Volume 5 — DISEASES OF THE NERVOUS SYSTEM. (continued 5)

S. K. Towle has reported the case of a man whom he had under his care at the Soldiers' Home near Milwaukee, Wis., as follows: “He had been a lieutenant in a volunteer regiment, and I gave him rather more privileges on that account, but after a time I found that he was more nearly an example of total depravity than I had ever seen. There was no truth in him, and he was intelligent enough to make his lies often seem plausible to me as well as to others. By his writing and talking and conduct generally he kept the patients and their friends in a ferment, and gave me more trouble than the whole hospital besides. He had a small scar about the middle of his forehead, which he said was due to a slight flesh wound from a glancing ball in battle. While he was under my care an older brother came to see him, and he told me that up to the time his brother, my patient, who so tried my patience, entered the army he was almost a model young man, amiable and affectionate, the pet of the whole family and intimate friends; ‘But,’ said he, ‘ever since he came back he has been possessed of a devil if ever any one was.’ After a time, much to my delight, he asked for a transfer to the Soldiers' Home at Dayton, Ohio, which I got for him with commendable alacrity; and he went there. His conduct at Dayton was the same as with me, but after a few months he quite suddenly died, when an autopsy was made. In sawing open the skull, at the point of the small scar on his forehead the saw came directly upon the butt end of a conical bullet, two-thirds of which projected through the skull, piercing the membranes and into the brain. The internal table of the skull had been considerably splintered by the ball, the pieces not being entirely separated, and there was evidence of severe chronic inflammation all around, and quite a collection of pus in the brain where the ball projected into it. Here was the devil that had possessed the poor fellow—that not only took his life, but destroyed his character, lost him the love and esteem of his friends, and doomed him for half a dozen years to do things he would most have hated and despised when he was himself. Dunlap, the assistant surgeon at Dayton, told me that he found in this man's trunk letters from several—half a dozen, I think, at least—women in various places, from which it appeared that he was engaged to be married to each one of them. The letters were neatly tied up in packages, each one's separately, in several instances with photographs supposed to be of the writers, and the date of reception and reply was noted on many of the letters in a business-like way.”

As Westphal well says¹⁵ of such persons, “They often think correctly and logically, and show reflection and deliberation to a certain degree; but there is a certain something lacking, and there are some general conceptions, general processes of thought and judgment, of which they are incapable. Their mentality stops short on a certain plane, especially in matters of judgment where every even uneducated person easily succeeds. They sometimes act as if they had good judgment and common sense, of which they are really destitute, particularly in regard to the proprieties of life and their proper social relations and duties. Certain of the finer feelings are absolutely impossible of development in them. Through their various nets, perverted by their mental defect, the patients often seem perverse (bösartig), passionate (leidenschaftlich), although of true sustained passion they are incapable. What seems passion is a sudden idea or fitful impulse to which they yield at once. Moral insanity is a defect in the affective sphere, but also an intellectual defect of a peculiar kind, which is often concealed under the mask of a perverted moral sense, and which requires time and practice on the part of the physician for its detection.”

¹⁵ Berl. klin. Wochenchrift, 1878, No. 15.

Moral insanity is quite certain to pursue a downward course, although something can be done by training, general hygiene, simple diet, mental discipline, avoiding overwork, a judicious choice of the few occupations of which the moral insane are capable, and a constant steadying hand to help them try to keep their balance.

IMPULSIVE INSANITY is perhaps more properly called instinctive monomania, as the morbid impulse is usually shown in only one insane propensity at a time. Like moral insanity, its manifestations are commonly periodic, or at least alternating. Under the name of emotional insanity it furnishes sympathetic juries with an excuse for finding not guilty of murder women who kill their betrayers and husbands who shoot a wife's seducer. It is a not uncommon symptom in a considerable proportion of the persons suffering from the various forms of insanity. As a separate disease it is quite rare, and includes those persons whose insanity is manifested, as Marc says, by what they do rather than by what they say. The insane impulse does not come from any logical process. It is rarely provoked by or associated with a criminal motive, except in an analogous way to the production by excitement of an epileptic attack, to which, indeed, it offers some points of similarity. There would be reason to doubt the existence of the disease unless other indications of mental degeneration were present, especially where there is proof of a criminal motive or where the criminal act and the prisoner's statements are the sole evidence of unsoundness of mind. Unconsciousness, even temporary, and loss of memory, are not symptoms of instinctive monomania. On the contrary, the mind is quite clear, and resists successfully the insane impulse so long that the person affected with it has often gained confidence that he will never yield to it; and he soon learns the fact that, there being in circumstances external to himself no reason for the crime suggested to the mind with such force, temptations do not occur to the act. While the impulse lasts a great variety of distressing mental symptoms accompany it, so intense that the impulse often cannot be resisted, and then the terrible brain-tension is relieved. I doubt whether hallucinations of hearing are found in impulsive insanity, and incline to think that all the reported cases where crimes of impulse have been committed in obedience to a voice commanding the individual to do this or that act of violence are more properly classified under other forms of mental disease. One kind of instinctive monomania sometimes disappears to be replaced by another. In developing boys and girls there is not seldom a pathological mental state during which lying, stealing, running away from home, etc. are common for several months or a few years; but this is a curable condition, and does not by any means necessarily end in instinctive monomania.

Suicidal insanity is probably the most common form of instinctive monomania. The force, or even presence, of the suicidal impulse is largely dependent upon the general tone of the system. The suicidal idea is common; it occurs to the minds of a vast number of sane people at one time or another under adverse circumstances. Hysterical women talk a lot of nonsense on the subject. Self-destruction due to self-depreciation, weariness of life, and general gloom is not uncommon in the insane temperament. It is also a refuge to proud and sensitive people who have sacrificed their honor. But this is quite different from suicidal insanity, in which the impulse is often strongest at a time when there are the most reasons for living and the greatest happiness in life if the tormenting demon urging to self-murder could be excluded. Such people finally kill themselves, in spite of their best resolutions and efforts to the contrary, if the various faculties of the mind become more and more involved as the disease goes on and the power of self-control is progressively weakened. More general insanity of the degenerative type is sometimes developed from suicidal insanity.

Homicidal insanity is fortunately still rarer than the last-mentioned form, although motiveless homicidal ideas occur to husbands and wives and parents with reference to those dearest to them, under conditions of prolonged mental strain or exhaustion, during pregnancy and the puerperal state, and at the climacterium. In suspected crimes the evidence of homicidal insanity should be clear and should rest upon the general signs of the degenerative mental state. Homicidal impulses are common enough among the insane. Just as there are persons who do not dare to have sharp instruments in their rooms for fear of killing themselves, so there are others to whose minds axes, knives, and razors suggest imperative conceptions of plans for killing another. It is difficult in either case for the physician to satisfy himself at what point real insanity begins. Seclusion under the morbid influences of an asylum is very bad treatment for the individual, and symptoms which seem very serious often disappear by restoring the general health. In a recent case,¹⁶ where a youth of nineteen was acquitted of the murder of his mother on the ground of homicidal insanity, he knew that the act was wrong, realized that he had committed a crime, and was full of grief for it, as occurs in all such cases. It is the rule, too, that there is some condition of mental defect or degeneration out of which the homicidal insanity is developed.

¹⁶ Quarterly Journal of Mental Science, October, 1883, p. 387.

Dipsomania, a rare manifestation of impulsive insanity, differs entirely from the acquired alcohol habit, drunkenness, acute or chronic alcoholism, delirium tremens, or habitual intoxication, all of which conditions are also more readily developed in the neuro-psychopathic constitution than in persons with healthy brains, and may reach a point constituting insanity. Dipsomania is periodic, uncontrollable, and associated with other evidences of the insane diathesis. The prognosis is unfavorable. The treatment is to improve the general nervous tone and to seclude the patient during his attacks.

Pyromania and kleptomania are not rare as symptoms of insanity of the marked forms which are observed in asylums. As manifestations of impulsive insanity—that is, as constituting a form of insanity—they are associated with other evidences of mental defect or degeneration. Burning and stealing alone are not indications of insanity. As such, they are without sane motive, and directed to objects in burning or stealing which there is no gain to the person and usually no gratification except the sense of relief which comes from yielding to the impulse, and of distressing mental symptoms if the impulse is resisted.

Nymphomania in the female, satyriasis in the male, and the various perverse and degrading methods of gratification of the sexual instinct, may, when joined with other evidences of mental or nervous disorder, constitute one form of impulsive insanity. Erotomania, an ideal attachment without erotic feeling, is a more common mental disease, but the other evidences of insane conduct are quite striking. The same statement holds true of the many perverted instincts which, according to circumstances, are or are not manifestations of the defective brain-inhibition of disease. Animal impulse as a form of impulsive insanity I had been inclined to doubt until I recently saw two cases of as extreme mental suffering as I ever witnessed, in two refined ladies who had suffered also from some cerebral symptoms, occasional dizziness, and suicidal insanity, but who had no other symptoms of cerebral disorder than those which are grouped under the head of insane diathesis, and they not marked. It is not associated with any erotic feeling or with particular persons. There is more rapid wasting in flesh and strength and loss of sleep than in the other forms of impulsive insanity, and, in my experience, greater dread of yielding to the demon of unrest.

The perverted sexual instinct, with a feeling of repugnance to the opposite sex, has thus far been observed chiefly in persons who have been addicted to masturbation. It is marked by a passion for some individual of the same sex, by other evidences of the neuropathic condition, and commonly by a grotesque imitation of the habits or dress of the opposite sex.

The indications for treatment in impulsive insanity are cod-liver oil, the bromides, simple non-stimulating diet, open-air life, judiciously regulated exercise, mental occupation so far as is possible, and removal from suggestive surroundings and associations. The prognosis is not favorable as to the final result. If the symptoms disappear on restoration of the general health, other marked indications of cerebro-mental disorder are pretty certain to appear sooner or later.

HYSTERICAL INSANITY is one of the states of mental degeneration, much less common among men than among women, arising from the further development of a neurosis, hysteria, and probably to a great extent due to bad training. Hysterical symptoms, quite marked, are very common among young persons and in single women of all ages in simple mania. They are not uncommon in simple melancholia and in other forms of mental disease. They add somewhat to the gravity of the prognosis in these cases. They constitute a group of symptoms which I suppose to be understood by those authors who speak of hysterical insanity as a disease in which the cure-rate is high. But hysterical insanity, as quite distinct from other psychoses, is quite a different matter. It is characterized by extreme and rapid mobility of the mental symptoms—amnesia, exhilaration, melancholic depression, theatrical display, suspicion, distrust, prejudice, a curious combination of truth and more or less unconscious deception, with periods of mental clearness and sound judgment which are often of greater degree than is common in their families; sleeplessness, distressing and grotesque hallucinations of sight, distortion and perversion of facts rather than definite delusions, visions, hyperæsthesias, anæsthesias, paræsthesias, exceeding sensitiveness to light, touch, and sound, morbid attachments, fanciful beliefs, an unhealthy imagination, abortive or sensational suicidal manœuvres, occasional outbursts of violence, a curious combination of unspeakable wretchedness alternating with joy, generosity, and selfishness—of gifts and graces on the one hand and exactions on the other. The mental instability is like a vane veered by every zephyr. The most trifling causes start a mental whirlwind. There is no disease giving rise to more genuine suffering or appealing more strongly for the sympathy which, freely given, only does harm. One such person in the house wears out and outlives one after another every healthy member of the family who is unwisely allowed to devote herself with conscientious zeal to the invalid.

The PROGNOSIS is unfavorable. While the symptoms may be alleviated and a nominal cure may be effected, a relapse or the development of some other troublesome form of insanity or neurosis is the rule, to which the exceptions occur for the most part in women in whom there is also some serious curable uterine disease or a state of excessive physical prostration which can be relieved.

The TREATMENT of hysterical insanity demands tact and educating power which will tax to the utmost the ingenuity of the wisest physician. Sympathetic friends, and sympathy in general, are useful in moderation, but they oftener do great harm, because they are excessive; and the care which does good is that which, while being kind and firm, tends to develop strength and character. The will and the imagination are so extraordinarily powerful that their wise direction and government constitute the most important part of successful treatment. Diversion, occupation, and the development of self-control, with careful attention to the general laws of health, are quite important. The temptation to use drugs is, like the fascination of being pitied and petted, very great, as alcohol, chloral, or opium often acts like magic for the time being, and there is generally a craving for one or all of them. But they are utterly demoralizing in the end. The habitual use of stimulants and narcotics in such cases only increases the evil. The fact must be recognized that the hysterical insane are often least responsible where they seem most so, and that they must be treated with unending patience, kindness, gentle firmness, and a wise ignoring of most of the symptoms. Simple palliative sedatives which cannot do harm must sometimes be used, but the general rule, the less active treatment the better, is safest. In the few cases where benefit has been got from removal of the ovaries, healthy or diseased, the improvement, if it shall prove to be lasting, will probably be attributable to the great physiological shock from the operation rather than to any relation of the ovaries to the disease. Removal from home is usually advisable for a time at least—often it is necessary; and if residence in an asylum is not thought to be wise, properly-selected hydropathic establishments or private asylums are useful. Living in a judicious physician's home is desirable when a suitable one can be found. In an asylum a rational letting-alone treatment is found to be the most successful. If the patient remains at home, hired nurses should be in charge of the patient, or at least not members of the family. Safe seclusion will be found necessary for the few who will not otherwise be prevented from committing crimes and offences of startling ingenuity or conspicuous publicity.

EPILEPTIC INSANITY arises from a neurosis, epilepsy, which almost inevitably ends in mental deterioration of greater or less degree, from scarcely noticeable impairment to complete dementia. The insanity may be a continuous state; it may be subsequent to the epileptic attack, or precede it, or take the place of it. Epileptic dementia is more nearly allied to idiocy than dementia following other mental diseases, and it is associated with a degree of moral perversion and brutality which is quite uncommon in other dementia. The insanity following or preceding the epileptic attack is attended with stupor, delusions of persecution, confusion, transitory fury, or a condition quite analogous to somnambulism or cerebral automatism; and the same may be said of insanity replacing the epileptic attack, except that the most common condition in it is a violent maniacal fury, with unconsciousness, and subsequent nearly if not quite complete amnesia. The forms of mental impairment are progressive in the vast majority of cases. The other forms are more amenable to the usual treatment of epilepsy, and sometimes diminish in severity as the disease advances and the mind becomes weakened. In the fury which takes the place of the epileptic convulsion there is in nearly every case—I am inclined to think in all cases—an intellectual aura, a slight change of action, observable early enough to give warning of the approaching storm, which can always be mitigated, and often entirely prevented, by absolute rest in bed and the use of chloral and the bromides.

Although some few epileptics become well without treatment, and a small number permanently recover under treatment, the PROGNOSIS is even less favorable for the epileptic insane. The care of insane epileptics should embrace, in the first place, safety to the community by secluding those dangerous to it, and, second, the usual hygienic and medical treatment of epilepsy.

Epileptic vertigo, analogous to petit mal, is a transitory mania, often associated with passing delusions.

With regard to the responsibility of the epileptic insane—and, indeed, all epileptics—the facts should be borne in mind that their mental state is usually one of such instability that a slight irritation of any kind is apt to induce a full or modified convulsion, and that under provocation they commit partly volitional crimes, for which they are not fully responsible.

HYPOCHONDRIACAL INSANITY differs only in degree from hypochondriasis, described on a subsequent page. It is an incurable manifestation of one type of the mental degenerations. It is slowly progressive, and often ends in dementia. It differs from hypochondriacal melancholia in being an evolution of mental defect or degeneration, and in the fact that the mental depression, which is usually of a mild, periodic, or impulsive form, is secondary to the other symptoms, and not, as in hypochondriacal melancholia, the mental condition out of which the hypochondriacal symptoms are evolved.

The TREATMENT consists in attention to the general laws of health, occupation, and a fattening diet. It is seldom successfully managed without occasional recourse to an asylum at least, and oftenest a permanent residence in hospitals, occasionally changing, is quite necessary.

PERIODIC INSANITY, usually mania or melancholia, is marked by attacks recurring at more or less regular intervals, with a partial but not complete return to the previous mental health between them. It is one of the incurable degenerative mental diseases. The seeming recovery is only apparent, and the mental deterioration is progressive, although quite slow. The form of insanity is also not seldom a folie raisonnante (affective or moral insanity) with periods of all sorts of excesses, destructive tendencies, tramp-life, destructive acts, drunkenness, stealing, indecent exposure, etc. In the intervals, which may be short or long, and which sometimes correspond to certain seasons of the year, the mental condition is still a pathological one, with the usual signs of mental degeneration, thereby being differentiated from recurrent insanity, one of the curable psychoneuroses, in which there is a state of mental health between the successive attacks, but no sort of regularity or periodicity in the recurrences. The prognosis is unfavorable, except in so far as a quiet life in an asylum tends to prolong the intervals between the periodic outbreaks, as well as to prevent annoyance to the community during them.

CIRCULAR INSANITY (Alternating insanity, Folie circulaire, Folie à double forme, Folie à formes alternes, Die cyclische Psychose, Das circuläre Irresein) consists in a psycho-rhythm or succession, in uniform order in each particular case, of (1) mental exaltation in all degrees, from mild exhilaration or even gayness to acute mania, and (2) mental depression of all conditions, torpor, or anergic stupor. These two opposite mental conditions are separated in the vast majority of cases by a shorter or longer interval of the normal mental state, in which, however, there is soon observed some mental impairment, however slight, rarely amounting to pronounced dementia except in old age. Sometimes the three states shade off into each other, so that it is difficult to say just where one begins and the other ends; less often the transition is abrupt, sometimes during sleep. The interval between the two opposite conditions of mind may succeed either of the other mental stages, but the order once established is maintained. The duration of the vicious circle varies in succeeding attacks, sometimes becoming longer, sometimes shorter, in the progress of the disease. The relative duration of the three succeeding mental condition also varies, but the type of each remains identical, or at least changes very gradually. The state of mental exaltation often resembles moral insanity, with all sorts of immoral impulses and tendencies, and may then properly be called an insanity of action. The depression sometimes goes no farther than sluggishness of will. The tendency of the disease is to shorten life only slightly, if at all, except from the chance of suicide in the depressed state and from exhaustion when the excited stage is one of active mania. The shortest duration of the cycle in my experience has been twenty-four hours, and the longest reported extends over several years. It sometimes remains an affective insanity in its whole course, without delusions and with little more dementia than might happen from simply a corresponding advance in age without mental disease.

During the period of excitement some supervision or control will usually be desirable, and removal to some retreat or asylum will often be necessary. In the depressed stage the indications are to maintain the general health, to meet the chances of suicide, and if there are delusions to obviate the risks of danger to other persons. If the interval of comparative mental health is of considerable duration, the ordinary occupation of the patient can commonly be followed at that time for a number of years, rarely for life; but a better result may be looked for if the patient's circumstances are such that he can give up active and anxious work for some quiet occupation not involving great care.

PRIMARY INSANITY (primäre Verrücktheit, primordiale Verrücktheit, originäre Verrücktheit) is usually a further development of an hereditary predisposition to mental disease. The term primary monomania, although used as an equivalent for primäre Verrücktheit, seems to me too narrow for a disease in which the leading delusion may change so many times. Primary insanity is sometimes congenital, and may be developed also by injury or by disease involving the brain early in life or during the physiological changes at puberty, possibly by self-abuse, in persons of an unstable mental organization. It often develops so slowly with the character as to almost seem part of it, until it reaches such a degree of insane delusion of self-importance and expansive ideas as to be unmistakable insanity. There are also delusions of persecution, distrust, and suspicion, erotomania, and moral perversion, in spite of high claims to superior character, and indeed in spite of a high standard of life in some particulars. Perhaps the most striking symptom of primary insanity is the great variety of imperative conceptions (Zwangsvorstellungen) by virtue of which the individual is impelled, by a force often irresistible, to commit various offences against propriety and the laws, even to murder, as well as to perform countless acts of unwisdom or folly. There are usually physical indications of chronic or old cerebral disease, or of defect or degeneration in the incomplete or asymmetrical development of the brain, which, however, may be no more than are found in persons who might not be classed as of unsound mind. Attacks of simple mania (mental excitement) of short duration are quite common, and there is a progressive impairment of the higher faculties of the brain—those which come last in a high order of civilization—although there may be acuteness of memory, perspicacity, and shrewdness which seem altogether phenomenal as compared with the other mental qualities. There is no form of mental disease which is better expressed by the word craziness than primary insanity, no other in which the victim is more thoroughly in the grasp of his malady, and yet no other in which he is more likely to be held responsible for the crazy acts which he may perform, because his inherent mental state, out of which his generally deluded frame of mind is evolved, gives rise to delusive ideas of such a character that they are not universally recognized, even by physicians of experience in mental disease, as insane delusions, but are considered by some of them as the prevarications of a criminally-minded person. When these persons commit crimes, too, they often do so with methods and motives quite like those of the ordinary criminal.

The PROGNOSIS in primary insanity, after the disease is fully developed, is in the highest degree unfavorable. It remains to be seen how much can be done by moral training in childhood and youth to correct the evil tendency. The education of those who get into the courts and insane asylums, so far as my knowledge of such cases goes, has been bad to the last degree, so that, in my opinion, there has been a fair difference of opinion as to which of them the law should treat as criminals and which as insane persons.

TREATMENT for the most part requires absolute control of the individual, which there is usually no one in the family sound enough to maintain. If begun early, training away from home may accomplish much. Restraint in some institution is commonly called for, but the vast majority of the primary insane are allowed to take their chances in the world, and as many end in jails and prisons or on the scaffold as in asylums.

The states of mental defect and degeneration, except in the case of idiocy or marked imbecility, are not associated with such obvious physical evidences of deviation from a normal mental standard as to make them pathognomonic. While asymmetry and other cerebral defects are frequently observed in them, it must be acknowledged with Schüle that similar and as extensive gross intracranial anomalies are found in persons who could not be called of unsound mind, and that this statement holds true even of primary insanity, in which some writers have laid so much stress upon the value of any indication of imperfect or asymmetrical cerebral development. Any defect in the brain, however, is far more common among persons of unsound mind than among those of sound mind, and therefore in doubtful cases it is of a certain value as corroborative evidence of mental infirmity or impairment.

Spitzka places as signs of the insane constitution (1) atypical asymmetry of the cerebral hemispheres as regards bulk; (2) atypical asymmetry in the gyral development; (3) persistence of embryonic features in the gyral arrangement; (4) defective development of the great interhemispheric commissure; (5) irregular and defective development of the great ganglia and of the conducting tracts; (6) anomalies in the development of the minute elements of the brain; (7) abnormal arrangement of the cerebral vascular channels,—at the same time acknowledging that there are cases of insanity of inherited origin in which cerebral defects are not discernible. It is too early to estimate the value and importance of the finer or qualitative cerebral defects as giving rise to insanity. Benedikt finds them also in criminals.

With regard to responsibility before the law, the statutes of no country provide for any criterion by which accountability is defined in these cases; medical witnesses differ in opinion as to their criminality, and the courts are obliged to interpret the law to suit individual cases.

The states of mental defect and degeneration are not sharply defined. They run more or less into one another. The fact should also be kept in mind that isolated symptoms and groups of symptoms belonging to them are repeatedly found in curable conditions of physical and mental exhaustion in neurotic persons.

The degenerative mental states are thought to be increasing, to furnish material for the increase in the otherwise curable insanities, and to thus include much of that portion of the community which is most filling up our institutions with incurable cases. It is probably in the prevention of them, or at least in the proper training and disposition of children affected with them or predisposed to them, that the most can be done to stay the increase of insanity. Perhaps at some time unwise marriages of passion and sentiment will be less common than now, and the rights of children to a fair start in life more considered.

Psychoneuroses.

AFFECTIVE MENTAL DISEASE is a folie raisonnante, one of the reasoning insanities, sometimes called moral insanity, and very like the moral insanity already described, except in the absence of signs of mental degeneration and in the fact that it is a curable disorder. It is an insanity of action, marked by scarcely noticeable mental impairment. It often is the early stage of more serious mental disease, and not seldom its symptoms remain, as simply change of character, after the striking symptoms of extensive mental disorder have disappeared. It also exists and is cured without the appearance of more pronounced insanity. At the time of the climacteric it is a form of mental disorder not uncommon among women, who, however, usually fail to recognize it as such until they have recovered. Maudsley includes under this head simple melancholia, simple mania, and moral alienation, but it will be more convenient for the present purpose to use the term affective mental disease as indicating a curable moral alienation or change of character affecting the intellect chiefly so far as the judgment and sense of propriety only are concerned, and not dependent upon constitutional defect or developed degenerative mental state. There is usually slight exhilaration or depression, which alternates or varies from time to time.

The PROGNOSIS is favorable.

The TREATMENT is brain-nutrition, with those general measures already described.

HYPOCHONDRIASIS, as Flint¹⁷ well says, belongs in the list of disorders of the mind, although the mental alienation is not regarded as amounting to insanity. The mental state is one of morbid imagination and apprehension rather than of definite delusion, and it consists in a belief in the existence, present or to come, of maladies and diseased conditions for which there is no foundation in fact, in spite of sufficient proof of their unreality. There is usually, not always, mental depression. Its causes lie in conditions, usually obscure, which lower the tone of the general health, including hereditary weaknesses, or depress the vitality of the brain either by physical wear or mental worry, and the exhausting influence of functional disorders or of organic diseases which may not be discovered before the autopsy. Disappointment, bad habits, want of proper mental occupation are often at fault.

¹⁷ Practice of Medicine, p. 854.

The physical symptoms of hypochondriasis are commonly those associated with impaired digestion and nutrition—namely, anæmia, dyspepsia, neurasthenia, constipation, flatulence, headache or a feeling of discomfort after using the brain, less appetite, slight loss of flesh, disordered sleep.

The mental indications are more or less melancholy, indisposition to exertion, irritability, diminished power of self-control, and an inability to cease except temporarily from interpreting signs, proved to be trivial, as indicating grave maladies or as forewarnings of severe disease to come. Sometimes the fixed idea is limited to a single false conception, but oftener slight changes in physical symptoms or differing phases of morbid introspection produce a complete kaleidoscope of pictures of fancied misery. The whole catalogue of diseases, or a large part of it, may be exhausted, with the help of some of the many foolish treatises always ready for hypochondriacs or from reading medical books and talking with charlatans, who are consulted at rapid intervals, one after another, both by those who wander from office to office and those who take to their beds. The most common type of hypochondriasis arises, directly or indirectly, in some form of unhealthy or false ideas regarding the sexual function, and in the idea that some imagined or exaggerated abuse of it has produced or will produce most serious evils; but there is not an organ of the body which may not be the basis for the unwholesome thoughts. Not seldom there is simply the delusion of especial weakness or sensitiveness or delicacy.

Hypochondriasis may be only the early stage of more serious mental disease. It may be one manifestation of an hereditary neurosis or psychoneurosis, or it may arise from deterioration of the body's vitality by organic disease, especially of the abdominal or pelvic organs or through some incurable weakness or functional disorder. In either of these cases its cause and duration will be determined by the clinical history. As an uncomplicated psychoneurosis hypochondria lasts from a few months to a number of years, with very little change in its prominent symptoms, resulting in recovery for the most part, becoming chronic in a moderate proportion of cases, and rarely proving fatal except by some accidental complication, including suicide.

The PATHOLOGY AND MORBID ANATOMY of the disease are unknown.

The differential DIAGNOSIS consists in the exclusion of other diseases.

The PROGNOSIS is favorable in uncomplicated cases.

TREATMENT consists in measures to improve the general health, especially a full diet carefully selected, hydro-therapeutics, massage, gymnastics, horseback riding, walking, rowing, abundant and agreeable exercise in the open air, and the management of the patient's surroundings so as to lighten the mind and relieve from worry, perhaps by travel, sea-voyages, etc. Argument is commonly worse than useless, but there should be a decided impression given that the generally morbid state is due to ill-health. The risk of suicide is so small that restrictions of liberty directed to its prevention do more harm than good. It goes without saying that bad habits should be reformed, narcotics should be avoided, and a healthy occupation should be encouraged, or, if possible, insisted upon. The difficulties in treatment are fully as great with the highly-educated superstitious and credulous people whom we find in the literary and professional circles as in the ignorant and weak-minded.

MELANCHOLIA (Die Melancholie, Schwermuth, Tiefsinn, Trübsinn, Lypemanie, Mélaneolie, Aliénation partielle depressive, Monomanie triste, Phrenalgie, Psychalgia) is one of the functional mental diseases, in the sense that the pathological condition of the brain upon which it depends is not yet known, although it is thought to begin with disturbances in circulation and nutrition, which end, if not resulting in cure, in atrophic, degenerative, and inflammatory states, indicating, in the great majority of cases, extensive brain disease. As a rule, melancholia first appears in a slight change of character; the patient is said by his friends to be not quite like himself. After some days or months, as the case may be, the symptoms develop into settled gloom associated with mental pain—the state known as

Simple Melancholia (Mélancolie raisonnante), in which the events of life are correctly observed, but, incorrectly interpreted, are the source of constant apprehension, self-depreciation, depression, and despondency. There are no delusions, properly speaking, and yet there is a disposition to take the dark-side view even of circumstances which promise favorably, which amounts to a generally deluded state of mind. Commonly there is increased irritability, now and then a genuine moral insanity, and occasionally in neuropathic constitutions the state of mind already described under the head of Impulsive Insanity, of which the suicidal impulse is the least infrequent. Sometimes there are no physical indications of disease, but as a rule there are headache, increased sensibility to light and noise, sleeplessness, restlessness, impaired appetite and digestion, gastro-intestinal catarrh, marked loss of flesh, diminished or abolished sexual desire, and in women usually delayed menstruation or amenorrhœa. A few persons are able to keep up, in an irregular sort of way, their customary employment. In the majority of cases it is impossible to concentrate the mind upon work, mental occupation fatigues the brain, and the physical strength is too impaired for steady labor. Suicide is thought of probably in nearly every case, as it is by many sane people at some time in their lives, but it is very seldom committed unless there are such disgraceful or distressing acts performed or suffered by them as would tempt to suicide in sane people. There is no danger of deliberate homicidal acts in persons of good character. A criminally disposed person would more readily commit murder in simple melancholia than if free from that disease.

Simple melancholia may be the initial stage of almost all of the mental diseases, especially acute mania, paralytic dementia, and the severer forms of melancholia. It may be differentiated from the first stage of mania only by waiting until other symptoms appear or not, and the same is true with regard to distinguishing it from the forms of melancholia involving danger to life. In the latter case, however, there is much greater difficulty in diagnosis, inasmuch as insane delusions may be concealed, and there may be so slight a change in the patient's behavior when delusions appear in his mind that the closest observation is needed to guard against them. The simple melancholia marking the first stage of paralytic dementia is characterized by noticeable although often slight mental impairment—a distinctly diminished capacity for work, of which the individual himself is not seldom conscious, whereas in the disease simple melancholia the mind's usual power is exerted, provided its attention can be withdrawn from morbid introspection and concentrated upon any subject, as it commonly can be for a while.

Melancholia with delusions (acute melancholia) is commonly a further development of simple melancholia, but sometimes its course is so rapid that if there is a period of mental depression without delusion it is overlooked. The earliest and most common delusion is some form of causeless self-reproach with regard to some matter, whether trivial or important, or of groundless self-accusation, of impossible sins of omission or commission, but generally of some vague, undefinable fault, as having irretrievably offended God or committed the unpardonable sin, etc. Often this and an unfounded belief in self-unworthiness are the only delusions present, and in that case within narrowed limitations the mind acts soundly in other matters. The feeling of personal fault or sin often expands to a sense of the justice of punishment, and the consequent delusion that all sorts of terrible things are to happen—poverty, the poorhouse, or some great unknown dread, even involving family and friends; and from personal sin or fault it is only a step to the belief that the world is all wrong, and to the certainty that everything is going to worse than ruin. Illusions of sight and hearing may magnify common fires and locomotive whistles into general conflagrations of the world and shrieks of tormented persons. Hallucinations of the special senses may create visions of all sorts of imaginary horrors, sounds of voices saying every possible dreadful thing, odors most disagreeable, tastes most vile. Anæsthesia prompts the delusion of death, and hyperæsthesia of burning, freezing, scalding, etc. Some mysterious force within them, which they can neither explain nor understand, drives them to automatic acts of all kinds—to obscenity, profanity, verbigeration, intonation of sentences, wailing, screaming, destructiveness, etc. In cases of exceptional severity the mind seems deluded on almost every subject: the food is poisoned, the atmosphere is deadly, the world loses all its reality, friends their identity, things their substance. They are to be burned alive, starved, quartered, suffocated, smothered, drowned. Every conceivable and inconceivable thing is to happen. The delusions are nearly always of the illogical or unsystematized kind, although systematized delusions of persecution are met, for the most part, in incurable cases. Deliberate plans of suicide are formed in most cases, and are to be suspected in all. Homicidal attempts are apt to be made upon persons whom it is desired to save from impending calamities. Suicidal, and less often homicidal, impulses occur. Suicide and homicide from deliberation need, to be successful, (1) the opportunity, (2) lack of power of self-control, and (3) a strong determination. Sometimes there is the will without the opportunity, or the opportunity with self-control; and for this reason persons in danger of killing themselves or others often for months escape any acts of violence. Not seldom, too, they determine to kill themselves or family in a particular way, and neglect other chances so long that they are thought to be not meditating destruction of self or others. When the determination or impulse to suicide or homicide is persistent and desperate, no means are too horrible and no opportunities too hopeless to be attempted. There is no reason for a special name for these symptoms, but they have been called suicidal melancholia and homicidal melancholia. No more is there any justification of the term hypochondriacal melancholia for melancholia with hypochondriacal symptoms.

In melancholia with delusions there is sooner or later, in the majority of cases, refusal to eat, from lack of appetite, nausea, or disgust of food, from disagreeable hallucinations of taste or smell, from delusions that it is a sin to eat, that the stomach is full, that the mouth is sealed or the throat obstructed, that the food is not and cannot be paid for, that eating will do no good, etc., from a wish to commit suicide by starving, or in the states of stupor (attonitäts-zustände) from mental torpor or stupidity. Sometimes there is resistance to the calls to eat, urinate, or defecate by virtue of resistive melancholia—a condition to resist and oppose everything—or from delusions that it will destroy the soul, etc. to follow the natural inclinations. Refusal of food may be under certain conditions instinctive and conservative. It is the exception for the bodily functions to be well performed. Usually, there is obstinate constipation, with headache, coated tongue, greater variation in daily temperature than is usual in health, accelerated pulse, and rapid wasting in flesh. The various anomalous sensations observed in functional diseases of the nervous system are common. Masturbation is a not infrequent symptom of loss of self-control in both sexes.

Acute melancholia is sometimes confounded with delusional insanity with mental depression. In the former the delusions are evolved from the mental state; in the latter, the mental state from the delusions. In the former the delusions are for the most part unsystematized: the patient cannot state why he believes them to be true; in the latter there is correct reasoning from false premises: the delusions are logical or systematized and of a depressing character, so that a belief in them naturally gives rise to sadness.

Before the courts the fact should be kept in mind that persons with acute melancholia have diminished power of self-control by virtue of their disease, and so yield more readily to temptation than in health. They also may have imperative conceptions—ideas so strong that they cannot, or can with difficulty, resist carrying them out even when they know them to be wrong; and there may be sudden outbursts of almost maniacal excitement. They are often able to make wills and perform contracts, in form and in detail, as well as ever, when they are so filled with insane delusions as to be on the point of killing themselves and their families. There is impaired capacity, however, of recognizing the relations of persons and things to one another, a distinct moral perversion, and a diminished recognition of obligations and sense of responsibility. In other words, they are not always fully themselves on those points in which they seem to be so, and yet patients in asylums with acute melancholia have been known to give the best of advice to their business-partners.

Melancholia with stupor (melancholia attonita) appears like complete dementia or a mindless state, but there are now and then evidences of intelligence. The mind is filled with overwhelming and terrible delusions, which paralyze the will and place mental and physical activity for a while in abeyance. It arises commonly in the course of the less profound form of melancholia, after some great mental shock, and there is a condition of marked anæmia of the brain, probably symptomatic rather than pathognomonic, which if not soon relieved goes on rapidly to atrophy and degeneration. Except when there are attacks of frenzy, which may occur at any time, there is little danger of active violent acts except suicide, desperate refusal of food, and determined resistance to any care or treatment. There are the usual indications of physical exhaustion.

In melancholia agitata the mind is clear and active, the opposite of the condition last described, and the distressing delusions produce such a degree of motor excitement arising from the mental suffering that the disease closely simulates acute mania. The mind not only reacts as readily as in health to distressing ideas, but abandons itself more fully to their domination through diminished will-power and lack of self-control. Almost blind acts of desperation and fury are committed from which the utmost vigilance can hardly save them.

The three severe forms of melancholia just described are interchangeable in the same person during the course of his illness, so that the states of frenzy and stupor are more properly called symptoms than classes of disease.

Melancholia among children is more common than the books state it to be, although rarely met in the asylums. Magnan has reported a suicidal case in a child four years old, and it occurs up to the latest years of life.

The DURATION of simple melancholia is from a few weeks to a dozen years; of acute melancholia, from a month to two or three years, after which it is apt to end in chronicity; melancholia stupida (with stupor) is usually curable, if at all, in the first year, although relapses are frequent, and in melancholia agitata from a year to three years is the common limit of the possibility of a cure.

The PROGNOSIS in simple melancholia is favorable. Including cases treated out of asylums, probably 90 per cent. recover; in acute melancholia, uncomplicated with other diseases, not far from two-thirds recover; in melancholia attonita less than half get well; and in melancholia agitata nominal recovery occurs perhaps in a third of the cases, although I doubt whether complete restoration to health is seen often.

In chronic melancholia the process of mental deterioration is slow. As the mind becomes impaired the delusions lose their activity and the mind reacts less readily, so that a state of less suffering and greater calm is reached, and the patients are often useful workers in asylums for many years, or remain in their own homes a constant source of anxiety to those who understand their condition. Many of them commit suicide.

In treatment of melancholia the first indication is to protect society and the individual against acts of violence. Homicidal acts are not to be feared in simple melancholia, unless in persons of bad character and ugly temper, or in those few cases with the symptoms, in addition, of moral insanity or impulsive insanity. Suicide is so rare that precautions will not often be needed against it, provided the patient is so frank or so transparent that the appearance of distinct delusions may be detected and then guarded against. In cases of long standing, especially in persons beyond middle age, this is extremely difficult, and their treatment outside of asylums must always be attended with risk. In the other forms of melancholia the fact should be taken for granted that the patient is suicidal, and he may be also homicidal, so that he should be watched constantly and efficiently, and never left alone or with weak or helpless persons, no matter how free from suicidal determination or impulse he may have appeared. The puerperal mother, especially, is a source of the greatest danger to her child, even when she seems natural and fond. The degree and kind of watching varies, according to the severity of the case, from the constant presence or close proximity of some responsible person, who may sleep in the same room with the usual home-surroundings, to the most vigilant and wakeful personal care every moment day and night, and removal of every source of possible self-injury. In some few cases this can be well done only in an asylum or in a padded room. Some form of restraint, either personal or by confining or limiting the movements of the hands in rare cases of exceptional desperation, will be found necessary.

Placing the patient in an entirely healthy atmosphere is next in importance. In the very earliest stage quiet, recreation, change of scene, and association with a pleasant and judicious companion are often sufficient to effect a cure. If the disease is pronounced, rest and removal from sources of irritation are more important until convalescence, when travel may be tried. The question of removal from home and commitment to an asylum should be decided upon the grounds already stated in considering the general treatment of mental diseases. The degree in which the patient should have exercise, occupation, and recreation or be let alone will be determined for each individual case. The fact should be borne in mind that the disease is a debilitating one, and that it arises in conditions of mental or physical exhaustion. Massage and a modified rest-cure, without seclusion, are beneficial in some cases, especially of elderly people. Baths and the cold pack should be used with discrimination. Electricity, where it does not give rise or add to delusions, is a useful tonic, especially in passive cases. There are very few patients of such desperate frenzy as to require confinement of the hands, and that should only be done with an attendant close at hand. Whatever is done, nothing should be attempted which excites delusions unless it be absolutely necessary. Fresh air, and an abundance of it, are very important. Experience and careful study of the particular case will be needed to know how far to press the taking of food. But the necessary amount should be given by the stomach-tube if ordinary means fail, and it is better to use it early rather than tire the patient out with ineffectual attempts with spoons, etc. Whether the nasal or œsophageal tube be used—of which I prefer the latter—the greatest care should be taken not to inject food into the lungs, the throat being so devoid of sensitiveness sometimes that the tube may be passed into the trachea. Nutrient enemata may be relied upon for a week or two if the patient is in bed, but no longer.

Tonics are indicated—cod-liver oil with bark, the hypophosphites, dilute phosphoric acid, malt. Strychnia, iron, and quinine should be used with caution, as they often cause disagreeable headache with indisposition to sleep. Fattening food will be found useful in most cases. The few fat melancholies need nitrogenous food and graduated exercise. Constipation will be corrected in many cases by a full, laxative diet, cod-liver oil, malt, or it may be beer. Mineral water or Sprudel salts are usually indicated. A pill containing aloin, strychnia, belladonna, mastich, or even colocynth or podophyllin, may be needed in obstinate constipation.

Medicines to control restlessness and sleeplessness should be avoided if possible. Hydrate of chloral, opium, bromides, valerian, sometimes increase the difficulty, and the objections to their prolonged use are obvious, and yet they must sometimes be used for a time. The bromides, with cannabis indica, valerianate of zinc, camphor, and hyoscyamus, may serve an excellent purpose for a time. Opium and its preparations, where they agree, act like magic in producing mental calm and sleep. They may relieve constipation and increase the desire for food, but the danger of the opium habit is so great that their use should be decided upon only in extreme cases, and the effect should be watched from dose to dose, each one of which should be given under medical direction. Wilful masturbation, one of the signs of loss of self-control which occurs in the best of people, cannot be corrected by drugs or appliances, but only by constant watching and by placing the individual where his self-respect, as soon as it can be appealed to, will keep him from it. If it is uncontrollable and symptomatic, fresh air and exercise, and, if necessary, bromides or opiates in moderate doses, with a tonic (not iron), should be used.

MANIA (Manie, Exaltation générale), according to Morel, meant, in the original Greek, folie or madness, while Esquirol derives it from the Greek word meaning moon, making the words maniac and lunatic equivalent. The word mania is still used in this loose way, even by writers on mental disease, as a synonym of insanity. Its use is properly restricted to conditions of mental exhilaration or excitement with motor activity. The morbid anatomy of the disease is not yet made out, and the indications of hyperæmia observed in the acute stage after death are no greater than are found in diseases in which mania is not a symptom. In its final stages atrophic, degenerative, and inflammatory signs are abundant and well marked.

Simple mania¹⁸ (manie sans délire, manie raisonnante), an exaltation of the mental faculties similar to the exhilaration produced by too much wine, with an accelerated flow of ideas, impaired judgment, and motor activity, without definite delusions, delirium, or incoherence, has been called an insanity of action, affective insanity, folie raisonnante, and even moral insanity, from which it differs in being marked by constant mental elation and exaltation of the physical functions, and not necessarily by striking moral perversion. It is a mental erethism, an exaggerated gayety, an uncontrollable exhilaration, an unbounded joy, an excessive anxiety, a perpetual anger, unusually good spirits, increased intellectual and physical energy, with such striking loss of self-control, diminished powers of reflection, and so decided weakening of the judgment that all sorts of unwonted errors of commission or omission may be performed. Under its influence many fortunes have been lost, many reputations have been ruined, and the happiness of many families has been sacrificed before the existence of insanity was suspected, except possibly by a very few persons. Indeed, the wit is usually so sharpened, the flow of ideas often so clear and rapid, the capacity for brain- and body-work without fatigue is generally so increased, that not seldom the patient is remarked upon as being unusually well. The most troublesome symptoms arise from the tendency to squander property, to drink alcoholic liquors to excess, and, especially in women, to allow the exalted sexual desires to get control of the judgment and reason, thereby bringing about unfortunate marriages or scandalous relations with the opposite sex. In women there is commonly increased menstrual flow.

¹⁸ Also called by some writers moral insanity, folie morale, folie des actes, folie or manie instinctive.

The course of the disease is without material change, and the duration is from several weeks to a number of years. When it does not constitute the initial stage of other types of mental disease, especially severer forms of mania, circular insanity, general paralysis, or (in the neuropathic constitutions and at the critical ages) mental degeneration, the termination is in recovery in about 90 per cent. of the cases, although sometimes some moral impairment or deterioration in character remains for life. The recklessness incident to the disease leads to unusual risks, now and then to fatal accidents. Simple mania rarely becomes chronic.

TREATMENT involves the necessity of proper control to prevent scandals, disasters, and perhaps crimes. The matter of the degree of seclusion and control should be governed by the general considerations already mentioned in the general treatment of insanity, bearing in mind that repression of the motor energy, except to prevent exhaustion, does harm. The demand for food is enormous; its supply should be abundant and judiciously chosen with reference to easy digestion. Frequent prolonged warm baths and cool applications to the head are indicated, and the usual palliatives for headache, sleeplessness, constipation, etc. The surroundings should be such as to favor rest and undisturbed sleep, and to dispel sources of excitement, whether they arise in certain associations, localities, occupations, or persons.

Acute mania (Tobsucht) follows an incubative stage of simple melancholia, often of simple mania, and rarely bursts out without previous indications of disease. Delusions, unsystematized and illogical, are abundant; the ideas flow so rapidly that the mechanism of speech is not adequate to their expression; the motor excitement is intense. In the most severe forms there is mental confusion, delirium, incoherence of ideas, and furious muscular action, to the point often of acts of destructiveness and self-injury. The clothing is torn to shreds, and no act of violence is too wild not to be attempted without warning. The skin is hot, the tongue heavily coated, the pulse accelerated, the temperature elevated, more, probably, than would be accounted for by the physical activity—from one to two or three degrees—now and then, in conditions of exhaustion, a little below the normal. Just as there is liable to be maniacal frenzy in the course of severe melancholia, so in acute mania outbursts are seen of desperately suicidal melancholic frenzy. Unless great care is used to keep up the strength, and often in spite of it, exhaustion rapidly sets in, under the influence of which the symptoms are very much aggravated. The amenorrhœa in women in this condition is conservative.

The COURSE AND DURATION of acute mania vary within wide limits, with an average of not far from six months, with recoveries in about 60 per cent. of first cases uncomplicated by pneumonia, chronic disease, or a marked neuropathic state: 5 or 6 per cent. die, chiefly from pneumonia, phthisis, accidents, or exhaustion, seldom suicide. Incurable cases drop slowly into dementia or into chronic delusional insanity, the motor excitement subsiding. The delusional insanity may be simply a stage in the process toward dementia.

In the DIAGNOSIS of acute mania, unless great care is used, the physician sometimes finds that he has sent to the asylum a case of acute, especially infectious disease, in the early stage and with unusual manifestations of febrile delirium. The indications for avoiding this unfortunate mistake are care and time in making diagnoses.

In the TREATMENT of acute mania the matter of foremost importance is that the physician should be able to sufficiently control his patient to prevent harm, and that he should have him in such a place as to give him an abundance of fresh air, unhampered by annoying and irritating limitations of his free will, restrictions of his liberty, and repression of his motor excitement. The risks of injury to others must be reasonably provided against. It goes without saying that few homes meet these indications: very few people can command a house to be converted into a virtual hospital, with the care of trained physicians to direct every little detail of treatment, and proper nursing. The public asylum, therefore, or the private retreat must usually be depended upon. In the case of quiet young people, especially of young women whose illness may be of such a nature as to justify their marrying after recovery, and in the acute mania following childbirth, it is well worth the physician's while to make an effort to keep the patient in a private house when the conditions are such as to make such a course practicable. To the rest and quiet which may be had under such circumstances, with all the goings on of the house regulated to the patient's comfort and convenience, to prolonged hot baths, a full simple diet, given with the stomach-tube if necessary, as few medicines as can be got on with, the supervision of the nurses by some judicious member of the family, and the gentleness (combined, of course, with proper firmness) of home-influences, I attach very great importance in properly selected cases. But I attribute as much to the restful influence of keeping the patients among familiar scenes, and where some familiar face and voice can reassure them in their comparatively clear moments, instead of their being agitated and distressed to know how to account for the strange people and cell-like room of the insane ward to which they will awaken from their delirium in the hospital. It is something to avoid the excitement of commitment and removal to an asylum, with all that they involve, as well as the sight of demented patients, whose noise may make sleep impossible just when it is most needed. Acute mania seems to me to arise much less often than other mental diseases in definite associations which need to be escaped from for successful treatment.

The term subacute mania is used by some writers for the milder cases of acute mania, just as acute delirious mania is a term which is applied to those violent cases of acute mania in which furious and prolonged delirium marks the disease, and in which there is a high death-rate and low proportion of recoveries.

In chronic mania the motor excitement, mental instability, and, sooner or later, delusions, if not present at the beginning, as is usual, continue. The progress to dementia is commonly slow, and there are few cases which it is wise to treat away from an asylum or its dependencies on account of the possible danger to others from sudden exacerbations of the disease or through uncontrolled violent impulses.

Although there is no pathological condition distinctive of mania in its curable stage, conditions indicating hyperæmia are usually found, whether as a result of the disease or its underlying cause, and sometimes meningitis. In chronic mania there is in the terminal stages evidence of atrophic and degenerative changes which do not distinguish it from other forms of mental disease.

ACUTE DELIRIUM is the typhomania of Bell. Its prevailing mental state is of mania oftener than of melancholia. It resembles the worst cases of typhoid fever so closely, and it is so uncommon a form of disease, that the mistake has often been made of sending typhoid-fever patients to insane asylums. The mistake is unnecessary, as the clinical features of typhoid fever are so well marked that with sufficient care and delay they may be recognized if the physician does not commit the common error in mania of being too much afraid of his patient to examine him thoroughly. The tendency to exhaustion in acute delirium is rarely successfully combated, as the motor excitement is so intense and the delirium so furious that nourishment to meet the tremendous demands of the system can seldom be given, and death is the usual result. Recoveries are rare, but less uncommon in the melancholic than in the maniacal form.

Little need be said in the way of TREATMENT, except that in so speedily fatal a disease it is well to keep the patient at home, if he can be properly cared for there.

TRANSITORY INSANITY is used by Krafft-Ebing¹⁹ (Transitorisches Irresein) as indicating mental disease differing from other insanity only in the fact that it is of short duration—namely, from two to six days. If it is applied to sudden and transient outbursts of mania, with delirium, loss of power of self-control, and inability to clearly recollect the circumstances of the attack and what happened during its continuance, it is a rare disease, occurring for the most part in epileptics and in persons under the influence of alcohol or addicted to its habitual use. It is sometimes, under the latter-named condition, called alcoholic trance. It consists in an automatic state resembling the epileptic delirium, which may occur also in sleep and resemble somnambulism. The actions are guided by co-ordinated will without conscious intelligence, and may consist in crimes and brutalities and foolishness entirely inconsistent with the character in health. It seldom lasts more than a few hours. When caused by alcohol or as a symptom of epilepsy, it may occur without other marked inciting cause; otherwise it is commonly due to mental shock. Several cases happened during the mental excitement of the first battle in our civil war. The most striking case within my own experience was that of a man who under the strain of prolonged grief and the mental shock of a great fire destroying a large part of the town in which he lived, perhaps moderately affected by alcohol, suddenly grasped an axe and cut off with one blow the head of a beloved child. He was found in the street without knowing how he had got there or what he had done.

¹⁹ Irrenfreund, 1883, p. 113.

One attack is the rule, although several, probably of an epileptic nature, have been reported. It is an extremely difficult condition to diagnosticate with certainty, and is therefore often the refuge of criminals and a resource of criminal lawyers. The most likely honest mistake liable to be made regarding it is to confound it with an outburst of passion.

PRIMARY DEMENTIA (Acute dementia, Stuporous insanity, Anergic stupor) is a disease chiefly of youth and early maturity in persons of inherited weakness or under the influence of prolonged exhausting conditions, to which some mental shock usually adds the immediate cause. Although most of the cases are under the age of twenty-five, it occurs up to forty-five. Masturbation is so common a symptom in its course—and it may be one of the debilitating and enervating factors constituting a predisposing cause—that most of the primary dementia is classed in some asylums as insanity of masturbation. There may be an initial stage of a number of days, marked by moderate melancholia or by maniacal excitement, but there is usually mental torpor advancing rapidly to pronounced dementia. In rare cases there is marked chorea, and slight choreic movements are often observed. The course of primary dementia may be subacute and advance with extreme slowness.

There is no overwhelming delusion paralyzing the mind, so to speak, as in melancholia attonita (melancholia with stupor). In acute cases the brain quickly falls into a state of profound anæmia, precisely such as is found post-mortem in starved dogs, and loses its power to a greater or less extent of reacting to the stimulus of the senses. There is little or no sensation of hunger, the sensory nerves are nearly or quite paralyzed, the bladder and rectum become distended until urine and feces are voided unconsciously or at least uncontrolled, and voluntary movements almost cease, although the muscles are capable of acting if directed: if led or pushed, the patient walks; if placed in a chair or bed, remains there; and in the worst cases lies on the floor quite inattentive to all the decencies of life unless constantly looked after. There is always partial, and there may be complete, anæsthesia, to such an extent that even the involuntary muscles do not respond to the ordinary stimuli. There is rapid loss of flesh, very sluggish circulation, and feeble heart-action. After recovery the patient speaks of the stage of his greatest illness as a blank in his memory.

This description of pronounced cases of primary dementia of the most severe type needs modification as applied to milder cases, which may exist in all degrees, down to a state of mental impairment of very moderate extent.

The mental impairment may be progressive and quite incurable, but also so slight in the beginning, and may make such slow progress, as to entirely escape detection for several years, and then attract attention at first by the lowered plane of character and loss of self-control in little matters of daily life, rather than by the intellectual deterioration, which by that time has become quite marked. This subacute form of primary dementia in young people rarely finds its way into the insane asylum until the second, third, or fourth year of its course, and then its progress is slowly downward. It has none of the eccentric or grotesque features of hebephrenia, and little of its emotional disturbances.

Subacute primary dementia in the later years of maturity, just before or several years before the climacteric, is of grave import, as it indicates the development of an hereditary predisposition to insanity in a form which not only offers no reasonable hope of recovery, but also is quite certain to manifest a change of character which is even more difficult to treat and properly control than the intellectual failure. As it is most likely to arise under circumstances of wear and worry, its symptoms may be for a long time attributed to disappointment or bad temper. After the dementia becomes pronounced its downward course is seldom otherwise than very rapid.

SECONDARY DEMENTIA is a convenient name for the curable dementia which appears at the subsidence of acute symptoms occasionally in mania, and rarely in melancholia—that is, just about the beginning of the period of convalescence. It is also called secondary stupor.

In primary and secondary dementia, resulting in recovery, the progress of the disease is rarely otherwise than very rapid, and unless a cure takes place in a few months at the outside, secondary changes occur in the brain and the tendency is to terminal or incurable dementia. So many cases are treated outside of asylums that it is difficult to estimate the cure-rate, but it is probably not less than 60 or 70 per cent., although it is quite common in the apparent cures for the brain to remain on a lower intellectual or moral plane than if the disease had not occurred.

TREATMENT does not involve the necessity of removal from home in the acute cases, except when that is demanded for convenience of treatment. There is no melancholia to suggest the possibility of suicide, and no mental exhilaration or motor excitement to make restraint necessary. The most important indications are met by abundant, easily-assimilated food, which must usually, for a time at least, be given with a spoon or by the stomach-tube; fresh air, attention to the processes of digestion, relief of the gastro-intestinal catarrh by the usual remedies, stimulating baths, tonics, stimulants, and general galvanism. Proper care in emptying the bladder and rectum and entire cleanliness will suggest themselves.

In mild cases a tonic and stimulating regimen, including sea-bathing and gymnastics, will often be sufficient.

In the subacute cases young people are easily depressed by the asylum associations, but there is usually a time in the progress of the disease when home-discipline is too weak for them, and they must be sent away; older people have usually complications in their home-life such as to make a change desirable for the comfort of the household. Recoveries are extremely exceptional.

In all cases there is little to be gained in keeping up home-associations for so disturbing, distressing a disease after there is pronounced dementia.

Medicines, other than tonics, are of little use, except opiates to control various distressing nervous symptoms, including masturbation, but they should be used with great caution.

KATATONIA (Katatonie of Kahlbaum; Katatonische Verrücktheit of Schüle) presents, with more or less regularity of appearance, symptoms of (1) mild melancholia without the characteristic mental pain; (2) mental excitation, sometimes ecstatic, with cataleptiform conditions; (3) confusion and torpor or apathy. There is an underlying well-marked intellectual impairment, slowly advancing in incurable cases to pronounced dementia. Delusions, more of the unsystematized than of the systematized character, but resembling both, constitute a prominent part of the disease from the beginning. Verbigeration and a curious sort of pomposity are usually found in more or less pronounced degree. The delusions are mixed. They are exalted, hypochondriacal, melancholic, with all sorts of self-accusation, and may be full of suspicion, fears of poisoning, and ideas of persecution. Hallucinations of the special senses and illusions are not uncommon. If the term katatonia is not used, or at least if a special place in the nosology were not given this disease, it would be difficult to know whether to class these cases as primary dementia, melancholia with delusions, delusional insanity, or confusional insanity.

The verbigeration, when it exists, and the expression of delusions are often associated with a manner on the part of the patient suggesting disbelief in them, and sometimes the patient smiles or laughs at the astonishing character of his statements. There is a self-conscious element at times, suggesting mimicry or hysteria; a certain pathos is universal; opposition and contradiction, even to refusal to eat, leave the bed, dress, wash, are quite common; and nurse and physician are tired out with the monotony of the mental and physical state. Well-marked catalepsy is not common in my experience, although it occurs; and in all cases I have seen the mental state and physical atony suggesting that condition. Little attention has as yet been given to katatonia in asylums in this country. Judging from my own experience, it is not a common disease.

Its CAUSES apparently lie in prolonged mental exhaustion and inattention to bodily health. I have been led to suspect syphilis as at least a predisposing cause.

The COURSE AND DURATION of katatonia are tedious, and even if there is apparent recovery from the first attack, the tendency is to relapses and to slowly-advancing dementia and death from those causes of which dements in hospitals die, especially phthisis. I have never seen a complete and permanent recovery.

The MORBID ANATOMY of katatonia suggests a deep-seated neurosis, the precise nature of which we do not understand. In terminal stages there are atrophy and degeneration and all that goes with them.

The CLINICAL HISTORY of katatonia is so characteristic that it need be confused with the other diseases already mentioned as simulating features of it, and with the early stage of general paralysis, only through insufficient observation or too hasty diagnosis.

It is difficult to treat katatonia without the conveniences of a hospital.

PRIMARY CONFUSIONAL INSANITY is a term recently introduced for a form of mental disease of which the most marked features are moderate fever rapidly developed, confusion, incoherence, and mild delirium. The onset of the disease is rapid. In some of the cases which I have seen the diagnosis was made of typhoid fever, although the clinical marks of that disease were absent, the general appearance of the patient in the two diseases being quite similar.

There is no real melancholia or exaltation, no rapid flow of ideas, and no dementia. Hallucinations of the special senses are common; there is a consciousness of illness; the delusions are unsystematized, and the confusion of ideas frequently goes to the point of not being able to recognize persons and places. The usual signs of fever are present for a few days, but the temperature rarely exceeds 102° F., and soon drops to nearly or quite the normal.

The COURSE of the disease is quite rapid, and if recovery does not take place in several weeks or a few months, chronic insanity with delusions or dementia of various degrees may be expected.

The MORBID ANATOMY is not distinctive of this condition in the early stage, and we cannot yet differentiate it from simple fevers by the post-mortem. If ending in incurability, the atrophic and degenerative changes of chronic mental disease are found.

As regards removal from home, the considerations already referred to should be the guide. It is a good rule to keep the patient at home if a suitable one for the purpose, and to resort to the asylum in case of chronicity or troublesome complications.

PRIMARY DELUSIONAL INSANITY (Folie systematisée, Verrücktheit²⁰) differs from secondary delusional insanity in the facts that the disease arises primarily, and not secondarily to other mental diseases; that there is little or no mental enfeeblement in the early stage; and that the delusions, although fixed and systematized, are limited. It has the advantage of allowing the avoidance of the misleading terms monomanie of the French and monomania of English and American writers, the narrower forms of which may be included under the term primary insanity (primäre Verrücktheit), including the further developments of the neuropathic constitution, especially those with the physical marks of degeneration described by Sander as originäre Verrücktheit, and those marked by imperative conceptions and such delusions of self-importance, suspicion, etc. as seem to some people evidence of insanity, while by others they are considered as simply false beliefs not indicating mental disease. Unlike primary insanity, which is one of the states of mental defect and degeneration, and incurable, primary delusional insanity may occur in persons of healthy mental organization, and may end in recovery,²¹ although it is one of the most distinctly hereditary forms of insanity, generally speaking.

²⁰ Called also by some writers Wahnsinn, although they use the term for secondary delusional insanity also.

²¹ Some writers include both diseases under the term monomania, and make both incurable degenerative states, which is contrary to my experience. Clouston also has seen cures in what he calls monomania (primary delusional insanity) without the neuropathic taint.

There are several subdivisions of primary delusional insanity, according to the character of the delusions: (1) with delusions of unseen agency, suspicion, and persecution; (2) with delusions of personal exaltation; (3) with delusions transformed from sensations.

Delusions of unseen agency, suspicion, and persecution appear either acutely and expand very rapidly in a few weeks, or from a very insidious beginning so gradually that they may exist for months or years before they are detected. The general indications of illness consist in impaired sleep, slight loss of flesh, some reserve or shyness in relations with other people, and diminished ability to concentrate the mind in the usual occupations. The mental impairment at first is very slight, and shows itself (1) in the readiness with which the absurd delusions are believed and the fixedness of their hold on the mind, and (2) in the diminished general power of judgment and self-control in the little matters of daily life, at first so slight that it is not seen except in matters requiring some effort to maintain the customary equilibrium. Hallucinations, especially of hearing, appear. In the progress of the disease the mind loses power of self-control more and more, the delusions become more fixed, concealment is no longer possible, and the patient is so annoyed or angered that he repeatedly seeks relief from the courts (Querulantenwahnsinn) or commits some act of violence in self-defence. The common delusions are of marital infidelity, attempts at poisoning, mesmerism, electricity, influence through telegraphs, telephones, poisoned air, etc., signs of which are evolved directly from the consciousness or transformed from common sights and sounds, such as ringing of bells, striking of clocks, simple ordinary motions, etc. The delusions in time produce a state of mental depression.

In some cases the primary delusion is of personal exaltation, attended with persecution and mental depression. The individual thinks himself some great personage unjustly deprived of his rights.

Delusions of grandeur or of personal exaltation develop in the same way, usually subacutely from what might seem a foolish fancy rather than an insane belief. The Napoleons, kings, queens, greatest financiers, gods, etc. of the insane asylums are those who reason correctly if one concedes the truth of their false premises, until the progress of the disease produces such general brain-enfeeblement that their premises and their reasoning from them are both insane. The delusions lose their fixedness, and their force too, in the general lowering of the mind's strength, and complaints and boasts and acts of anger become fewer, and finally cease.

The COURSE of the disease is nearly always subacute in the beginning and chronic to the end in the two forms of primary delusional insanity—that is, with (1) delusions of persecution and mental depression, and (2) delusions of grandeur. A few cases with acute development result in recovery, most of which relapse. The course is for the most part to chronic delusional insanity attended with moderate dementia.

The MORBID ANATOMY is not known, except that atrophic and degenerative changes—not distinctive, however—are found in the terminal stages.

The patient is rarely willing to be treated as an ill person, for he is sure of the correctness of his delusions. If during the first attack he can be entirely removed from his daily associations by change of scene and travel, or, if that is not possible, by admission or commitment to an asylum, before the delusions become fixed and while it is still safe for him to be at large, there is reasonable chance of recovery. Second or third attacks very seldom end in recovery unless they arise from alcoholic excess, when entire abstinence for a sufficient length of time affords fair hope of a favorable result, except in cases of long-standing drunkenness.

TREATMENT, when the delusions have become fixed, involves, chiefly, safety to society or its comfort. The patients rarely commit suicide, driven to desperation by their delusions of persecution when they are particularly horrible. The more common tendency is to acts of violence toward others, so that seclusion in an asylum is usually the only safe course to pursue for delusions which one week may be directed against certain persons who can easily be gotten out of the way, the next week may be directed against others, and so on indefinitely. Delusions of grandeur may be only a nuisance or annoyance, but may at any time become sources of danger. The course is, for the most part, to slowly-advancing dementia. Asylum treatment offers no chances of recovery in cases not depending upon alcoholic excess, but becomes necessary for the protection of society.

Transformed delusions (sensorielle Verrücktheit) arise usually in some anomaly of sensation, which probably directs the delusions already forming in a mind in the early stage of disease rather than causes the disease. The causes lie in a deep-seated exhaustion of the nervous system, especially in the neuropathic constitution and profound hysteria. Various anomalous sensations give rise to a belief in delusions as to their being caused by individuals for a purpose, or to their being an indication of all sorts of impossible and most extraordinary changes in the part: the chest is of stone, the leg of brass, the head on fire, the hand ice, and so on indefinitely. Hallucinations and a cataleptiform state are common. The variety of delusions which may arise is almost endless, and they may have their origin in the unhealthy action of any organ in the body: one of the most troublesome forms, called ovarian insanity by Skae, causes single women of severely continent lives to imagine all sorts of impossible marital relations with men whose lives are equally beyond scandal and above suspicion.

Without proper care the COURSE of the disease is to slowly-advancing dementia; and this may be expected when there is organic disease of any important organ of the body.

Before the delusions are fixed, diversion, change of scene, travel under agreeable circumstances and judiciously regulated, may be of great benefit. In the later stage of firmly-fixed delusion asylum treatment offers more chances of success.

In all the forms of primary delusional insanity the whole history of the case is difficult to get at, and there may be, and usually is, so strong a tinge of possibility at least, if not of actual probability, in the delusions, in the early stage of the disease, that a correct diagnosis cannot be arrived at until the time and opportunity for a cure have passed.

DOUBTING INSANITY (Folie du doute, Maladie du doute, Grübelsucht) is classed by Régis²² as a form of melancholia (mélancolie délirante), on the ground that it has the three elements of melancholia—namely, fixed ideas (délire) of a sad nature, general mental depression, and tendency to suicide. The melancholia is secondary, however, rather than primary, and doubting insanity belongs more properly under the head of a psycho-convulsive mental disease closely allied to delusional insanity, like which it is more commonly a manifestation of psychoneurotic heredity, appearing for the most part among the cultivated classes. It consists in an uncontrollable doubt and indecision, unanswerable by any degree of rational explanation, regarding the occupations, duties, or events of the day, religion, a future life, the commonest acts, or the most abstruse problems of life. Doubting insanity essentially depends upon an anomalous action of the will, with imperative conceptions and impulses. It is classed by some writers as a monomania of the degenerative type. Schüle calls it Verrücktheit sensu strictiori, using the term Verrücktheit also for the three forms of primary delusional insanity just described.

²² Manuel pratique de Médecine mentale.

Délire du toucher, an insane dread of touching certain objects, and the morbid fear of defilement, called by Hammond mysophobia (similar names may be multiplied indefinitely), belong in the same category.

There are mild cases of all these forms of disease, which seem like simple weakness of character, others requiring for treatment the conveniences of the retreat for nervous and mental diseases, with a fair prospect of recovery, and still others tending to chronicity in which hallucinations, delusions, and dementia appear only as a further development into another form of insanity. They may, in mild degrees, be symptoms in the course of other mental diseases, especially melancholia, like many other manifestations of morbid mental energy, such as Doctor Johnson's inability to enter a room with his left foot first or to pass a lamp-post without striking it with his cane, etc.

PRIMARY MENTAL DETERIORATION or PRIMARY BRAIN ATROPHY is a term suggested for a curable impairment of the mind arising from brain-exhaustion in persons, usually men, between the ages of from fifty-five to sixty-five. I have found it in some cases associated with interstitial nephritis and with degenerative disease of the walls of the heart, and have suspected atheroma of the cerebral arteries or possibly endo-arteritis of specific or other origin. It occurs at a time when atrophy of the brain is naturally taking place. There are the usual indications of physical wear and such marked deterioration of the mental powers as to seriously interfere with the capacity to attend to customary business and every-day duties, and to closely simulate the early stage of paralytic dementia. There occur also, in a certain proportion of cases, epileptiform convulsions, slight attacks of dizziness, petit mal, and always disappearance of sexual power and desire. There may or may not be headache. The patient recognizes his condition, his mental depression does not far exceed the physiological limit, and there is no reasonable risk of suicide, except from reasons which would impel a sane man to it.

Under the influence of rest, if begun early, tonics, and a strict regard to the laws of health the symptoms commonly disappear if there is no organic disease. I have never seen the brain recover its tone to the extent of making it safe or even possible to resume the previous kind and amount of work. In a certain proportion of cases there is striking mental impairment, even dementia, and the primary atrophy of the brain sometimes makes rapid progress to unconsciousness and death.

It is not possible to say, by the degree of atrophy found post-mortem, whether there was or was not primary mental deterioration during life.

The TREATMENT consists in entire freedom from care, rest from work, travel, tonics, etc.

As mental disease is more than a brain disease, and is a disease of the intellect, each age from infancy up (and each individuality) impresses its peculiar mark upon it, and there are certain terms in common use to express insanity associated with certain physiological processes whose meaning should be explained.

INSANITY OF CHILDHOOD is for the most part only a further development of a congenital state of mental defect. I have seen, however, well-marked mania, melancholia, primary dementia, and primary delusional insanity before the age of puberty. Typical acute mania I have seen twice in children two years old, apparently arising in normal brains after severe injuries to the head. This is quite uncommon, and the number of cases thus far observed is too few to make me feel sure that my own experience of a favorable result as to recovery in uncomplicated cases will be generally confirmed. At best, after a cure there is a more or less decided arrest of brain development.

HEBEPHRENIA (insanity of pubescence and adolescence) occurs within the ages of fourteen and twenty-three or thereabouts. Like insanity in general among persons in early life, it most commonly indicates an hereditary predisposition to mental or nervous diseases or an early-developed brain defect or injury, possibly an exalted emotional state or an increased nervous sensitiveness produced by masturbation. It is a mild form of primary dementia, modified by the mental changes going on during adolescence. Indeed, it is simply an exaggeration and prolongation of the curious psychological development of that period, too well known to need description, which goes on in the most insidious way possible through months or years of what seems silliness, absurd fancies, foolish sentimentality, egotism, impaired common sense, and diminished judgment and self-control, to a slowly-advancing dementia, which even then is not always recognized as disease. The result is an arrest of brain development on various planes of intellect, and a preservation of the youth's tastes and sense and intelligence, as modified by the morbid propensities characterizing an unhealthy development of the change from boyhood or girlhood and youth to adult life, with the adult's strength—a curious combination of intellectual brightness, it may be, with lack of mind. For this characteristic condition Westphal uses the expressive term Permanenz der Flegeljahre (permanence of the usually transitory state, which then commonly results in permanent arrest of brain development on the plane of the mind at a definite age of adolescence); and yet there may be more than that—mental deterioration, which in years may lead to pronounced dementia. Cases of primary dementia occurring within the years of puberty and adolescence are often classed as hebephrenia and conversely, so that one term, primary dementia, is thought sufficient by many writers on insanity.

In the early stage there is sadness, hardly amounting to melancholia, and it usually constitutes an important symptom to the end, although, like all the other changes in the mental state, it is superficial to the extent of at times seeming almost insincere. Masturbation is common. Occasional outbursts of violence are also common, often with mental confusion, incoherence, or stupor, and in severe cases there occur, usually, attacks of temporary fury, with distressing or agonizing hallucinations of sight and hearing, and delirium, which may all last for a very short time or for a number of days. In young women and girls these outbursts may be coincident with menstruation or in the intervals. The countenance loses somewhat in expression in all cases, and becomes almost vacant or quite so in those in which the dementia becomes well marked. A mild form of the disease is quite common, and consists in an undue intensity or a prolongation of the curious psychological phenomena commonly observed during adolescence. It is marked by aimlessness, changeability, self-assertion, exaggerated self-consciousness, with, perhaps, propensity to lie or steal or run away from home, and ending without any apparent damage to the mind, except that the individual is less of a success in life than he would have been but for his illness.

The course is slow, and although in the majority of cases mental impairment is arrested before reaching what may be properly called complete dementia, in well-marked cases the duration of the disease is long and its results last for life. In many cases progress continues with extreme slowness to extinction of the mental faculties. Oftener the individual simply, in a certain sense, fails to reach that stage of intellectual maturity and strength which he otherwise would have attained. It is not always easy to draw the line between the psychological and the pathological changes that take place during the years of adolescence, and there are many mild cases of hebephrenia in which various kinds of failure in life are due to this disease rather than to the faults or vices to which the failure may be attributed.

In TREATMENT irritability, restlessness, absence of a power and sense of responsibility, and sleepless, excitable nights, are the most difficult symptoms to combat. The restlessness and irritability often lead to refusal to be reasonably controlled and to a tendency to wander away from home with theatrical displays, so as, in the case of girls particularly, to require restraint, especially if the excitability should be so great as to amount to outbursts of violence or should lead to sexual improprieties.

The fact should be borne in mind that there is a diseased brain which needs nutrition, rest, and discipline, which must be proportioned to suit each case. Outdoor, simple life, with sea-bathing, carefully-selected diet, without too much meat, exercise, mental training limited to the requirements of each patient, are the chief reliances. Iron, cod-liver oil, and arsenic are useful tonics. Stimulants, including tea and coffee, should be avoided. Quiet nights and necessary repose can be secured by bromides, exercise, and opiates used sparingly, which also control the impulse to masturbation. A sound education, a healthy experience of the rough and tumble of youthful life, and the careful avoidance of processes and habits of indulgence will often prevent the symptoms of disease from growing into traits of character and habits of life. On the other hand, in some cases there is a half-conscious struggle between the fine traits of character and the demoralizing influences of the disease, and a most pathetic effort to keep the better nature's supremacy over the lower impulses set free or developed by the destructive tendencies of a fearful malady.

MENSTRUAL INSANITY differs from other periodic insanity in not being necessarily a further development of an hereditary or acquired state of mental degeneration, and in being curable in a fair proportion of cases.

INSANITY OF GESTATION, PUERPERAL INSANITY, AND INSANITY OF LACTATION do not call for any further comment than the remark that they represent causes and conditions rather than types of disease.

CLIMACTERIC INSANITY in women and in men is usually a curable folie raisonnante—insanity of action or affective insanity, which may develop into secondary dementia or chronic insanity with delusions. It does not necessarily include all acute forms of insanity occurring at the climacterium, but only those slowly developing with the physiological changes going on.