Popular Science Monthly/Volume 6/March 1875/The Mental Aspects of Ordinary Disease
|THE MENTAL ASPECTS OF ORDINARY DISEASE.|
By J. MILNER FOTHERGILL, M. D.,
JUNIOR PHYSICIAN TO THE WEST LONDON HOSPITAL.
SO long as the mind was regarded as something separated from the body, or only united to it by feeble ties, bodily conditions could have nothing to do with mental phenomena—insanity was a disease of the soul. The monk, standing over a miserable lunatic chained to a staple in the wall, and flogging him in order to make him cast his devil out, was a logical outcome of this hypothesis. The union of psychology and physiology is the closing of the circuit, in one direction, of the pursuit after knowledge, and marks the initiation of a rational comprehension of the mind and of its relation to corporeal conditions. How such mistaken ideas of the word melancholia, as those entertained by the monk in his capacity of physician for diseases of the mind, could have attained their sway in the face of the maxim mens sana in corpore sano, only becomes intelligible when we remember the ignorance, the superstitious prejudices, the contempt for knowledge of the natural man, which found their highest expression during the monkish supremacy of the dark ages. Slowly but surely was the emancipation of the intellect from the fetters of priestly tyranny achieved. The days of the minor Trinity—the soul, the mind, and the body—are numbered; the advent of a physiological psychology is at hand. That insanity which was regarded as an indication of some disease of the soul, in whose production the body had no share, is now known to be linked with appreciable pathological changes, and in many instances is amenable to physical remedial agents. Thought is the product of the cells of the gray matter of the brain—the result of a change of form in inorganic matter taken into the system as food, of which acids and other products of oxidation, of retrograde tissue-metamorphosis, are the waste.
Such being the case, it is obvious, then, that bodily conditions will affect the nutrition of the brain, or rather of the cerebral cells, and so modify their products. It is not necessary to go into the more pronounced conditions called insanity for the evidences of such influence; they are to be found in the varying mental attitudes of common life. It is true, however, that the study of the more marked cases furnished by insanity, with their deeper shadows and clearer definitions, is the best preparation for the proper recognition and discrimination of the finer shades, the slighter changes, which exist among the sane. More especially is this the case in attempting to analyze the varying emotions. At one time all looks bright, cheerful, and encouraging; at another, the same prospect looks cheerless and tinted with despair. This change depends upon physical conditions, and a more pronounced physical state not only involves the emotional centres, but implicates the intellectual processes. Thus, a slight amount of bile in the blood, or an excess of renal products, may depress a man with hopeless despair or drive him into paroxysms of violent passion. The delirium of fever is a familiar instance of the influence exercised by passing bodily conditions upon the brain and its product—thought.
When the nutrition of the brain is good, we experience an agreeable sense of well-being, which shows itself distinctly in after-dinner geniality. When the nutrition is imperfect, or the arterial blood is of abnormal composition, the consequences are a mixture of irritability and bad temper, blended with depression. We are all familiar with the crossness of the hungry man; when fasting, crossness is interchangeable with hunger—is often its substitute, and forms a contrast with the amiability of repletion. Especially is this irritability seen in those whose digestive powers are weak. A similar irritability is the ordinary mental attitude of convalescence from acute disease, and either precedes or runs into and coexists with the keen appetite usually found at that time. They are linked together by something more positive than coincidence.
The dependence of modifications of the functional activity cf the cerebral cells upon other corporeal conditions than changes in the blood is now well recognized. There are communicating fibres by which the brain receives impressions of varying character from different organs. An impression coming in from some far-away point stimulates or inhibits the action of the cerebral cells. So strong may be the impression that actual insanity may result, as in the case, related by Schroeder van der Kolk, of a lady who became insane whenever her womb became displaced, and sane again as soon as it was returned to its place.
The effect of several morbid states is to stimulate the brain into greater activity. A non-medical but most acute observer and able writer says:
"It seems even that bodily pain and disease are not only compatible with, but may directly contribute to, the loftiest efforts of the intellect. They sometimes positively enhance its powers. The effect of some disorders and of certain sorts of pain upon the nerves is to produce a cerebral excitation; and the stimulus thus communicated to the material organ of thought renders it for the time capable of unusual effort. Men under the stirring influence of severe pain are capable of a degree of imaginative and ratiocinative brilliancy which astonishes themselves and all who have known them only in ordinary moods of comfort. Torpid faculties become vigorous and sparkling. Forgotten knowledge is recovered. Marvelous gleams of insight are vouchsafed them. The wonderful eloquence of Robert Hall was doubtless greatly owing to the stimulating influence of a terrible spinal malady. Dr. Conolly mentions a gentleman whose mental faculties never reached their full power except under the irritation of a blister.
Abnormal and unsound conditions of the bodily organs sometimes give us glimpses of mental powers and possibilities far exceeding any thing of which ordinary health is capable. The phenomena of some nervous disorders are positive revelations, and most startling ones, of what the human intellect, disengaged from matter or under favorable material conditions, might achieve and learn."
When Greg talks of intellect disengaged from matter, he is led away into poetical metaphor, which is, however, allowable in one who is not a professed physiologist.
We are all familiar with the effects of alcohol upon the intellectual powers. A gentleman mentioned by Dr. Willis, who was liable to periodical attacks of insanity, said that he expected the paroxysms with impatience, because, during them, he enjoyed a high degree of pleasure. "Every thing appeared easy to me. No obstacles presented themselves either in theory or practice. My memory suddenly acquired a singular degree of perfection. Long passages of Latin authors occurred to my mind. In general, I have great difficulty in finding rhythmical terminations, but then I could write verse with as great facility as prose."
There are two distinct physical conditions under which the intellect seems to possess a power and a brilliancy much exceeding the normal standard. These two conditions are: 1. The initial or pretubercular stage of pulmonary phthisis; and, 2. The condition of chronic gout. Whatever difference of opinion may exist as to the explanation of the cause of this high state of mental activity, there can be none as to the fact. There is, as it were, almost an aureole of intellectual light around the heads of those who are about to enter the fated pathway of pulmonary tuberculosis. To what it is due, it is difficult to say. One factor may be some accession of arterial blood to the cerebral cells in excess of the normal flow. We know that there are usually an accelerated pulse-rate and a heightened temperament in such cases. There may be some nerve-communication between the lungs and the vaso-motor nerves of the cerebral vessels, of which we are as yet but dimly conscious, which may some day explain the matter to us. As to the intellectual power of the gouty, there is less difficulty in explaining it. In the first place, the blood of the gouty is highly charged with nitrogenized matter. Carpenter has pointed out ("Human Physiology," sec. 62) how desirable a nitrogenized diet is for the evolution of nerve-force, while Liebig dilates upon the effect of food upon the disposition, in his well-known "Letters on Chemistry." M. Metz, of Mattray, found the value of a liberal dietary in giving strength of will to irresolute boys in his reformatory. An excess of nitrogen in the system, and especially in the blood, acts as a stimulant to the brain-cells in the case of the gouty. This, however, is but half of the matter; there is an equally, or even more important factor, in the condition of the circulation.
Careful investigation has demonstrated to us the state of the circulation in chronic renal inadequacy. There is usually decided hypertrophy of the left ventricle, and a high arterial tension, originating in a contracted condition of the terminal arteries. As a consequence of this tension, the blood-pressure on the brain is well sustained; and a free supply of arterial blood, rendered perhaps more than ordinarily stimulating by the presence of nitrogen in excess, evokes a heightened activity of the cerebral cells. Simple hypertrophy of the heart is mostly found in the subjects of chronic renal changes. That there is a certain explosiveness in the gouty, together with much mental activity, is simply a clinical fact. The excess of nitrogen in the blood stands in a suggestive relationship to the explosive irritability, while the high blood-pressure is evidently causally related to the heightened mental activity. The two factors requisite for rapid evolution and discharge of force by the cerebral cells are found together under the above-named combination. If the changes in the circulation are imperfect, and the blood-pressure is but low, or even normal, the gouty person is not mentally inactive, but is despondent.
Bichat observed that the length of the neck exercises an influence over the mental activity of the individual. Persons with short necks have a better sustained power of work than those who have long necks, or, in other words, other things being equal, the brain, which is superimposed on a short neck, has an advantage over the brain fed by a long carotid artery. Van der Kolk is in agreement with Bichat upon this point. An extensive series of observations inclines me to agree with them.
Van der Kolk also quotes from Haller the observation that rickety children have generally large heads, and possess quick perceptive faculties; and that the blood-vessels of their heads are distinguished for their large calibre. Certainly such children are commonly very precocious. There is a point, however, in relation to this matter which must not be overlooked. Rickety children are usually of scrofulous tendency, and in the scrofulous there is usually an excess of lithates in the blood, which will not be without the ordinary effect exercised by nitrogen on the brain. The great Dutchman also states, "It is a known fact that hunchbacked individuals, in whom the blood flows more quickly and strongly toward the brain, are remarkable for vivacity of spirit." It will not do, in this consideration, to leave out of the question the possibility of a mental factor; that the physical deformity turns the mind of the individual toward mental cultivation as a compensation for bodily defects. Granting this, we must also remember that mere will and perseverance exercise a limited influence, and only permit a brain to make the most of itself. What exists there potentially, it may draw out into actual manifestation; but with this the power of the will ceases. An effort of the will may and does dilate the blood-vessels of the brain, and permits larger circulation through it; but the general blood-pressure in the systematic vessels is an important matter in sustaining the intercranial flow. If the general blood-pressure in the vessels of the head and neck is high and well maintained, then a brain can work up to a much higher power, just as a steam-engine may be worked up to a higher pressure, and so become actually more powerful.
While we recognize the fact that mental conditions are causally associated with the amount of the blood-supply, indeed to a great extent rest upon it, it must not be supposed that I wish to under-estimate the importance of the condition of the cerebral cells themselves, either as to their inherited peculiarities, or as to the conditions produced by the experience of the individual. Such consideration is, however, without the sphere of the present paper, which deals with cerebral manifestations in relation to ordinary disease, and not with those ailments which belong to the province of the alienist physician. To one form of disorder of the cerebral cells alone may reference be made here, and that is as to the effects of mental over-strain. Brain-tissue can be developed by exercise, and worn out by overwork. When this latter condition has been induced, there exists that irritability which forms part of the early stage of the exhaustion of nerve-matter. In all overtried brains there is much irritability and tendency to manifest what we term temper. This fact we learn in time about the individual, but we are somewhat slow to recognize it in the abstract. It is socially desirable and important that such recognition be more general.
In considering the associations existing between cerebral manifestations and certain conditions of the organism, and the effect exercised by the latter upon the former, it is important to bear in mind that the brain is divided into two vascular areas: 1. The anterior, fed by the internal carotids; and, 2. The posterior, fed by the basilar artery; nor is the amount of inosculation in the intercranial circulation such as would allow vicarious action-to make good a deficiency caused by an interference with the direct supply of either area. These two vascular areas contain brain-cells with different properties and functions. There is much reason to believe that the emotions and systematic sensations lie on the posterior area; and that the intellectual and motor powers, together with general peripheral sensations, lie on the anterior area. In other words, the posterior area is associated with the organic processes of the system; the anterior with the animal life—with the relation of the organism to its surroundings. The vaso-motor nerves of these two areas are differently derived. The nerves of the cerebral arteries spring from the lower ganglion of the great sympathetic nerve in the neck, into which run the fibres ascending from the abdomen; while the carotid arteries derive their vasomotor supply from the middle and upper ganglia. Thus we can see how the emotions sympathize with the organic processes, especially those located in the abdomen, and so can see melancholia in a new light; can comprehend how mental depression may wait upon and depart with abdominal disturbance. The disturbance does not extend to the intellectual processes; the emotions alone are involved. The sense of well-being, or of discomfort, depending upon systemic conditions, tells of the relation existing between the emotions and the organic processes; and the nerve-tracks just described enable us to comprehend the subject more clearly.
There is an interesting point connected with this division of the cerebral hemispheres, and the functions of each division, to which we may advert. It is the association existing between states of emotional depression and abdominal disease, and the comparative absence of such depression in affections of the lungs. Marshall Hall writes: "The temper of the patient is singularly modified by different disorders and diseases. The state of despondency in cases of indigestion forms a remarkable contrast with that of hopefulness in phthisis pulnionalis, and other serious organic diseases."
In diseases of the lungs, the condition of depression is rarely present, and, when so present, is possibly due to some abdominal complication; though, of course, some of the existing depression may be fairly attributed to the anxiety naturally arising from an intelligent comprehension of the danger impending. In tuberculosis of the lung there is commonly such an emotional attitude in the patient as has earned for itself the designation of spes phthisica. Here the hopefulness is as irrational as is the depression of some other affections. The consumptive patient just dropping into the grave will indulge in plans stretching far into the future, ignoring his real condition, and the impossibility of any such survival as he is calculating upon. It is a curious yet a familiar state. Hope seems to rise above the intelligence, just as in certain abdominal diseases there is a depression which defies its corrections. The intellect is not equal to finding the true bearings or of correcting the exalted emotional centres. In curious relation to these conditions stand well-known differences of the pulse. In chest-diseases the pulse is usually full, sometimes bounding; in abdominal disease it is small and often thready. The pulse of pneumonia and the pulse of peritonitis are distinctly dissimilar and contrast with each other. It is well known that there is much more tendency to collapse in abdominal than in thoracic disease; taking the conditions of the pulse together with the emotional attitudes of these affections, the synthesis is unavoidable that some effect is produced by the tubercular disease in the lungs upon the emotional centres as opposite to the effect of abdominal disease as are the varied effects upon the pulse; and further that the result is probably produced through the circulation. The explanation which is shadowed out, for it really does not amount to more, is that abdominal disease causes a depletion of the emotional centres—of which depression is the outward indication—while phthisis leads to a plethoric state associated with exalted emotional conditions. In either case the intellectual and volitional centres appear unequal to the task of maintaining the balance which normally exists. As a matter of fact, there are certain mental attitudes found in some diseases which are so regularly present, so well marked and pronounced, that they may fairly be included as a part of the rational symptoms. So commonly is mental depression found along with biliary disturbance that the name melancholia was given to these conditions of mental gloom; and modern observation is but establishing the propriety of the term.
Allied in essence to melancholia is the panphobia, or "low spirits," common to women generally, but especially found in the habitués of our out-patients' rooms. It is the cry of the suffering brain for better nutrition, for a more liberal supply of arterial blood. There is much emotional mobility and the patient is easily moved to a flood of tears by the slightest exciting cause. Under different circumstances relief from the depression is sought in alcohol, and this is the most depraved, the most hopeless, and the deadliest of all forms of habitual intoxication, the more hopeless from its being based on physical conditions; or it stimulates the spinster and the widow to a pseudo-religious existence, where the religious fervor is the measure of the cravings of the ungratified physiological aspirations.
We do not consider, perhaps, because the subject is repugnant to us, how much our psychical attitude, even to religious, the highest of all thought, is based upon conditions of the body; that body which theologians of the old school denominate vile, which they would trample under foot, nay, even ignore, yet which is reigning supreme and dominating and directing them in their highest aspirations. What a terrible revelation this gives us of the psychological attitude of the monk, who thought to subdue his inborn passions by scourgings, fastings, sleeplessness, and religious exercises, when all the while he w r as the victim of their thwarted and riotous activity as they crowded his mental horizon with gloomy or sensual images and presented a future of everlasting damnation to his superstitious vision!
Another form of psychical disturbance is furnished by the perturbations termed hysterical attacks, and which usually occur under circumstances of repressed passion. There are an excitability and mobility about the person which tell how the emotional centres are quivering and vibrating under the tension to which they are subjected, and the emotional oscillations, from weeping to laughing, indicate that the emotions are no longer under the control of the volitional centres. This loss of equilibrium becomes more marked when any disturbance of the bodily health leaves the organism at the mercy of these emotional storms. Hysterical attacks are generally explosive discharges of the emotional centres, as epilepsy is of the motor or mania transitoria (demoniacal possession) is of the volitional centres. They all resemble the "blowing of the engine" when it has stood still some time and the steam-pressure is becoming dangerously high.
Much mental instability is found among sufferers from chronic heart-disease, and many and pronounced are the mental modifications induced. In one case, I remember well, a very old patient, who was the subject of aortic obstruction, became remarkably polite when the results of the cardiac lesion were very marked, a mental attitude far removed from that which he habitually assumed. Usually a totally opposite character of change is produced, and the effect is to cause the mental operations to be imperfect, unsustained and unequal, while there are present suspicion, doubtfulness, vacillation, and caprice. Indeed, the mental change is usually for the worse; and along with intellectual enfeeblement there is an alteration of the emotional products which we have seen to be allied with cerebral depletion. The false and morbid feelings which are the products of imperfectly nourished cerebral centres bear the same relation to normal thought that Emerson says evil does to good—it is good in the making; and more perfect elaboration of the outcomes of emotional centres would give us healthy instead of morbid feeling.
The mental attitude of sufferers from heart-disease is usually one of caprice, unsustained volition, together with suspiciousness and groundless fear—imperfect emotional products.
Another marked mental attitude is furnished by those who suffer from gout in any of its forms, for suppressed gout is the most protean of diseases. We have already seen how gout-poison stimulates the intellect in the earlier stages of granular kidney; what we may now consider is the mental modification produced by advanced disease. There is a mixture of explosiveness, the gouty temper, with suspicion and depression, the consequences of spasm of the intra-cranial arteries. Instead of the well-sustained blood-pressure of the early stages with the stimulant gout-poison irritating the cerebral cells into activity, we have the stimulant quality of the blood together with an impaired and insufficient supply. The resultant product is a blended compound of irritability and suspicion, bad temper and anxiety, the latter all the more aggravating from a consciousness that it is not mere illusion, but an emotional hallucination.
Such individuals are the terror of their dependents and the bêtes noires of their domestics. There is such a villainous state of temper, at times ascending to ferocity, that the person becomes simply intolerable; the unfortunate sufferers themselves being still further tortured by the haunting impression that they are utterly unreasonable, and that their attitude does not arise from any provocation from without, but that it takes its origin in some abnormal condition existing within. In one case well known to me the sufferer sought relief in religious exercises, in resort to her Bible and to prayer—it is needless to say without the desired result. What she needed was not spiritual discipline, not correction of the mind through the soul's portals, for she was a truly good and high-minded woman, but a remedying of the bodily condition on which the mental state causally depended. As a matter of fact, well-directed treatment produced a restoration of the normal feelings and emotions which all the spiritual exercises had signally failed to achieve.
Another peculiar and fairly-pronounced mental attitude is that furnished by the victim of cancer. The form assumed here is that of sullen and defiant submission to the inevitable. There is rarely any active and positive attempt made by the sufferers themselves to avert their doom. There is, as it were, a volitional control exercised over the impulses, which is marked, and the sufferer submits to a grip he sees no chance of eluding. But it must not be supposed that there is an abolition of the instinct of self-preservation; it is merely subordinated. That this is the actual attitude is shown by the fact that when the mind is wandering at the last, especially in gastric cancer, which interferes so much with nutrition, the patients in their delirium commonly ask for a knife in order to excise the hostile malignant growth which is involving their existence.
The mental attitude of pyæmia (alteration of the blood by pus) is, again, quite distinct from any of the foregoing. It is that of absolute indifference. From the first long shivering fit which marks the initiation of the fateful disease, the mental attitude is usually that of imperturbable indifference. Marked by utter unconcern as to the course of the disease, it contrasts very strikingly with the ill-founded hopefulness of hectic, and especially of pulmonary phthisis. Of course it is not asserted that the mental attitudes described are invariable and ever present in the different diseases; only that they are so common that they cannot be regarded as mere coincidences.
In diabetes mellitus, too, there is a condition of mental languor and depression, which is as marked as the muscular lethargy and lassitude manifested by sufferers from that affection, and which often precedes those physical symptoms which we are too much inclined to regard as the chief indications of that disease.
The condition of the mind in the delirium of fever is a subject of much interest, albeit it is surrounded by many difficulties. The great one is that people at large are too much accustomed and inclined to regard delirium as aimless, objectless mental action—a chaos of broken ideas and unconnected thoughts, or an uncovering of the sewers of the mind, the revealing of secrets not always innocent. The first is the way in which they regard it in others, the latter, the form in which they apprehend it in themselves, so that there is not given to it that intelligent attention the subject deserves; nor are those immediately and constantly around the delirious patient likely to possess a calm, dispassionate, and competent capacity to attend to what is going on in his mind, so far as it finds expression in words. The anxious relatives and the overworked paid nurse do not possess the qualities requisite for correct observation of this complex condition, even if they could be induced to make the nature of the delirium the object of their attention. The impressions remaining on my own mind of my thoughts during a pretty sharp and well-sustained delirium, due to a grave attack of scarlatina, are that there were two leading ideas dominant in my mind: the one in relation to my surroundings, the other in relation to my aims and my occupation. The first, though less predominant, were distinctly the more vivid impressions, and they were not only very unpleasant, but their remembrance is ineffaceable. They arose chiefly through the weakened senses, especially the sense of sight. The bedroom I had occupied for years had been rearranged to adapt it to the necessities of a sick-room, and, on waking, the eye did not immediately recognize it. This at once gave a direction to the wandering thoughts, and the leading idea was to get home. The opposition offered to my attempt to escape seemed to me so unjust and improper that violence must be resorted to in order to overcome it, and then followed a wild, delirious struggle, terminating in complete exhaustion. This opposition engendered a strong feeling of personal dislike, blended with suspicion toward those around me, and their kind attentions were interpreted by the reeling brain as unjustifiable interference with natural and intelligible wishes. The remembrance of the feeling of dislike thus originated remains sufficiently strong to occasionally tint the thought yet; for the residua remaining in the cerebral cells exercise an influence on the thought-currents when passing over them.
The other source of disturbance was the influence of the lines of thought which were predominant in the mind ordinarily. These formed the chief subject of my wanderings during the delirious period. At times, the impression that certain patients ought to be seen would become so vivid that I desired to be dressed in order to pay the required visits. Opposition to this, of course, aroused indignation and resentment, and strengthened the suspicions already excited by the restraint exercised to prevent, as I imagined, my returning home.
The remembrance of the condition is still sufficiently vivid to explain the mental attitude of those whose intellect is waning, either from dotage or from a like condition of brain-failure inaugurated by acute disease. Why their relations, who attempt to contradict or to control them—not always with the happiest tact—are objects of dislike and suspicion, is intelligible enough; as also why attendants who humor and cajole them are thereby endowed with a potential, undue influence. The brain, becoming less and less functionally capable, is more and more unequal to the correction of its ill-founded or unjust dislike.
There is nothing monstrous in the mental products; there is just that deviation from the rule that might be anticipated when the functional activity is modified by structural changes. There is not a new line of thought instituted, leading in opposite directions to the normal thought, but a misdirection of the ordinary mental processes. There is, however, a certain amount of illusion which, when pronounced, or when the effect upon the brain-cells is such as to cause an evolution of distinctly-erroneous thought, or actual hallucinations, indicates that the frontier of sanity is crossed.
Such considerations will enable us to observe and to comprehend that initiatory stage of mental impairment which precedes obvious and well-marked dotage. The earlier stages, the lighter shades of mental failure, of waning brain-power, are distinct enough to the trained eye, long before those more obvious changes are reached which are recognized by the untrained observer. Such mental changes are commonly found in those undergoing degenerative physical changes, not only in the very aged, but in those passing into premature decay; in fact, mental impairment and decay are but the evidences or outcomes of the implications of brain-tissue in the general degeneration. We are, of course, most familiar with such changes in the very old, in whom we regard them as almost normal. The mental grasp is imperfect and illusive; petulance and caprice are the characteristics, especially of those in whom the intellect was never very strong. Their intellectual vision is deceptive and untrustworthy. A dim consciousness of some such change obtains in the mind, and makes them deeply suspicious and extremely susceptible, and ready to take offense at the slightest indication by others of a knowledge of their growing incapacity. Nor can we feel surprised at this sensitive suspiciousness. Mental decay cannot be a pleasant matter for those undergoing it, and no wonder they are excessively jealous of any alteration of manner or attitude.
A similar condition of enfeeblement, combined with excessive jealousy and deep-rooted suspicion, is furnished by those who have anticipated the normal time of senile decay by habits of drunkenness. The man who is beginning to yield under persistent alcoholization, and who feels that his powers are giving way, is generally suspicious and jealous, if not actually malicious. The intellect undergoing premature degeneracy is more readily and easily provoked than is that of a person entering normal dotage; while there is often coexistent a certain amount of spasmodic vigor of temporary active irritability. Such persons are simply dangerous to those dependent upon them, and not to be trusted—their mischievousness being only restrained by their incapacity to execute or put in force their malicious designs.
There are two other mental attitudes which are not directly associated with bodily disease, but which exercise so distinct an influence over physical conditions, especially in sickness, that they may not improperly be considered here, though not quite falling within the scope of this paper. One is that condition of mental impairment in which the intellect becomes servile. It is usually shown by elderly people, who are utterly dependent on the bounty, and therefore on the will, of others. That such a condition of helpless submission should obtain under these circumstances, and especially in women, is readily to be conceived. The utter helplessness and entire abolition of self-confidence so induced have a most pernicious effect upon the mental processes; the intellect becomes restricted, and solely directed toward observing and accommodating themselves to the varying moods and passing caprices of those upon whom they depend. Chameleon-like, they change color with every new shade of opinion with which they come in contact, until at last they lose their individuality altogether. The mental condition of these unhappy beings is pitiable in the extreme; there is a paralysis of all volition. "Everywhere and ever, to be weak is to be miserable," and cunning is the only refuge of the feeble. This mental attitude is a matter of moment, and needs recognition when such persons become objects of medical care, and must be included in the formation of a prognosis; the mental instability and tendency to oscillate being very troublesome, and interfering with the working of every systematic plan. Under totally different circumstances, a similar brain-starvation is manifested by those persons who voluntarily cultivate a mental predisposition to religio-melancholia. Their aspirations, originally directed by their surroundings, are ultimately guided by an artificial substitute for the will which they in time develop. It is the psychical side of a question of which the physical side has been discussed before. The intellectual imbecility eventually reached under these circumstances is something pitiable. The intellect is prostrated before an irritable conscience, rendered morbidly sensitive by persistent self-introspection fostered by vigils, developed by fasting, and misdirected by a cramped and imperfect education. The influence exercised by this condition of intellectual enfeeblement also becomes practically important when any line of treatment has to be pursued, and especially so in that complex combination of dyspepsia and constipation to which such persons are so subject. With such persons, the plainest and simplest truths of the natural man seem to take on the aspect of most abstruse and difficult problems; the fullest explanations and clearest directions are insufficient to enable their enfeebled intellects to grasp the subject. Superstitious credulity displaces reasonable belief, and enervates the mind until it can evolve no healthful thought; the morbid activity of pseudo-religious sentiments induces such a palsy of the moral nature, that it becomes incapable of rising in revolt or of seeking to escape its intellectual thraldom.
In those who are exhausted and worn out by toil, either mental or physical, or both combined, but usually by strenuous bodily labor, united with petty mental anxieties and fretting, wearing thought, a condition of brain-degeneration is produced, which exercises much effect upon the progress of any ailment requiring medical treatment. This class of cases occupies a sort of disputable ground, a border territory which scarcely permits of their being included in hand-books of insanity, nor yet in the ordinary systems of medicine. They are considered here among the aspects—not as outcomes of disease, as are the mental attitudes described in the earlier divisions of this paper, but rather as mental conditions, not normal nor yet insane, which exercise much influence over the progress and course of ordinary ailments.
Finally, there is a condition of temporary, evanescent brain-impairment, which is produced by acute disease, and especially by severe attacks of fever. The mental faculties are usually somewhat impaired by severe attacks of typhoid fever, and soldiers, after recovery from such, are not put on sentry duty for months, as they are pretty certain to forget the watchword and countersign. At other times, more marked impressions are made; certain acquirements are entirely lost, or the mind may even become a smoothed tablet. Many curious instances of such effects are furnished by Abercrombie, in his well-known work, "The Intellectual Powers," and by Carpenter, in his recent work on "Mental Physiology." Commonly enough, this passing condition of brain-impairment is followed by an accession of mental vigor and a condition of intellectual activity which remain permanently and exercise an excellent influence over the after-life of the individual.
The relations of body and mind are becoming much more comprehensible and better understood since Science has shaken off the incubus of theological teaching as to the severance of soul and body; that baneful psychology is now thoroughly undermined; the erroneous and mischievous superstructure is cracking and gaping on every side, and ere long the ground occupied by a crumbling ruin will be covered by a gradually growing erection, based on a foundation of facts, and reared by an expanding intelligence.