INSANITY 105 ignorant; all he can say is that, when its histological integrity is impaired, he has reason to believe that " some functions become torpid and oppressed, while others are excited into preternatural activity" (Bucknill and Tuke). It must be stated, however, that in a considerable propor tion of cases the nature of the ultimate condition is fore shadowed from the very commencement by the character of the initial symptoms. Simple depression of feeling may be the first and last symptom of insanity, or it may gradu ally increase in intensity till it attains the extreme and most complicated form of melancholia, In like manner simple excitement and exaltation of feeling may characterize a case from beginning to end, or it may culminate more or less rapidly in active mania, without the intervention of other psychical symptoms. As to the duration of the prodromal period, in the mass of cases nothing can be stated with certainty ; it can only be said that, as a general rule, the incidence of melancholia is more slow than that of mania. Putting aside exceptional cases, it may be stated that, whereas the former is a matter of months or weeks, the latter is a matter of weeks or days. The initial mental symptoms having been already de scribed, it remains only to say that the general system becomes coincidentally affected ; functional disturbances of the digestive organs soon manifest themselves, and the nutrition of the body becomes defective. To this implica tion of other systems consequent on impairment of the trophesial (nourishment-regulating) function of the brain can be traced a large amount of the errors which exist as to the causation of idiopathic melancholia and mania. Very frequently this secondary condition is set down as the primary cause ; the insanity is referred to derangements of the stomach or bowels, when in fact these are, concomitantly with the mental disturbance, results of the cerebral mischief. Doubtless these functional derangements exercise consider able influence on the progress of the case by assisting to deprave the general economy, and by producing depressing sensations in the region of the stomach. To them may probably be attributed, together with the apprehension of impending insanity, that phase of the disease spoken of by the older writers as the stadium melancholicum, which so frequently presents itself in incipient idiopathic cases. During the earlier stages of the prodromal period it is impossible, in the majority of cases, for the physician to predict, with anything like certainty, whether the case may culminate in acute melancholia or acute mania. But as it progresses the irritability and restlessness which ushered in the malady become intensified ; sleep is either irregular or may be lost for nights together ; further degeneration of the brain constituents necessarily follows, and the loss of controlling power over ideas is manifested in excitement in one of two ways (1) by the domination of one set of ideas, which are for the most part of a depressed character, or (2) by a tendency to follow lines of thought suggested by accidental external circumstances. Although in the one case there is a concentration and in the other a diffusion of ideas, there is the common result of occlusion of the individual from a normal process of thought, inconsequence of his inability to review external circumstances correctly. 1. Acute Idiopathic Melancholia presents itself in three degrees of intensity : (1) simple depression of feeling, (2) depression of feeling with delusion, (3) depression of feeling with mania or delirium. The second and third of these conditions may supervene on the first, or any one of them may singly characterize the case. Simple Depression of Feeling. In no form of insanity is the sane mind more prone to project a psychological scheme of causation than in that of which simple depression of feeling is the predominant symptom. The restlessness and irritability which accompany anxiety, grief, and worry, and the consequent exhaustion and depression, suggest a psychological continuity. There is, however, a very dis tinct difference between depression of feeling within the limits of health and the depression of feeling resulting from morbid processes going on in the brain, and in symptoms there is a distinct line of demarcation. A mere fit of depression, from whatever cause, does not prevent a man from using his intellectual faculties ; circumstances influence him, and he can review his position ; but where the limit of health is passed the normal influence of external circum stances is lost. This indication is accompanied by a gloomy apathy ; the memory of the past is misery, the present is unendurable, and there is no hope in the future ; every thing is black within and without, every incident feeds the melancholy, every suggestion of hope is parried, and every appeal to the reason falls dead on the ear of the sufferer. This latter symptom the inoperativeness of appeals to the reason is a feature of all forms of insanity, and it is therefore well to notice it particularly when treating of the simplest. What to the sane mind is the simplest proposi tion, to the insane appears either utterly false in itself, or to have no bearing on the position. The power of comparing idea with idea, the faculty of discriminating their differences, or the perception of agreement in the midst of difference is lost in a word, the judgment is impaired or utterly in abeyance. The common everyday expression "out of his judgment," employed to indicate that a man is insane, is psychologically accurate, and logically applicable in all forms of insanity. A strong tendency to suicide frequently presents itself ; the utmost ingenuity is exercised to accomplish this object, the whole mental energies being concentrated upon it. It is impos sible to render in terms the general as well as facial expression of the melancholic ; it cannot be simulated with success before any one conversant with the condition. Depression of Feeling ivith Delusion. Idiopathic melan cholia symptomatized by simple depression of feeling may become gradually complicated with delusion and hallucination, or this complicated condition may follow immediately on the initial symptoms. The delusions and hallucinations of idiopathic melancholia may be divided into three classes : (1) those traceable to perverted sensation produced by implication of the functions of the general system ; (2) those apparently dependent on the nature of the primary causating train of emotion ; and (3) those which it is impossible to connect with any particular influ ence, either psychical or somatic. The first class contains the delusional symptoms resultant on atony of the alimentary canal, which, by producing obstinate constipation, catarrhal affections of the stomach and bowels, and dyspepsia, cause sensations which are referred by the insane mind to supernatural influences : he believes that he has serpents or worms inside him, that his gullet is closed, or that his bowels are so obstructed as to render relief by the natural passage impossible. As a direct result of this delusion food is systematically refused, and it often becomes necessary to resort to artificial feeding by the stomach-pump or some allied apparatus. Hallucinations and illusions of smell and taste may be referred to the same causes as the delusions just spoken of : the foetor of the breath due to dyspepsia may suggest to the melancholic that he is surrounded by a poisonous atmosphere, and that everything near him stinks; and the foul tongue of the same condition may be productive of hallucinations of taste, and may even lead up to the very common delusion that his food is poisoned. Such distinct objective starting points, however, do not suggest themselves for hallucinations of vision and hearing ; these can only be regarded as incidental results of the morbid cerebral con dition of which the process of production is unknown. Hallucinations of sight are comparatively rare ; when they XIII. 14
