punished, and the voices of his wife and family. His temperature was 98°. He was tremulous and shaky, and could not walk far. He could not write, or drink out of a tumbler without spilling the contents on the floor. His tongue was foul, and very tremulous he could scarcely put it out at all. His appetite was gone, and he affirmed the meat we gave him was the flesh of his children. He was put on the bromide of potassium and steel, was fed with liquid custards, which contained six pints of milk and ten eggs a day in addition to some solid food. He was taken out to walk in the open air till he was tired three times a day, and he had a constant attendant by day and night to prevent him doing any harm to himself or others. Several times, without any warning and with no provocation, he has rushed at and broke windows, struck attendants, upset tables covered with dishes, and jumped into our pond. He never could tell after doing them why he did these things. After three months' treatment he was scarcely any better. He would not read, or play games, or take any interest in anything, or speak to anyone except when spoken to. But in six months he is now much improved, and showing signs of recovery, which I do not expect to be perfect however.

In such cases recovery is slow, and is very apt to be incomplete, if it occurs at all. A chronic degeneration of the whole. of the brain plasma has begun. The intellectual power, the power of application, origination, and independent energising are weakened, the delusions of suspicion are apt to persist, the morals and self-respect are apt not to be regained, lying, stealing, and cowardice are indulged in. The affection for wife and children is impaired. Those symptoms run on for a year or two, and then we have dementia supervening. But this termination is not invariable. First attacks are often recovered from in a way, even second attacks will be got over, but third and fourth attacks seldom completely. Instead of dementia, we have sometimes in young subjects delusional insanity supervening. I have one such man, with a tremulous tongue that he always puts out to one side, who affirms he is

LECTURE XIII.

RHEUMATIC AND CHOREIC INSANITIES.
GOUTY INSANITY.

PHTHISICAL INSANITY.

THE two first varieties of mental disease may be conveniently studied together. There can be no doubt now entertained as to the close connection between chorea and rheumatism; as we shall see, this connection is shown very vividly in rheumatic insanity, which is also an acute choreic insanity. Cerebro-spinal rheumatism has long been known, but in some of its types it does not come within the scope of a book on mental disease. In one variety of it, however, the most prominent symptoms are an acute delirious mania and choreic muscular movements of a violent character. The ordinary course of an attack of rheumatic insanity is seen in the following case in a typical form.

J. F., admitted January 17, 1870, æt. 24, married. First attack of insanity. Mother died of consumption. Father alive and well, and no relative insane or rheumatic. In health she was of a reserved and quiet but nervous disposition, steady respectable habits, and fond of her children. The predisposing cause of her illness seemed to have been an accumulation of debilitating and depressing influences, viz., ill-usage by her husband, poverty, cold, hard work, with insufficient food during the three years since she was married, and having nursed her second child for fifteen months up to the period of her attack. These things caused a certain amount of depression of spirits. The exciting cause of her malady was an attack of rheumatism, not of a very acute character, which had lasted for two months before she became insane. She had pains in the back of her

neck, pains and much swelling of fingers, hands, feet, and legs, and some feverishness; but she was never so bad as to be quite confined to bed. A week before admission she suddenly ceased to complain of her rheumatic pains, and simultaneously with this relief she showed signs of mental derangement, and violent chorea of head, arms, and legs commenced. Her first mental symptoms were a sort of absence of mind and inattention to what was passing around her, taking no notice of questions put to her or of her children. Before being sent to the asylum, in addition to this mental inattention, there was great excitement. She tore her clothes, and tried to jump out of a secondstory window into the street. She was quite sleepless, and the choreic movements had increased greatly in intensity. Her limbs were never still a moment, and she threw her whole body about.

She was much excited on admission, her memory almost gone, and with difficulty can be got to speak at all in answer to questions, but talks incoherently in monosyllables about the doctor who had attended her. The only question she can be got to answer is to tell her name. The existence of delusions could not be ascertained. She is a dark-complexioned woman with black hair; rather thin, muscles flabby. Eyes dark brown and sparkling feverishly, pupils contracted, equal in size. There are very violent choreic movements of the muscles of her face, head, arms, and legs. Anything she attempts to say or do voluntarily is accompanied by extravagant grimaces, twitchings, and contortions. Reflex action is diminished. Cannot articulate more than single words at a time, and those imperfectly. Cannot stand or walk, and was carried with great difficulty; no tenderness of spine; lungs normal, respirations twenty per minute; heart beating quickly but regularly, no cardiac murmur. Pulse 108, strong. Tongue clean and moist; will not take food. Urine clear, acid, sp. gr. 1015; no albumen or deposits. Has not menstruated since beginning of last pregnancy. Temperature 100-4°. Several bruises on body, especially over right buttock. She was carried to bed and ordered beef-tea and some brandy.

She did not sleep, and on the following day the choreic movements of the legs ceased, which became quite paralysed and nearly devoid of common sensibility, the reflex action in them being absent. Bladder paralysed, the urine having to be drawn off once, after which she could pass it. Muscles of eyelids and eyes quite under control. Not so the tongue, which she can scarcely put out at all, and then with a jerk to one side. Mental excitement abated, and speaks better. M. T. 994°, E. T. 90.6°, M. P. 80, E. P. 84. Takes liquid food; 8 oz. wine, strong beef-tea, and extra diet. She improved slowly until on the 23rd January (six days after admission) her state was as follows:-"Chorea much less severe, complains of pain in knees, evidently of a nervous kind, for pressure slowly and carefully made does not increase it. Common sensibility somewhat exaggerated in legs, and some power of voluntary movement has returned to them, but she has little reflex movement. Takes food well, bowels regular, no sweating, mentally confused, depressed, no memory, suspicious, will not believe a word said to her, wonders where she is and how she came here. M. T. 98-4°, E. T. 99°, M. P. 108, E. P. 100."

24th Jan.-To-day twitching of fingers only, except when she attempts any voluntary movements. More power of voluntary movement in left leg than right, which is almost paralysed. Right knee slightly swollen. Reflex movement slight, and more active in left than right leg. Tongue twitches when put out, and goes towards right side. Temperature the same. She has hallucinations of sight and touch, saying that she sees an old woman coming behind her and eating her food, so that she cannot get any of it, and that one foot has been cut off. Is depressed, weeps and groans.

29th Jan.-Has had a relapse; chorea worse in left arm; complains of pains in arms and legs. Complains of a burning feeling all over her. A large slough forming in right buttock where it had been bruised. She complains much of the pain of this. She still cannot tell correctly the place touched on her legs, but when pinched she screams. Requires to be fed with a

spoon, shows an aversion to food, though she is evidently hungry. M. T. 100°, E. T. 97°, M. P. 116, E. P. 116. She has no affection of sight, and no sparks or motes before her eyes. 5th Feb. She now has so far recovered the power of her legs that she can stand. Chorea almost gone when she makes no voluntary movements. Mentally a mixture of stupor and depression, as before, and the hallucinations of sight and touch remain. M. T. 99-8°, E. T. 101°, M. P. 120, E. P. 120.

She gradually improved, and her temperature fell until, on the 19th February, she was reported as having only very slight chorea in hands, but as still complaining of the pains in legs. Mentally she was still confused, but her memory was returning. M. T. 98.2°, E. T. 98°, M. P. 94, E. P. 100.

She did not progress quite steadily, for on the 23rd February her M. T. was 99.2°, E. T. 99°, M. P. 100, E. P. 108, and she was some days worse with the chorea than others: but yet she was so far improved as to be, on the 15th March, out of bed nearly all day, able to walk, but the reflex action was much impaired in legs, and the left hand partially paralysed, and she had the sensation as if she did not feel the ground under her feet. Tongue now is simply unsteady when put out. Mentally less depressed, but still confused; very sceptical and much inclined to hide herself from observation; fancies she is watched. Temperature down to 97.8° in the morning. Is 120 lbs. in weight.

2nd April.-"Believes now what she is told, and is almost rational; but her right hand is swollen, though quite painless. Chorea rather worse, and she cannot sleep so well as usual." The sleeplessness increased, and the choreic movements began to trouble her exceedingly at night, and on the 4th her M. T. was 99-2° and her pulse 104 and weak. As an experiment I gave her 20 grains of chloral in the morning, which made her slightly drowsy, and quite stopped the choreic movements till the evening, when they came on again, and she could not sleep. I then gave her 40 grains of chloral. She slept soundly; the chorea