Chapter XXI: Act 1837: (In re Blewitt, 1880, 5 P.D. 116) (6)

(b) When we turn, however, to the potentiality of infection by
micro-organisms introduced from without into the system we are upon
surer if not upon entirely definite ground. A special form of insanity
called by Weber, who first described it, the delirium of collapse, was
observed by him to follow certain infectious diseases such as typhus
fever and pneumonia. In later years it has been frequently observed to
follow attacks of influenza. Recently our views have broadened and we
find that the delirium of collapse is an acute, confusional insanity
which may arise without any previous febrile symptoms, and is in fact
one of the common forms of acute insanity. The nature of the physical
symptoms, the mental confusion and hallucinations which accompany it,
as well as the fact that it frequently follows some other infective
disease, leave no doubt as to its toxic origin. A similar and
analogous condition is presented by incidence of general paralysis
after a previous syphilitic infection. The symptoms of general
paralysis coupled with the extensive and rapid degeneration of not
only the nervous but of the whole of the body tissues point to a
microbic disease of intense virulence which, though probably not
syphilitic, is yet induced, and enhanced in its action by the previous
devitalizing action of the syphilitic toxin. There is abundant
evidence to show that emotions which powerfully affect the mind, if
long continued, conduce towards a condition of metabolic change, which
in its turn deleteriously affects the nervous system, and which may
terminate in inducing a true toxic insanity.

One of the best examples of insanity arising from micro-organisms is
that form which occurs after childbirth, and which is known as
puerperal mania. Other insanities may, it is true, arise at this
period, but those which occur within the first fourteen days after
parturition are generally of infective origin. The confusional nature
of the mental symptoms, the delirium and the physical symptoms are
sufficient indications of the analogy of this form of mental
aberration with such other toxic forms of insanity as we find arising
from septic wounds and which sometimes accompany the early toxic
stages of virulent infectious diseases such as typhus, diphtheria or
malignant scarlet fever.

The infective origin of puerperal mania is undoubted, though, as yet,
no special pathogenic organism has been isolated. Dr Douglas (_Ed.
Med. Journ._, 1897, i. 413) found the staphylococcus pyogenes aureus
present in the blood in one case; Jackman (quoted _loc. cit._) found
the micrococcus pneumonial crouposae in one case; while Haultain (_Ed.
Med. Journ._, 1897, ii. 131) found only the bacillus coli communis in
the blood and secretions of several cases. From our experience of
similar mental and physical symptoms produced as a result of septic
wounds or which succeed surgical operations there seems to be no doubt
that several forms of micrococci or streptococci of a virulent
character are capable by means of the toxins they exude of causing
acute delirium or mania of a confusional clinical type when introduced
into the body.

(c) Accidental and voluntary poisonings of the system which result in
insanity are illustrated by the forms of insanity which follow
phosphorus or lead poisoning and by Pellagra. The voluntary
intoxication of the system by such drugs as morphia and alcohol will
be treated of below.

2 and 3. Mechanical injuries to the brain arise from direct violence
to the skull, from apoplectic hemorrhage or embolism, or from rapidly
growing tumours, or from arterial degeneration.

Forms of Insanity.

The forms of insanity may be divided into (I.) Congenital Mental Defect and (II.) Acquired Insanity.

I. _Congenital Mental Defect._--The morbid mental conditions which fall to be considered under this head are _Idiocy_ (with its modification, Imbecility) and _Cretinism_ (q.v.).

Idiocy.

IDIOCY (from Gr. [Greek: idiôtês], in its secondary meaning of a deprived person). In treating of idiocy it must be carefully borne in mind that we are dealing with mental phenomena dissociated for the most part from active bodily disease, and that, in whatever degree it may exist, we have to deal with a brain condition fixed by the pathological circumstances under which its possessor came into the world or by such as had been present before full cerebral activity could be developed, and the symptoms of which are not dependent on the intervention of any subsequent morbid process. From the earliest ages the term _Amentia_ has been applied to this condition, in contradistinction to _Dementia_, the mental weakness following on acquired insanity.

The causes of congenital idiocy may be divided into four classes: (1) hereditary predisposition, (2) constitutional conditions of one or both parents affecting the constitution of the infant, (3) injuries of the infant prior to or at birth, and (4) injuries or diseases affecting the infant head during infancy. All these classes of causes may act in two directions: they may produce either non-development or abnormal development of the cranial bones as evidenced by microcephalism, or by deformity of the head; or they may induce a more subtle morbid condition of the constituent elements of the brain. As a rule, the pathological process is more easily traceable in the case of the last three classes than in the first. For instance, in the case of constitutional conditions of the parents we may have a history of syphilis, a disease which often leaves its traces on the bones of the skull; and in the third case congenital malformation of the brain may be produced by mechanical causes acting on the child in utero, such as an attempt to procure abortion, or deformities of the maternal pelvis rendering labour difficult and instrumental interference necessary. In such cases the bones of the skull may be injured; it is only fair, however, to say that more brains are saved than injured by instrumental interference. With regard to the fourth class, it is evident that the term congenital is not strictly applicable; but, as the period of life implicated is that prior to the potentiality of the manifestation of the intellectual powers, and as the result is identical with that of the other classes of causes, it is warrantable to connect it with them, on pathological principles more than as a mere matter of convenience.

Dr Ireland, in his work _On Idiocy and Imbecility_ (1877), classifies idiots from the standpoint of pathology as follows: (1) Genetous idiocy: in this form, which he holds to be complete before birth, he believes the presumption of heredity to be stronger than in other forms; the vitality of the general system is stated to be lower than normal; the palate is arched and narrow, the teeth misshapen, irregular and prone to decay and the patient dwarfish in appearance; the head is generally unsymmetrical and the commissures occasionally atrophied; (2) Microcephalic idiocy, a term which explains itself; (3) Eclampsic idiocy, due to the effects of infantile convulsions; (4) Epileptic idiocy; (5) Hydrocephalic idiocy, a term which explains itself; (6) Paralytic idiocy, a rare form, due to the brain injury causing the paralysis; (7) Traumatic idiocy, a form produced by the third class of causes above mentioned; (8) Inflammatory idiocy; (9) Idiocy by deprivation of one or more of the special senses.

The general conformation of the idiot is generally imperfect; he is sometimes deformed, but more frequently the frame is merely awkwardly put together, and he is usually of short stature. Only about one-fourth of all idiots have heads smaller than the average. Many cases are on record in which the cranial measurements exceed the average. It is the irregularity of development of the bones of the skull, especially at the base, which marks the condition. Cases, however, often present themselves in which the skull is perfect in form and size. In such the mischief has begun in the brain matter. The palate is often highly arched; hare-lip is not uncommon; in fact congenital defect or malformation of other organs than the brain is more commonly met with among idiots than in the general community. Of the special senses, hearing is most frequently affected. Sight is good, although co-ordination may be defective. Many are mute. On account of the mental dullness it is difficult to determine whether the senses of touch, taste and smell suffer impairment; but the impression is that their acuteness is below the average. It is needless to attempt a description of the mental phenomena of idiots, which range between utter want of intelligence and mere weakness of intellect.

The term _Imbecility_ has been conventionally employed to indicate the less profound degrees of idiocy, but in point of fact no distinct line of demarcation can be drawn between the conditions. As the scale of imbeciles ascends it is found that the condition is evidenced not so much by obtuseness as by irregularity of intellectual development. This serves to mark the difference between the extreme stupidity of the lowest of the healthy and the highest forms of the morbidly deprived type. The two conditions do not merge gradually one into the other. Absolute stupidity and sottishness mark many cases of idiocy, but only in the lowest type, where no dubiety of opinion can exist as to its nature, and in a manner which can never be mistaken for the dulness of the man who is less talented than the average of mankind. Where in theory the morbid (in the sense of deprivation) and the healthy types might be supposed to approach each other, in practice we find that, in fact, no debatable ground exists. The uniformity of dulness of the former stands in marked opposition to the irregularity of mental conformation in the latter. Comparatively speaking, there are few idiots or imbeciles who are uniformly deprived of mental power; some may be utterly sottish, living a mere vegetable existence, but every one must have heard of the quaint and crafty sayings of manifest idiots, indicating the presence of no mean power of applied observation. In institutions for the treatment of idiots and imbeciles, children are found not only able to read and write, but even capable of applying the simpler rules of arithmetic. A man may possess a very considerable meed of receptive faculty and yet be idiotic in respect of the power of application; he may be physically disabled from relation, and so be manifestly a deprived person, unfit to take a position in the world on the same platform as his fellows.

Dr Ireland subdivides idiots, for the purpose of education, into five grades, the first comprising those who can neither speak nor understand speech, the second those who can understand a few easy words, the third those who can speak and can be taught to work, the fourth those who can be taught to read and write, and the fifth those who can read books for themselves. The treatment of idiocy and imbecility consists almost entirely of attention to hygiene and the building up of the enfeebled constitution, along with endeavours to develop what small amount of faculty exists by patiently applied educational influences. The success which has attended this line of treatment in many public and private institutions has been very considerable. It may be safely stated that most idiotic or imbecile children have a better chance of amelioration in asylums devoted to them than by any amount of care at home.

In the class of idiots just spoken of, imperfect development of the intellectual faculties is the prominent feature, so prominent that it masks the arrest of potentiality of development of the moral sense, the absence of which, even if noticed, is regarded as relatively unimportant; but, in conducting the practical study of congenital idiots, a class presents itself in which the moral sense is wanting or deficient, whilst the intellectual powers are apparently up to the average. It is the custom of writers on the subject to speak of "intellectual" and "moral" idiots. The terms are convenient for clinical purposes, but the two conditions cannot be dissociated, and the terms therefore severally only imply a specially marked deprivation of intellect or of moral sense in a given case. The everyday observer has no difficulty in recognizing as a fact that deficiency in receptive capacity is evidence of imperfect cerebral development; but it is not so patent to him that the perception of right or wrong can be compromised through the same cause, or to comprehend that loss of moral sense may result from disease. The same difficulty does not present itself to the pathologist; for, in the case of a child born under circumstances adverse to brain development, and in whom no process of education can develop an appreciation of what is right or wrong, although the intellectual faculties appear to be but slightly blunted, or not blunted at all, he cannot avoid connecting the physical peculiarity with the pathological evidence. The world is apt enough to refer any fault in intellectual development, manifested by imperfect receptivity, to a definite physical cause, and is willing to base opinion on comparatively slight data; but it is not so ready to accept the theory of a pathological implication of the intellectual attributes concerned in the perception of the difference between right and wrong. Were, however, two cases pitted one against another--the first one of so-called intellectual, the second one of so-called moral idiocy--it would be found that, except as regards the psychical manifestations, the cases might be identical. In both there might be a family history of tendency to degeneration, a peculiar cranial conformation, a history of previous symptoms during infancy, and of a series of indications of mental incapacities during adolescence, differing only in this, that in the first the prominent indication of mental weakness was inability to add two and two together, in the second the prominent feature was incapacity to distinguish right from wrong. What complicates the question of moral idiocy is that many of its subjects can, when an abstract proposition is placed before them, answer according to the dictates of morality, which they may have learnt by rote. If asked whether it is right or wrong to lie or steal they will say it is wrong; still, when they themselves are detected in either offence, there is an evident non-recognition of its concrete nature. The question of moral idiocy will always be a moot one between the casuist and the pathologist; but, when the whole natural history of such cases is studied, there are points of differentiation between their morbid depravation and mere moral depravity. Family history, individual peculiarities, the general bizarre nature of the phenomena, remove such cases from the category of crime.

_Statistics._--According to the census returns of 1901 the total
number of persons described as idiots and imbeciles in England and
Wales was 48,882, the equality of the sexes being remarkable, namely,
24,480 males and 24,402 females. Compared with the entire population
the ratio is 1 idiot or imbecile to 665 persons, or 15 per 10,000
persons living. Whether the returns are defective, owing to the
sensitiveness of persons who would desire to conceal the occurrence of
idiocy in their families, we have no means of knowing; but such a
feeling is no doubt likely to exist among those who look upon mental
infirmity as humiliating, rather than, as one of the many physical
evils which afflict humanity. Dr. Ireland estimates that there is 1
idiot or imbecile to every 500 persons in countries that have a
census. The following table shows the number of idiots according to
official returns of the various countries:--

+-------------------+--------+---------+--------+------------+
| | | | | Proportion |
| | Males. | Females.| Total. | to 100,000 |
| | | | | of Pop. |
+-------------------|--------|---------|--------|------------|
| England and Wales | 24,480 | 24,402 | 48,882 | 150 |
| | | | | |
| Scotland | 3,246 | 3,377 | 6,623 | 148 |
| | | | | |
| Ireland | 2,946 | 2,270 | 5,216 | 117 |
| | | | | |
| France (including | 20,456 | 14,677 | 35,133 | 97 |
| cretins) (1872) | | | | |
| | | | | |
| Germany (1871) | -- | -- | 33,739 | 82 |
| | | | | |
| Sweden (1870) | -- | -- | 1,632 | 38 |
| | | | | |
| Norway (1891) | 1,357 | 1,074 | 2,431 | 121 |
| | | | | |
| Denmark (1888-89) | 2,106 | 1,751 | 3,857 | 200 |
+-------------------|--------|---------|--------|------------+

For the United States there are no later census figures than 1890 when
the feeble-minded or idiotic were recorded as 95,571 (52,940 males and
42,631 females). In 1904 (_Special Report of Bureau of Census_, 1906)
the "feeble-minded" were estimated at 150,000.

The relative frequency of congenital and acquired insanity in various
countries is shown in the following table, taken from Koch's
statistics of insanity in Württemberg, which gives the number of
idiots to 100 lunatics:--

Prussia 158 | France 66
Bavaria 154 | Denmark 58
Saxony 162 | Sweden 22
Austria 53 | Norway 65
Hungary 140 | England and Wales 74
Canton of Bern 117 | Scotland 68
America 79 | Ireland 69

It is difficult to understand the wide divergence of these figures,
except it be that in certain states, such as Prussia and Bavaria,
dements have been taken along with aments and in others cretins. This
cannot, however, apply to the case of France, which is stated to have
only 66 idiots to every 100 lunatics. In many districts of France
cretinism is common; it is practically unknown in England, where the
proportion of idiots is stated as higher than in France; and it is
rare in Prussia, which stands at 158 idiots to 100 lunatics.
Manifestly imperfect as this table is, it shows how important an
element idiocy is in social statistics; few are aware that the number
of idiots and that of lunatics approach so nearly.

Acquired Insanity.

II. _Acquired Insanity._--So far as the mental symptoms of acquired insanity are concerned, Pinel's ancient classification, into _Mania_, _Melancholia_ and _Dementia_, is still applicable to every case, and although numberless classifications have been advanced they are for the most part merely terminological variations. Classifications of the insanities based on pathology and etiology have been held out as a solution of the difficulty, but, so far, pathological observations have failed to fulfil this ideal, and no thoroughly satisfactory pathological classification has emerged from them.

Classifications are after all matters of convenience; the following system admittedly is so:--

Melancholia.
Mania.
Delusional Insanity.
Katatonia.
Hebephrenia.
Traumatic Insanity.
Insanity following upon arterial degeneration.
Insanities associated or caused by: General Paralysis; Epilepsy.
Insanities associated with or caused by Alcoholic and Drug
intoxication: Delirium Tremens, Chronic Alcoholic Insanity,
Dipsomania, Morphinism.
Senile Insanity.

The general symptoms of acquired insanity group themselves naturally under two heads, the physical and the mental.

General symptoms.

The physical symptoms of mental disease generally, if not invariably, precede the onset of the mental symptoms, and the patient may complain of indefinite symptoms of malaise for weeks and months before it is suspected that the disorder is about to terminate in mental symptoms. The most general physical disorder common to the onset of all the insanities is the failure of nutrition, i.e. the patient rapidly and apparently without any apparent cause loses weight. Associated with this nutritional failure it is usual to have disturbances of the alimentary tract, such as loss of appetite, dyspepsia and obstinate constipation. During the prodromal stage of such conditions as mania and melancholia the digestive functions of the stomach and intestine are almost or completely in abeyance. To this implication of other systems consequent on impairment of the trophesial (nourishment-regulating) function of the brain can be traced a large number of the errors which exist as to the causation of idiopathic melancholia and mania. Very frequently this secondary condition is set down as the primary cause; the insanity is referred to derangements of the stomach or bowels, when in fact these are, concomitantly with the mental disturbance, results of the cerebral mischief. Doubtless these functional derangements exercise considerable influence on the progress of the case by assisting to deprave the general economy, and by producing depressing sensations in the region of the stomach. To them may probably be attributed, together with the apprehension of impending insanity, that phase of the disease spoken of by the older writers as the _stadium melancholicum_, which so frequently presents itself in incipient cases.

The skin and its appendages--the hair and the nails--suffer in the general disorder of nutrition which accompanies all insanities. The skin may be abnormally dry and scurfy or moist and offensive. In acute insanities rashes are not uncommon, and in chronic conditions, especially conditions of depression, crops of papules occur on the face, chest and shoulders. The hair is generally dry, loses its lustre and becomes brittle. The nails become deformed and may exhibit either excessive and irregular or diminished growth.

Where there are grave nutritional disorders it is to be expected that the chief excretions of the body should show departures from the state of health. In this article it is impossible to treat this subject fully, but it may suffice to say that in many states of depression there is a great deficiency in the excretion of the solids of the urine, particularly the nitrogenous waste products of the body; while in conditions of excitement there is an excessive output of the nitrogenous waste products. It has lately been pointed out that in many forms of insanity indoxyl is present in the urine, a substance only present when putrefactive processes are taking place in the intestinal tract.

The nervous system, both on the sensory and motor side, suffers very generally in all conditions of insanity. On the sensory side the special senses are most liable to disorder of their function, whereby false sense impressions arise which the patient from impairment of judgment is unable to correct, and hence arise the psychical symptoms known as hallucinations and delusions. Common sensibility is generally impaired.

On the motor side, impairment of the muscular power is present in many cases of depression and in all cases of dementia. The incontinence of urine so frequently seen in dementia and in acute insanity complicated with the mental symptom of confusion depends partly on impairment of muscular power and partly on disorder of the sensory apparatus of the brain and spinal cord.

The outstanding mental symptom in nearly all insanities, acute and recent or chronic, is the failure of the capacity of judgment and loss of self-control. In early acute insanities, however, the two chief symptoms which are most evident and easily noted are depression on the one hand and excitement or elevation on the other. Some distinction ought to be made between these two terms, excitement and elevation, which at present are used synonymously. Excitement is a mental state which may be and generally is associated with confusion and mental impairment, while elevation is an exaltation of the mental faculties, a condition in which there is no mental confusion, but rather an unrestrained and rapid succession of fleeting mental processes.

The symptoms which most strongly appeal to the lay mind as conclusive
evidence of mental disorder are hallucinations and delusions.
Hallucinations are false sense impressions which occur without normal
stimuli. The presence of hallucinations certainly indicates some
functional disorder of the higher brain centres, but is not an
evidence of insanity so long as the sufferer recognizes that the
hallucinations are false sense impressions. So soon, however, as
conduct is influenced by hallucinations, then the boundary line
between sanity on the one hand and insanity on the other has been
crossed. The most common hallucinations are those of sight and
hearing.

Delusions are not infrequently the result of hallucinations. If the
hallucinations of a melancholic patient consist in hearing voices
which make accusatory statements, delusions of sin and unworthiness
frequently follow. Hallucinations of the senses of taste and smell are
almost invariably associated with the delusion that the patient's food
is being poisoned or that it consists of objectionable matter. On the
other hand, many delusions are apparently the outcome of the patient's
mental state. They may be pleasant or disagreeable according as the
condition is one of elevation or depression. The intensity and quality
of the delusions are largely influenced by the intelligence and
education of the patient. An educated man, for instance, who suffers
from sensory disturbances is much more ingenious in his explanations
as to how these sensory disturbances result from electricity,
marconigrams, X-rays, &c., which he believes are used by his enemies
to annoy him, than an ignorant man suffering from the same abnormal
sensations. Loss of self-control is characteristic of all forms of
insanity. Normal self-control is so much a matter of race, age, the
state of health, moral and physical upbringing, that it is impossible
to lay down any law whereby this mental quality can be gauged, or to
determine when deficiency has passed from a normal to an abnormal
state. In many cases of insanity there is no difficulty in
appreciating the pathological nature of the deficiency, but there are
others in which the conduct is otherwise so rational that one is apt
to attribute the deficiency to physiological rather than to
pathological causes. Perversion of the moral sense is common to all
the insanities, but is often the only symptom to be noticed in cases
of imbecility and idiocy, and it as a rule may be the earliest symptom
noticed in the early stages of the excitement of manic-depressive
insanity and general paralysis.

The tendency to commit suicide, which is so common among the insane
and those predisposed to insanity, is especially prevalent in patients
who suffer from depression, sleeplessness and delusions of
persecution. Suicidal acts may be divided into accidental, impulsive
and premeditated. The accidental suicides occur in patients who are
partially or totally unconscious of their surroundings, and are
generally the result of terrifying hallucinations, to escape from
which the patient jumps through a window or runs blindly into water or
some other danger. Impulsive suicides may be prompted by suddenly
presented opportunities or means of self-destruction, such as the
sight of water, fire, a knife, cord or poison. Premeditated suicides
most frequently occur in states of long continued depression. Such
patients frequently devote their attention to only one method of
destruction and fail to avail themselves of others equally
practicable. As a rule the more educated the patient, the more
ingenious and varied are the methods adopted to attain the desired
result.

The faculty of attention is variously affected in the subjects of
insanity. In some the attention is entirely subjective, being occupied
by sensations of misery, depression or sensory disturbances. In others
the attention is objective, and attracted by every accidental sound or
movement. In most of the early acute insanities the capacity of
attention is wholly abolished, while in hebephrenia the stage of
exhaustion which follows acute excitement, and the condition known as
secondary dementia, loss of the power of attention is one of the most
prominent symptoms. The memory for both recent and remote events is
impaired or abolished in all acute insanities which are characterized
by confusion and loss or impairment of consciousness. In the excited
stage of manic-depressive insanity it is not uncommon to find that the
memory is abnormally active. Loss of memory for recent but not remote
events is characteristic of chronic alcoholism and senility and even
the early stage of general paralysis.

Of all the functions of the brain that of sleep is the most liable to
disorder in the insane. Sleeplessness is the earliest symptom in the
onset of insanity; it is universally present in all the acute forms,
and the return of natural sleep is generally the first symptom of
recovery. The causes of sleeplessness are very numerous, but in the
majority of acute cases the sleeplessness is due to a state of
toxaemia. The toxins act either directly on the brain cells producing
a state of irritability incompatible with sleep, or indirectly,
producing physical symptoms which of themselves alone are capable of
preventing the condition of sleep. These symptoms are high arterial
tension and a rapid pulse-rate. The arterial tension of health ranges
between 110 and 120 millimetres of mercury, and when sleep occurs the
arterial tension falls and is rarely above 100 millimetres. In
observations conducted by Bruce (_Scottish Medical and Surgical
Journal_, August 1900) on cases of insanity suffering from
sleeplessness the arterial tension was found to be as high as 140 and
150 millimetres. When such sleep was obtained the tension always sank
at once to 110 millimetres or even lower. In a few cases suffering
from sleeplessness the arterial tension was found to be below 100
millimetres, accompanied by a rapid pulse-rate. When sleep set in, in
these cases, no alteration was noted in the arterial tension, but the
pulse was markedly diminished.

Melancholia.

MELANCHOLIA.--Melancholia is a general term applied to all forms of insanity in which the prevailing mental symptom is that of depression and dates back to the time of Hippocrates. Melancholic patients, however, differ very widely from one another in their mental symptoms, and as a consequence a perfectly unwarrantable series of subdivisions have been invented according to the prominence of one or other mental symptoms. Such terms as delusional melancholia, resistive melancholia, stuporose melancholia, suicidal melancholia, religious melancholia, &c. have so arisen; they are, however, more descriptive of individual cases than indicative of types of disease.

So far as our present knowledge goes, at least three different and distinct disease conditions can be described under the general term melancholia. These are, acute melancholia, excited melancholia and the state of depression occurring in _Folie circulaire_ or alternating insanity, a condition in which the patient is liable to suffer from alternating attacks of excitement and depression.

_Acute Melancholia_ is a disease of adult life and the decline of life. Women appear to be more liable to be attacked than men. Hereditary predisposition, mental worry, exhausting occupations, such as the sick-nursing of relatives, are the chief predisposing causes, while the direct exciting cause of the condition is due to the accumulation in the tissues of waste products, which so load the blood as to act in a toxic manner on the cells and fibres of the brain.

The onset of the disease is gradual and indefinite. The patient suffers from malaise, indigestion, constipation and irregular, rapid and forcible action of the heart. The urine become scanty and high coloured. The nervous symptoms are irritability, sleeplessness and a feeling of mental confusion. The actual onset of the acute mental symptoms may be sudden, and is not infrequently heralded by distressing hallucinations of hearing, together with a rise in the body temperature. In the fully developed disease the patient is flushed and the skin hot and dry; the temperature is usually raised 1° above the normal in the evening. The pulse is hard, rapid and often irregular. There is no desire for food, but dryness of the mouth and tongue promote a condition of thirst. The bowels are constipated. The urine is scanty and frequently contains large quantities of indoxyl. The blood shows no demonstrable departure from the normal. The patient is depressed, the face has a strained, anxious expression, while more or less mental confusion is always present. Typical cases suffer from distressing aural hallucinations, and the function of sleep is in abeyance.

Acute melancholia may terminate in recovery either gradually or by crises, or the condition may pass into chronicity, while in a small proportion of cases death occurs early in the attack from exhaustion and toxaemia. The acute stage of onset generally lasts for from two to three weeks, and within that period the patient may make a rapid and sudden recovery. The skin becomes moist and perspiration is often profuse. Large quantities of urine are excreted, which are laden with waste products. The pulse becomes soft and compressible, sleep returns, and the depression, mental confusion and hallucinations pass away. In the majority of untreated cases, however, recovery is much more gradual. At the end of two or three weeks from the onset cf the attack the patient gradually passes into a condition of comparative tranquillity. The skin becomes moister, the pulse less rapid, and probably the earliest symptom of improvement is return of sleep. Hallucinations accompanied by delusions persist often for weeks and months, but as the patient improves physically the mental symptoms become less and less prominent.

If the patient does not recover, the physical symptoms are those of mal-nutrition, together with chronic gastric and intestinal disorder. The skin is dull and earthy in appearance, the hair dry, the nails brittle and the heart's action weak and feeble. Mentally there is profound depression with delusions, and persistent or recurring attacks of hallucinations of hearing. When death occurs, it is usually preceded by a condition known as the "typhoid state." The patient rapidly passes into a state of extreme exhaustion, the tongue is dry and cracked, sordes form upon the teeth and lips, diarrhoea and congestion of the lungs rapidly supervene and terminate life.

_Treatment._--The patient in the early stage of the disease must be
confined to bed and nursed by night as well as day. The food to begin
with should be milk, diluted with hot water or aerated water, given
frequently and in small quantities. The large intestine should be
thoroughly cleared out by large enemata and kept empty by large normal
saline enemata administered every second day. Sleep may be secured by
lowering the blood pressure with half-grain doses of
erythrol-tetra-nitrate. If a hypnotic is necessary, as it will be if
the patient has had no natural sleep for two nights in succession,
then a full dose of paraldehyde or veronal may be given at bed-time.
Under this treatment the majority of cases, if treated early, improve
rapidly. As the appetite returns great care must be taken that the
patient does not suddenly resume a full ordinary dietary. A sudden
return to a full dietary invariably means a relapse, which is often
less amenable to treatment than the original attack. Toast should
first be added to the milk, and this may be followed by milk puddings
and farinaceous foods in small quantities. Any rise of temperature or
increase of pulse-rate or tendency to sleeplessness should be regarded
as a threatened relapse and treated accordingly.

_Excited Melancholia._--Excited melancholia is almost invariably a disease of old age or the decline of life, and it attacks men and women with equal frequency. Chronic gastric disorders, deficient food and sleep, unhealthy occupations and environments, together with worry and mental stress, are all more or less predisposing causes of the disease. The direct exciting cause or causes have not as yet been demonstrated, but there is no doubt that the disease is associated with, or caused by, a condition of bacterial toxaemia, analogous to the bacterial toxaemias of acute and chronic rheumatism.

The onset of the disease is always gradual and is associated with mal-nutrition, loss of body weight, nervousness, depression, loss of the capacity for work, sleeplessness and attacks of restlessness, these attacks of restlessness become more and more marked as self-control diminishes, and as the depression increases the disease passes the borderland of sanity.

In the fully developed disease the appearance of the patient is typical. The expression is drawn, depressed, anxious or apprehensive. The skin is yellow and parchment like. The hair is often dry and stands out stiffly from the head. The hands are in constant movement, twisting and untwisting, picking the skin, pulling at the hair or tearing at the clothes. The patient moans continuously, or emits cries of grief and wanders aimlessly. Mentally the patient, although depressed, miserable and self-absorbed, is not confused. There is complete consciousness except during the height of a paroxysm of restlessness and depression, and the patient can talk and answer questions clearly and intelligently, but takes no interest in the environment. Some of the patients suffer from delusions, generally a sense of impending danger, but very few suffer from hallucinations.

Physically there is loss of appetite, constipation and rapid heart action, a great increase in the number of the white blood corpuscles, particularly of the multinucleated cells which are frequently increased in bacterial infections. In the blood serum also there can be demonstrated the presence of agglutinines to certain members of the streptococci group.

The course of the disease is prolonged and chronic. The acute symptoms tend to remit at regular intervals, the patient becoming more quiet and less demonstratively depressed; but as a rule these remissions are extremely temporary. Excited melancholia is a disease characterized by repeated relapses, and recoveries are rare in cases above the age of forty.

_Treatment._--There is no curative treatment for excited melancholia.
The patient must be carefully nursed; kept in bed during the
exacerbations of the disease and treated with graduated doses of
nepenthe or tincture of opium, to secure some amelioration of the
acute symptoms. Careful dieting, tonics and baths are of benefit
during the remissions of the disease, and in a few cases seem to
promote recovery.

_Folie circulaire_, or alternating insanity, was first described by Falret and Baillarger, and more recently Kraepelin has considerably widened the conception of this class of disease, which he describes under the term "manic-depressive insanity." Of the two terms (_folie circulaire_ and manic-depressive insanity) the latter is the more correct. _Folie circulaire_ implies that the disease invariably passes through a complete cycle, which description is only applicable to very few of the cases. Manic-depressive insanity implies that the patient may either suffer from excitement or depression which do not necessarily succeed one another in any fixed order. As a matter of fact, the majority of patients who suffer from the disease either have marked excited attacks with little or no subsequent depression, or marked attacks of depression with a subsequent period of such slight exaltation as hardly to be distinguished from a state of health.

Depression of the manic-depressive variety, therefore, may either precede or follow upon an attack of maniacal excitement, or it may be the chief and only obvious symptom of the disease and may recur again and again. The disease attacks men and women with equal frequency, and as a rule manifests itself either late in adolescence or during the decline of life. Hereditary predisposition has been proved to exist in over 50% of cases, beyond which no definite predisposing cause is at present known. A considerable number of cases follow upon attacks of infective disease such as typhoid fever, scarlet fever or rheumatic fever. The actual exciting cause is probably an intestinal toxaemia of bacterial origin; at all events, mal-nutrition, gastric and intestinal symptoms not infrequently precede an attack, and the condition of the blood--the increase in number in the multinucleated white blood corpuscles and the presence of agglutinines to certain members of the streptococci group of bacteria--are symptoms which have been definitely demonstrated by Bruce in every case so far examined.

If the depression is the sequel to an attack of excitement, the onset may be very sudden or it may be gradual. If, on the other hand, the depression is not the sequel of excitement, the onset is very gradual and the patient complains of lassitude, incapacity for mental or physical work, loss of appetite, constipation and sleeplessness often for months before the case is recognized as one of insanity. In the fully developed disease the temperature is very rarely febrile, on the contrary it is rather subnormal in character. The stomach is disordered and the bowels confined. The urine is scanty, turbid and very liable to rapid decomposition. The heart's action is slow and feeble and the extremities become cold, blue and livid. In extreme cases gangrene of the lower extremities may occur, but in all there is a tendency to oedema of the extremities. The skin is greasy, often offensive, and the palms of the hands and the soles of the feet are sodden.

Mentally there is simple depression, without, in the majority of cases, any implication of consciousness. Many patients pass through attack after attack without suffering from hallucinations or delusions, but in rare cases hallucinations of hearing and sight are present. Delusions of unworthiness and unpardonable sin are not uncommon, and if once expressed are liable to recur again during the course of each successive attack. The disease is prolonged and chronic in its course, and the condition of the patient varies but little from day to day. When the depression follows excitement, the patient as a rule becomes fat and flabby. On the other hand, if the illness commences with depression, the chief physical symptoms are mal-nutrition and loss of body weight, and the return to health is always preceded by a return of nutrition and a gain in body weight.

The attacks may last from six months to two or three years. The intervals between attacks may last for only a few weeks or months or may extend over several years. During the interval the patient is not only capable of good mental work but may show capacity of a high order. In other words this form of mental disorder does not tend to produce dementia; the explanation probably being that between the attacks there is no toxaemia.

_Treatment._--There is no known curative treatment for the depression
of manic-depressive insanity, but the depression, the sleeplessness
and the gastric disorder are to some extent mitigated by common sense
attention to the general health of the body. If the patient is thin
and wasted, then treatment is best conducted in bed. The diet should
be bland, consisting largely of milk, eggs and farinaceous food, given
in small quantities and frequently. Defecation should be maintained by
enemata, and the skin kept clean by daily warm baths. What is of much
more importance is the fact that in some instances subsequent attacks
can be prevented by impressing upon the patient the necessity for
attending to the state of the bowels, and of discontinuing work when
the slightest symptoms of an attack present themselves. If these
symptoms are at all prominent, rest in bed is a wise precaution,
butcher-meat should be discontinued from the dietary and a tonic of
arsenic or quinine and acid prescribed.

Mania.

MANIA.--The term mania, meaning pathological elevation or excitement, has, like the term melancholia, been applied to all varieties of morbid mental conditions in which the prevailing mental symptom is excitement or elevation. As in melancholia so in mania various subdivisions have been invented, such as delusional mania, religious mania, homicidal mania, according to the special mental characteristics of each case, but such varieties are of accidental origin and cannot be held to be subdivisions.

Under the term mania two distinct diseased conditions can be described, viz. acute mania, and the elevated stage of _folie circulaire_ or manic-depressive insanity.

_Acute Mania._--Acute mania is a disease which attacks both sexes at all ages, but its onset is most prevalent during adolescence and early adult life. Hereditary predisposition, physical and mental exhaustion, epileptic seizures and childbirth are all predisposing causes. The direct exciting cause or causes are unknown, but the physical symptoms suggest that the condition is one of acute toxaemia or poisoning, and the changes in the blood are such as are consequent on bacterial toxaemia.

The onset is gradual in the large majority of cases. Histories of sudden outbursts of mania can rarely be relied on, as the illness is almost invariably preceded by loss of body weight, sleeplessness, bad dreams, headaches and symptoms of general malaise, sometimes associated with depression. The actual onset of the mental symptoms themselves, however, are frequently sudden. A typical case of the fully developed disease is not easily mistaken. The patient is usually anaemic and thin, the expression of the face is unnatural, the eyes widely opened and bright; and there is great motor restlessness, the muscular movements being purposeless and inco-ordinate. This inco-ordination of movement affects not only the muscles of the limbs and trunk but also those of expression, so that the usual aspect of the face becomes entirely altered. The temperature is generally slightly febrile. The tongue and lips are cracked and dry through excessive shouting or speaking. There is often no desire for food or drink. The heart's action is rapid and forcible. The skin is soft and moist. The urine is scanty, turbid and loaded with urates. The white blood corpuscles per cubic millimetre of blood are markedly increased, and the blood serum contains agglutinines to certain strains of streptococci which are not present in healthy persons. Sensibility to pain is lost or much impaired. Such patients will swing and jerk a broken limb apparently unaware that it is broken. Sleep is absent or obtained in short snatches, and even when asleep the patient is often restless and talkative as if the disease processes were still active.

Mentally the patient is excited, often wildly so, quite confused and unable to recognize time or place. Answers to questions may sometimes be elicited by repeated efforts to engage the attention of the patient. The speech is incoherent, and for all practical purposes the patient is mentally inaccessible. This state of acute excitement lasts usually for two or three weeks and gradually passes into a condition of chronic restlessness and noise, in which the movements are more coordinate and purposeful. The confusion of the acute stage passes off and the attention can be more readily attracted but cannot be concentrated on any subject for any length of time. The patient will now recognize friends, but the affections are in abeyance and the memory is defective. The appetite becomes insatiable, but the patient does not necessarily gain in weight. This stage of subacute excitement may last for months, but as a rule favourable cases recover within six months from the onset of the disease. A recovering patient gradually gains weight, sleeps soundly at night and has periods of partial quiescence during the day, particularly in the morning after a good night's sleep. These lucid intervals become more and more prolonged and finally pass into a state of sanity. Some cases on the other hand, after the acute symptoms decline, remain confused, and this state of confusion may last for months; by some alienists it is described as secondary stupor.

The symptoms detailed above are those typical of an attack such as is most frequently met with in adult cases. Acute mania, however, is a disease which presents itself in various forms. Adolescent cases, for instance, very commonly suffer from recurrent attacks, and the recurrent form of the disease is also to be met with in adults. The recurrent form at the onset does not differ in symptoms from that already described, but the course of the attack is shorter and more acute, so that the patient after one or two weeks of acute excitement rapidly improves, the mental symptoms pass off and the patient is apparently perfectly recovered. An examination of the blood, however, reveals the fact that the patient is still suffering from some disorder of the system, inasmuch as the white blood corpuscles remain increased above the average of health. Subsequent attacks of excitement come on without any obvious provocation. The pulse becomes fast and the face flushed. The patient frequently complains of fullness in the head, ringing in the ears and a loss of appetite. Sleeplessness is an invariable symptom. Self-control is generally lost suddenly, and the patient rapidly passes into a state of delirious excitement, to recover again, apparently, in the course of a few weeks. Recurrent mania might therefore be regarded as a prolonged toxaemia, complicated at intervals by outbursts of delirious excitement. Acute mania in the majority of cases ends in recovery. In the continuous attack the recovery is gradual. In the recurrent cases the intervals between attacks become longer and the attacks less severe until they finally cease. In such recovered cases very frequently a persistent increase in the number of the white blood corpuscles is found, persisting for a period of two or three years of apparently sound mental health. A few cases die, exhausted by the acuteness of the excitement and inability to obtain rest by the natural process of sleep. When death does occur in this way the patient almost invariably passes into the typhoid state.

The residue of such cases become chronic, and chronicity almost invariably means subsequent dementia. The chronic stage of acute mania may be represented by a state of continuous subacute excitement in which the patient becomes dirty and destructive in habits and liable from time to time to exacerbations of the mental symptoms. Continuous observation of the blood made in such cases over a period extending for weeks reveals the fact that the leucocytosis, if represented in chart form, shows a regular sequence of events. Just prior to the onset of an exacerbation the leucocytosis is low. As the excitement increases in severity the leucocytosis curve rises, and just before improvement sets in there may be a decided rise in the curve and then a subsequent fall; but this fall rarely reaches the normal line. In other cases, which pass into chronicity, a state of persistent delusion, rather than excitement, is the prevailing mental characteristic, and these cases may at recurrent intervals become noisy and dangerous.

_Treatment._--Acute mania can only be treated on general lines. During
the acute stage of onset the patient should be placed in bed. If there
is difficulty in inducing the patient to take a sufficient quantity of
food, this difficulty can be got over by giving food in liquid form,
milk, milk-tea, eggs beaten up in milk, meat juice and thin gruel, and
it is always better to feed such a patient with small quantities given
frequently. Cases of mania following childbirth are those which most
urgently demand careful and frequent feeding, artificially
administered if necessary. If there is any tendency to exhaustion,
alcoholic stimulants are indicated, and in some cases strychnine,
quinine and cardiac tonics are highly beneficial. The bowels should be
unloaded by large enemata or the use of saline purgatives. The
continuous use of purgatives should as a rule be avoided, as they
drain the system of fluids. On the other hand, the administration of
one large normal saline enema by supplying the tissues with fluids,
and probably thereby diluting the toxins circulating in the system,
gives considerable relief. A continuous warm bath frequently produces
sleep and reduces excitement. The sleeplessness of acute mania is best
treated by warm baths wherever possible, and if a drug must be
administered, then paraldehyde is the safest and most certain, unless
the patient is also an alcoholic, when chloral and bromide is probably
a better sedative.

_The Elevated Stage of Folie Circulaire or Manic Depressive Insanity._--As previously mentioned in the description of the depressed stage of this mental disorder, the disease is equally prone to attack men and women, generally during late adolescence or in early adult life, and in a few cases first appears during the decline of life. Hereditary predisposition undoubtedly plays a large part as a predisposing cause, and after that is said it is difficult to assign any other definite predisposing causes and certainly no exciting causes. As in the stage of depression, so in the stage of excitement the first attack may closely follow upon typhoid fever, erysipelas or rheumatic fever. On the other hand many cases occur without any such antecedent disease. Another fact which has been commented upon is that these patients at the onset of an attack of excitement often appear to be in excellent physical health.

The earliest symptoms of onset are moral rather than physical. The patient changes in character, generally for the worse. The sober man becomes intemperate. The steady man of business enters into foolish, reckless speculation. There is a tendency for the patient to seek the society of inferiors and to ignore the recognized conventionalities of life and decency. The dress becomes extravagant and vulgar and the speech loud, boastful and obscene. These symptoms may exist for a considerable period before some accidental circumstance or some more than usually extravagant departure from the laws and customs of civilization draws public attention to the condition of the patient. The symptoms of the fully developed disease differ in degree in different cases. The face is often flushed and the expression unnatural. There is constant restlessness, steady loss of body weight, and sleeplessness. In very acute attacks there are frequently symptoms of gastric disorder, while in other cases the appetite is enormous, gross and perverted. The leucocytosis is above that usually met with in health, and the increase in the early stages is due to the relative and absolute increase in the multinucleated or polymorphonuclear leucocytes. The hyperleucocytosis is not, however, so high as it is in acute mania, and upon recovery taking place the leucocytosis always falls to normal. In the serum of over 80% of cases there are present agglutinines to certain strains of streptococci, which agglutinines are not present in the serum of healthy persons. The changes in the urine are those which one would expect to find in persons losing weight; the amount of nitrogenous output is in excess of the nitrogen ingested in the food.