Chapter XXII: Act 1837: (In re Blewitt, 1880, 5 P.D. 116) (7)

Mentally there is always exaltation rather than excitement, and when excitement is present it is never of a delirious nature, that is to say, the patient is cognizant of the surroundings, and the special senses are abnormally acute, particularly those of sight and hearing. Hallucinations and delusion are sometimes present, but many cases pass through several attacks without exhibiting either of these classes of symptoms. The patient is always garrulous and delighted to make any chance acquaintance the confidant of his most private affairs. The mood is sometimes expansive and benevolent, interruption in the flow of talk may suddenly change the subject of the conversation or the patient may with equal suddenness fly into a violent rage, use foul and obscene language, ending with loud laughter and protestations of eternal friendship. In other words the mental processes are easily stimulated and as easily diverted into other channels. The train of thought is, as it were, constantly being changed by accidental associations. Although consciousness is not impaired, the power of work is abolished as the attention cannot be directed continuously to any subject, and yet the patient may be capable of writing letters in which facts and fiction are most ingeniously blended. A typical case will pass through the emotions of joy, sorrow and rage in the course of a few minutes. The memory is not impaired and is often hyper-acute. The speech may be rambling but is rarely incoherent.

The course of the attack is in some cases short, lasting for from one to three weeks, while in others the condition lasts for years. The patient remains in a state of constant restlessness, both of body and mind, untidy or absurd in dress, noisy, amorous, vindictive, boisterously happy or virulently abusive. As time passes a change sets in. The patient sleeps better, begins to lay on flesh, the sudden mental fluctuations become less marked and finally disappear. Many of these patients remember every detail of their lives during the state of elevation, and many are acutely ashamed of their actions during this period of their illness. As a sequel to the attack of elevation there is usually an attack of depression, but this is not a necessary sequel.

The majority of patients recover even after years of illness, but the attacks are always liable to recur. Even recurrent attacks, however, leave behind them little if any mental impairment.

_Treatment._--General attention to the health of the body, and an
abundance of nourishing food, and, where necessary, the use of
sedatives such as bromide and sulphonal, sum up the treatment of the
elevated stage of manic-depressive insanity. In Germany it is the
custom to treat such cases in continuous warm baths, extending
sometimes for weeks. The use of warm baths of several hours' duration
has not proved satisfactory.

Delusional Insanity.

DELUSIONAL INSANITY.--Considerable confusion exists at the present day regarding the term delusional insanity. It is not correct to define the condition as a disease in which fixed delusions dominate the conduct and are the chief mental symptom present. Such a definition would include many chronic cases of melancholia and mania. All patients who suffer from attacks of acute insanity and who do not recover tend to become delusional, and any attempt to include and describe such cases in a group by themselves and term them delusional insanity is inadmissible. The fact that delusional insanity has been described under such various terms as progressive systematized insanity, mania of persecution and grandeur, monomanias of persecution, unseen agency, grandeur and paranoia, indicates that the disease is obscure in its origin, probably passing through various stages, and in some instances having been confused with the terminal stages of mania and melancholia. If this is admitted, then probably the best description of the disease is that given by V. Magnan under the term of "systematized delusional insanity," and it may be accepted that many cases conform very closely to Magnan's description.

The disease occurs with equal frequency in men and women, and in the majority of cases commences during adolescence or early adult life. The universally accepted predisposing cause is hereditary predisposition. As to the exciting causes nothing is known beyond the fact that certain forms of disease, closely resembling delusional insanity, are apparently associated or caused by chronic alcoholism or occur as a sequel to syphilitic infection. In the vast majority of cases the onset is lost in obscurity, the patient only drawing attention to the diseased condition by insane conduct after the delusional state is definitely established. The friends of such persons frequently affirm that the patient has always been abnormal. However this may be, there is no doubt that in a few cases the onset is acute and closely resembles the onset of acute melancholia. The patient is depressed, confused, suffers from hallucinations of hearing and there are disturbances of the bodily health. There is generally mal-nutrition with dyspepsia and vague neuralgic pains, often referred to the heart and intestines. Even at this stage the patient may labour under delusions. These acute attacks are of short duration and the patient apparently recovers, but not uncommonly both hallucinations and delusions persist, although they may be concealed.

The second or delusional stage sets in very gradually. This is the stage in which the patient most frequently comes under medical examination. The appearance is always peculiar and unhealthy. The manner is unnatural and may suggest a state of suspicion. The nutrition of the body is below par, and the patient frequently complains of indefinite symptoms of malaise referred to the heart and abdomen. The heart's action is often weak and irregular, but beyond these symptoms there are no special characteristic symptoms.

Mentally there may be depression when the patient is sullen and uncommunicative. It will be found, however, that he always suffers from hallucinations. At first hallucinations of hearing are the most prominent, but later all the special senses may be implicated. These hallucinations constantly annoy the patient and are always more troublesome at night. Voices make accusations through the walls, floors, roofs or door. Faces appear at the window and make grimaces. Poisonous gases are pumped into the room. Electricity, Röntgen rays and marconigrams play through the walls. The food is poisoned or consists of filth. In many cases symptoms of visceral discomfort are supposed to be the result of nightly surgical operations or sexual assaults. All these persecutions are ascribed to unknown persons or to some known person, sect or class. Under the influence of these sensory disturbances the patient may present symptoms of angry excitement, impulsive violence or of carefully-thought-out schemes of revenge; but the self-control may be such that although the symptoms are concealed the behaviour is peculiar and unreasonable. It is not uncommon to find that such patients can converse rationally and take an intelligent interest in their environments, but the implication of the capacity of judgment is at once apparent whenever the subject of the persecutions is touched upon.

All cases of delusional insanity at this stage are dangerous and their actions are not to be depended upon. Assaults are common, houses are set on fire, threatening letters are written and accusations are made which may lead to much worry and trouble before the true nature of the disease is realized.

This, the second or persecutory stage of delusional insanity, may persist through life. The patient becomes gradually accustomed to the sensory disturbances, or possibly a certain amount of mental enfeeblement sets in which reduces the mental vigour. In other cases, the disease goes on to what Magnan calls the third stage or stage of grandiose delusions. The onset of this stage is in some cases gradual. The patient, while inveighing against the persecutions, hints at a possible cause. One man is an inventor and his enemies desire to deprive him of the results of his inventions. Another is the rightful heir to a peerage, of which he is to be deprived. Women frequently believe themselves to be abducted princesses or heirs to the throne. Others of both sexes, even more ambitious, assume divine attributes and proclaim themselves Virgin Marys, Gabriels, Holy Ghosts and Messiahs. Cases are recorded in which the delusions of grandeur were of sudden onset, the patient going to bed persecuted and miserable and rising the following morning elated and grandiose. In this stage the hallucinations persist but appear to change in character and become pleasant. The king hears that arrangements are being made for his coronation and waits quietly for the event. The angel Gabriel sees visions in the heavens. The heirs and heiresses read of their prospective movements in the court columns of the daily papers and are much soothed thereby. In short, no delusion is too grotesque and absurd for such patients to believe and express.

Cases of delusional insanity never become demented in the true sense of the word, but their mental state might be described as a dream in which an imaginary existence obliterates the experiences of their past lives.

_Treatment._--No treatment influences the course of the disease.
During the stage of persecution such patients are a danger to
themselves, as they not infrequently commit suicide, and to their
supposed persecutors, whom they frequently assault or otherwise annoy.

Katatonia.

KATATONIA.--This disease, so called on account of the symptom of muscular spasm or rigidity which is present during certain of its stages, was first described and named by K. L. Kahlbaum in 1874. Many British alienists refuse to accept katatonia as a distinct disease, but as it has been accepted and further elaborated by such an authority as E. Kraepelin reference to it cannot be avoided.

Katatonia attacks women more frequently than men, and is essentially a disease of adolescence, but typical cases occasionally occur in adults. Hereditary predisposition is present in over 50% of the cases and is the chief predisposing cause. Childbirth, worry, physical strain and mental shocks are all advanced as secondary predisposing causes. The disease is one of gradual onset, with loss of physical and mental energy. Probably the earliest mental symptom is the onset of aural hallucinations. For convenience of description the disease may be divided into (1) the stage of onset; (2) the stage of stupor; (3) the stage of excitement.

The symptoms of the stage of onset are disorders of the alimentary tract, such as loss of appetite, vomiting after food and obstinate constipation. The pulse is rapid, irregular and intermittent. The skin varies between extreme dryness and drenching perspirations. In women the menstrual function is suppressed. At uncertain intervals the skeletal muscles are thrown into a condition of rigidity, but this symptom does not occur invariably. The instincts of cleanliness are in abeyance, owing to the mental state of the patient, and as a result these cases are inclined to be wet and dirty in their habits.

Mentally there is great confusion, vivid hallucinations, which apparently come on at intervals and are of a terrifying nature, for the patient often becomes frightened, endeavours to hide in corners or escape by a window or door. A very common history of such a case prior to admission is that the patient has attempted suicide by jumping out of a window, the attempt being in reality an unconscious effort on the part of the patient to escape from some imaginary danger. During these attacks the skin pours with perspiration. The patient is oblivious to his surroundings and is mentally inaccessible. In the intervals between these attacks the patient may be conscious and capable of answering simple questions. This acute stage, in which sleep is abolished, lasts from a few days to four or six weeks and then, generally quite suddenly, the patient passes into the state of stupor. In some cases a sharp febrile attack accompanies the onset of the stupor, while in others this symptom is absent; but in every case examined by Bruce during the acute stage there was an increase in the number of the white blood corpuscles, which, just prior to the onset of stupor, were sometimes enormously increased; the increase being entirely due to multiplication of the multinucleated or polymorphonuclear leucocytes.

In the second or stuporose stage of the disease the symptoms are characteristic. The patient lies in a state of apparent placidity, generally with the eyes shut. Consciousness is never entirely abolished, and many of the patients give unmistakable evidence that they understand what is being said in their presence. Any effort at passive movement of a limb immediately sets up muscular resistance, and throughout this stage the sternomastoid and the abdominal muscles are more or less in a state of over-tension, which is increased to a condition of rigidity if the patient is interfered with in any way. This symptom of restiveness or negativism is one of the characteristics of the disease. The patient resists while being fed, washed, dressed and undressed, and even the normal stimuli which in a healthy man indicate that the bladder or rectum require to be emptied are resisted, so that the bladder may become distended and the lower bowel has to be emptied by enemata. The temperature is low, often subnormal, the pulse is small and weak, and the extremities cold and livid. This symptom is probably due in some part to spasm of the terminal arterioles. Mentally the symptoms are negative. Though conscious, the patient cannot be got to speak and apparently is oblivious to what is passing around. Upon recovery, however, these cases can often recount incidents which occurred to them during their illness, and may also state that they laboured under some delusion. Coincidently with the onset of the stupor sleep returns, and many cases sleep for the greater part of the twenty-four hours. The duration of the stuporose state is very variable. In some cases it lasts for weeks, in others for months or years, and may be the terminal stage of the disease, the patient gradually sinking into dementia or making a recovery. The third stage or stage of excitement comes on in many cases during the stage of stupor: the stages overlap; while in others a distinct interval of convalescence may intervene between the termination of the stupor and the onset of the excitement. The excitement is characterized by sudden impulsive actions, rhythmical repetition of words and sounds (verbigeration), and by rhythmical movements of the body or limbs, such as swaying the whole frame, nodding the head, swinging the arms, or walking in circles. The patient may be absolutely mute in this stage as in the stage of stupor. Others again are very noisy, singing, shouting or abusive. The speech is staccato in character and incoherent. Physically the patient, who often gains weight in the stage of stupor, again becomes thin and haggard in appearance owing to the incessant restlessness and sleeplessness which characterize the stage of excitement. The patient may, during the stage of onset, die through exhaustion, or accidentally and unconsciously commit suicide usually by leaping from a window. During the stuporose stage symptoms of tubercular disease of the lungs may commence. All the adolescent insane are peculiarly liable to contract and die from tubercular disease. Accidental suicide is also liable to occur during this stage. The stage of excitement, if at all prolonged, invariably ends in dementia. According to Kraepelin 13% of the cases recover, 27 make partial recoveries, and 60% become more or less demented.

_Treatment._--No treatment arrests or diverts the course of katatonia,
and the acute symptoms of the disease as they arise must be treated on
hospital principles.

Hebephrenia.

HEBEPHRENIA.--This is a disease of adolescence (Gr. [Greek: hêbê]) which was first described by Hecker and Kahlbaum and more recently by Kraepelin and other foreign workers. Hebephrenia is not yet recognized by British alienists. The descriptions of the disease are indefinite and confusing, but there are some grounds for the belief that such an entity does exist, although it is probably more correct to say that as yet the symptoms are very imperfectly understood. Hebephrenia is always a disease of adolescence and never occurs during adult life. It attacks women more frequently than men, and according to Kahlbaum hereditary predisposition to insanity is present in over 50% of the cases attacked. The onset of the disease is invariably associated with two symptoms. On the physical side an arrested or delayed development and on the mental a gradual failure of the power of attention and concentrated thought. The onset of the condition is always gradual and the symptoms which first attract attention are mental. The patient becomes restless, is unable to settle to work, becomes solitary and peculiar in habits and sometimes dissolute and mischievous. As the disease advances the patient becomes more and more enfeebled, laughs and mutters to himself and wanders aimlessly and without object. There is no natural curiosity, no interest in life and no desire for occupation. Later, delusions may appear and also hallucinations of hearing, and under their influence the patient may be impulsive and violent. Physically the subjects are always badly developed. The temperature is at times slightly elevated and at intervals the white blood corpuscles are markedly increased. The menstrual function in women is suppressed and both male and female cases are addicted to masturbation. According to Kraepelin 5% of the cases recover, 15% are so far relieved as to be able to live at home, but are mentally enfeebled, the remaining 80% become hopelessly demented. The patients who recover frequently show at the onset of their disease acute symptoms, such as mild excitement, slightly febrile temperature and quick pulse-rate. When recovery does take place there is marked improvement in development. The subjects of hebephrenia are peculiarly liable to tubercular infection and many die of phthisis.

There is no special treatment for hebephrenia beyond attention to the
general health.

Traumatic Insanity.

INSANITY FOLLOWING UPON INJURIES TO THE BRAIN, OR APOPLEXIES OR TUMOURS OR ARTERIAL DEGENERATION. (a) _Traumatic Insanity._--Insanity following blows on the head is divided into (1) the forms in which the insanity immediately follows the accident; (2) the form in which there is an intermediate prodromal stage characterized by strange conduct and alteration in disposition; and (3) in which the mental symptoms occur months or years after the accident, which can have at most but a remote predisposing causal relation to the insanity. The cases which immediately succeed injuries to the head are in all respects similar to confusional insanity after operations or after fevers. There is generally a noisy incoherent delirium, accompanied by hallucinations of sight or of hearing, and fleeting unsystematized delusions. The physical symptoms present all the features of severe nervous shock.

In those cases in which there is an intervening prodromal condition, with altered character and disposition, there is usually a more or less severe accidental implication of the cortex cerebri, either by depression of bone or local hemorrhage, or meningitic sub-inflammatory local lesions. Most of the cases during the prodromal stage are sullen, morose or suspicious, and indifferent to their friends and surroundings. At the end of the prodromal stage there most usually occurs an attack of acute mania of a furious impulsive kind. The cases which for many years after injury are said to have remained sane will generally be found upon examination and inquiry to exhibit symptoms of hereditary degeneration or of acquired degeneracy, which may or may not be a consequence of the accident.

The most common site of vascular lesion is one of the branches of the middle cerebral artery within the sylvian fissure, or of one of the smaller branches of the same artery which go directly to supply the chief basal ganglia. When an artery like the middle cerebral or one of its branches becomes either through rupture or blocking of its lumen, incapable of performing its function of supplying nutrition to important cerebral areas, there ensues devitality of the nervous tissues, frequently followed by softening and chronic inflammation. It is these secondary changes which give rise to and maintain those peculiar mental aberrations known as post-apoplectic insanity.

Various characteristic physical symptoms, depending upon the seat of the cerebral lesion, are met with in the course of this form of insanity. These consist of paraplegias, hemiplegias and muscular contractures. Speech defects are very common, being due either to the enfeebled mental condition, to paralysis of the nerve supplying the muscles of the face and tongue, or to aphasia caused by implication of those parts of the cortex which are intimately associated with the faculty of speech. Mental symptoms vary considerably in different cases and in accordance with the seat and extent of the lesion. There is almost always present, however, a certain degree of mental enfeeblement, accompanied by loss of memory and of judgment, often by mental confusion. Another very general mental symptom is the presence of emotionalism which leads the patient to be affected either to tears or to laughter upon trifling and inadequate occasions.

Cerebral tumours do not necessarily produce insanity. Indeed it has been computed that not one half of the cases become insane. When insanity appears it is met with in all degrees varying from slight mental dulness up to complete dementia, and from mere moral perversion up to the most intense form of maniacal excitement. On the physical side the various symptoms of cerebral tumour such as coma, ataxia, paralysis, headache, vomiting, optic neuritis and epileptiform convulsions are met with. All forms of so-called moral changes and of changes of disposition are met with as mental symptoms and all the ordinary forms of insanity may occur in varying intensity; but by far the most common mental change occurring in connexion with cerebral tumour is a progressive enfeeblement of the intelligence, unattended with any more harmful symptoms than mental deterioration which ends in complete dementia.

Insanity due to Arterial Degeneration.

(b) _Arterial Degeneration._--Arterial degeneration is a common cause of mental impairment, especially of that form of mental affection known as "Early" dementia. It also predisposes to embolism and thrombosis, which often results in the paralytic and aphasic groups of nerve disturbance, and which are always accompanied by more or less marked interference with normal cerebral action.

The commonest seat for atheroma of the cerebral vessels is the arteries at the base of the brain and their main branches, especially the middle cerebral. As a general rule the other arteries of the cerebrum are not implicated to the same extent, although in a not inconsiderable number of cases of the disease all the arteries of the brain may participate in the change. When this is so, we obtain those definite symptoms of slowly advancing dementia commencing in late middle life and ending in complete dementia before the usual period for the appearance of senile dementia. The same appearances are met with in certain patients who have attained the age in which senile changes in the arteries are not unexpected. As a rule atheroma in the cerebral vessels is but a part of a general atheroma of all the arteries of the body. Atheroma is common after middle life and increases in frequency with age. The chief causes are syphilis, alcoholism, the gouty and rheumatic diatheses and above all Bright's disease of the kidneys. Perhaps certain forms of Bright's disease, owing to the tendency to raise the blood pressure, are of all causes the most common.

It is not easy to say to what extent, alone, the arteriosclerosis is effectual in inducing the gradual failure of the mental powers, and to what extent it is assisted in its operation by the action on the brain-cells of the general toxic substances which give rise to the arterial atheroma. In any case there can be no question that the gradual mechanical diminution of the blood-supply to the cortex caused by the occlusion of the lumen of the arteries is a factor of great importance in the production of mental incapacity.

General Paralysis.

GENERAL PARALYSIS OF THE INSANE (syn. General Paralysis, _dementia paralytica_, progressive dementia) is a disease characterized by symptoms of progressive degeneration of the central nervous system, more particularly of the motor centres. The disease is almost invariably fatal. Apparent recoveries do very occasionally occur, though this is denied by the majority of alienists. The disease is in every case associated with gradually advancing mental enfeeblement, and very frequently is complicated by attacks of mental disease.

General paralysis, which is a very common disease, was first recognized in France; it was identified by J. E. D. Esquirol, and further described and elaborated by A. L. J. Bayle, Delaye and J. L. Calmeil, the latter giving it the name of _paralysie générale des aliénés_.

As first described by the earlier writers the disease was regarded as being invariably associated with delusions of grandeur. At the present day this description does not apply to the majority of cases admitted into asylums. The change may be explained as being either due to an alteration in the type of the disease, or more probably the disease is better understood and more frequently diagnosed than formerly, the diagnosis being now entirely dependent on the physical and not on the mental symptoms. This latter may also be the explanation why general paralysis is much more common at the present day in British asylums than it was. The total death-rate from this disease in English and Scottish asylums rose from 1321 in 1894 to 1795 in 1904.

General paralysis attacks men much more frequently than women, and occurs between the ages of 35 and 50 years. It is essentially a disease of town life. In asylums which draw their patients from country districts in Scotland and Ireland, the disease is rare, whereas in those which draw their population from large cities the disease is extremely common.

Considerable diversity of opinion exists at present regarding the causation of general paralysis. Hereditary predisposition admittedly plays a very small part in its causation. There is, however, an almost universal agreement that the disease is essentially the result of toxaemia or poisoning, and that acquired or inherited syphilitic infection is an important predisposing factor. A history of syphilitic infection occurs in from 70 to 90% of the patients affected. At first it was held that general paralysis was a late syphilitic manifestation, but as it was found that no benefit followed the use of anti-syphilitic remedies the theory was advanced that general paralysis was a secondary auto-intoxication following upon syphilitic infection. The latest view is that the disease is a bacterial invasion, to which syphilis, alcoholism, excessive mental and physical strain, and a too exclusively nitrogenous diet, only act as predisposing causes. This latter theory has been recently advanced and elaborated by Ford Robertson and McRae of Edinburgh.

Whatever the cause of general paralysis may be, the disease is essentially progressive in character, marked by frequent remissions and so typical in its physical symptoms and pathology that we regard the bacterial theory with favour, although we are far from satisfied that the actual causative factor has as yet been discovered.

For descriptive purposes the disease is most conveniently divided into three stages,--called respectively the first, second and third,--but it must be understood that no clear line of demarcation divides these stages from one another.

The onset of general paralysis is slow and gradual, and the earliest symptoms may be either physical or mental. The disease may commence either in the brain itself or the spinal cord may be primarily the seat of lesion, the brain becoming affected secondarily. When the disease originates in the spinal cord the symptoms are similar to those of locomotor ataxia, and it is now believed that general paralysis and locomotor ataxia are one and the same disease; in the one case the cord, in the other the brain, being the primary seat of lesion. The early physical symptoms are generally motor. The patient loses energy, readily becomes tired, and the capacity for finely co-ordinated motor acts, such as are required in playing games of skill, is impaired. Transient attacks of partial paralysis of a hand, arm, leg or one side of the body, or of the speech centre are not uncommon. In a few cases the special senses are affected early and the patient may complain of attacks of dimness of vision or impairment of hearing. Or the symptoms may be purely mental and affect the highest and most recently acquired attributes of man, the moral sense and the faculty of self-control. The patient then becomes irritable, bursts into violent passions over trifles, changes in character and habits, frequently takes alcohol to excess and behaves in an extravagant, foolish manner. Theft is often committed in this stage and the thefts are characterized by an open, purposeless manner of commission. The memory is impaired and the patient is easily influenced by others, that is to say he becomes facile. In other cases a wild attack of sudden excitement, following upon a period of restlessness and sleeplessness may be the first symptom which attracts attention. Whatever the mode of onset the physical symptoms which characterize the disease come on sooner or later. The speech is slurred and the facial muscles lose their tone, giving the face a flattened expression. The muscular power is impaired, the gait is straddling and the patient sways on turning. All the muscles of the body, but particularly those of the tongue, upper lip and hands, which are most highly innervated, present the symptom of fine fibrillary tremors. The pupils become irregular in outline, often unequal in size and either one or both fail to react normally to the stimuli of light, or of accommodation for near or distant vision.

As the disease advances there is greater excitability and a tendency to emotionalism. In classical cases the general exaltation of ideas becomes so great as to lead the patient to the commission of insanely extravagant acts, such as purchases of large numbers of useless articles, or of lands and houses far beyond his means, numerous indiscriminate proposals of marriage, the suggestion of utterly absurd commercial schemes, or attempts at feats beyond his physical powers. The mental symptoms, in short, are very similar to those of the elevated stage of manic-depressive insanity.

Delusions of the wildest character may also be present. The patient may believe himself to be in possession of millions of money, to be unsurpassed in strength and agility, to be a great and overruling genius, and the recipient of the highest honours. This grandiose condition is by no means present in every case and is not in itself diagnostic of the disease. But mental facility, placid contentment, complete loss of judgment and affection for family and friends, with impaired memory, are symptoms universally present. As the disease advances the motor symptoms become more prominent. The patient has great difficulty in writing, misses letters out of words, words out of sentences, and writes in a large laboured hand. The expression becomes fatuous. The speech is difficult and the facial muscles are thrown into marked tremors whenever any attempt at speech is made. The voice changes in timbre and becomes high-pitched and monotonous. The gait is weak and uncertain and the reflexes are exaggerated. In the first stage the patient, through restlessness and sleeplessness, becomes thin and haggard. As the second stage approaches sleep returns, the patient lays on flesh and becomes puffy and unhealthy in appearance. The mental symptoms are marked by greater facility and enfeeblement, while the paralysis of all the muscles steadily advances. The patient is now peculiarly liable to what are called congestive seizures or epileptiform attacks. The temperature rises, the face becomes flushed and the skin moist. Twitchings are noticed in a hand or arm. These twitchings gradually spread until they may involve the whole body. The patient is now unconscious, bathed in perspiration, which is offensive. The bowels and bladder empty themselves reflexly or become distended, and bedsores are very liable to form over the heels, elbows and back. Congestive seizures frequently last for days and may prove fatal or, on the other hand, the patient may have recurrent attacks and finally die of exhaustion or some accidental disease, such as pneumonia. In the second stage of the disease the patient eats greedily, and as the food is frequently swallowed unmasticated, choking is not an uncommon accident. The special senses of taste and smell are also much disordered. We have seen a case of general paralysis, in the second stage drink a glass of quinine and water under the impression that he was drinking whisky.

The third stage of the disease is characterized by sleeplessness and rapid loss of body weight. Mentally the patient becomes quite demented. On the physical side the paralysis advances rapidly, so that the patient becomes bedridden and speechless. Death may occur as the result of exhaustion, or a congestive seizure, or of some intercurrent illness.

The duration of the disease is between eighteen months and three years, although it has been known to persist for seven.

No curative measures have so far proved of any avail in the treatment
of general paralysis.

Epileptic Insanity.

INSANITY ASSOCIATED WITH EPILEPSY.--The term "epileptic insanity," which has for many years been in common use, is now regarded as a misnomer. There is in short no such disease as epileptic insanity. A brain, however, which is so unstable as to exhibit the sudden discharges of nervous energy which are known as epileptic seizures, is prone to be attacked by insanity also, but there is no form of mental disease exclusively associated with epilepsy. Many epileptics suffer from the disease for a lifetime and never exhibit symptoms of insanity. The majority of patients, however, who suffer from epilepsy are liable to exhibit certain mental symptoms which are regarded as characteristic of the disease. Some suffer from recurrent attacks of depression, ill-humour and irritability, which may readily pass into violence under provocation. Others are emotionally fervid in religious observances, though sadly deficient in the practice of the religious life. A third class are liable to attacks of semi-consciousness which may either follow upon or take the place of a seizure, and during these attacks actions are performed automatically and without consciousness on the part of the patient.

When epileptics do become insane the insanity is generally one of the forms of mania. Either the patient suffers from sudden furious attacks of excitement in which consciousness is entirely abolished, or the mania is of the type of the elevated stage of folie circulaire (manic-depressive insanity) and alternates with periods of deep depression. In the elevated period the patient shows exaggerated self-esteem, with passionate outbursts of anger, and periods of religious emotionalism. While in the stage of depression the patient is often actively suicidal.

Epileptic patients who suffer from recurrent attacks of delirious mania are liable to certain nervous symptoms which indicate that not only are the motor centres in the brain damaged, but that the motor tracts in the spinal cord are also affected. The gait becomes awkward and laboured, the feet being lifted high off the ground and the legs thrown forward with a jerk. The tendon reflexes are at the same time exaggerated. These symptoms indicate descending degeneration of the motor tracts of the cord.

If the mental attacks partake of the character of elevation or depression the mental functions suffer more than the motor. These patients, in course of time, become delusional, enfeebled and childish, and in some cases the enfeeblement ends in complete dementia of a very degraded type.

Where insanity is superadded to epilepsy the prognosis is unfavourable.

Toxic Insanity.

INSANITY ASSOCIATED WITH OR CAUSED BY ALCOHOLIC AND DRUG INTOXICATION.--The true rôle of alcoholic indulgence in the production of insanity is at present very imperfectly understood. In many cases the alcoholism is merely a symptom of the mental disease--a result, not a cause. In others, alcohol seems to act purely as a predisposing factor, breaking down the resistance of the patient and disordering the metabolism to such an extent that bodily disorders are engendered which produce well-marked and easily recognized mental symptoms. In others, again, alcohol itself may possibly act as a direct toxin, disordering the functions of the brain. In the latter class may be included the nervous phenomena of drunkenness, which commence with excitement and confusion of ideas, and terminate in stupor with partial paralysis of all the muscles. Certain brains which, either through innate weakness or as the result of direct injury, have become peculiarly liable to toxic influences, under the influence of even moderate quantities of alcohol pass into a state closely resembling delirious mania, a state commonly spoken of as _mania a potu_.

_Delirium Tremens._--Delirium tremens is the form of mental disorder most commonly associated with alcoholic indulgence in the lay mind. Considerable doubt exists, however, as to whether the disease is directly or secondarily the result of alcoholic poisoning. Much evidence exists in favour of the latter supposition. Delirium tremens may occur in persons who have never presented the symptom of drunkenness, or it may occur weeks after the patient has ceased to drink alcohol, and in such cases the actual exciting cause of the disease may be some accidental complication, such as a severe accident, a surgical operation, or an attack of pneumonia or erysipelas.

The early symptoms are always physical. The stomach is disordered. The desire for food is absent, and there may be abdominal pain and vomiting. The hands are tremulous, and the patient is unable to sleep. At this stage the disease may be checked by the administration of an aperient and some sedative such as bromide and chloral. The mental symptoms vary greatly in their severity. In a mild case one may talk to the patient for some time before discovering any mental abnormality, and then it will be found that confusion exists regarding his position and the identity of those around him, while the memory is also impaired for recent events. Hallucinations of sight and hearing may be present. The hallucinations of sight may be readily induced by pressure upon the eyeballs. If the symptoms are more acute they usually come on suddenly, generally during the evening or night. The patient becomes excited, suffers from vivid hallucinations of sight and hearing which produce great fear, and these hallucinations may be so engrossing as to render him quite oblivious to the environment. The hallucinations of sight are characterized by the false sense impressions taking the forms of animals or insects which surround or menace the patient. Visions may also appear in the form of flames, goblins or fairies. The hallucinations of hearing rarely consist of voices, but are more of the nature of whistlings, and ringings in the ears, shouts, groans or screams which seem to fill the air, or emanate from the walls or floors of the room. All the special senses may be affected, but sight and hearing are always implicated. Delirium tremens is a short-lived disease, generally running its course in from four to five days. Recovery is always preceded by the return of the power of sleep.

The patient must be carefully nursed and constantly watched, as
homicidal and suicidal impulses are liable to occur under the
terrifying influence of the hallucinations. The food should be
concentrated and fluid, given frequently and in small quantities.

_Chronic Alcoholic Insanity._--Almost any mental disorder may be associated with chronic alcoholism, but the most characteristic mental symptoms are delusions of suspicion and persecution which resemble very closely those of the persecution stage of systematized delusional insanity. The appearance of the patient is bloated and heavy; the tongue is furred and tremulous, and symptoms of gastric and intestinal disorder are usually present. The gait is awkward and dragging, owing to the partial paralysis of the extensor muscles of the lower limbs. All the skeletal muscles are tremulous, particularly those of the tongue, lips and hands. The common sensibility of the skin is disordered so that the patient complains of sensory disturbances, such as tinglings and prickings of the skin, which may be interpreted as electric shocks. In some cases the mental symptoms may be concealed, but delusions and hallucinations, particularly hallucinations of sight and hearing, are very commonly present. The delusions are often directly the outcome of the physical state; the disordered stomach suggesting poisoning, and the disturbances of the special senses being interpreted as various forms of persecution. The patient hears voices shouting foul abuse at him; all his thoughts are read and repeated aloud; electric shocks are sent through him at night; gases are pumped into his room. Sexual delusions are very common and frequently affect marital relations by arousing suspicions regarding the fidelity of wife or husband; or the delusions may be more gross and take the form of belief in actual attempts at sexual mutilations. The memory is always impaired.

Patients who in addition to chronic alcoholism are also insane are always dangerous and liable to sudden and apparently causeless outbursts of violence.

_Dipsomania._--Dipsomania is a condition characterized by recurrent or periodic attacks of an irresistible craving for stimulants. The general bodily condition has a great deal to do with the onset of the attack, that is to say, the patient is more liable to an attack when the bodily condition is low than when the health is good. The attacks may be frequent or recur at very long intervals. They generally last for a few weeks, and may be complicated by symptoms of excitement, delusions or hallucinations.

_Treatment_ consists in attention to the general health between
attacks, with the use of such tonics as arsenic and strychnine. During
the attack the patient should be confined to bed and treated with
sedatives.

_Morphinism._--The morphia habit is most commonly contracted by persons of a neurotic constitution. The mental symptoms associated with the disease may arise either as the result of an overdose, when the patient suffers from hallucinations, confusion and mild delirium, frequently associated with vomiting. On the other hand, mental symptoms very similar to those of delirium tremens may occur as the result of suddenly cutting off the supply of morphia in a patient addicted to the habit. Finally, chronic morphia intoxication produces mental symptoms very similar to those of chronic alcoholism. This latter condition, characterized by delusions of persecution, mental enfeeblement and loss of memory, is hopelessly incurable. The patient is always thin and anaemic on account of digestive disturbances. There is weakness or slight paralysis of the lower limbs, and the skeletal muscles are tremulous.

_Treatment._--The quantity of the drug used must be gradually reduced
until it is finally discontinued, and during treatment the patient
must be confined to bed.

Senile Insanity.

SENILE INSANITY.--States of mental enfeeblement are always the result of failure of development or of structural changes in the cortical grey matter of the brain. If the enfeeblement is due to failure of development or brain damage occurring in early life, it is spoken of as _idiocy_ or imbecility. Every form of insanity which occurs after a certain period of life is apt to be regarded by some observers as senile, but although the failing mental power may colour the character of the symptoms it cannot be regarded as correct to designate, for instance, a recurrent form of mania as senile merely because it necessarily manifests itself in a subject who has lived into the senile period. On the other hand, many persons first suffer from mental derangement at an advanced period of life without at the same time manifesting any marked failure of mental power, while others only manifest their insanity as a result of the decay of their mental faculties.

From this statement it will be seen that senile insanity is a complex of different conditions, some of them accompanied by dementia, others without dementia.

_Senile Dementia_ is distinguished occasionally into "senile" properly so called, and "presenile" dementia, which supervenes at middle age or even earlier.

The occurrence of dementia is sometimes preceded by an acute hallucinatory phase, accompanied by mania or melancholia; but as a general rule, in the presenile cases, by neurasthenia, indifference, and mental apathy which extends to a disregard for the ordinary conventions and the means of subsistence.

It has pithily been remarked that the age of a man is the age of his blood-vessels. The two conditions of senile and presenile dementia cannot therefore be separated scientifically. From a clinical point of view, however, the two are distinguishable in so far as their symptoms are concerned, for the presenile cases are more complete and the process of dementia achieves its consummation earlier and quicker, while in the senile the gradual disease of the arteries and the slow decay of the mental faculties offer a different background for the manifestation of mental symptoms. Moreover, the senile patients more frequently present symptoms of recurrent attacks of acute insanity, a more pronounced emotionalism, and a greater tendency to restlessness at night. The presenile cases, on the other hand, except at the commencement of their malady, are usually free from acute and troublesome symptoms and present chiefly an apathetic indifference and irresponsiveness on the mental side, and on the physical side a neurasthenic and enfeebled bodily state. In both conditions memory is greatly impaired.

Added to senile dementia there is often found a condition of mania or melancholia or even of systematized delusional insanity. The chief symptoms of the maniacal attacks are the great motor restlessness and excitement, which are worst during the night time. Sleep is almost always seriously disturbed, and the patients rapidly become exhausted unless carefully nursed and tended. The actions of senile maniacs are often puerile and foolish, and they may exhibit impulses of a homicidal, suicidal or sexual character. The melancholic cases are also extremely restless, and their emotion is loudly expressed in an uncontrollable manner. They often have delusions of persecution. Their cries and groans have an automatic character, as if the patient, though compelled to utter them, did not experience the mental pain which he expressed. They also, many of them, eat their food ravenously, although a few obstinately refuse it. The senile delusional cases may manifest any of the classical forms of paranoia described above, but their delusions are of a rudimentary and unfinished type. The most common of all senile delusions is that they are being robbed. They therefore often hide their small valuables in corners and out-of-the-way places, and as their memories are very defective they are afterwards unable to find them. Others, who live alone, barricade their doors and try to prevent any one entering for fear of thieves. Delusions of ambition in senile subjects are usually of a very improbable and childish character. Hallucinations are generally present in the senile delusional cases.

The _treatment_ of senile insanity is from the medical point of view
not hopeful; it resolves itself largely into instructions for careful
nursing, suitable feeding, and the protection of the patient from all
the physical dangers to which he may be exposed.

_Statistics._--The statistics of lunacy are merely of interest from a
sociological point of view; for under that term are comprised all
forms of insanity. It is needless to produce tables illustrative of
the relative numbers of lunatics in the various countries of Europe,
the systems of registration being so unequal in their working as to
afford no trustworthy basis of comparison.

Even in Great Britain, where the systems are more perfect than in any
other country, the tables published in the Blue Books of the three
countries can only be regarded as approximately correct, the
difficulty of registering all cases of lunacy being insuperable. On
the 1st of January 1907, according to the returns made to the offices
of the Commissioners in Lunacy, the numbers of lunatics stood thus on
the registers:--

+------------------+--------+----------+---------+
| | Males. | Females. | Totals. |
+------------------+--------+----------+---------+
| England and Wales| 57,176 | 66,812 | 123,988 |
| Scotland | 8,594 | 8,999 | 17,593 |
| Ireland | 12,254 | 11,300 | 23,554 |
+------------------+--------+----------+---------+
| Gross total | 78,024 | 87,111 | 165,135 |
+------------------+--------+----------+---------+

These figures show the ratio of lunatics to 100,000 of the population
to be 354 in England and Wales, 312 in Scotland, and 538 in Ireland.

_Numbers of Lunatics on the 1st of January of the years 1857-1907
inclusive, according to Returns made to the Offices of the
Commissioners in Lunacy for England and Wales, Scotland and Ireland._

+------+---------+----------+----------+
| | England | | |
|Years.| and | Scotland.| Ireland. |
| | Wales. | | |
+------+---------+----------+----------+
| 1858 | .. | 5,823 | .. |
| 1859 | 36,762 | 6,072 | .. |
| 1860 | 38,058 | 6,273 | .. |
| 1861 | 39,647 | 6,327 | .. |
| 1862 | 41,129 | 6,398 | 8,055 |
| 1863 | 43,118 | 6,386 | 7,862 |
| 1864 | 44,795 | 6,422 | 8,272 |
| 1865 | 45,950 | 6,533 | 8,845 |
| 1866 | 47,648 | 6,730 | 8,964 |
| 1867 | 49,086 | 6,888 | 8,962 |
| 1868 | 51,000 | 7,055 | 9,086 |
| 1869 | 53,177 | 7,310 | 9,454 |
| 1870 | 54,713 | 7,571 | 10,082 |
| 1871 | 56,755 | 7,729 | 10,257 |
| 1872 | 58,640 | 7,849 | 10,767 |
| 1873 | 60,296 | 7,982 | 10,958 |
| 1874 | 60,027 | 8,069 | 11,326 |
| 1875 | 63,793 | 8,225 | 11,583 |
| 1876 | 64,916 | 8,509 | 11,777 |
| 1877 | 66,636 | 8,862 | 12,123 |
| 1878 | 68,538 | 9,097 | 12,380 |
| 1879 | 69,885 | 9,386 | 12,585 |
| 1880 | 71,191 | 9,624 | 12,819 |
| 1881 | 73,113 | 10,012 | 13,062 |
| 1882 | 74,842 | 10,355 | 13,444 |
| 1883 | 76,765 | 10,510 | 13,882 |
| 1884 | 78,528 | 10,739 | 14,088 |
| 1885 | 79,704 | 10,918 | 14,279 |
| 1886 | 80,156 | 11,187 | 14,590 |
| 1887 | 80,891 | 11,309 | 14,702 |
| 1888 | 82,643 | 11,609 | 15,263 |
| 1889 | 84,340 | 11,954 | 15,685 |
| 1890 | 86,067 | 12,302 | 16,159 |
| 1891 | 86,795 | 12,595 | 16,251 |
| 1892 | 87,848 | 12,799 | 16,688 |
| 1893 | 89,822 | 13,058 | 17,124 |
| 1894 | 92,067 | 13,300 | 17,276 |
| 1895 | 94,081 | 13,852 | 17,665 |
| 1896 | 96,446 | 14,093 | 18,357 |
| 1897 | 99,365 | 14,500 | 18,966 |
| 1898 | 101,972 | 14,906 | 19,590 |
| 1899 | 105,086 | 15,399 | 20,304 |
| 1900 | 106,611 | 15,663 | 20,863 |
| 1901 | 107,944 | 15,899 | 21,169 |
| 1902 | 110,713 | 16,288 | 21,630 |
| 1903 | 113,964 | 16,658 | 22,138 |
| 1904 | 117,199 | 16,894 | 22,794 |
| 1905 | 119,829 | 17,241 | 22,996 |
| 1906 | 121,979 | 17,450 | 23,365 |
| 1907 | 123,988 | 17,593 | 23,554 |
+------+---------+----------+----------+

There is thus an increased ratio in England and Wales of lunatics to
the population (which in 1859 was 19,686,701, and in 1907 was
estimated at 34,945,600) of 186.8 per 100,000 as against 354.8, and in
Scotland of 157 as against 312 per 100,000. The Irish figures on the
same basis have increased from 130.9 in 1862 to 538.1 in 1907. The
publication of these figures has given rise to the question whether
lunacy has actually become more prevalent during the last twenty
years, whether there is real increase of the disease. There is a
pretty general consent of all authorities that if there has been an
increase it is very slight, and that the apparent increase is due,
first to the improved systems of registration, and secondly (a far
more powerful reason) to the increasing tendency among all classes,
and especially among the poorer class, to recognize the less
pronounced forms of mental disorder as being of the nature of
insanity. Thirdly, the grant of four shillings per week which in 1876
was made by parliament from imperial sources for the maintenance of
pauper lunatics has induced parochial authorities to regard as
lunatics a large number of weak-minded paupers, and to force them into
asylums in order to obtain the benefit of the grant and to relieve the
rates. These views receive support from the fact that the increase of
private patients, i.e. patients who are provided for out of their own
funds or those of the family, has advanced in a vastly smaller ratio.
In their case the increase, small as it is, can be accounted for by
the growing disinclination on the part of the community to tolerate
irregularities of conduct due to mental disease. And again, careful
inquiry has failed to show a proportional increase of admissions into
asylums of such well-marked forms as general paralysis, puerperal
mania, &c. The main cause of the registered increase of lunatics is
thus to be sought for in the improved registration, and parochial and
family convenience. If there is an actual increase, and there is
reason for believing that there is a slight actual increase, it is due
to the tendency of the population to gravitate towards towns and
cities, where the conditions of health are inferior to those of rural
life, and where there is therefore a greater disposition to disease of
all kinds.