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two of my four cases there was deafness along with the imbecility, showing that the effects of the disease had not been confined to the brain convolutions, but had also affected the centres of special sensation.

The form of insanity that follows small-pox is of the same character as that of scarlatina, but is even more incurable. That of typhus and typhoid is more clearly the result of brain exhaustion from those diseases when they have continued for a long time. The patient seems to come out of the fever, showing no particular symptom of weakness of mind or insanity until some weeks afterwards, when he takes an attack of acute excitement, or “gets into a low way, and a long continued intractable depression results. Tuke and Bucknill and Maudsley say that the insanity that follows typhus is of a more incurable kind than that resulting from typhoid. Sydenham describes the form of insanity that used to follow ague, and in his time this seems not to have been uncommon. He calls it a peculiar form of mania, and says that the long continuance of the fever, and its being of a quartan type, seem to produce the mental symptoms more than any other circumstances. If treated by the exhibition of strong evacuants it degenerates into hopeless fatuity. My single case of the disease was that of a sailor who had regular attacks of ague, drank hard, lived on salt provisions during his voyage home, and on his arrival had an acute maniacal attack. He was thin, pale, and slightly scorbutic. I treated him with abundant diet, malt liquors, fresh air, quinine and iron, and a few draughts of chloral at bedtime, and he was quite well again in two months, having gained 20lbs. in weight in that time. In this case, of course, there were the other causes of brain exhaustion as well as the ague.

Of my ten cases only the last mentioned patient, and one of the scarlet fever cases, had acute symptoms of any sort, and they were the only ones who recovered. All the others were incurable, six of them being hopelessly demented, and the two others hopelessly melancholic. There was hereditary predisposition to insanity in only three of the ten cases.

Post-febrile insanity may be said, therefore, to be generally characterised by sub-acute symptoms, to result clearly from the brain being poisoned by zymotic poison and exhausted by fever, not to require a hereditary tendency for its development, and to be a most incurable form of insanity from the beginning

While on the subject of fever and insanity, a very singular fact deserves notice. The delirium that so often accompanies all sorts of fevers and inflammations is wonderfully like the maniacal symptoms of many kinds of insanity, and unquestionably the general state of the brain cells must be much the same in the two conditions, yet I never knew an attack of inflammatory or feverish delirium to run on without an intermission into an attack of maniacal excitement, however predisposed the patient might be to insanity. How little do the mere general symptoms of a disease of the nervous system indicate to us its essential nature and true pathology!

Insanity of Oxaluria and Phosphuria.-All writers on the urine have noticed the hypochondriasis, depression of mind, want of energy and originating power, and the irritability that often go along with the presence of much oxalate of lime or phosphates in the urine. Dr. Prout thought that the mental state was probably the cause of those abnormal products in the urine, and he especially mentions "a nervous state of the system, and particularly mental anxiety or fear,” as causes that “ will frequently produce in many people an excess of the salt in the urine."*

Golding Bird says that “persons affected with oxaluria’ are generally remarkably depressed in spirits, hypochondriacal, extremely nervous, painfully susceptible to external impressions, and in many cases labour under the impression that they are about to fall victims to consumption.” He says, in reference to phosphuria, that there are cases with this condition characterised by high nervous irritability, following injury to the spine. The late Dr. Begbie directed special attention to oxaluria as a cause of a nervous disorder which was characterised by a very highly neurotic condition of the patient. He says such patients are commonly in the prime of life, belong usually to the upper classes, and have indulged freely in the good things, especially the sweets of the table. He says their sufferings often threaten their mental condition. “They are usually peevish, sensitive, and irritable, or dull and desponding, and melancholic." “They are not unfrequently hurried to the brink of mental derangement.” His theory of the causation of these miseries is that they “flow from the oxalic diathesis from a poison generated during the process of digestion and assimilation, carried into the blood by the ordinary channels, but limited in its pernicious consequences by the busy agency of the urinary organs in separating it from the circulation, and discharging it from the system.” Several of the cases he gives were certainly almost insane, but I fancy few such require asylum treatment. He shows that the nervous symptoms are apparently a result of the oxaluria, and disappear under the treatment that cures it. There is, on the other hand, no doubt of the fact that oxalates may be found in very great abundance in the urine of persons in good health. Lehmann, Bence Jones, and Garrod, and many others, direct special attention to this fact. The former, along with many other physicians, think that its appearance is not at all essentially connected with any special disease or train of symptoms. Speaking generally, the chemical physicians who have written on the urine take this view, while the clinical physicians take the opposite.

* Prout, p. 176, 2nd ed.

G. Bird, p. 250 and 307.

Dr. Skae held the opinion that there were certain cases of insanity with melancholic symptoms, directly dependent on the oxaluric and phosphuric conditions. They were usually men rather over the prime of life, who had exhausted their brain power by over work. They were frequently suicidal. The prognosis was very favourable in these cases.

Undoubtedly one of the strong arguments in favour of the view that such a variety of insanity exists, and one of the most certain means of saying that any particular case should be classed under it, is the fact that the treatment for oxaluria under which it disappears seems to cure the insanity also.

It of course be said that we know so little of the real conditions associated with oxaluria that it is scarcely justifiable to assign it as a cause of any form of insanity. The conditions under which the oxaluria appears may be merely the symptom of some other disease of which the morbid psychosis is also a part, or it may be the result of the disordered brain condition instead of being its cause. I think probably Dr. Skae would have said, in answer to this, “Well, supposing this is so, yet if there is a characteristic and special form of mental disease in any way associated with oxaluria, and the knowledge of this fact will help us to understand its course, its prognosis, and its treatment better than we should have been able to do without this knowledge, then that is all I mean by calling it an insanity of oxaluria or phosphuria. It is the chief value of my system of classification that it is



bound by no principle, etiological or other, except that of enabling us to know something more about our cases, than the old system, and classifying them in more natural

Insanity of Brights Disease. - Though not mentioned on Dr. Skae's list, there is a variety of mental derangement, half delirium and half mania, which results from uræmic poisoning. I have met with two cases of this disease, and Dr. Grainger Stewart says he has also seen a case of this kind. It usually occurs in chronic cases of Bright's disease, with contracted kidneys, where there has been enlargement of the heart, and a tendency to dropsy for some time, and where the central nervous system has been long subjected to the influence of imperfectly purified blood. The symptoms present are mania of a delirious kind, with extreme restlessness, delusions as to the persons round the patient, an absolute want or fear of jumping through windows, or other actions that would kill or injure the patient. The symptoms are characterised by remissions, during which the patient is quiet, and rather composed in mind, but rational, and very prostrate in body. One of my cases was a man of 50, with a family history of insanity, who had once been much depressed in mind (but was not in an asylum) after a fever. He seems to have had heart disease for many years, and to have had Bright's disease for at least two or thrce years previous to his admission into the asylum. He had dropsy of his legs for some weeks before the mental symptoms began. He was at first morose and irritable to å inorbid degree, and steadily got worse in mind, his symptoms changing to exaltation and excitement, fancying he could do wonders, bad absurd schemes of making money, and threatened to murder everyone near him. On admission he was in a state of mental exaltation and excitement, gesticulating, saying he has been married, and had no children (which were delusions), and his memory quite gone. His speech was thick and indistinct, his tongue coated, his pupils dilated, and slowly sensitive to light, the reflex action

* The following case has been kindly sent me by my friend Dr. Grainger Stewart:-"Wm. M., æt. 39, a light-house keeper, applied for advice at the Royal Infirmary, July 21st, 1871, complaining of lowness of spirits and want of appetite. His friends explained that his depression had been such as to compel him to give up his employment, that he had been jealous of his wife, and required constantly to be looked after. His urine contained oxalates. Ordered to be looked after, and to take 20 drops of nit. hyd. acid, dilute, three times a day. 31st, greatly better; no oxalates. Aug. 20th, quite well.”

of the cord dulled, and temperature below normal; legs cedematous ; his lungs were dull at bases, his heart hypertrophied, had a loud murmur with first and second sound; urine contained much albumen, and a few tube casts, sp. gr. 1020. This man alternated between this state of mind and that of a drowsy, stupid, but fairly rational condition, till two days before his death, when he got semi-comatose, with fits of delirium. He only lived five weeks after admission, or about two months from the appearance of his mental symptoms. This is a typical case of the disease. No doubt the mental cells of his brain were the weak point of his central nervous system from his hereditary predisposition to insanity, and the uræmic poison took effect there instead of causing convulsions.*

The Morbid Psychology of Criminals. By DAVID NICOLSON,

M.B., Medical Officer, Her Majesty's Convict Prison, Portsmouth.

(Continued from page 551, vol. xx.)


Melancholy, including Hypochondriasis, Home-sickness,

and Self-innocence as to Crime. We have seen that Simple mental weakness, the first form of weakmindedness, is neither more nor less than a want of mind, in some degree. In it the higher emotions are blunt, perception is dull, and all the processes are backward or sluggish.

In the States of depression which make up the second form of weakmindedness, the general condition of mind may be described as one of inertia, in the presence of a prominent activity in one direction. In well marked cases of morbid mental depression (not limiting ourselves just now to mere weakmindedness), the perceptive, intellectual, and reasoning faculties which are the normal belongings of the individual are made latent through torpidity of volition. The will is without energy; it is incapable of exertion; it cannot act; it is paralysed. This want of volitional power appears to be induced by an intense activity of self-consciousness, which

* Since the above was written, Dr. Wilks has directed attention to “Mania as a symptom of Bright's Disease.” Jo. Ment. Sci., July, 1874, p. 243.

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