so until an outbreak of excitement and agitation, to which they are liable periodically, reduces them. The physiognomy is blank and expressionless, especially when the patient is spoken to, or it expresses only in coarse traits the predominant mood; it is often also prematurely aged.

Lastly, there is a group of demented patients in whom nearly all traces of mind are extinguished: they must be fed, moved, clothed, and cared for in every way; they evince little or no sensibility; their only utterance is a grunt, a moan, a whine, or a cry; and the only movements which they make of their own accord are to rub their heads, their hands, or other parts of their bodies, or to continue some other meaningless and monotonous movements. They represent the lowest of the degrees of dementia-the last term of mental degradation to which it is possible for a human being to sink. Their life is in truth little more than a vegetative existence; mental dissolution has anticipated bodily dissolution; and if they are not carried off by pneumonia, tubercle, or some other welcome bodily disease, as they sometimes are, they die from effusion on the brain, serous or hæmorrhagic, or from atrophy thereof, or from the effects of accident to which, in consequence of their apathetic helplessness, they are much exposed. It is a robust faith which infixes the certitude of a resurrection to life eternal of this mind which is seen to dawn with the opening functions of the senses, to grow gradually as the body grows, to become mature as it reaches maturity, to be warped as it is warped by faulty inheritance, to be sick with its sicknesses, to decay as it decays, and to expire as it expires.

Before leaving this subject it will be proper to take notice that dementia is not always chronic, secondary, and incurable, but sometimes acute, primary, and curable. Acute dementia,

when it occurs, is usually the effect of some severe mental or bodily shock. It has followed the shock of a serious attempt at strangulation. One observes it in greater or less degree after an epileptic fit or a succession of such fits, occasionally in an extreme form; for example, in one case that came under my notice that of a delicately constituted person who was said to have had "fits" from time to time-what was called a slight

'faintness," but was probably an epileptic vertigo, was followed by a blank confusion of mind, an entire incoherence, and a complete inability to recognise anybody or anything-a condition, in fact, of extreme dementia, which lasted for a few days. After a severe attack of acute mania, as after the delirium of fever in some instances, a condition of mental confusion and feebleness may be left, which is truly a temporary dementia and is gradually recovered from. Again, acute dementia is sometimes caused by a moral shock. A pale, delicate, fragile, blue-eyed young lady once came under my care after she had been ill for a week. She had scarcely taken any food, and was much exhausted. Her vacant, wandering eyes were devoid of all intelligent perception, and her countenance was blank and expressionless. There was a restless, agitating movement to and fro of the body generally, and of the head in particular, with a low monotonous moaning. She was speechless, and it was impossible to fix her attention or to elicit any kind of intelligent response. She took no food except what was forced into her mouth, and was inattentive to the calls of nature. Within three months she recovered under suitable treatment. She had suffered a great disappointment of her affections; menstruation had ceased; and acute dementia had followed. In another case, a young gentleman, nineteen years of age, of pale and delicate appearance, with large prominent grey eyes, who had been hard worked as clerk in an office, and whose life out of it had not been satisfactory to his friends, was suddenly attacked with a quasi-hysterical attack of incoherence. There was blank confusion of mind; he neither uttered nor otherwise expressed anything indicating intelligence in his mind, and showed no sign of understanding what was said to him by others; and there were occasional periods of confused excitement. He took no food except what was forced upon him, and he was inattentive to the calls of nature. Recovery took place within a month.

The late Dr. Skae described, under the name of sexual insanity, a form of acute dementia met with according to him both in the male and female sex, but more often in the latter, which he believed to be produced by the moral and physical effects of sexual

intercourse upon the nervous system. There is some reason to think that habits of excessive self-abuse have been the cause of a similar form of derangement sometimes in persons of feeble constitution and highly nervous temperament.

The examples which I have given will serve to exhibit the general features of acute dementia, and to indicate the favourable character of the prognosis. The mental functions are abolished for the time by reason of some severe shock to their nervecentres, and the abeyance of them is shown by the expressionless countenance of the patient, his passive attitude of body or meaningless movements, perhaps by an occasional aimless and confused excitement, by his inability to understand what is said or to say what can be understood, and by loss of general sensibility. If recovery does not take place soon, as in most cases it does, there is danger lest the disease pass into chronic and incurable dementia.

NOTE.

In mentioning, at p. 319, the species of insanity which has been described as agoraphobia, reference should have been made to three cases described in the Archiv f. Psychiatrie u. Nervenkrankheiten, Band VII., 2 Heft, and to the Annales Médico-Psychologique, November, 1876, p. 405. One of the patients says of himself:-" From my early youth-in my sixteenth year-I could scarcely cross a large open space alone, or even a large open space in a church or in a concert-room, without suffering from an overwhelming feeling of distress." To cross a square alone he must go round the houses. If he had a companion and was engaged in conversation he had no difficulty. If he attempted it alone, he must fix his eye upon a cart, carriage, or person in the middle of the square as a point to be aimed at, and so get across from one object to another. In vain he had tried to overcome his fears. It was not actual giddiness, but an indescribable distress that affected him. I have recently seen a similar case of a nervous gentleman who cannot cross a square, but must go round by the houses, unless he is accompanied.

CHAPTER IX.

CLINICAL GROUPS OF MENTAL DISEASE.

WHEN We have to do with insanity in medical practice-that is to say, when we have to think how a particular case has been caused, what course it will run, how it will end, and what sort of treatment should be used, we do not so much consider whether the symptoms are mania or melancholia as we do what constitutional diathesis underlies, or what bodily disturbance accompanies, the derangement. It is certain that we get inore help generally from the exact observation and appreciation of such bodily states than we do from the mental symptoms alone: for example, whether a mental disorder is maniacal or melancholic is not of much moment, but the recognition of a gouty disposition, of a syphilitic infection, of a commencing paralysis, of a puerperal cause, and the like, will help us much. It is proper, therefore, to enumerate and describe the principal clinical varieties of mental disorder. To the late Dr. Skae belongs the merit of having insisted strongly upon this clinical classification of mental diseases, and of having been the first to sketch, although vaguely, the leading features of numerous groups.

General Paralysis of the Insane.

For many years now-since Bayle first distinguished thema group of cases presenting characteristic features have been described under this head, and they unquestionably constitute the most definite and satisfactory example of a clinical variety

of mental disease. For that reason I begin with them. They represent a form of disease which is characterised by a progressive diminution of mental power, and by a paralysis which creeps on stealthily, increases gradually, and invades progressively the whole muscular system. The concurrence and concurrent increase of mental and motor disorder are not accidental but constant: the patient loses the power of performing both ideas and movements, and gets worse and worse gradually in both respects until he dies. In the great majority of cases there are extremely exalted delusions of personal power, or wealth, or grandeur; but as they are not present always, it is impossible to make the character of the delusion a necessary part of the definition of the disease. Indeed. all the varieties of mental symptoms-melancholia, mania, monomania, dementia— may be inet with in different cases of general paralysis; but what will be observed always is, that whether the symptoms are melancholic or maniacal, there is a marked weakness of the understanding and memory which there is not in ordinary cases of melancholia and mania.

General paralysis gets a painful interest from the fact that it attacks those who seem to be in the prime of life and at the full height of their energy, and that it selects so many of its victims in the better classes of society. Hereditary predisposition is less often met with than in other forms of mental disease; and there is no little uncertainty as to what is the most frequent exciting cause. Sexual excesses I hold confidently to have that evil pre-eminence, but I doubt not that a certain temperament, oftentimes of a genial and expansive kind, must co-operate. Those who reject this opinion object that the sexual excitement observed is really an effect of the malady, and that it counts among its victims more respectable married persons than unmarried persons of incontinent lives. Neither objection has the weight which at first sight it appears to have. No doubt there is oftentimes increased sexual excitement at the beginning of the disease-I overlook not that-but there is not even then corresponding sexual power, and very soon the excitement vanishes in complete impotence. It is not to this temporary excitement that I refer, but to the steady sexual excesses which