Page:Encyclopædia Britannica, Ninth Edition, v. 13.djvu/118

108 INSANITY occurs between the ages of thirty-five and fifty ; it is, however, met with prior to the first-mentioned age, less frequently after the latter period of life. Statistics show that the decade between forty and fifty is the one during which the disease is most likely to occur. Men are more subject to it than women, in the proportion of, at least, eight to one ; in women the symptoms are less strongly pronounced, and the disease runs its course more slowly. Although the relative frequency of the disease appears to be equal in the higher and lower classes of society, statistics show that the town artisan is more liable to it than the agricultural labourer. In the lower grades of society general paralysis is much more common in England than in Scotland or Ireland ; in certain English asylums general paralytics constitute from a sixth to an eighth of the inmates, whilst in Scotch and Irish district asylums the proportion does not amount to more then 2 or 3 per cent. The progressive character of the disease is marked by three stages, termed the prodromal, the acute, and the ter- miuative. The prodromal stage is marked by a somewhat incongruous congeries of mental symptoms, consisting of total change in the habits and disposition, general restless ness and irritability, impairment of memory, extravagance in thought and action, and a peculiar facility closely followed by, or intercurrent with, the bodily symptoms of impaired mobility of the face and tongue. For the purposes of diagnosis the physical are more important than the mental phenomena. As a rule the bouleversement of disposition is peculiarly well marked ; the impairment of memory consists, not only in the blurring and confusion of past events, but in the forgetting of the occurrence of one minute in the next, purposes formed and intentions expressed are forgotten almost as soon as formed and expressed. This want of fixity is also shown by the non- recognition of the lapse of time, and by the manner in which violent passion is suddenly changed into amiability. To the same cause may probably be traced the peculiar facility of disposition of the general paralytic ; even at this early stage there are indications of the optimism which, as the case progresses, affords the characteristic psychical symptom. In the prodromal period it is manifested by a degree of morbid vanity, general exaltation, and a tendency to regard all things in the brightest possible light. The physical symptoms consist in a finely fibrillar action of the muscles of the tongue, twitching of the upper lip, hesitancy of speech, and a loss of facial expression ; the tongue symptom consists of a rapid agitation of its surface, the voluntary movements of the whole organ not being entirely under control, e.g., it is protruded with a jerk ; the upper lip hangs and trembles before utterance like that of one struggling against weeping; the hesitancy of speech can best be illustrated by saying that it is identical with the slurring of words in the first stage of intoxication, the patient "speaks thick;" the face assumes a mask-like want of expression the muscular power being impaired to such a degree as to cause change of expression to be a compara tively slow process. As the disease advances there is greater excitability, and the general exaltation of ideas becomes so great as to lead the patient to the commission of insanely extravagant actions, such as purchases of large numbers of useless articles, or of lands and houses far beyond his means, numerous indiscriminate proposals of marriage, the suggestion of utterly absurd commercial schemes, or attempts at feats utterly beyond his physical powers. Not unfrequently he is found committing theftuous acts. The acute period is frequently ushered in by maniacal symptoms which generally assume the type of what is termed by French writers delire ambitieux. Delu sion of the wildest character may now present itself ; the patient may believe himself to be in possession of millions of money, to be unsurpassed in strength and agility, to be a great and overruling genius, and the recipient of the highest honours. Every idea is expanded and exalted, whether it relates to time, space, or personal attributes. Although grandiose and extravagant delusion is very frequent, existing as it does in about one-half of all cases, it is by no means such a persistent symptom as the bien etre, which condition is the diagnostic of the disease in that it is invariably present. This is shown by perfect contentment with himself and all things around him, by I the constant use of superlatives and such expressions as | "all right," "splendid," "first rate"; he speaks of his health as robust, "never better in my life," even when there is grave constitutional disturbance ; he is unaffected by the death of child, or wife, or nearest friend. He is Utterly unsuspicious, lost to all appreciation of social relations, and facile in the extreme. Synchronously with this condition, the physical symptoms become exacerbated ; the tongue and facial symptoms already spoken of increase in intensity, and in addition impairments of the motor i powers of the extremities present themselves, consisting in a loss of co-ordinating power, not in a loss of muscular strength. Thus the gait becomes straddled and uncertain ; there is a widening of the basis of support ; he has to pick his steps as he goes up and down stairs, and is apt to trip over small obstacles ; the action of walking resembles that of a half-drunk man. Later on the arms become involved. The pupils are often irregular. The third or terminative staye is marked by " epileptiform " or more properly apoplectiform attacks, the general condition becoming more and more degraded. By this time the patient is almost bedridden ; actual palsy often occurs. Towards the end certain of the semivoluntary muscles are affected ; bed-sores may form ; and he may die slowly of exhaustion or suddenly during an apoplectiform attack. General paralysis runs its course in from one to four years ; more rapid and more protracted cases are on record, but, taken over all, eighteen months may be stated as its average duration. The disease is incurable. II. TRAUMATIC INSANITY. Generally speaking, insanity is not developed for some months or even years after receipt of the injury, but in the interval the patient suffers from headache, more especially after mental effort, irascibility of temper, confusion of thought, and consequent inaptitude for business, weakened memory, and a constant feeling of fatigue. If this condition is not overcome, a progressive dementia sets in, of which the special character is violence of temper, and a tendency to impulsive action. This dementia is generally complicated with maniacal attacks intervening at uncertain periods and marked by furor or violence. Dipsomania or insane drinking is a not very uncommon result, apart from all other indications of aberration. Prognosis is unfavourable. III. INSANITY ASSOCIATED WITH OTHER NEUROSES. Epileptic Insanity. In the intervals between the fits the patient is generally stupid and dull of apprehension. Im mediately before or after fits, or, as some believe, occasionally taking their place, mania of a violent and furious, of a subacute, or of an ecstatic character presents itself. All authorities recognize epileptic insanity as the form most dangerous to the public. Prognosis is unfavourable. Hysterical Insanity. The symptoms described in the article HYSTERIA may become so exacerbated as to amount to insanity. Superadded to these may be delusions of a sexual nature. The most extreme form of mental dis turbance supervening on hysteria is acute mania of a very violent character ; it is generally of a delirious nature, but does not usually continue for any great length of time. It is open to question whether the "fasting girls" and women with "stigmata" should not be included among the