if they do not see the necessity for it. All that is necessary is to explain the reasons for his opinion, point out the risks, and that the responsi- bility rests on them, not on the doctor. It may in some rare cases be necessary, before certifying, to get a letter from a responsible person, protecting the doctor from risk of a legal action. This is a risk no medical man in signing a certificate of lunacy should subject himself to if he can help it. Eecent English lunacy statutes debar actions if there is no reasonable ground for imputing to the doctor want of good faith or 2 u 674 DUTIES OF MEDICAL MEN IN reasonable care, a Judge of the High Court having power to stop proceedings on application ; while the Scotch law debars actions after twelve months from the patient's discharge from the asylum ; but if, in spite of this, under the common law, actions can still be brought against medical men for doing a statutory duty in a legal way, they must just protect them- selves by a letter of indemnification, or as best they can. In the case of pauper patients the chief responsibility undoubtedly rests on the medical man, to whom the relieving officers or inspectors of poor must refer the question of asylum treat- ment, and virtually are obliged to act on his opinion. The doctor runs the risk of an action accordingly. In solving the question of whether a patient should be certified as a lunatic or not, the first thing, of course, to ask oneself is — " Is the patient insane 1 " And it is well to be prepared to say what kind of insanity he labours under. To determine this question, one must have evidence of mental disease observed by oneself, but may also use any facts prov- ing it as ascertained from others who have seen the patient. If he is insane, then comes the further question — " Is he a proper person to be detained under care and treatment 1 " Many persons are insane in a medical and even in a legal sense, yet have so much self-control left, or their mental peculiarities are so slight and harmless, that they are not proper persons to be detained under care and treatment. I would say that the chief things that constitute the statutory fitness are — danger to themselves or others ; disturbance of the public peace ; inability to care for and manage themselves and their affairs ; acute mental symptoms of any kind • or amenability to curative treatment which cannot be applied without certification. No doubt all sorts of considerations social, monetary, and domestic — come in before determining the expediency of certification. One has to ask what are the reasons for his removal from home, how he will be likely to look on it after his recovery, and how will it affect him and his affairs generally ] Then, of course, it is proper, having RELATION TO MENTAL DISEASES. 675 determined that he should be certified, to ask what legal risk there is to yourself or to his relations. I knew an undoubt- edly dangerous lunatic who kept himself out of an asylum by bribing one member of his family by money gifts to oppose his seclusion under all circumstances, and by threatening any one of his children who might move in the matter with disin- heritance in his will. It may be necessary to see the patient several times before you can make up your mind. When those questions have been answered, and you proceed to certify, then (a) fill in the first and purely formal part of the certificate in all cases as if it were an important business and legal document, looking at tlw directions on the margin. Our profession is not always sufficiently particular about this. Lawyers look on this part as of much importance. Not to designate the patient, and put in his residence at the proper place, is, according to Sir Cresswell Cresswell's judgment, to invahdate the whole document, and the English Commissioners always return it to the writer for correction if this is not done. The reason, no doubt, is, that there being ten thousand Thomas Jones in the country, it is necessary to discrimi- nate clearly which one is the lunatic you are certifying. In England and Ireland you must have seen the patient mthin a week of certification, in Scotland on the same day. (5) Then comes the most important part of all, viz., the " facts indicating insanity observed by myself." Without these facts the certificate is not vahd at all. Think of what the patient says, what he does, and what he looks like. By all means put in first the most evident and indisputable insane delusions the patient labours under, in as crisp and clear a way as you can. No evidence of insanity is so satis- factory to lawyers as insane delusions. N"ext to those in cogency come incoherence of speech, or shouting, or out- rageous conduct, or loss of memory and reasoning power. Put into the certificate some of the patient's very words, if possible. Next to those come such "facts " as relate to the 676 DUTIES OF MEDICAL MEN IN patient's appearance, expression of face, and manner. If you have known him before, any changes from his normal condition should be noted. By the way, in putting down delusions it is necessary often to add to a statement of one, the words " which is a delusion." Some things may be quite true, e.g., " He says he has £10,000 a year," and therefore needs this explanation. On the other hand, such delusions as " Says he is God Almighty " do not need anything of the kind. If any suicidal or homicidal expression can be got hold of, put it among the facts, but usually these have to come under the " facts communicated by others.'' Negative signs, such as absolute taciturnity, insensibility to impressions from without, are good enough "facts.'' It is better to put no " facts " that do not clearly indicate insanity, but there are some cases where the evidence must consist of lesser things than those I have mentioned, put in a cumulative way, e.g., " His manner is very peculiar. He is slightly incoherent and silly in speech. His memory is impaired somewhat. He has no sane interest in his affairs or in his relations or belongings. His eye is vacant in expression. His whole conversation gives me the impression that he is unfit to manage his affairs," were really all the facts observed by myself which I could put down as the result of one interview with a person of mildly enfeebled mind. It is better to use facts observed at the last interview. I could give instances of most ridiculous " facts " put into lunacy certificates by medical men. " He is incoherent in his appearance." "Eyes restless and wandering, but following the usual occupation of breaking stones.'' " Says she is in the family way (she had a baby in a few months)." " Beads his Bible, and is anxious about the salvation of his soul " are examples. Never put in such statements as these — " He has no delu- sions." " His self-control is not lost." Those are not un- common, but they go to prove sanity, not insanity. (<■) The " facts indicating insanity communicated to me KELATION TO MENTAL DISEASES. G77 by others," that follow, are very important as subsidiary and not essential points of the certificate. Among them you can insert descriptions of previous aggravations of conduct and speech, of attempts or threats of suicide, or danger to others. You must put down the name of your informant. {d) The signature, residence, and dating must be carefully done. After the whole certificate is completed, I advise every man to run it over carefully. Few men are so accurate that they will not sometimes omit something. The greatest tact is necessary often to bring out the real condition of a patient's mind. This is often impossible, in fact, even when you know on good evidence that he is insane. Especially is this the case when he thinks you are a doctor come to certify him. He then naturally conceals his delu- sions, and puts his best foot foremost. Sometimes a little stratagem is necessary. The weak are always cunning, and it seems as if this quality was exaggerated in some insane patients. By all means get the cue to his delusions, if they exist, and as full a knowledge of the patient's case as you can before you see him. I have more than once entirely failed to educe facts enough on which to found a certificate in the case of a man I knew to be insane and dangerous. I do not consider it a justifiable thing to give the patient drink in order to make him speak what is in his mind, or to bring out his peculiarities. In England and Scotland patients may be placed under treatment in asylums on " emergency orders," given by a relative or friend and one medical certificate. In England they can be detained on such orders for seven ' days, and in Scotland for three days without any magistrate's or sherifl's order, which can be got within these times. 3. Medical men have to give certificates of sanity as zcell as of insanittj sometimes. These need great care, much circum- 1 A new Lunacy Bill now before ravliament reduces this to four days. 678 DUTIES OF MEDICAL MEN IN spection, and considerable inquiry into the facts of a man's life and behaviour. I have on two occasions had insane patients leave the Asylum and return to me with certificates of sanity got from incautious doctors. In one case the patient produced and kept it as a good joke. It would be an awkward thing for the certifier if, after getting such a certifi- cate, the patient went and made a will, or killed himself. In a way, a certificate of sanity needs more inquiry before it is given than a certificate of insanity. Certificates of sanity are needed to set aside a Curator Bonis, or committees of the person and estate in England, and often also before a man is allowed to resume employments and public appointments. 4. Management of Property ; Civil Rights — When a man is ipso facto deprived of his civil rights and the control of his property by leing put into a lunatic asylum, or is so insane or wealc-minded that he cannot properly transact business, he must have his property looked after and administered for his benefit, and a legal process has to be gone through for that purpose. In England and Ireland affidavits have first to be given, stating facts indicating insanity, and especially incapacity to manage property, which are sent to the Lord Chancellor. On them, as prima facie proof, an inquisition de lunatico inquirendo is held by a Master in Lunacy, sent to the patient's residence for the purpose, at which medical and other sworn evidence is taken. If the patient is found lunatic, one person is com- monly appointed " committee of the person," to control the person, and another " committee of the estate," to manage the property, and no further certificates are needed for placing him in an asylum. If the patient demands it, and the Court thinks it right, a jury may be called ; if not, the Master sits alone and reports his decision or that of the jury to the Lord Chancellor. This is a cumbrous and expensive, though an efficient and fair process. If the property is small, the pro- cess is simpler and cheaper. Some such process should be provided for doubtful and important cases, but in ninety-nine out of a hundred it is an unnecessary waste of money and RELATION TO MENTAL DISEASES. 679 judicial talent. The ordinary Scotch process is far simpler and less expensive. Two doctors sign certificates " on soul and conscience" of the man's "insanity or incapacity to manage his own affairs, or to give directions for their manage- ment," or some such form, and those are presented witli a petition from all his near relations, stating the amount of his property, to a Judge of the Court of Session, who orders them to be served on the patient and intimated in a certain place in the Court for eight days, after which, if there is no oppo- sition, a Curator Bonis is appointed, who then manages the lunatic's property, and acts for him, after finding due caution for the proper performance of his duties. He lias to present an account of Ms intromissions to the Court every year. The weak point of the Scotch system is, that usually no proper guardian of the lunatic's person is appointed. The nearest relative commonly acts as such. If the application is opposed, the Judge has power to investigate the facts in almost any way he thinks best, through the Sheriff of the County, through an expert, or by means of evidence in open Court. Occasionally a Curator Dative is appointed to control the person, but this, with the process of " Cognition," are cumbrous antiquated processes seldom resorted to. We need in Scotland an inexpensive but efficient process, combined with the procedure for the appointment of the Curator Bonis, to appoint a guardian of the person. Differences of opinion between the curator and the relatives I have known to occur with us as to the disposal of the patient. 5. Medical men are often called on to give evidence as to the existence or not of mental disease in persons accused of crime, to enable the law to fix or to absolve from responsibility. In Scotland the procurator-fiscal usually has a medical adviser, with a view to determine the kind of proceedings to be taken in cases where crime, danger, or disturbance may have been the result of mental disease. The forms of insanity in which crime is usually committed are mania, epUeptio insanity, delusional insanity, and alcoholic 680 DUTIES OF MEDICAL MEN IN insanity, and sometimes puerperal insanity, delusional and homicidal melancholia, sometimes dementia and congenital imbecility, and also impulsive insanity where there are un- controllable homicidal, kleptomaniacal, pyromaniacal, destruc- tive, or animal impulses. Some of the complications of mental disease with the effects of drunkenness are often most puzzling both to medical men and to lawyers when crime has resulted from them. My experience is, that crime is usually com- mitted at the same stage of attacks of insanity that suicides are ordinarily committed, viz., in the incipient stage. Drunken- ness is held to aggravate crime, but alcoholic insanity exempts from punishment. There has always been a tendency towards a divergence of view between medical men and lawyers in regard to the amount and kind of mental disease that should exempt from punishment for crime. Certainly the law has gradually come round more and more towards the medical view, — has, in fact, recognised the facts of nature in mental disease. Judge Tracey held that, except a criminal was irresponsible as a " wild beast," he should suffer punishment. Lord Mansfield held that a "knowledge of right and wrong" was the test. The twelve Judges declared in M'Naughton's case that a knowledge of right and wrong in relation to the act committed should be the true legal test ; Lord Denman said that legal responsibility should depend on the presence or absence of insane delusion ; Lord Moncreiff has laid it down that a man's habit and repute as to sanity among his fellow-men who knew him well should determine his legal responsibility for any crime committed. At last the new criminal code as proposed by Mr Justice Stephen would make the man's power of con- trolling his actions the test, and with that view every medical man will agree. He says — " The proposition which I have to maintain and explain is, that if it is not, it ought to be, the law of England that no act is a crime if the person who does it is, at the time when it is done, prevented, either by defective mental power or by any disease affecting his mind, from con- KELATION TO MENTAL DISEASES. 681 trolling kis own conduct, unless the absence of the power to control has been produced by his own default." While Judges during three centuries were laying down these rules of law, men that we now hold to be insane were taking away their own lives by the hundred every year, most of them knowing it to be " wrong " and yet doing it — a " crime," and a " motive- less " one in most cases. Those suicides, legal " crimes," were surely thus exhibiting to all who had eyes to see, that, in such cases at all events, something was interfering to make inoperative every natural instinct, every effort of will, and every motive of ordinary human action — that something being disease and disordered function of the brain. But judges and lawyers often use terms in a technical sense, and in the same way construe statutes and former judicial decisions so that their effect becomes entirely different from what they seem. No doubt there are many difficult cases — cases on the borderland of disease, cases where vice and mental disease are mixed up puzzlingly, cases of mild enfeeblement of mind, cases of drink voluntarily taken, when its effects were well known, and after being taken crime has been committed in a condition of delirium or short frenzy. "We must admit we have no definite test as yet for detecting minute degrees of mental disturbance. I only wish we medical men were placed in a more satisfactory position before giving evidence. The whole facts on both sides are seldom put before us, and we are often regarded and treated in the witness-box as partisans — a position that we should resent as derogatoi y to science. Either we ought to be appointed as Assessors to the Court, or the Court should ask for our Report on which we could be cross-examined. At present many of the persons solemnly condemned to death for the crime of murder are found after- wards to be insane by. a private medical inquiry ordered by the Home Secretary, no evidence as to the prisoner's mental state having been submitted to the judge and jury, a pro- ceeding that surely tends to show that our methods of trial are far from being perfect. 682 DUTIES OF MEDICAL MEN IN 6. We are often appealed to as to the capacity of a man to make a will, or to transact ordinary business, to enter into ordinary contracts, or to contract marriage. The principles on which, our opinion should be founded for the three latter purposes are just those on which we act in determining the question of sending a patient to an asylum. In regard to will-making, great attention has been directed to the subject, and there are certain fixed legal and medical principles that should be kept in mind by us. The great trouble is that we are usually not consulted at the time of making the will, when the real capacity of the testator could be examined into, but are placed in the witness-box after he is dead, with one-sided imperfect information, and with every motive operating on the side that consults us to prevent us getting at all the facts. In will-making we must enlarge our ideas of the disturbances of the mental functions of the brain beyond those comprised under technical insanity. The senile dotard, the apoplectic, the man exhausted in strength from disease and approaching death, the man confused in mind from fever and drink, the man distracted by terrible pain, the man whose condition is weakened so that he is made mentally unresisting and facile by disease and by the near approach of death, may all require their testamentary capacity to be tested. It is most important that a skilled and experienced medical man should be asked to examine impartially into the testamentary capacity of such cases before the destination of great sums of money is irrevocably decided by a document that above all things needs soundness of judgment for its validity. It would be well were our profession more called on for this purpose. I was once told by a distinguished counsel, with a large experience in the Probate Court, that he had never known a will upset where a respectable doctor had witnessed it after examining into the testator's state of mind, and an agent of repute had drawn it up, neither of them taking any benefit under its provisions. It may be held as proved by legal decisions that a lesser RELATION TO MENTAL DISEASES. 683 amount of mental capacity is needed for making a valid will than for managing property or enjoying personal liberty. Patients in asylums have made good wills during remissions of their disease, the "lucid intervals" of the older writers. Patients with insane delusions that did not affect the pro- visions of the will have been held by the highest tribunals to have made good wills (Banks v. Goodfellow). Very facile persons have made good wills, and those on the point of death constantly make wills that stand, while wills with the most absurd provisions have stood in law. There are now three cases in which wUls have been made by patients immediately before they committed suicide, and they have been upheld by the Scotch Court of Session. "When a medical man is asked to examine into the testa- mentary capacity of a patient he should insist on seeing the patient alone, or at all events only in the presence of a nurse or a family agent, and the first thing to be ascertained is this — (a) " Is the patient free from the influence of drink or drugs, and in his usual state 1 " Then — (5) " Does he know the nature of the act he is to perform, and the effect of the document he is to sign'?" The next thing («) is to find out if he is not influenced in the doing of it, or in regard to any of its provisions, by insane delusion, or by an insane or morbidly enfeebled state of mind. Then (d) ascertain if there is facility of mind from bodily disease, intemperate habits, weakness or any other cause, or undue influence being exercised from without. Here is where you will find the benefit of being alone with the patient. I remember an old dying man confessing to me, when alone with him in these circumstances, that his niece, who was also his nurse and constant companion, was really compelling him against his judgment to make a will in her favour, his own volitional and resistive power being weakened by his state of bodily weakness and dependence. The influence exerted on many patients in bodUy weakness, especially if it has been prolonged, by a nurse constantly in attendance is sometimes absohitely 684 DUTIES OF MEDICAL MEN IN dominant, and quite irresistible by the will of tlio patient. A very interesting bit of medico-psycliology tliis is. The influence of previous intemperate habits is often so damaging to the mental power as to interfere with proper testamentary capacity. The memory is then chiefly affected, but nothing is more common than for alcoholics to take morbid and irrational prejudices against their relations, and delusions of all sorts, especially of suspicion, as the result of the brain damage from alcoholic poisoning. Supposing you are satisfied so far ; the next thing (e) is to make the intending testator go over the particulars of the disposition he wishes to be made, without prompting, or suggestion, or leading questions. And ho should be made to do this twice with certainly a quarter of an hour's interval between the two statements. It is often well to make him tell. the names of all his near relations. Sometimes a man wants to make a will, whose memory is so affected that he has forgotten the existence and the names of relations so near that they have claims on his attention at such a time. You can then see if the disposition is a natural one, and find out from him the motives for the will being made, for the omission of any relatives, and for any provision of it that may seem strange. Lawyers and the public are apt to regard the naturalness and reasonableness of the will as being an absolute test of whether it should stand, irrespective of the state of brain and mind of the testator. We have to ask whether the whole motives of action of the man quoad the will, are sane, reasonable, and uninfluenced by morbid motives ! Is it a natural will in the circumstances ? Is it the act of the man himself exercising his own will spontaneously. I remember being called to see a man who was dying of bronchitis and heart disease, with his breathing impeded, his strength ebbing away, and his mental power impaired by the non-oxygenated blood supplied to his brain. He had made a will in favour of a former mistress, and was in a state of great remorse, and wanted to leave his money, which was considerable, to his relatives. But he could EELATION TO MENTAL DISEASES. 685 not twice over remember all the provisions — these being a little complicated. I refused on this account on two occasions to say he had testamentary capacity. But, as sometimes happens, he became more clear in mind before death, and I was hurriedly sent for late one night to see him. He went clearly twice over the provisions he wished made in his will, and told me why he wished these made. His reasons were natural and right. The lawyer was there with the document drawn up, and the testator had just power to make his mark before he died. Yet this will was held good in law in spite of an attempt to upset it. (/) Ascertain if possible from him if he had intended to will his property as proposed before his illness, and for how long. Try and get independent testimony from others on this point. The next thing {g) you have to ascertain is if the intending testator knows in a general way the amount of the property he has to bequeath. I lately, on getting to that point in the case of a very sensible-looking man, was astonished at being told by him that he was worth £100,000, which I knew to be quite impossible, and of course no will was made. (7t) Ascertain what brain disease, if any, the patient labours under, carefully considering the question as to whether the convolutions are affected by such disease. The most common brain disease under which patients ■vvill be found to labour is apoplexy or paralysis. This may exist in any degree, and may be accompanied by any mental condition from almost perfect soundness and force up to complete fatuity, facility, and want of memory. The usual morbid emotional outbursts of weeping, or irritabihty, especially if the patient is aged, often indicate loss of mental power and of volitional resistance. Persons so damaged in brain are often irri- table, prejudiced, delusional, and even vindictive as the result of their disease. It is most necessary not to let a good motive make us sanction a bad will, however natural its provisions may be, however much trouble or expense it may save. I am fre- quently asked to sanction wills being made by persons unfit 686 DUTIES OF MEDICAL MEN IN to make them, on account of the convenience of having a will or the saving of expense and trouble. I have found but little realisation of the impropriety or illegality of getting dying people, or those whose minds were enfeebled from paralysis, who did not really know what they were doing, to sign wills as a matter of convenience, even among conscientious reputable people. In examining patients as to will-making it is very necessary and desirable to be perfectly impartial, to make no suggestion and express no opinion of one's own as to the justice or propriety of the settlement to be made, and on no account to say anything that would influence the testator in his views as to the disposition of his property. 7. The detection of feic/ned insanity is a duty sometimes laid on a medical man. There are no fixed rules or tests by which feigned insanity can be detected. I need hardly say we have first to see if the type presented is that of an ordinary kind of insanity. Most imitators mix up incoherent maniacal symp- toms with silliness, and will talk no sense at all, and pretend to know nothing. In fact, they overdo their part. The patient should be carefully watched all the time, sometimes ostenta- tiously watched to keep him at it for a long time, and then again when he does not know he is observed. No sane man can imitate the dry skin and lips, furred tongue, constant restlessness by day and night, high temperature, and constant sleeplessness of acute delirious mania which for a short time feigners often try to simulate. A man imitating the shouting, &c., of acute mania perspires freely, while an acutely maniacal patient seldom does so. The sensibility to pain should be tested, and sometimes, in prisons, a battery is found useful in the case of old crafty malingerers. I have heard of a man being put under the influence of a drug before the doctor was known to be coming, in order to produce a real stupidity with confusion of mind. I have been deceived by a clever imitator of acute mania so far as my conclusions were arrived at from one visit. Epilepsy and epileptic mania are very commonly imitated. EELATION TO MEXTAL DISEASES. 687 I liave known a really insane man assume an exaggerated insanity to make his friends think the asylum was doing liim harm ; and a sort of grotesque semi- volitional imi- tation of mania is common in hypochondriacal melancholies to convince their friends how ill they are ; while in hysterical girls imitations of maniacal attacks and of imcon- sciousness are very common to excite sympathy and attract attention. 8. One of tlie most dificult and often most responsible duties that faU to a mediccd man's lot is to give confidential family advice about engagements to marry wJien one party lias been insane, is threatened tcith insanity, or has an insane heredity, to advise as to tlie education and profession of children of a very neurotic heredity, or to advise as to the significance of sudden changes of conduct and sudden outbrealcs of givss im- morality, or of a tendency to unnatural crime, or otlier motive- less and unaccountable conduct in previously reputable sane people. Such advice may have the most serious consequences. My feeling is always against the marriage of women who have been insane. I always advise young men or young women to avoid marrying into a very neurotic and insane stock. The risk is very great. I quite agree with the French medical opinion that there is a special tendency for members of neurotic families to intermarry, and an affective "affinity" among such that tends towards love and marriage. That is no doubt bad for the race, and as physiologists we should try and stop it when we can. To have a neurotic young man marry a fat, phlegmatic young woman may be admissible, and a good safe stock may result. But what are we to say about the marriage of the neurotic, thin, hysterical young women, with insanity in their ancestry? We know they will not make good or safe mothers. Therefore, in them we ought to discourage marriage. However good its physio- logical effect might be, in some cases, on the individual, bad mental and bodily quaUties, as well as tendencies to disease, are thus propagated to future generations. They leave the world 688 DUTIES OF MEDICAL MEN IN worse than they found it thereby, the disease and therefore the misery in it being increased. The possible compensation of a genius once in an age is not to be trusted to. I believe a healthier kind of genius would result from better stock. Science, till it discovers a way of correcting such bad stock, must say, " Do not propagate it." A sporadic case of insanity, or of senile break-down imitating insanity, may occur in almost any family. That would not warrant any such advice about the marriage of relations as I have been giving. The relatives of such a case may all be perfectly sound. I am speaking of families in which the neurotic temperament, and especially those in which the nervous diathesis, is present. If such persons are to marry, do not let them marry too young, and let them marry into a sound, muscular, fat, non-nervous stock. Though the contrary has been the rule, my advice has over and again been taken, and engagements to marry not entered into on the ground of bad heredity. If you are asked about any young man or woman — "Will he or she become insane or not?" — say that science does not yet enable us to answer that question certainly, As to the mode of education of the children of insane or neurotic parents, there can be no doubt whatever that it ought to be on very stringent physiological lines, and under medical advice. Such children should all be brought up in the country, and fed mostly on milk and cereals, and should have lots of fresh air, and no improper excitement ; they should have well-ventilated class-rooms, short school-hours, and their lives and time should be systematised. Their weak points should be corrected by their modes and conditions of life. They should be kept fat, if possible, one and all. They should have no alcohol, and no tobacco till after twenty-five. At the coming on of the reproductive period of life special care should be taken with them. The sexual appetite is most difficult to manage in them and by them. It is often strong, disturbed, and apt to take unnatural forms, while the power EELATION TO MENTAL DISEASES. 689 of control over it is apt to be small. lirotic imaginations are apt to become the dominant factors of life and conduct. The development of control should be the chief aim in their educa- tion. The occupations they choose should not imply intense head work, nor a sedentary life, nor excitement. JIake them colonists, sending them back to nature, or get them into fixed salaried places with sj'stematio work and a regular holiday. The worst of it is that such persons often tend to do exactly the reverse of all this. Some especially neurotic children need very special modes of education. I have seen cases who could not safely be sent to ordinary schools. Through precocious steal- ing, lying, and vice they were constantly getting into trouble. They were without much moral sense or self-control, and had erratic, motiveless ways. I have seen good results with such children sometimes by placing them in a quiet family in the country, under motherly care, under special rules and guid- ance, and away from much temptation. Such children are the stock out of which the insane, the persistent masturbators, the dipsomaniacs, and the motiveless " instinctive " criminals arise, with a poet or a genius to redeem the class once in a century and to vindicate nature's law of compensation in the world. 2X LECTURE XX. A SUMMAKY OF THE GEXEKAL TKEATMENT AND :*rAXAGEMEXT OF INSANITY LOOKED AT AS A WHOLE: AND ON THE USE OF HYPNOTICS, SEDATIVES, AND :\IOTOE DE- PEESSANTS. Insanity as a disease — Urgent questions to be fdcr-d as to causation, heredity, diathesis, former di->ease3, concealment of symptoms — Mental symiitoms— Bodily symptoms — Examination of patient — Diseases that simulate insanity — Dangers — Treatment — Nursing — Home treatment— Treatment in lodgings or hired house — Asylum treatment — Why a patient should be sent to an asylum— Legal forms — Food and feeding— Food-medicines-Alwholic stimulants — Tonics and nerve stimulants— Exercise and fresh air TO-rsM» rest — Occupation and amusements— Hypnotics, sedatives, and motor de- pressants — General principles of use — Dangers of abuse — What do ■we desire to attain ? — Opium in melancliolia — raraldehyde — Sul- phonal — The bromides and cannabis indica — Hyoscine. Inaaiiify a diafM-iK. — The different varieties of insanity Lave for the most part different symptoms, risks, and termina- tions, and they commonly imply some difference of treatment, but tliey have also many features in common in management and treatment. A man's " mind is aJIected," and with this there are bodily symptoms. The practitioner has therefore before him a "disease," as popularly understood, to treat. From this point of view it may be useful, especially to busy practitioners, in this clo.sing lecture to summarise and condense the views scattered over the preceding lectures, and to enunciate the general principles of treatment appHcable to insanity as a whole. 1 have often been a.-ked to do so by medical friends, SUMMARY OF TEBATMENT OF INSANITY. 691 wlio found the discussion of tlie special varieties of the disease and the clinical illustrations too long for emergencies. Urgent Questions. — "When a patient's mind has given way, or is threatening to do so, there are certain questions that the doctor should pass before his mind seriatim, and come to some sort of conclusion about them, either at the time or as the case develops. The chief of these are : — What is the probable cause of the mental disturbance ? Is it from within the man or from -without him 1 An evolution of his heredity '! An almost necessary incident in his development or decadence 1 A result of the conditions of his previous life, his environment having been inharmonious? Had he by his conduct or mode of life anything to do with bringing on the disaase? Or is it the direct result of some cause from within ? Then comes the further question — Are there more causes than one in opera- tion ] Most cases have more than one cause. It will depend on how these questions are answered whether the next can be favourably regarded. Can the cause or causes be removed, and how ? The relatives will always assign a cause for such a strange thing as insanitj'-, but they will be wrong as often as not. It is most important in most cases to get information as to the heredity of the patient, both in regard to mental disease and the neuroses ; and it is well to find out the heredity and personal diathesis especially in regard to consumption, rheumatism, gout, syphilis, &c. The developmental diseases which the patient has suffered from should not be lost sight of, especially the early neuroses. The next set of questions relate to the symptoms present : Are all the symptoms really exhibited ? or is the patient, by voluntary effort or otherwise, concealing important symptoms ? Is there anything below the surface of the case? Remember that relatives and friends tend to minimise certain mental symptoms and greatly to exaggerate others. They think little of mental depression and delusions so long as the outward conduct is not much changed, while they are frightened unduly about incoherence, 692 SUMMARY OF TREATMENT OF INSANITY. threats, noise, or violence, or about what seems to them loss of consciousness. To what extent are the symptoms purely mental or chiefly mental, and to what extent are there bodily symptoms or accompaniments ? Have they come on gradually or suddenly ? Are they progressing or stationary 1 Are the great organic functions affected or not ? Mental Symptoms. — Depression, suicidal tendencies, eleva- tion, excitement, delusions, stupor, impulsiveness, silliness, loss or perversion of affections, incoherence of speech, loss of memory, mental automatism, dominating and fixed ideas> suicidal and dangerous tendencies, are the chief mental symptoms to be inquired into. Bodily Symptoms. — These are present in most cases of in- sanity. Preliminary headaches, all kinds of perverted sensa- tions in head and in body, sleeplessness, losing of flesh, anorexia, constipation, changed expression of face and eye, changed tastes for food and drink, altered secretions, slightly elevated temperatirre with a tendency to an evening rise, tremblings of facial milscles, impaired articulation, especially in the case of difficult words, a dry skin, motor paralysis, are the chief bodily symptoms in ordinary cases to be inquired into. The question must ahvays be asked. Is there organic disease of the brain or spinal cord, or nerves ? Examination of Patient. — The examination into every bodily symptom, into the condition of every organ, cannot be too thorough. Mental symptoms constantly depend on reflex irritation of the cortex from the peripheral organs. Always, for instance, try to find a bodily cause for a delusion. Diseases that Simulate Insanity . — Keep in mind tliat though the delirium of fevers is emphatically mental disorder, it is not reckoned technical insanity that should be certified and sent to asylums. The following are the chief diseases that may be attended by cerebro-mental symptoms simulating insanity, viz., typhoid, typhus, small-pox, scarlet fever before the eruption comes out, meningitis, traumatic injury to head, mental shock, hysteria, ursemic delirium and coma, cerebro- SUMMARY OF TREATMENT OF INSANITY. 693 spinal meningitis, drunkenness, the effects of opium and other neurotic drugs. Danger. — Then comes the very urgent question of danger. Does it exist? and in what form? ^Vliat are the risks, in short ? Are they to the patient's hfe, by direct attempts at suicide ? or by indirect means, such as taking too little or no food ? Are there risks to others ? And to whom 1 Is there risk of exhaustion by excessive cortical action? Or are the risks those of neglect of organic functions? Or neglect of the conditions of life necessary for health or recovery, such as exercise, fresh air, rest or sleep ? Eisks to reputation, to fortune, to business, to position, have all to be thought of. A medical man cannot be too candid with the relatives and friends of a mentally affected patient as to the risks of the case. Treatment. — Then comes the most serious question of Treatment and Management. Almost the first thing to he considered in aU such cases is : who is to be the responsible nurse, or companion, or observer of the case? Can a really good, experienced, skilful nurse or attendant be got? This is a, sine qua non in most cases. A "bodily nurse," even a good one, is often quite unreliable, both for the observation of mental symptoms, for appreciating risks, for acting in emergencies, and even for the routine treatment and manage- ment. Good nurses can often be got from asylums, and most nursing institutions have nurses with " mental " experience and training. The Medico-Psychological Association has lately instituted a course of training and an examination that ■will no doubt in time produce a body of trained male and female attendants and mental nurses available for the public, each with a certificate that will be a guarantee of special knowledge. In some cases the disease can be cut short by treatment or by altering the conditions of life. Change of scene often is good. Travel is good in the very beginning of a few mental cases, but it should not be fast travel. A sea voyage, that favourite recommendation of despair, often does far more harm than good, and is attended with many risks. 694: SUMMARY OF TREATMENT OF INSANITY. Ildw many suicides havis I known to result from this cau'se ! But there are cases where it is the best thing to advise. A course of mineral waters and baths, or a hydropathic with a good system of baths, is a far safer recommendation, and suitable for most cases, but even that is often too public or too exciting. Home Treatment, Treatment in Lodgings, and Asylum Treat- ment. — It is one of the most important decisions that has to be come to in the treatment of decided mental disease, whether the patient shall remain at home, shall be sent to suitable lodgings, or shall be sent to an asylum. There are comparatively few grave cases except acute puerperal mania, short attacks of delirious mania and alcoholism, that can be best treated at home, and then only among the well-to-do, where good nursing and suitable rooms can be got, and the attack does not last long, runs a definite course, and does not need for its treatment much open air and exercise. When a case of mental disease becomes quiet and chronic, with no urgent symptoms and no great tendency to degeneration of habits or mental condition, home is sometimes a suitable residence if there is a responsible head of the house, personal nursing, and general medical guidance. When the case is not doing well at home or is not likely to do well, then comes the question of a hired house or rooms, to be tried before an asylum is resorted to, or during the whole attack. In selecting a house or rooms the following principles should guide us. It should be in the country or in the quiet suburbs of a town, but not too isolated. It should have an inclosed garden with good walks. It should have easy access to the country roads. Eooms on the ground floor should nearly always be selected. Before use, all door keys should be taken out and kept by the nurse. If an inside bolt is on the W.C. it should be taken ofi', and the windows should have stops put on, so that the lower sash cannot be raised more than five inches. Sunshine and cheerfulness should be prime motives for selecting a living-room. SUMMARY OF TKEATMEXT OF INSANITY. 695 During the treatment in rooms medical visitation should be frequent ; tliis has a good moral effect on the patient, and keeps the nurses up to the mark and prevents them thinking they are only " keepers " for the safety of the patient rather than nurses for his cure. All precautions against suicide and danger should be carefully taken and stringently enforced. If the case lasts long, special means must be taken to provide amusement for the patient and break the monotony. Visits ef relatives, while often exciting and harmful in the acute stage, do much good, and keep everybody up to the mark later on. Change of rooms may be needful to secure change of air and scene. I have treated almost every kmd of case, from' acute, violent, raving mania to the mildest melanchoha, in private houses and in lodgings, and very many with success. It is largely a question of house, nurse, and money. It is of course very expensive, and faUs in many instances. The forms of insanity most suitable for treating in such a way, or that it is most desirable so to treaty are mild melan- cholia, adolescent insanity while recent, puerperal insanity, some cases of hysterical insanity, mild cases of mania that look as if they would run a short or regular course, lacta- tional insanity, that of pregnancy, senile insanity in the very aged, and some eases of alcoholic insanity. The advantages are that the " name of an asylum " and of technical insanity is avoided, a most important matter in some cases. Professional reputation and success are lesS' likely to suffer ; appointments run less risk ; the patient is far better pleased when he recovers, and his friends are more satisfied. But the patient's recovery must be the paramount considera- tion. He has the right to have the best chance of living, and not dying mentally. Its disadvantages are the want of con- stant medical supervision and of a medical routine of life and disciphne, the diificulty of getting responsibleand skilled nurses, the want of freedom of walking in some cases, the risk of disturbing neighbours, tlie greater risk of suicide, the 696 SUMMARY OF TEEATMENT OF INSANITY. friction of nurse and patient left so long together, the irrita- tion of personal control, the monotony of the life, and the want of the stimulus of institution life. Poverty almost always implies an asylum as securing the best treatment in nearly all forms of insanity. Long con- tinuance of acute symptoms also does so. Intense and subtly-schemed suicidal attempts, great violence and homi- cidal impulses, very dirty habits, much noisiness, and non- recovery after a reasonable time, should suggest asylum treatment, Eemember that the nurses may be a little influ- enced in their reports by the fact that their pay ceases when the case is removed from their care, and we ourselves are in the same position. A good asylum has the advantage of a healthy situation, large grounds, extensive walks, a suitable dietary, a healthy regime of living, regularity, order, system, which in many cases are all most therapeutic. It has proper rooms for violent cases, plenty of skilled nursing and medical supervision that can scarcely be obtained at home or in lodgings; then it has suitable occupations and amusements. Good modern asylums have special means of segregating the different classes of patients. The different parts of the house are specially adapted to the state and cure of the different varieties of mental disease. They have villas, hospital wards, and seaside houses. They are, in fact, mental hospitals, built and conducted on scientific principles, with everything to cure and to antagonise mental disease. The effect of being placed in such a hospital is in some cases simply wonderful. All this makes for recovery most powerfully. No case should be allowed to drift into incurability without such an institution being tried. Its disadvantages are the risk of annoyance from the presence of fellow-patients in a still worse state of mind the chance of seeing dirty and degraded cases that shock a patient during convalescence, the risk that listlessness and apathy should degenerate into dementia from want of interest in life and too little exercise of volitional power. Some people too SUMMARY OF TREATMENT OF INSANITY. 697 and they are of tlie predisposed neurotic supersensitive folks, have all their lives a foreboding horror of "a madhouse." How great a blessing it would be to poor aiSicted humanity, both the insane and their much to be pitied relatives, if every vestige of prejudice and terror were removed from the idea of a mental hospital. A doctor sending a case to an asylum should have in mind that there are two events, either of which will probably make the relatives blame him and say that he has made a mistake in recommending the step — these are death, or recovery within a week or a fortnight after admission. If the latter occur, the patient will be likely to join in the disapproval. Legal Forms. — Before an asylum is decided on, the relatives should be distinctly told that it implies formal legal papers and medical certificates being iilled up, and that a magistrate's or sheriff's order will be needed — all this, though not imply- ing pubHcity, yet placing the patient in the category of the technical insane. The full reasons, pro and con, should be explained to them, and I always advise my medical friends not to be too urgent, but to temporise for a little if the relatives are unwilling or will not give immediate consent, except the symptoms are very urgent or very dangerous in character. Let them see the patient, and be fully convinced of the expediency and necessity of the step in the patient's interests. The forms required can be got at any asylum, usually also from any inspector of poor in Scotland. When there are no special reasons to the contrary, it is usually far better for the patient to be taken to the asylum by a near relative and nurse or attendant than the family doctor. Especially the asylum doctor should have nothing directly to do with it if he can. Don't let him be connected, in the patient's mind, with the decision to be sent from home, and avoid deceiving the patient. Conimonly say that he is to be placed under a doctor's care in order to get better. I know the difficulty of this, and the terrible temptation to deceive him as to his destination ; but the effect of such deception is 698 SUMMARY OF TREATMENT OF INSANITY. often very bad for liim, and lastingly so. It makes liim mas- picious of every one, and sets his back up against necessary treatment. In my experience, human ingenuity in prevarica- tion reaches its limits in the lies told to patients as to where they are going, and why they are going, when they are being brought to asylums. 1 Food and Feeding. — In all cases the questions of food and feeding is one of the first considerations. Food must always be tempting, nourishing, and well served. For most acute cases it requires to be liquid or nearly so, and often repeated. Nothing is so good, and nothing can be given so easily, as milk or liquid custards, each made of a pint of milk, just under theboilingpoint, into which two or three eggs, after being beaten, are stirred in with sugar, a tablespoonful of sherry, and a little nutmeg. One of these custards is a meal, which the patient can drink off in a minute ; or if he refuses absolutely, it can be poured into his stomach quite easily through a funnel attached to a long rubber tube, No. 12 or 14 catheter size, passed through one nostril. Strong soups, with plenty of vegetable juice, jellies, and fruit juices, can also be easily given. Depend upon it, under-feeding is far more risky to recovery than over- feeding. Fatten and nourish your patient is a rule to which there are marvellously few exceptions in mental medicine. Food-Medicines and StimulanU. — Cod-Hver oil and the emulsions of which it is the chief constituent, and the malt extracts, are exceedingly useful in melancholia, senile insanity, and other cases with innutrition. In many such cases and in neurasthenic cases wines and malt beverages are useful both for digestion, nourishment, and sleep, and they are easily given. Try stiff doses of spirits, suitably diluted and hot, to procure sleep in some cases of acute excitement Tonicg and Nerve Stimulants. — I use an enormous quantity of quinine in the treatment of all my patients who are run down in body, or whose appetites are poor. I also use much ' See paper by Dr ¥. A. Elkina in Edinburgh Medical Journal, March 1892. SUIIMAKY OF TREATMENT OF INSANITY. 699 iron ill anaemic cases, and the dilute mineral acids are distinct brain stimulants, as experimentally demonstrated by Professor Roy. The ■whole class of tonics is of undoubted service and should be largely given, each medicine for five or six weeks, and then a change of tonic being made. The class of direct nerve stimulants, of which strychnine is the best typo, and which forms the most active constituent of the numerous syrups (Easton's, Fellows', &c.), should not be given indis- criminately. They may cause cortical excitement ; they often stimulate the sexual nisus, and they frequently aggravate insomnia. They are not suitable in most acute cases, nor in excitable motor melancholies, in most super- sensitive neurasthenics, in most hysterical and masturbational cases, and whenever convulsive symptoms exist. But in early simple melanchoha, in most cases where, the acute symptoms having passed over, there is lethargy and a tendency to fall into dementia, and where the nerve tone is low without much nervous excitability, they do much good. Exercise and Fresh Air versus Rest. — In my experience, moderate and suitable exercise in the fresh air is one of the sheet-anchors of treatment, and is worth all the physic if there was no choice between the two. Of course it must not be taken up to exhaustion. It must be prescribed and Avatched as a powerful medicine is prescribed and watched. AVe all know that it can soothe and stimulate, can cure insomnia and cause it, can help digestion and stop it, and that it may tend to good bodily nourishment or to thinness according as it is physiologically or injudiciously used. It manifestly tends towards glandular action, towards regularity of action of the bowels, towards normal metabolism of every kind. "Wherever there is motor restlessness or nervous fidgetiness, it affords the best outlet for superfluous energising. I have tried massage as a substitute, so as to get its good effects without exhaustion. !My oj)inion of massage in mental diseases is that it suits very few cases indeed, and does positive harm to most melancholies, 700 SUMMARY OF TEEATMENT OF INSAXITY. but there are marked exceptions to this. Some psychiatrists have lately taken up rest as if it were the opponent and opposite instead of being the complement of exercise in the fresh air, and as usual when a matter looks controversial, have run down exercise and accused it of doing serious harm, or said it was in many or most cases not needed ; they quote the starved and exhausted early melancholic when he first comes to an asylum, or the case of " typhoid " mania, or the acute puerperal woman, or the weak and restless senile case, and they say, " "We put such cases to bed and give them rest." But who in his senses ever exercised such cases more than in tlie gentlest way, and that only after some days or weeks of restful treatment 2 Some physicians are now talk- ing of " brain rest " by lying in bed and being confined to his room, with gentle massage, or even by being confined in a strait jacket, for the acutely maniacal patient who is fairly strong and stout. By all means let this plan be tried, but my whole medical experience has been valueless and misleading if for the majority of such cases regulated exercise in the open air is not a remedy, natural and rational, and such "rest" as confinement and restraint is not an aggravation. "Rest" of this sort for the acutely maniacal was tried in old times by restraint and seclusion in rooms and airing-courts, with the result of a high mortality, a low recovery-rate, and an abundant residuum of chronic mania and dementia, degraded habits, and danger to themselves and others. I know one or two physicians who get most of their cases from large cities adopt this routine method of putting every patient to bed for a few days, with feeding and observation. This may suit some cases well, but I cannot agree that it is a rational mode of treatment as a routine measure. Occupation and Amusement. — The insane man like the sane must have something to do, and we must so condition his work that it takes up his attention, diverts him from intro- spective morbidness, and keeps the current of his thoughts^ and feelings in physiological clianncls. Simple mechanical SUMMARY OF TREATMENT OF INSANITY. 701 work sucli as gardening is best ; along with that the natural tendencies towards social pleasures and amusements must be strengthened. For mental disease tends to arrest and destroy the social instincts. To take a man " out of himself " wlien melancholy, to make him laugh when he is sad, to provide him with cheerful company when lonely, seem such obvious measures of treatment that one would have thought them psychiatric truisms as well as being the alphabet of common sense. Asylums for the insane have become pleasant ho§pitals and homes largely through the slow development of suitable occupations and amusements for the patients. The most experienced and the most thoughtful of their physicians have devised new amusements, and have endeavoured to apply them as they would medicines to each individual case. They one and all have lauded and encouraged such a system of moral and mental therapeutics, and distraction from morbid thinking and feeUng. But lately voices have been raised against this assured dogma of mental medicine. As usual there is some truth in the contention. There are certain of the insane for whose morbidly excitable brains certain amuse- ments are unsuitable or harmful, and in a few of the most acute cases they are out of the question. But no phj^sician that I have ever known ever used unsuitable amusements to any extent or persistently for such cases any more than they used strychnine in a convulsive case or the bromides in stupor. Dificulties. — The general treatment of insanity needs never- ceasing care, endless devising to meet individual symptoms, sleepless vigilance to avert serious catastrophes, and the most watchful observation of symptoms bodily and mental. It implies a medical alertness and resource, a provision for emergencies of all sorts, and a knowledge of human nature that are needed in no other branch of therapeutics. Any- thing that implies that "medicine out of a bottle" only will cure the disease is utterly to be deprecated. The whole con- ditioning of a patient's life must be faced. Any mode of treatment of insanity that is easy is sure to be wrong. 702 SUMMARY OF TEEATMENT OF INSANITY. Human nature is not simple, and insanity is a disorder of human nature in its deepest recesses. It has resulted from departures from nature's laws for many generations. It means evolutionary unfitness for the life struggle. We have been weariedly struggling to understand what it is, and slowly advancing in the knowledge that makes for cure. Let us not lose ground by retrograde experiments. On the Use of Hypnotics, Sedatives, and Motor Depressants in the Treatment of Mental Diseases} — Four cases out of five of recent mental disease have either sleeplessness, or active brain excitement, or morbid motor activity, as part of their symptoms at some time. The other symptoms present, mental and bodily, often seem to be of less importance than those to the patient's relatives and to his physician. Their urgency and troublesomeness seem to call for direct and immediate medical treatment in a very large number of such cases. While as physicians we fully recognise that these are symp- toms, and not the disease itself, yet they all so manifestly tend toward brain exhaustion, that it is very natural to adopt means for their relief. And the most obvious medical means are the use of hypnotic, sedative, and motor depressant drugs. I do not say that such drugs are as curative as they seem, though I fully admit that their use is sometimes curative. And few practitioners but frequently find their use inevitable. The temptation to use them is sometimes overwhelming. But the dangers of using them to excess are great and numerous. I hope I am not wrong in the opinion I have formed that as they have been used they have often done more harm than good as regards cure, though it may be said that the sum-total of the present relief they have afforded has been so great a boon to the sufferings of humanity, that their disuse would be a cruelty not to be thought of. To go into their use fully in each form and phase of mental disease, in each several temperament, diathesis, and age, would 1 Vide Araerimn Journal nf llie Mcdim.1 Sciences, April 1889. A paper by autlior. SUMMARY OF TEEATMENT OF IXSA>"ITY; 703, require a treatise, and our knowledge is not yet exact enougli to enable anyone to do so. Even fully to state the principles that shoiild guide us in their use, so far as I know them, and the risks to be guarded against, would take up much time. Nowadays most of us want to take our medical reading in a concentrated form. I have had much experience of their use and some proofs of their abuse. I have experimented carefully with many sedative and hypnotic drugs, but I find it very diffi- cult to condense my experience, and lay down such rules or jjrineiples of general application that would be of use to others. When one considers for a moment the conditions of giving hypnotics and sedatives, it is seen how complicated those con- ditions are. We are giving drugs to act primarily and chiefly on the functions of the cerebral cortex, that representation of all organs, that co-relator of all functions, that differentiator of all sensations, that only true originator of the higher activities, mental and bodily, and that most delicate and com- plex of organised structures in nature. It is the great inheritor, too, of hereditary qualities, good and bad, and the "seat" of mind. This governing organ, of such infinite delicacy, has gone wrong in some of its highest functions, and we send up to it, through the blood, coarse chemicals, or alter its blood supply, or affect its functions by reflex influences in order to set them right. In order to have most kinds of mental disease at all we commonly need bad conditions of living for many generations. The cortical protoplasm has become degenerate or disturbed through its bad heredity, and is unresistive to unphysiological conditions affecting the individual, who has probably for years lived under such evil conditions. The sins of ancestry and of self at last produce their natural fruit in an attack of what we call mental disease, but wluch would be better named cortical disease. "We then use powerful poisons in modified doses to arrest or modify cortical function. ^Vho can think that the evil conditions of generations and the unphysiological courses of half a lifetime will be counteracted by a few doses of drugs ? 704 SUMMARY OF TREATMENT OF INSANITY. For we must never forget in. the use of all hypnotic and seda- tive drugs whatsoever, that essentially they are cortical poisons and arresters of function when given in full doses. By experi- menting we have found out the doses that first stimulate and then half arrest function. But young medical men have to learn for themselves by experience the practical lesson that all neurotic medicines are in their full action poisons, before they realise the fact. We use their half effects to modify nervous energising in order that modification in one direction may arrest dangerous action in another, may stop dynamic ex- haustion, and encourage trophic repair, may so diminish undue reflex excitability in nervous centres that dangerous reaction, mental and bodily, shall not take place. Such good results we try to attain while we know that in most cases favourable conditions of life or the vis medieatrix really " cure " the disease. The mere statement of the problem shows its diffi- culties and its risks. I would lay it down as a principle that few cases of mental disease should be treated by hypnotics and sedatives alone. They may be nece.ssary in many cases as a part of the treat- ment, but there are always other indications which must be carried out to secure real and permanent recovery. To feed the patient, to restore his nervous and nutritive energy, to rest his brain in some cases, to restore to normal action every function that is abnormal, to direct his mental working into healthy channels, to exercise his muscles and lower centres so as to get physiological and safe outlets for spare energy, to improve his controlling powers, to restore his emotional faculties by getting him to feel natural pleasure and interest in something, to rouse his power of attention to healthy and safe objects, and by healthy and pleasant surroundings to make his environments healing — these must necessarily be our fi.rst considerations. The chief questions we should always put to ourselves when using hypnotics and sedatives, are — Are those drugs disorder- ing any other functions, while mitigating the wakefulness and SUMMARY OF TEEATMENT OF INSANITY. 705 restlessness ? Is tlie patient's mental state really improved througli tlie sleep and quiet produced 1 Is tlie natural ten- dency to recover in any way interfered with ? Does the patient gain or lose weight? — a most important test. If sleeplessness is the most urgent symptom, is the continued use of a hypnotic tending to restore the natural sleep habit or not ? How does the patient look as to expression of face and eye after the drug sleep we have been giving him 1 How does he feel in the morning — refreshed or otherwise 1 Is the use of our drug forming a bad brain habit that it will be difficult to overcome ? Is it causing a loss of the higher inhibitory power, while giving the patient present relief ? There are very many cases of mental disease in the incipient stage, where what is pleasant to the patient is not necessarily good for him. There are many others where wo require especially to strengthen his own volition to help his cure. An early case of melancholia that takes opium or chloral may get to like these drugs so well that he will not follow out the measures that will lead to his real and complete recovery. We need, before giving such drugs to any case, first to make up our minds from the symptoms present whether it is a pure hypnotic that is needed, or a general sedative, or a diminisher of reflex irritability, or a motor depressant, or a combination of these. Different cases have such totally different symptoms in mental disease, the same person is often variously affected by the same drug at different times and phases of his malady ; and the drug tolerance and idiosyncrasy are so different as between one person and another that we have much need to select our drugs carefully for the symptom and the patient to be treated. I would put paraldehyde and chloral as the types of pure hypnotics ; sulphonal as a hypnotic sedative ; the bromides and their combinations with cannabis indica and hyoscyamus as the types of the sedatives and diminishers of reflex irritability, cerebral and spinal; and liyoscine, as the type of drug that especially depresses the functions of the cortical motor centres. 2y 706 SUMMARY OF TREATMENT OF INSANITY. The effects we may legitimately aim at and hope for in the treatment of mental diseases by hypnotics and sedatives com- bined with other treatment are :— 1. To cut short a commen- cing attack of melancholia or mania in some cases. 2. To re-establish the sleep-habit of the brain. 3. To tide over short attacks that have a natural tendency to recover, through making the patient manageable by nurses in an ordinary private house. 4. To enable cases with severe attacks to be kept home long enough to satisfy patient's relatives that the attack is a " confirmed " one. 5. To give needed sleep and rest to relatives and nurses. 6. To combat temporarily dangerous symptoms. 7. To take the edge off the worst symptoms of cases who are being treated during a long attack, so letting other measures have full effect. 8. To subdue severe and exhaustive symptoms, and so save the patient s strength and life. 9. To satisfy and soothe the minds of such patients as will have some such drug. 10. To quiet screaming or noise for the sake of others. The most common case that has to be treated by the general practitioner of medicine is that of a man threatened with melancholia, who has the preliminary symptoms of sleep- lessness, depression of spirits, want of interest in anything, and irritability with fears and, perhaps, suspicions of all sorts — who has, in fact, the general symptoms of brain exhaustion. In addition to the rest, the exercise, the change, the fresh air, the fattening easily digested food, the tonics and nerve stimai- lants, and the walking we prescribe for such a case, we are justified, and frequently compelled, to try a hypnotic, if fresh air and fatigue, baths hot and cold, modified massage or warm bottles to abdomen do not restore the sleep. I am not in favour of opium for many such cases in however small doses, because my experience is that it diminishes the appetite, and the patient does not gain, but tends to lose in weight, while a liabit and a craving are apt to be set up. But competent and experienced physicians in Germany, France, and in this country use opium or morphia in small doses in such cases. SUMMARY OF TREATMENT OF INSANITY. 707 and commend it liiglily. They say it promotes the nutrition of the brain, soothes mental depression, and causes sleep. I have seen such effects in a few cases. Chloral I once believed in far more strongly than I do now. It is a drug, the prolonged use of which in some cases certainly tends toward thinness, toward a haggard look in the morning, and toward diminished mental inhibition, as shown by a habit and craving for its continued use. Combined with the bromides, in 15 or 20 grain doses, it is a good hypnotic for short periods, especially in alcoholism. Paraldehyde. — The drug I have used most extensively for the past nine years, and like far better than any other pure hypnotic I have ever tried, is paraldehyde. This is so valuable, so rehable, and so free from risks, near or remote, that I think it cannot be too widely known by the profession. It is mainly a pure hypnotic, though I have lately seen it recommended in small doses as a stimulant, and for the vomiting of pregnancy. It acts so quickly, that often the patient is sound asleep in five minutes after getting the dose. Out of hundreds of cases in which we have used it here it caused sickness in only a few, headache and disagreeable feelings iu a few, a general " discomfort " in one, or diarrhoea and sickness in a very few. It does not interfere with the appetite for food next morning, nor ordinarily disturb the stomach or bowels. After a paraldehyde sleep there is no headache, no lassitude, and several sane patients to whom I have given it have said that even the refreshed, comfortable feeling they have after natural sleep is present after it. That seems too good to be true in very many instances. I have no belief in any drug sleep being quite equal to natural sleep, in being "jSTature's sweet restorer.'' I am satisfied of this im- portant fact, however, in regard to paraldehyde, that while the first part of the sleep after a dose is drug sleep, this passes gradually into what is really natural slumber. In fact, it puts to sleep, and nature continues the slumber. Another fact of perhaps greater importance still is this, the use of paraldehyde 708 SUMMARY OF TKEATMENT 01' INSANITY. for a time will, in some cases, restore the sleep-habit of brain, and its use can then be discontinued readily, and with no felt want and craving by the patients. It is of no use, but the contrary, given through the day as a sedative. It seems to act on the very highest cortical cells, and not on the motor areas, cortical or basal. In cases of mania I often add a drachm of one of the bromides to the dose at bedtime, and in very acute and restless cases a drachm of "bromidia." It sometimes excites when given in too small doses. Its nauseous taste is the worst thing about it. It may be given l)er rectum, and acts well in this way. The proper dose of paraldehyde varies enormously according to the case. Generally I begin with 40 minims or a drachm, and go up to 2 drachms in ordinary cases. In very many cases of confirmed insomnia, in melancholia, and in acute mania, I have given 3 and even 4 drachms, and in one case 6 drachms. I had a general paralytic patient who took 4 drachms every night for a fortnight. A lesser dose did not cause sleep. Here we commonly give it mixed with tincture of quillaya and a few drops of chloric ether in cinnamon water or in capsules. Its bad taste cannot be quite got over, however, and patients always smell of it for twenty-four hours after the last dose. I do not know how much would be a poisonous dose, but a nurse by mistake once gave a patient of mine, a small-sized woman in weak health, an ounce, with' the result that she slept a stertorous sleep for twelve hours, the heart's action not being interfered with, nor the reflexes, but rousing and coffee on several occasions during the night only very par- tially brought her to consciousness while under its influence. She seemed none the worse afterwards. I have never seen paraldehyde afl'ect the heart's action in any way except to strengthen it shortly after being given. I look on ils action as being in some respects half-way between that of ether and alcohol, but with a far more decided hypnotic efi'cct than either. SUilMAEY OF TREATMENT OF INSANITY. 709 I liave had many cases in ■\vliicli its nightly use for periods of from one week to six has been followed at once, on its being stopped, by a restoration of the natural sleep-habit. The first case of that kind I had was a recent but very marked one of suicidal melancholia with restlessness in a woman at the climacteric, who, after its use for a month, at once began to sleep soundly for six hours every night, and soon made a complete recovery. The next, and the most remarkable I have yet met with, was one of suicidal melancholia with great impulsiveness, who had not slept naturally for more than an hour or two at a time for two years. As she required a special night attendant, I knew the facts accurately. She was put on paraldehyde in drachm doses every night. This dose needed to be doubled to get seven hours' sleep. This was continued every night for six weeks. She gained in weight, and took her food well during that time. It was then stopped, and the patient at once began to sleep naturally, has never needed a draught since for a period now of eighteen months, and very soon we were able to discontinue the special night attendant. Such a case makes a very deep impression on anyone who has the heavy responsibility of treating it. The result is in accordance with the physiology of the brain so far that we know that habits and "periodicities" are normal characteristics of its functions that can often be broken or restored by outward conditions, There are some cases of very acute mania and melancholia, and especially of the acute excitement of general paralysis, where half -ounce doses will not procure sleep, and I commonly do not push it beyond this. Sulphonal} — Next to paraldehyde, and many physicians would place it before that drug, comes sulphonal as a hypnotic. In addition to its sleep-producing effect, sulphonal acts very markedly as a sedative and motor-depressant, and can be 1 I have not had the same experience of ti-ional as of sulphonal, but their effects are very analogous, and in one or two cases trional seems to act as the better hypnotic. Its dose is about 15 grains. 710 SUMMAKY OF TEEATMEffT OF INSANITY. used during the day for those effects. Its action is entirely different in many ways from paraldehyde. It takes from an hour to two hours instead of five minutes to act. Its effects last often for two days and nights instead of one night. It often causes giddiness and unpleasant sensations in the morning. It should he used in doses of from 10 to 40 grains, with a very rare use of 60 grains. It should be given at least one hour before bedtime if used as a hypnotic. It is best given in hot milk, not being soluble to any extent. The kind of cases in which it acts best are those with some motor excitement, restlessness, noise, and general troublesome- ness of management. In the stage where the patient feels agitated and afraid of an acute attack coming on I have over and over again seen its use produce calm and comfort, apparently arresting the attack at an early stage. It acts admirably in small doses, say 1 5 grains twice a day, in senile restlessness and mild excitement. I have thus kept many such cases at home, soothing gently their downward path, who would have had to be sent to asylums. It acts well in simple mania with restlessness, but fails except with dangerous doses in very acute or delirious mania. In melancholia with agita- tion it subdues the motor symptoms, but leaves the patient usually more depressed in mind. It stupefies and bewilders such cases too much. In recurrent cases of mania and folie circulaire, and in chronic mania, its effects are admirable and often, as I have already pointed out, curative, or nearly so. It may be safely used in moderate doses in cases with organic brain disease. In the first stage of general paralysis, with intense maniacal excitement and impulsiveness, I have used it in large and repeated doses with the effects of immediate quietude and manageability, and after a few weeks of this, the patients were found to have passed out of the excited stage into that of the quiet of the second stage. Alcoholic insanity is often controlled and cured by the drug. I have referred (p. 247) to its remarkable effect in arresting the tendency to mania in folie circulaire. SUMMARY OF TREATMENT OF INSANITY. 711 The evil effects and dangers of siiphonal are its tendency to accumulate and cause a drowsy stuporose hebetude, with a collapsed appearance and weak pulse, resembling bromism, and in a very few cases to cause the very serious and danger- ous condition of hsematoporpliyrinuria. The urine ' becomes bright red, and the patient is found to be low, exhausted, sometimes paralysed, and often vomits. There is the utmost risk to life. "We as yet cannot tell why this condition should occur. It should always be kept in mind as a possible contin- gency. In moderate doses sulphonal does not depress the vaso- motor tone or the heart's force to any extent. Its use should always be intermitted for a day or two once a week. Fre- quently one dose every other night will produce sleep for two nights running. In mania one dose twice a week I have known to keep the patient manageable till the attack ended in its ordinary course. It does not excite a craving for its continuance, and it does not prolong the brain disturbance.^ The use of other mental and motor sedatives and depres- sants during the day in those forms of mental disease charac- terised by motor excitement is a still more difficult problem than the use of hypnotics at night. Such a use is far more liable to abuse, and is essentially more unphysiological. The temptation towards such a use, for present ends, is so great without reference to the " natural course " of the case toward recovery that we need to be very careful how we employ them. The former heroic doses of antimony, digitalis, and of opium, the prodigious douches of old, we have now almost absolutely discarded. We see plainly that the motor quiet thus obtained was not half-way to cure, but perhaps part way to death. The questions we ask now are. Can we conserve strength and pre- vent exhaustion and death through over-motor energy by the use of sedatives ? Can we take off the keen edge of the motor 1 Dr Oswald, Glasgow Medical Journal, Dec. 1894. ^ See two papers, one by Dr J. C. Mackenzie in the Journal of Mental Science for Jan. 1891, and the other by Dr Carlyle Johnstone in the same Journal for Jan. 1892. 712 SUMMARY 01? TREATMENT OF INSANITY. excitement, so that some patients can be made more manage- able, and be treated at home. Can we so diminish motor excitement that the patients can be safely taken out to walk and work, and so get rid of part of their spare energy in normal ways? Can we so diminish impulsiveness that danger to the patient and others may be lessened without interfering with recovery, or with health in incurable cases? Can we, during special paroxysms and bodily diseases, tem- porarily diminish motor action with safety ? If excessive motor energy is generated in the brain cortex, it is surely a reasonable hypothesis, that it should generally get its natural outlet in muscular action. But there are limits to all excesses of action. If antipyrin, on the whole, does harm in an ordi- nary case of pneumonia with a temperature of 103° and puts off recovery, it does not follow that it or a cold bath does not save a patient's life when the temperature is running above 10G°. Patients sometimes die of the exhaustion of over- motor excitement. How do we know in any such case that if over-exertion had been controlled by drugs or mechanical restraint for a few days, the crisis might not have passed in the ordinary " course of the case " ? There is, in my opinion, legitimate scope for the use of sedatives and motor depressants in mental diseases both from physiological and clinical data. Which are the best and safest measures and drugs to use 1 A categorical and uncon- ditioned answer cannot be given to this question. Of one thing I am quite sure from my experience : Do not use during the day a pure hypnotic like chloral or paraldehyde, either alone or in combination, as a sedative or motor depres- sant. That is the weak point of "bromidia." Another principle which I laid down twenty years ago I still adhere to — Use the bromides frequently in combination with nearly all sedatives and motor depressants. They make a lesser dose of the latter more equably and more safely effectual as compared with a large dose given alone. They prolong the sedative effect. They diminish motor reflex SUJIMAKY OF TREATMENT OF INSANITY. 713 excitability in the whole of tlie motor centres, and they may be said to strengthen tlio whole function of inhibition thereby. They are very safe and do not commonly tend to affect nutrition, but often the contrary. The Bromides and Cannabis Indiea. — The combination of the bromides with cannabis indiea, which I recommended in 1868,1 and have used continuously since, I still think one of tlie best sedatives, because it is mild in general effect, and does not affect the nutrition. Patients often gain in weight during its use, they can work and walk while under its in- fluence, and impulsiveness of all kinds is diminished by it. My original experiments, which were very carefully made, have been confirmed in the main by a very large subsequent clinical experience. Xot that all my hopes and expectations of twenty years ago in regard to the curative effects of this or any other sedative on cortical brain excitement have been realised. Few men have had to treat diseases for twenty years who are not at the end of the time more sceptical about drug treatment, and more inclined to trust to the ris medi- eafn'x under favourable conditions than they were at the beginning, on the whole. There are marked exceptions, no doubt, and the use of this combination as a sedative, motor depressant, and diminisher of reflex irritability in mildly maniacal cases, in certain cases of acute mania with hysterical symptoms and noise in women, in epileptic mania not of the unconscious delirious type, in chronic mania with paroxysms of exacerbation, in all cases of brain excitement with more or less regular periodicity of symptoms, and in many cases of suicidal melancholia characterised by motor excitement and homicidal violence — in all these I have used this combination, and found it an admirable sedative without disturbance of digestive functions and without loss of nutrition in a very large number of cases. I always weigh my patients while ^ ' ' The Action of Narcotic Medicines in Insanity, " being tlie Fotlier- gillian Prize Essay for 1872, by the author, Brit, ami Foreign Med. -Cliii: Scview for 1870 and 1871. 714 SUMMARY OF TKEATMENT OF INSANITY. tliey are taking any sedative or hypnotic drug, and if there is a continuous loss of body-weight I am inclined to stop the medicine and try how the case will run on without it. I commonly now begin with 10 minims of the tincture of cannabis and 30 grains of one of the bromides for a dose, rising to 45 minims of the former to a drachm of the latter. I commonly add some aromatic spirit of ammonia to the mixture as a cardiac stimulant, and also to keep the resin more in solution. The most alarming symptoms I have ever seen after its use in large doses resulted from the temporary failure of the heart's action in one ansemic case of chronic mania after a drachm dose of the tincture of cannabis with a drachm of bromide, and in another instance from a semi- comatose condition in a case of folie circulaire, during the excitement which I was attempting to " keep in check " by a continuous use of the mixture. In the former kind of case I now add some digitalis. In other cases, and for special indications, I am in the habit of adding the ammoniated tincture of valerian to the combination. This does specially well where there are hysterical symptoms. I sometimes add a little lupuline, hyoscyamus, or belladonna. The cannabis indica often increases the appetite and acts on the kidneys. The taste of this mixture is very bad, however, and we often have much difficulty with maniacal and sus- picious cases on this account. In some patients a few doses will be sufficient for the purpose we aim at, in other cases the drugs have to be given for weeks and even months. I have certainly kept many patients out of asylums by its use. When the excitement is very intense, and tending toward "dehrious mania," with dry tongue, sordes, and repugnance to food, then I cannot recommend this combination, nor indeed any other sedative, hypnotic, or narcotic drug. Nursing, stimulants, suitable feeding, tonics, and fresh air are in these circumstances alone to be relied on, if we wish our patients to have the best possible chance of recovery. In general paralysis and the excitement of organic brain disease I have often seen SU.MMAEY OF TREATMENT OF INSANITY. 715 tlie combination give great relief and quietude without any ill effect. The mental results were the following : There was less sudden impulsive action, the constant talking got less, the tendency to shouting was lessened or stopped, there was less resistiveness to control, there was a drowsy quietude induced. The emotional state was one of greater happiness, and intellec- tually there was less suspicion. In some cases hallucinations of hearing abated. In many cases walking and working could be engaged in. Inhibition was improved. The following symptoms should in my judgment make us hesitate to use the combination or stop its use, viz., a very weak, thready pulse, a very foul, creamy tongue increasing under the use of the drugs, a dry tongue and mouth, an increase of motor paralysis, a difficulty in equilibration and walking, a tendency to stupor, very cold extremities and pinched face, as if the general nervous and vital energy was very low and diminishing. Hyoscine. — If a pure motor depressant is indicated, there is no doubt that hyoscine is the best drug to get the effect of simple motor quietude. I have many cases of mania where the chief symptoms, and by far the most troublesome, are excessive restlessness, shouting, tearing, violence, and motor impulsiveness of all kinds. All the morbid energising of the cortex seems in such cases to be concentrated in the motor centres. Such patients are always troublesome, sometimes dangerous to others, and many of them tend to exhaust their strength to a dangerous extent. Now if any such case is in strong and vigorous general bodily health, and has a sound heart, hyoscine may be tried hypodermically in small doses of J^y gr. carefully watched, and going up to ^ gr. It is, so far as I have yet used it, a safe and a moderate depressant of voluntary motion, without narcosis or much mental confusion or drowsiness. So far as I have yet observed its effects, it is the best drug for this special effect. It has not in my cases affected the appetite, nor depressed the heart's action unduly. 716 SUMMARY OF TKEATMENT OF INSANITY. except in one case when -,\ gr. produced alarming stupor. I must say I have been afraid to push it in very restless and violent cases. Several strong persons of this kind labouring under acute mania resisted -^ gr., and I was afraid to push it further after my experience of hyosoyamine — an altogether dangerous drug. I should give it very guardedly indeed in general paralysis or in any case in which I suspected organic brain disease. The great facility of its hypodermic use makes it suitable for emergencies, and where the patient will not take a drug by the mouth. There are other drugs of this nature at our disposal. Chloral- amide, urethan, croton-chloral, monobromido of camphor and lupuline are all mild and useful hypnotics and sedatives. I shall conclude with a few principles of general application : 1. Make up your mind clearly from the symptoms present whether your patient needs a pure hypnotic, a general nervous sedative, or a simple motor depressant before you use any of these drugs. 2. Use all such drugs experimentally in each case at first, and watch their effects not only on the higher nervous functions, but on all the organs and their functions ; and on the general organism. 3. Even where there is sleep and quiet produced for the time with no apparently bad results, look to the general feeling of hien-etre, the recuperative energy, the expression of face and eyes after their use, and see if there is any undue reaction as if some energy that must have an " outlet " were merely being " suppressed '' for the time being. 4. Stop using such drugs as soon as possible, trying experi- mentally how the patient gets on without them. 5. Keep asking in every case- — " Are we sacrificing in any degree the highest function of mental inhibition by their use 1 " 6. Never omit general measures for the restoration of the health, nutrition, and higher nervous functions while you use such remedies. Keep weighing your patients regularly. 7. Paraldehyde is the purest and least harmful hypnotic SUMMAEY OF TEEATMEXT OF INSANITY. 717 yet introduced -when tlie insomnia is marked and intractable. Urethan and cliloralamide cannot compare with it. Opium and chloral have special dangers and disadvantages. 8. Sulplional and trional are safe and excellent hypnotics and sedatives as well as motor depressants. They seem to have a larger field of application than almost any of this class of drugs in mental disease. 9. Use the bromides as accentuators and prolongers of the effects of other drugs, and in order to be able to employ smaller doses than otherwise. 10. A combination of cannabis indica and the bromides is one of the most useful and least harmful of general sedatives. 11. Hyoscine is the best pure motor depressant, and its easy hypodermic use makes it very convenient where the patient refuses to take medicines by the mouth ; but it needs care. 12. 'We should never deeply narcotize an insane patient or one threatened with mental disease. 13. It is often as dangerous to use mere anodynes by the mouth or subcutaneously to relieve mental pain, as to subdue bodily pain by these means only, perhaps more so. 14. It is generaEy far better therapeutics to enable your patient to bear his mental pain and the effects of his insomnia by improving his general nervous tone and the nutrition of his brain and body, than merely to produce quiet and sleep by drugs. 15. It is commonly a safer thing for the patients, and tends more toward natural recovery from his disease, to provide a physiological outlet for morbid motor energy, than merely to depress it directly by drugs. 16. It is almost always preferable to treat cortical exhaus- tion, irritability, and undue reflex excitability by alternate rest and exercise, and by improving the fattening and nutri- tion of the body, than by continuous sedatives, the great exceptions being the treatment of epilepsy and convulsive affections by the bromides. 17. The use of a course of thyroid extract, given in 60 718 SUMMARY OF TREATMENT OF INSANITY, grain doses a day, to produce a sliort five or six days' fever, as recommended by Dr Lewis Bruce (see pp. 192, 294), is a most powerful therapeutic means in many cases. No case should be allowed to become incurable without a trial of this method. INDEX. Acute mania, 160. Acute dementia, 306, 321. Adolescence, psychology of, 590 ; insanity of, 696 ; mortality in, 609 ; recovery, signs of, in, 609 ; symptoms of, 606 ; treatment, 601 ; psychoses of, 609. Affections cooled by insanity, 167. Age at which insanity occurs, 211, and Plate V. Ague, insanity from, 653. Alcohol a cause of insanity, 481. Alcoholic insanity, 480 ; degenera- tion, 490. Alcoholism, acute, 482 ; chronic, 487. Alimentation psychologically con- sidered, 3. Alternating insanity, 219. Alternation in insanity, 240. Amenorrhoeal insanity, 522. Amentia, 10, 285. Amusement, 700. Ansmia in insanity of lactation, 563. Anaemic insanity, 650 ; brain, 506. Animal food : its effects on neurotic children, 216, 602. Animal impulse, 350. Aphasia and insanity, 425. Arnold, post-febrile insanity, 651. Arteries, lesions of, in brain syphUis, 469, and Plate VII. Asthma, insanity of, 661. Atkins, Dr, 667. Automatic Misery, 89. Baillarger first described circular insanity, 221. Ball, Prof. B., 198. Baths in melancholia, 132. Baths, hot, in mania, 176, 194 ; Turkish, in melancholia, 132. Beghie, Dr Warburton, 478, 660. Bell, Dr Luther, 172, 198. Belladonna as a, sleep producer, 218. Benedikt on the brains of criminals, 333. Bii-d, G., onoxaluria, 660. Blandford, Dr G. Fielding, 197, 401. Blistering in mania, 192. Boils in mania, 192. Brain, aufemic, 505, 650. Brain, functions of, as related to mental diseases, 13-20. Broadhurst, 464. Bromides in mania, 179; in circular insanity, 246 ; in epilepsy, 453, 457 ; as hypnotics, 218 ; as seda- tives, 713. Bright's disease, insanity in, 658. Brown, J. J., 87, 112 ; a new lesion in acute mania, 196, and Plate II. figs. 2, 4 ; on lesions in senile 720 INDEX. dementia, 645 ; on syphilitic arteries, 471. Brown, Dr R., 205. Bruce, Dr Lewis, 192, 294, 455. Bucknill and Tuke on post-febrile insanity, 653. Bucknill, Dr J. C, 197. Burton, 128. Buzzard, DrT., 464. Cadell, Dr, his case of syphilitic insanity, 466. Campbell, Dr J. A., cases of visceral melancholia, 60. Camphor as a sleep producer, 179, 218. Cat, maternal instinct in, 338. Cannabis Indioa in melancholia, 90, 133 ; in mania, 179 ; in alternat- ing insanity,246; a3sedative,713. Certificates of lunacy, 675 ; for Curator Bonis, 679. Certificates for treatment in private houses, 673. Certificates of sanity, 677. Chancery, affidavits for, 678. Children, insanity in sensitive, 31, 135, 139, 584. Chloral as a sleep producer, 218, 707 ; use and dangers of, in mania, 177 ; insanity from use of, 491. Chorea, its connection with rheu- matism, 494 ; delirium of, 502. Choreic insanity in early youth, 502 ; its epidemic forms, 503 ; prognosis, 502 ; treatment, 603. Christison, Sir R., 268. Chromatolysis, 20, and Plates XVI. , XVII., and XVIII. Circular insanity, 219 : causes of, 242 ; duration of, 226-236 ; fre- quency, 243 ; its nature, 221 ; pathology, 249 ; symptoms, 235 ; treatment, 245; termination, 244. Clark, Campbell, his case of hydro- cephalic idiocy, 304, 318, 371, 562 ; diabetic insanity, 668. Classification of insanity, 10-13. Climacteric insanity, 611 ; suicidal longings in, 614 ; pathological apiiearance in, 619; prognosis in, 620 ; statistics, 621 ; symptoms, 613. Climacteric, psychology of, 612. Climacteric in man, 617 ; in woman, 612. Communicated insanity, 375. Competitive examinations, mischief from, 135. Congestion of brain in acute mania, 195, and Plate IV. Conium in acute mania, 179. Connubial aftection altered in cli- macteric insanity, 614. Conscience a brain quality, 372. Consciousness lost in mania, 163 ; in epilepsy, 449 ; in stupor, 310. Convolutions, their structure and function, 14 ; supply of blood to, 5, 18. Convulsive melancholia, 96. Craving for stimulants in melan- cholia, 120. Cresswell, Sir Cresswell, 675. Cretinism, 305. Croom, Dr Halliday, on perversions of appetites during menstruation, 522, 523. Custards, 698. Curator Bonis, appointment of, 679. Cyanosis, insanity of, 661. De lunntico inquirendo, 678. Decoration, insane, 256. Deafmutism a hereditary neurosis, 306. Delirium in young children, 666. Delirium tremins, 22, 482. INDEX. 721 Delusions of melancholia, list of, 80 ; in idiots, 253. Delusions, sane and insane, 251 ; insane defined, 253 ; their legal importance, 274 ; should be tested, 23. Delusional mania, 198. Delusional melancholia, 57. Dementia, 280 ; its varieties, 285 ; alcoholic, 490 ; organic, 285, 420 ; primary, 297 ; secondary, 285 ; senile, 622 ; prognosis in, 290. Demonomania, 73. Denman, Lord, 680. Deprivation, idiocy by, 304 ; in- sanity by, 662. Desquamation, 119. Destructive impulse, 359. Diabetic insanity, 656. Diabolic possession, supiei'stitiou of, 72. Diathesis, the insane, 375 ; doc- trines of, 2. Diet. See Animal Food ; in melan- cholia, 127 ; in circular insanity, 245. Dietetic management of the nisus generativus, 541. Dipsomania, 361. Dissolution, 17. Dowse on prevalence of syphilis, 464, 465. Drummond, Dr, 405. Duncan, Dr Matthews, on fecundity, 590. Duret, 648. Education of girls, 581 ; of neurotic children, 688. Eggs in the treatment of acute mania, 182. Electricity in stupor, 293, 317 ; in detecting feigned insanity, 686 ; delusions of being tortured by, 71. Eliot, George, 593. Elkins, Dr F. A., 354, 655, 698. Enfeeblement, morbid, 280, Epileptic insanity, 435 ; counter irritations in, 455 ; hallucinations in, 447, 448 ; pathology, 445. 450 ; prevalence of, 456 ; religious emotionalism in, 440, 441 ; sui- cidal impulses in, 447 ; treatment of, 453. Epileptic, suicide of an, 449. Epileptics, criminal, 439. Epileptiform melancholia, 96 ; im- pulse, 350 ; convulsions in general paralysis, 394. Epilepsy, pathology of, 450 ; vacuo- lation of nucleus in, Plate IX., 451 ; compatible with sanity, 435 ; masked, 206, 43S. Eiiithelial granulations in ven- tricles, 411, and Plate II. fig. 3. Ergot in melancholic stupor, 317. Erotomania, 339. Evolution, 17. Esquirol's classification, 7, 161. Exaltation, physiological, 138. Examining patients, rules for, 20. Excited melancholia, 83. Expression of face in insanity, 78, 168. Falret on circular insanity, 221. Fattening an adolescent, 602. Feeding, forcible, 108, 698. Fears, morbid, SO, 266. Ferrier on brain localisation, 71, 165, 380. Flesh meat. See Animal Food. Folic a deux, 375. Folic a double forme, 219. Folic circulaire, 219 ; commence- ment of, 243 ; termination of, 243 ; treatment of, 245 ; pathology of, 249. Folic raisonnante, 159, 222. 2z 722 INDEX. Food, 698. Friends, Society of, insanity in, 600. GaiTod, Dr A. B., 505, 661. General paralysis, definition of, 380; developmental, 403 ; etiology and distribution, 405, 419 ; pathology, 406, and Plates I., II., VIII., XIII., XIV., and XV. ; stages of, 381 ; varieties, pathological, 390; varieties, sy mptomatological , 392; prevalence and ages, 419, and Plate V. ; its nature, 416., Goltz, Prof., 14. Gouty insanity, 504. Gowers, Dr W. R., 453. Greenlees, Dr T. D., 416. Gudden, Prof. V., 411. Gull, SirWm., 663. HiEmatoma auris, 96, 388, 597. Hiematoporphyrinuria, 178. Hallucination, a, defined, 165. Hemiplegia, 422 ; alternating, 86. Hereditary tendency, 3 ; of melan- cholic diathesis, 124. Heubner, 643. Hitzig, 165, 380. Home treatment expensive, 24 ; its advantages, 25. Homicidal mania, 207 ; melan- cholia, 103 ; impulse, 351. Howden. Dr J. C, 440. Howe, Dr, 304. Hutchinson, Jonathan, 464. Hygiene in neurotic children, 688. Hyoscyamus as a hypnotic, 217. Hyoscine, 133, 179, 715. Hyperkinesia, 329. Hypnotics in insanity, 177, 702. Hypnotism, 130. Hypochondria, 31. Hypochondriacal melancholia, 48. Hysterical insanity, 528 ; statistics of, 531. Hystero-epilepsy, 529. Idiocy, definition of, 297 ; by de- privation, 304 ; eclampsic, 301 epileptic, 302 ; geuetous, 300 hydrocephalic, 304 ; inflamma- tory, 303 ; microcephalic, 303 paralytic, 302 ; traumatic, 303 461. Illegitimacy a cause of puerperal insanity, 548. Illusion, an, defined, 165. Imbecility, 297 ; congenital, 298. Imperative Ideas, 375. Impulse, animal, 350 ; destructive, 359 ; homicidal, 351 ; insane, 329 ; suicidal, 356 ; uncontrol- lable, 329. Impulses, morbid, 341. Impulsive insanity, 329 ; a remark- able case of, 343. Incoherence in mania, 164, 166, and Plate III. Indecision, morbid, 39. Influenza, mental relationships of, 655. Inhibitory power defective, 331. Inhibitory insanity, 329. Inglis, T., on hystero-epilepsy with insanity, 529. Insane impulse, 329. Insanity of adolescence, 596 ; alco- holic, 480 ; amenorrhceal, 522 anemic, 650 ; of asthma, 661 of Bright's disease, 658 ; of car diac disease, 661 ; choreic, 494 circular, 219 ; climacteric, 611 of cyanosis, 661 ; by deprivation 662 ; diabetic, 656 ; epileptic, 435; ofexophthalmic goitre, 664 feigned, 686 ; gouty, 504 ; hys- terical, 528 ; inhibitory, 329 ; of lactation, 562 ; of lead poison- INDEX. 723 ing, 667 ; masturbation, 532 ; metastatic, 661 ; moral, 371 ; of myxoedema, 662 ; ovarian, 527 ; of oxaluria, 659 ; paralytic, 420 ; phthisical, 605 ; phosphaturia, 659 ; post-connubial, 667 ; post- febrile, 661 ; of pregnansy, 669 ; of puberty, 578 ; puerperal, 646 ; rheumatic, 494 ; senile, 622 ; syphilitic, 464 ; traumatic, 459. Insomnia, 702, 706. Ireland, "\V. \V., 277 ; on idiocy, 297, 300, 303. Initability defined, 336. Jackson, J. Hughlings, 17, 33, 206, 380 ; on syphilitic insanity, 464 ; epileptic insanity, 436. Jealousy, insane, 268. Jones, Dr Bence, 661. Johnstone, Dr Carlyle, 664, 711. Kahlbaum, 239. Kalmuck, 301. Katatonia, 239. Keith, Dr T., 602. Kleptomania, 11, 339, 368. Krafft-Ebing, Prof, 173, 198. Lactation, insanity of, 662 ; prog- nosis, 567 ; statistics of, 565 ; symptoms, 662 ; treatment, 665. Ladd, Prof., 17. Lancereaux, 465. Lawlessness, organic, 333. Laycock, T., on organic memory, 164 ; on the reflex function of the brain, 337 ; on general paralysis, 392. Laziness often a disease, 45. Lead poisoning, insanity of, 667. Lehmann, 661. Legal views about insanity, 680. Lewis, W. Bevan, 33, 123, 197, 401, 404, 412, 413, 414, 41,% 4.51, 466, 492, 606, 638, 642, 645. Locke, John, 255. Lycanthropia, 339. Maolaren, J., case of impulsive in- sanity, 343. Mackenzie, Dr J. C, 711. Macleod, Dr M., 562. Macphail, Dr, 286, 454. Macjiherson, Dr J., 274, 419. llajor, Dr H., on ssnile brains, 646. Jlania, 8, 137 ; a potu, 489 ; acute, 160 ; in children, 139 ; acute delirious, 163 ; chronic, 198 ; de- lusional, 198 ; emotional condi- tions, 212 ; ephemeral (transi- toria), 205 ; homicidal, 207 ; simple, 143 ; diagnosis, 272 ; definition of, 141 ; diet in, 174 ; first stage of, 161 ; second stage of, 163 ; pathology of chronic, 199 ; and Plate VIII. fig. 2 ; prevalence, 211, and PJate V. ; delusions in, 211 ; prognosis of, 212 ; terminations of, 214 ; pro- phylaxis in, 216 ; treatment of acute, 174, 180 ; caused by a new lesion, 196 ; and Plate II. fig. 2 ; periodic, 219 ; recurrent, 219. ilaniage in circular insanity, 245 ; in masturbational insanity, 542 ; with neurotic persons, 687. Mansfield, Lord, 680. Massage, 44. Masturbation, insanity of, 532 ; bodily signs in, 636 ; bromides in, 540 ; selflearned, 539 ; treat- ment of, 540 ; statistics of, 542. Maudsley, Dr H,, 278, 375, 502, 509, 663. Mechanical restraint in mania, 171. Medico-legal duties of medical men in mental diseases, 669. (24 INDEX. Megalomania, 119, 254. llelancholia, its definition and nature, 31 ; in children, 666 ; convulsive, 96 ; delusional, 57 ; epileptiform, 96 ; excited, 83 ; homicidal, 103; hypochondriacal, 48 ; organic, 99 ; resistive, 91 ; simple, 34 ; suicidal, 103 ; causa- tion of, 123 ; bodily symptoms of, 121 ; prognosis of, 48, 124 ; pro- ])hylaxi3, 134 ; delusions in, 80 ; religious, 73 ; termination of, 125 ; inception of, 119 ; preval- ence and ages, 121, and Plate V. ; lesions in brain in, 62, 70, 102, and Plate II. fig. 1 ; hereditary predisposition in, 123 ; treat- ment of, 126, 293. Melancholic diathesis, 30 ; persons, 29. Jlelancholy r. Melancholia, 31. Melancholy hereditary, 30. Memory, morbid, 1S5 ; in acute mania, 163, Mendel, Prof., 411. Menstruation, 75 ; insanity from suspended, 526 ; in acute mania, 190 ; psychology of, 522. Mental conditions liable to be mis- taken for insanity, 22. Merson, Dr, 622. Metastatic insanity, 661. Meynert, 83, 121, 411. Mickle, DrJ., 132, 411. Middlemass, Dr J., 389, 399, 407, 412, 452. Mierzejewski, 414. Milk in melancholia, 128 ; in acute mania, 174 ; in adolescent in- sanity, 602. Moncreiff, Lord, 680. Monomania (mono-psychosis), 8, 11, 251 ; of grandeur, 254; of sus- ])icion, 265 ; of unseen agency, 261 ; diagnosis of, 272 ; origin of, 273 ; prognoisis, 275 ; prophylaxis, 276 ; treatment, 275. Moral insanity, 371 ; Prichard's, 145, 222. Moreau de Tours on human de- generation, 481. Morel, 12, 206, 341, 375, 481, 508. Morselli on suicide, 104, 107. Motor depressants, 702. Mouth-openers, 109. Myxredema, 662. Narcotics, in melancholia, 132 ; in mania, 177. Necrophilism, 339. Neuralgia analogous to melancholia, 8. Neurasthenia, 44. Neurosis, insane, 11. Newington, Hayes, on alternating hemiplegia, 87 ; anergic stupor, 310 ; mania ii potu, 490 ; syphilo- matous insanity, 469. Nitrite of amyl in mania, 179. Nothnagel, Prof., 14. Nymjiliomania, 339. Obstinacy, morbid, in melancholia, 91. Old maid's insanity, 527. Opium tiselessin melancholia, 132 ; and in mania, 177 ; useful against sleeplessness, 218, 706. Organic dementia, 420. Organic melancholia, 99. Oswald, Dr, 711. Ovarian insanity, 527. Oxaluria, insanity of, 659. Paraldehyde, 133, 707. Paralysis. See General Paralysis. Paralysis of energy, 42 ; of feeling, 44. Paralytic insanity, 420 ; analogies, 423 ; causes, 422 ; congestive and INDEX. 725 epileptiform attacks in, 424 ; pathology of, 433 ; statistics, 432 ; symptoms, i?A. Paranoia, 159, 277, 378. Pathology of visceral melancholia, 60, 71, and Plate II. fig. 1 ; of acute mania, 195, and Plates XVI. figs. 3 and 4, XVII. figs. 1 and 2, XVIII. fig. 2, XIX. figs. 1 and 2 ; of excited melancholia, Plate XVII. fig. 3; Folic cir- culaire, 249, and Plate VI. ; general paralysis, 406, and Plates I. fig. 3; VIII., XIII., XIV., XV.,andXVII.fig.4; ofsyphilitic insanity, 470, and Plate VII.; of cells. Plates I. fig. 1 ; VIII., IX., XIII., and XV. figs. 6 to 10 ; of vessels. Plates II. fig. 4 ; VIII. fig. 1 ; IX., XIV., and XV. figs. 1 to 5 ; of neuroglia. Plates VIII. fig. 1, and XIV. fig. 2 ; of pia mater, Plate XIV. fig. 1 ; of epithelium, Plate II. fig. 3 ; of skull-cap, Plate VI. Periodicity in mental diseases, 221. Philipps, Dr Rees, 177. Phosphates in melancholia, 127. Phosphaturia, insanity of, 659. Phosphorus in mental depression, 127. Phthisica spes, 508. Plithisical insanity, 505 ; pathology of, 514, 516 ; prognosis, 519 ; statistics, 519 ; symptoms, 510. Phthisis common among the in- sane, 507 ; mental condition, 518. Pia mater adherent in general paralysis, 409, and Plate I. Pinel, 7. Planomania, 339. Podagrous insanity. See Gouty in- sanity. Post-connuhial insanity, 667. ^JPost-fehrile insanity, 651. Pregnancy, insanity of, 569 ; char- acter of, 569-572 ; prognosis, 673 ; suicidal tendency in, 573 ; statis- tics of, 573. Pregnancy, , its psychology, 569 ; suicidal tendency in, 573. Prichard's moral insanity, 145, 222. Primare Verriicktheit, 159, 378. Prout, Dr, 660. [See Oxaluria.) Psychalgia, 8, 10. Psychlampsia, 10, 137. Psyohocoma, 9, 11, 306. Psychokinesia, 10, 11, 329 ; general, 342. Psychology of menstruation, 522 ; of adolescence, 590 ; of the clim- acteric, 612 ; of old age, 623. Psych oneurosis, 10. Psychoparesis, 9, 11, 280. Psychorhythm, 8, 11, 219. Puberty, the period of, 578 ; in- sanity of, 578, 587. Puerperal insanity defined, 545 ; frequency, 555 ; heredity in, 656 ; pathology of, 564 ; prognosis in, 559, 560 ; statistics, 555 ; symp- toms, 546. Pulse in melancholia, 122. Pyromania, 339, Quinine in melancholia, 127, 293, 555. Rayner on the insanity of lead poisoning, 667. Reade, 464. Reasoning insanity, 222. Relapses in insanity, 219. Religious melancholia, 73. Reproduction psychologically con- sidered, 4, 681. Resistive melancholia, 91. Responsibility, legal, 335. Rest, 699. Reversion, 17. 726 INDEX. Restraint in mania, 171. Rheumatic insanity, 491. Robertson, A., on the insanity of lead poisoning, 667. Robertson, Dr G. M., 130, 141, 212. Robertson, DrW. f., 389, 407, 452. Romanes, Prof. G. .L, 17. Ronaldson, Dr Bruce, 539. Satyriasis, 339. Savage, Dr G. II., 197, 198, 290, 406, 667. Schroeder, Van der Kollc, 12, 451, 507. Sedatives, 702. Self-control, sane lack of, 331. Senile insanity, 622 ; statistics of, 625 ; hallucinations of healing in, 638 ; motor restlessness, 627 ; pathology of, 641 ; prognosis in, 640 : treatment, 647. Senility, psychology of, 623, Sensibility diminished in mania, 170. Septic inflammations in mania, 192, Septicaemia, and puerperal insanity, . 555. Shaw, Dr Clay, 409, 419. Shower baths, 293. Skae, C. II., case of trephining, 275, 461. Skae, Dr, his classification, 12, 435, 627, 531, 651. Smith, Willie, the homicide, 208. Somnambulism, 667. Spencer, Herbert, 17, 33. Spider-cell, 413. Stephen, Mr .Tustice, 680. Stewart, H. G., on monomania of unseen agency, 262 ; on delu- sional syphilitic insanity, 468, Stewart, Sir T. G., on insanity from Bright's disease, 658. Stimulants in melancholia, 128. Strychnine in mania, 180 ; in melan- cholia, 127 ; in threatened demen- tia, 293, 699. Study of mental diseases, 13-25. Stupor defined, 306 ; varieties of, 310 ; anergic, 821 ; epileptic, 326 ; melancholic, 81 1 ; para- lytic, 326 ; suggestion, 68, 130 ; sudden change of mind, 241; secondary, 325 ; causation of, 326 ; prognosis in, 327 ; treat- ment of, 328 ; jiathology of, 327. Suicidal melancholia, 103 ; impulse, 351 ; frequency of, 113. Suicide, case of, 307 ; a determined, 110 ; in an epileptic, 449 ; letter of a, 109 ; modes of committing, 107 ; watchfulness against, 112. Sully, J., 165. Sulijhoiial, 1.33, 178, 247, 709. Suspicion, monomania of, 265. Sunstroke, a cause of insanity, 459. Sydenham on insanity from gout, 504 ; from ague, 653. Symc, Prof., 443. Symptomatological classification, 10. Syphilis, its prevalence, 465. Syphilitic insanity, 464; delusional, 468 ; secondary, 466 ; syphilo- matous, 469, 475 ; vascular, 469 ; cephalalgia in, 478 ; pathology of, 470, 476 ; prognosis of, 480 ; treatment of, 478. Symmetrical lesions in brain, 477. Temperaments, doctrine of, 2 ; san- guine, 138. Temperature in insanity, 21 ; in mania, 148, 170 ; in children, 139 ; in puerperal insanity, 657. Tests of insanity made by lawyers, 680. Thyroid feeding, 192, 294, 064. Tracey, Judge, 680. Traumatic insanity, 459 ; idiocy. INDEX. 727 461 ; trepliiniug in, 460 ; preva- lence of, 46'2. Travel, 52, 129. Treatment, 693. Trional, 709. Tuezek, Prof., 413. Tuke, Dr D. Hack, 19", 308, 653. Take, Dr J. Batty, 304, 409, 411, 419, 561, 566. Tumours of brain and insanity, 427. Turner, Dr John, 169. Twins with hereditary neurosis, 216 ; with general paralysis, 406. Typhomania, 19S. Uncontrollable impulse, 329. Yacuolation of nucleus in epilepsy, 451, and Plate IX. Vaso-motor spasm, 103. Verrltcktheit, primiire, 159, 378. Visceral melancholia, 60 ; pathol- ogy of, 61, 71, and Plate II, fig.l. Voisin, Dr A., 411. Volitional insanity, 329. ^Valler, 643. Wallis, Dr J. A., 455. Wiglesworth, Dr J., 328, 562. Wilks on insanity from Bright's disease, 658 ; on syphilitic affec- tions, 465. Will-making, 683. Wilson, Dr G. R., 405, 587. Yellowlees, Dr D., 108 ; his case of homicidal mania, 208 ; his case of somnambulism, 668. NEILL ASl) COMPANY, LTD., PRINTERS, EMSEUEGH. PLATE 11. Five microscopic drawings. Fig. 1. Cells of semilunar abdominal ganglion of a very bad case of visceral melancholia, in a condition of atrophy, degeneration, and pigmentation. This patient had intense delusions that she had no stomach, and that her bowels were never moved. She had no appetite, she obstinately refused food, and died of exhaustion, though regularly fed with the stomach pump. Fig. 2. Shows a new lesion of the brain discovered by Dt J. J. Brown, in a case of acute mania in the Royal Edinburgh Asylum in 1877. This is a section from a convolution, showing its free surface at upper part of section, from which the pia mater had been re- moved, and in the part of grey substance drawn an enormous deposit of a new substance, taking up most of its middle layers. It appeared in masses, in smaller nuclei-like bodies, and also round the vessels. The larger cells seen in the inner layers of the grey sub- stance were somewhat degenerated and atrophied, their processes having disappeared. Fig. 3. An epithelial granulation, from, the floor of the fourth ventricle of a case of advanced general paralysis, showing enor- mous proliferation of the epithelial cells. There is one, or, at the most, two normal layers of delicate epithelial cells in this position ; but as seen in the section they have increased greatly, and have altered in appearance. At the summit of the granulation they are round, at its base flattened, while under it we observe a sclerosed layer of nervous tissue, with the neuroglia enormously increased in volume. Fig. 4 A small artery in the brain with all its coats enormously thickened, separated from each other, and its lumen almost obliter- ated, as found in some cases of syphilitic insanity, senile insanity, and other forms (after Dr J. J. Brown). Fig. 5. A portion of starved and atrophied brain substance, from a convolution of a case of senile insanity. The whole substance is loose, recticulated, and almost destitute of brain-cells in upper part of section, with only the packing tissues and vessels left. p. 729 PLATE II. PLATK III. Facsimile of a letter wi-itten by a mrjiiacal patient, showing in- coherence, rapid change of ideas, delusions, baUiicinations of sight, an insane aiiaociation of ideas, and an insane symboiism. PLATE IV. The appearance of a section of the anterior lobe of the brain in a patient who had died of the exhaustion of acute mania. It shows — a. The congested grey substance of the convolutions. b. Congested white substance near grey matter. c. An inner ring of still more intense congestion along the line of junction of the grey and white substances, and extending into the white substance. d. Limited vasomotor areas of congestion in the white substance. This is a type of the irregular vascularity seen in the brain very commonly in acute insanity, indicating probably during life a dis- turbed vaso-motor condition, which is a necessary accompaniment, and probably the effect of the cell disturbance. p. lil PLATE IV. *" PLATE V. A chart showing the relative prevalence of Melancholia (thin line), Mania (thick line), and General Paralysis (dotted line) in the Royal Edinburgh Asylam, and the age at which those three con- ditions are most prevalent. The numbers per 1000 of the total admissions run along the sides, and the ages along the top and bottom of the chart. It is seen that most cases of melancholia occur between 35 and 40, while the highest number suffering from mania occurred between 20 and 23. The melancholic line keeps high all through the end of life. General paralysis is scarcely found at all before 25, reaches its acme between 40 and 45, and is scarcely found at all after 57. While maniacal conditions rise highest as adolescence is completed between 20 and 25, they rise very high again at the period when melancholic conditions prevail most, between 35 and 40 ; that is when the mental and moral causes of insanity are most prevalent, when the business troubles, domestic worries, the afflic- tions, and the keen competitions of life are most common or most keenly felt. p. 732 PLATE V. C HART Showing the numbers per 1000 of To-fal admissions, and the A^es of 996 cases of Mania, 535cases of Melancholia, and 104 cases of General Paralysis, making together 1635 cases of the 1778 Total cases admitted into the Royal Edinburgh II A syl urn in Five y ears. /0-/S li-lO 10-2S iS-30 30-li 36-40 •«-« 46-60 soss BS-eo eo-e6 SS-70 70-75 76-80 80-86 8S-3Q *C£S\ ISO m ISO m ^ A DO / k V \\ / \ 110 m 90 80 70 60 so 40 30 20 W a \ ' N \ BO 70 60 so 40 30 \ A \ /' \, \ J \ \ ^ \ r "^ \, \ \ \ / V \ / 1 \ \ S. 7 s; \ w I / \ \ \ J ■■-'■ / '■■■■■- *-. v_ K- ^ 10-15 /S-^ff 20-25 25-30 30-35 35-40 ^0-45 "hd-SO 50-55 55-60 60-65 65-70 70-75 75-m eo-8s ss-ao Mania Melancholia. General Paralysis. PLATE VI. Great thickening of skull-cap anteriorly, with enormous deposits of new osseous tissue in an irregularly modulated way on the inner table of skull, in a case of alternating insanity of over twenty years' duration. This seems to be an aggravated example and type of what is almost universal in chronic insanity with periods of excitement. It is a proof of the structural effects of such repeated congestions of the branches of the carotid artery, even in the hardest tissue, and may be fairly considered to be of the same nature as the brain changes in the same cases, which are not so evident, but are no doubt far more important. The atrophy of the anterior lobes of the brain that usually accompanies such bony thickenings and deposits probably helps their growth, ihey being thus "compen- satory " to some extent, like the increased cerebro-spinal fluid. p. 733 PLATE VI. ^*f^ It - % -^^. / $\!^ir4li^ y'i<; G W»riK5TON«SON PLATE XV. Fig. I. Normal capillaries of human cerebral cortex. Sevan Lewis's fresh method, x 500. Fig. 2. Capillaries of cerebral cortex from a case of advanced general paralysis, showing marked thickening and granularity, and increase in number of nuclei. Bevan Lewis's fresh method, x 500. Fig. 3. Normal arteriole of human cerebral cortex. Bevan Lewis's fresh method, x 300. Fig. 4. Cerebral arteriole from a. case of advanced general paralysis, showing dense aggregation of round cells nj>on its walls, and the processes of hypertrophied spider cells attached to it. Bevan Lewis's fresh method, x 300. Fig. 5. Cerebral arteriole from a case of alcoholic insanity, show- ing general fibrous thickening and localised cellular aggregations. Bevan Lewis's fresh method, x 300. Fig. 6. Normal small pyramidal nerve-cells of third layer of cerebral cortex of child. Bevan Lewis's fresh method, x 500. Fig. 7. Nerve-cells of cerebral cortex of full-time foetus. Bevan Lewis's fresh method, x 500. Fig. 8. Nerve-cells of third layer of cerebral cortex, from a case of epileptic idiocy. [Patient aged 24.] Bevan Lewis's fresh method. X 500. The nerve-cells closely resemble those of the foetus, the only difference being that they show a degree of granular change in their protoplasm. A comparison of these two specimens (7 and 8) is most instructive as showing one stage in normal brain cell development in Fig. 7, and morbidly arrested development in Fig. 8 ; each corresponding to the respective mental developments of the individuals from whose brains they were taken. Fig. 9. Large pyramidal nerve-cells of frontal cortex, from a case of senile insanity in a patient aged 85. Bevan Lewis's fresh method. X 500. They show advanced pigmentary degeneration, with loss of many of their processes. Fig. 10. Large pyramidal nerve-cells of frontal cortex, from a case of secondary dementia. Patient had an attack of mania at the age of 21, which was not recovered from. He died at the age of 32, from phthisis. Bevan Lewis's fresh method, x 500. The nerve-cells show marked granular change in their protoplasm, and many of their processes, more especially the apical, are stunted. p. 742 PLATE XV. « -* Flg.e i ¥ A. k Rg. 7 A 4 ^ ^^. ^ j'l^. 7(2 G.W«re»STO~iSo PLATE XVI. The drawiugs in this and the following three plates were made from pre- parations stained by the methyl violet method of Dr W. F. Robertson, Path- ologist to the Scottish Asylums, formerly Pathologist to the Royal Edinburgh Asylum, after fixation of the tissues in Heidenhain's sublimate solution, and are intended to show the state of the-chromatic elements in the cells of the brain cortex in health and in mental disease. Pig. 1. Small pyramidal nerve-cell of cerebral cortex of a healthy young man who died suddenly while undergoing a small surgical operation, x 700. Observe the deeply stained Nissl bodies, or chromatic elements, in the protoplasm. They are here less distinct than in Pig. 2, owing chiefly to the circumstance that the tissues had undergone slight post mortem change, which causes some blurring of the sharp outline presented by these bodies in preparations from a perfectly healthy brain. The diffuse staining of the nucleus is to be attributed to the same cause. A normal cortical nerve-cell unaffected by cadaveric changes is shown in the next figure. A cell such as this, however, is a more useful standard for comparison with those in tissues from the insane, as it is rare that these can be obtained prior to the occurrence of a considerable amount oipost mortem, change. Fig. 2. Large pyramidal nerve-cell of cerebral cortex from a case of recurrent mania, showing normal Nissl bodies and nucleus, x 700. Note that the axis-cylinder process given off at the base is devoid of Nissl bodies. A minority of the cortical nerve-cells in sections from this case, the tissues from which were obtained in a very fresh condition, presented a perfectly healthy appearance. The majority, of which examples are shown in Figs. 3, 4, and Fig 1 in Plate XVII., were more or less markedly affected by ohromatolysis. The patient was a woman who for seven years had been subject to attacks of very acute mania, occurring every two or three months, with intervals of comparative sanity. Fig. 3. Large pyramidal nerve-cell of cerebral cortex from same case as Fig. 2, showing an early stage of ohromatolysis. x 700. Ohromato- lysis consists essentially in a process of fragmentation of the Nissl bodies. They break down into fine granules, show a decreasing affinity for basic dyes, and in very advanced stages entirely disappear. This process may affect the whole cell simultaneously, but more generally it begins in a special part of the cell and gradually extends. Frequently the part first affected is, as in this cell, the neighbourhood of the .spot from which the axis-cylinder process is given off. At a later stage the nucleus becomes involved by the morbid change, showing disintegration of its chromatin threads, and often shrinkage and displacement to the periphery of the cell-body. Ohromatolysis has been observed to follow a large number of different experimental lesions upon lower animals, such as section of nerves, various forms of poisoning, death from inanition and from want of sleep, as well as to occur in various diseases such as peripheral neuritis (in the cells of the anterior horns of the spinal cord). Its occurrence in general paralysis, acute mania, acute melancholia, and other forms of mental disease has now been described by many observers. Fig. 4. Large pyramidal nerve-cell of cerebral cortex from same case as Figs. 2 and 3, showing an advanced stage of ohromatolysis. x 700. p. 743 PLATE XVI. Fuj. J ''"\ Ji J ■¥ I Fi^. 4- G.W.TEBSTO-SSONS, PLATE XVII. Fig. 1. Large pyramidal nerve-cell of cerebral cortex from same case as Figs. 2, 3, and 4 in Plate XVI., showing more advanced chromatolysis. x 700. Fig. 2. Pyramidal nerve-cell of cerebral cortex from a case of acute delirious mania with death from exhaustion, showing advanced chromatolysis. x 700. About 50 per cent, of the cortical nerve- cells in this case showed distinct chromatolysis. Fig. 3. Pyramidal nerve-cell of cerebral cortex from an acute case of excited melancholia, showing advanced chromatolysis. X 700. From 30 to 40 per cent, of the cortical nerve-cells were found to be affected in this case. Fig. 4. Pyramidal nerve-cell of cerebral cortex from a case of early general paralysis, showing advanced chromatolysis. /^ 700. Note the displacement of the nucleus to the periphery. Only from 10 to 20 per cent, of the cortical nerve-cells showed distinct chrom- atolysis in this case, but a very large number of those affected presented the change in an advanced form. PLATE XVIII. The drawings in this and Plate XIX. were made from sections prepared by the Cox-Mirto modification of Golgi's method, and are intended to show the state of the neuron of brainr-cortex in health, and in mental disease as demonstrated by this method. Fig. 1. Small pyramidal nerve-cell of normal human cerebral cortex. X 250. a. Protoplasmic processes or dendrites. Note the gemmulse or thorns. 6. Axis-cylinder process or neuraxon. Note that it is devoid of gemmulse. c. Collateral with branches. Fig. 2. Axis-cylinder process of pyramidal nerve-cell of cerebral cortex from a, case of acute mania, with death from exhaustion. X 250. Shows varicose hypertrophy. A large proportion of the axis-cylinder processes of the cortical nerve-cells in this case presented this change. Varicose hypertrophy of the axis-cylinder process and varicose atrophy of the protoplasmic processes are found in much the same classes of cases as those in which ohromatolysis occurs. They represent by another method what is essentially the same morbid orange as chromatolysis in a somewhat advanced stage. p. 745 PLATE XVIII. Ftg. 2. PLATE XIX. Fig. 1. Pyramidal nerve-cell from a case of acute mania with death from exhaustion, x 250. Shows varicose atrophy affecting chiefly the apical dendrites. The majority of the cells were more or less affected by this change. Fig. 2. Pyramidal nerve-cell of cerebral cortex from same case as Fig. I. X 250. Shows a, more advanced stage of varicose atrophy. p. 746 PLATE XIX. ■<^- ..K ^^^ ^ No. 2a. London, 7, Great Marlborough Street, September, 1899. A SELECTION FROM J, X H. GHURGHILL'8 GHTSLOGUE, COMPRISING MOST OF THE RECENT WORKS PUBLISHED BY THEM. N.B. — ■/. &■ A. 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