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The duration of the disease is between eighteen months and three years, although it has been known to persist for seven.

No curative measures have so far proved of any avail in the treatment of general paralysis.

Insanity Associated with Epilepsy.—The term “epileptic insanity,” which has for many years been in common use, is now regarded as a misnomer. There is in short no such disease as epileptic insanity. A brain, however, Epileptic Insanity. which is so unstable as to exhibit the sudden discharges of nervous energy which are known as epileptic seizures, is prone to be attacked by insanity also, but there is no form of mental disease exclusively associated with epilepsy. Many epileptics suffer from the disease for a lifetime and never exhibit symptoms of insanity. The majority of patients, however, who suffer from epilepsy are liable to exhibit certain mental symptoms which are regarded as characteristic of the disease. Some suffer from recurrent attacks of depression, ill-humour and irritability, which may readily pass into violence under provocation. Others are emotionally fervid in religious observances, though sadly deficient in the practice of the religious life. A third class are liable to attacks of semi-consciousness which may either follow upon or take the place of a seizure, and during these attacks actions are performed automatically and without consciousness on the part of the patient.

When epileptics do become insane the insanity is generally one of the forms of mania. Either the patient suffers from sudden furious attacks of excitement in which consciousness is entirely abolished, or the mania is of the type of the elevated stage of folie circulaire (manic-depressive insanity) and alternates with periods of deep depression. In the elevated period the patient shows exaggerated self-esteem, with passionate outbursts of anger, and periods of religious emotionalism. While in the stage of depression the patient is often actively suicidal.

Epileptic patients who suffer from recurrent attacks of delirious mania are liable to certain nervous symptoms which indicate that not only are the motor centres in the brain damaged, but that the motor tracts in the spinal cord are also affected. The gait becomes awkward and laboured, the feet being lifted high off the ground and the legs thrown forward with a jerk. The tendon reflexes are at the same time exaggerated. These symptoms indicate descending degeneration of the motor tracts of the cord.

If the mental attacks partake of the character of elevation or depression the mental functions suffer more than the motor. These patients, in course of time, become delusional, enfeebled and childish, and in some cases the enfeeblement ends in complete dementia of a very degraded type.

Where insanity is superadded to epilepsy the prognosis is unfavourable.

Insanity Associated with or caused by Alcoholic and Drug Intoxication.—The true rôle of alcoholic indulgence in the production of insanity is at present very imperfectly understood. In many cases the alcoholism is merely a Toxic Insanity. symptom of the mental disease—a result, not a cause. In others, alcohol seems to act purely as a predisposing factor, breaking down the resistance of the patient and disordering the metabolism to such an extent that bodily disorders are engendered which produce well-marked and easily recognized mental symptoms. In others, again, alcohol itself may possibly act as a direct toxin, disordering the functions of the brain. In the latter class may be included the nervous phenomena of drunkenness, which commence with excitement and confusion of ideas, and terminate in stupor with partial paralysis of all the muscles. Certain brains which, either through innate weakness or as the result of direct injury, have become peculiarly liable to toxic influences, under the influence of even moderate quantities of alcohol pass into a state closely resembling delirious mania, a state commonly spoken of as mania a potu.

Delirium Tremens.—Delirium tremens is the form of mental disorder most commonly associated with alcoholic indulgence in the lay mind. Considerable doubt exists, however, as to whether the disease is directly or secondarily the result of alcoholic poisoning. Much evidence exists in favour of the latter supposition. Delirium tremens may occur in persons who have never presented the symptom of drunkenness, or it may occur weeks after the patient has ceased to drink alcohol, and in such cases the actual exciting cause of the disease may be some accidental complication, such as a severe accident, a surgical operation, or an attack of pneumonia or erysipelas.

The early symptoms are always physical. The stomach is disordered. The desire for food is absent, and there may be abdominal pain and vomiting. The hands are tremulous, and the patient is unable to sleep. At this stage the disease may be checked by the administration of an aperient and some sedative such as bromide and chloral. The mental symptoms vary greatly in their severity. In a mild case one may talk to the patient for some time before discovering any mental abnormality, and then it will be found that confusion exists regarding his position and the identity of those around him, while the memory is also impaired for recent events. Hallucinations of sight and hearing may be present. The hallucinations of sight may be readily induced by pressure upon the eyeballs. If the symptoms are more acute they usually come on suddenly, generally during the evening or night. The patient becomes excited, suffers from vivid hallucinations of sight and hearing which produce great fear, and these hallucinations may be so engrossing as to render him quite oblivious to the environment. The hallucinations of sight are characterized by the false sense impressions taking the forms of animals or insects which surround or menace the patient. Visions may also appear in the form of flames, goblins or fairies. The hallucinations of hearing rarely consist of voices, but are more of the nature of whistlings, and ringings in the ears, shouts, groans or screams which seem to fill the air, or emanate from the walls or floors of the room. All the special senses may be affected, but sight and hearing are always implicated. Delirium tremens is a short-lived disease, generally running its course in from four to five days. Recovery is always preceded by the return of the power of sleep.

The patient must be carefully nursed and constantly watched, as homicidal and suicidal impulses are liable to occur under the terrifying influence of the hallucinations. The food should be concentrated and fluid, given frequently and in small quantities.

Chronic Alcoholic Insanity.—Almost any mental disorder may be associated with chronic alcoholism, but the most characteristic mental symptoms are delusions of suspicion and persecution which resemble very closely those of the persecution stage of systematized delusional insanity. The appearance of the patient is bloated and heavy; the tongue is furred and tremulous, and symptoms of gastric and intestinal disorder are usually present. The gait is awkward and dragging, owing to the partial paralysis of the extensor muscles of the lower limbs. All the skeletal muscles are tremulous, particularly those of the tongue, lips and hands. The common sensibility of the skin is disordered so that the patient complains of sensory disturbances, such as tinglings and prickings of the skin, which may be interpreted as electric shocks. In some cases the mental symptoms may be concealed, but delusions and hallucinations, particularly hallucinations of sight and hearing, are very commonly present. The delusions are often directly the outcome of the physical state; the disordered stomach suggesting poisoning, and the disturbances of the special senses being interpreted as various forms of persecution. The patient hears voices shouting foul abuse at him; all his thoughts are read and repeated aloud; electric shocks are sent through him at night; gases are pumped into his room. Sexual delusions are very common and frequently affect marital relations by arousing suspicions regarding the fidelity of wife or husband; or the delusions may be more gross and take the form of belief in actual attempts at sexual mutilations. The memory is always impaired.

Patients who in addition to chronic alcoholism are also insane are always dangerous and liable to sudden and apparently causeless outbursts of violence.

Dipsomania.—Dipsomania is a condition characterized by recurrent or periodic attacks of an irresistible craving for