disease who died of phthisis I think is much more than the average), and five cases of adolescent insanity, and beyond these no special variety was found in the phthisical list. In going over those patients who had died of phthisis I had an opportunity of seeing a clinical fact in regard to the effect of the development of phthisis in one or two cases on a previously existing insanity. In such patients it often had the effect of producing a mental condition similar to the symptoms of phthisical insanity in patients who had not laboured under such mental symptoms before. Such patients became suspicious, sullen, irritable, and unsocial, some of them being also melancholic. One young man, J. P., who had been a cheerful, active fellow, sociable, and constantly playing the piano and singing, became moody, suspicious, impulsive, and irritable just before his chest was found to be affected, and while he was getting thin, not taking his food, and looking ill. LECTURE XIV. UTERINE OR AMENORRHOEAL, OVARIAN, AND THE INSANITY OF MASTURBATION. UTERINE OR AMENORRHOEAL INSANITY. No doubt the influence of woman's great function of menstruation is considerable on her normal mentalisation. It has a psychology of its own, of which the main features generally are a slight irritability or tendency towards lack of mental inhibition just before the process commences each month, a slight diminution of energy or tendency to mental paralysis and depression during the first day or two of its continuance, and a very considerable excess of energising power and excitation of feeling during the first week or ten days after it has entirely ceased, the last phase being coincident with woman's period of highest conceptive power and keenest generative nisus. As is well known to all physicians, many purely nervous derangements. and diseases, such as neuralgia, migraine, epilepsy, and chorea, are apt to be aggravated at the menstrual periods or to begin then. There are often perversions of the great instincts and appetites then. In some women the social instincts are then partly suspended, and in others there are perversions of the appetites for food and drink. Dr Halliday Croom has kindly given me the notes of two such cases. One young lady patient of his at every menstrual period pulls out and eats the bristles of the hair brushes in her own room, and sometimes goes into other rooms for more brushes for the same purpose. He has another lady patient, married, æt. 36, who, for fifteen years, has eaten at each menstrual period salt, dry oatmeal, and bits of sponge, and has been none the worse for this. I have met with (and what physician has not?) cases of women who had intense cravings for stimulants and narcotics at each menstrual period, and indulged those cravings, to their intense disgust and regret sometimes afterwards. Dr Croom gives me the notes of a case where the craving was for malt liquors only. The regular and normal performance of the usual functions of the uterus and ovaries is of the highest importance to the mental soundness of the female. Disturbed menstruation is a constant danger to the mental stability of some women; nay, the occurrence of absolutely normal menstruation is attended with great risk in many unstable brains. The actual outbreak of mental disease, or of its worst paroxysms, is coincident with the menstrual period in a very large number of women indeed. It does not follow from this, of course, that the menstruation caused the insanity in all such cases. The constant difficulty the physician has is to know whether the dis ordered or suspended menstruation is a cause or a symptom Nearly all the acute varieties of insanity disturb or suspend menstruation in women while the acute symptoms last. I find that attendants on the insane do not expect menstruation to be regular, if present at all, in cases of acute mania or of intensely excited melancholia. I also find that among the women patients in an asylum, taking them throughout, chronic and acute, the occurrence of menstruation is apt to cause an aggravation of the morbid mental symptoms present. The melancholics are more depressed, the maniacal more restless, the delusional more under the influence of their delusions in their conduct; those subject to hallucinations have them more intensely, the im pulsive cases are more uncontrollable, the cases of stupor stupid, and the demented either more enfeebled or tending to be excited. In the chronic insane, whose home the asylum is, and its regulations and routine their rules of life, we frequently find the menstrual periods a time when their subjection to the asylum discipline is not so absolute as usual, and their conformity to the ways of its daily life is not so unvarying. Of course more there are a great many exceptions to this in the chronic insanity of women, to whom the menstrual period makes no difference whatever. Those are usually patients affected by quiet mild dementia who work hard and are in good bodily health. At times we see special directions taken by those menstrual aggravations of mental disease, such as an accentuation of the emotional perversions that exist, an excitation of the amatory feelings towards the opposite sex, a stimulation of the habit of masturbation, or the occurrence of stupor and confusion in the whole of the mental processes. The last (stupor) is exceedingly apt to occur in young women during adolescence about their menstrual times. I have now a patient, J. Q., of 19, usually a bright, active girl, who, for about a week or ten days at her menstrual periods, becomes confused, stupid, and depressed-her face and whole muscular movements showing an extreme hebetude and slowness. Some few melancholic patients get maniacal at the menstrual periods; and I have seen a case of acute mania cease to be excited, and become depressed and fearful during menstruation. Taking the mass of the more chronic and quiet cases of insanity I find that menstruation is just about as regular as to time, and as normal in the amount of discharge lost, as among a similar number of average sane women. A very considerable number of female lunatics have the delusion that they are occasionally ravished by men at night, and this is usually more intense after menstruation. But apart from those general effects on all kinds of existing mental disease, of disordered or suspended menstruation, insanity in some few cases actually results de novo from this as an exciting or predisposing cause. Those cases may be conveniently termed uterine or amenorrhoeal insanity. Most of them, twothirds at least, are melancholic in character, the mental symptoms following the amenorrhoea, and passing away when regular menstruation returns. The following is a typical case of this sort:-J. R., æt. 20, of a neurotic but not an insane heredity. Comes of an "excitable" family. Had gone from a country district and farm work to domestic service in a city, where, after a year or two, she fell off in general health, and ceased to menstruate. She at once became depressed, took morbid and depressing views of religion, was forgetful, confused, and sleepless, and lost her appetite She wept without cause; was very obstinate, misinterpreting the object of our giving her medicine, making her work, walk, and keep herself tidy. She said she should be out of the world and was not fit to live, but never attempted suicide. She was ordered, and made to take, iron and aloes, with much fresh air and fattening diet. She got worse at first, and hallucinstions of hearing developed. She distinctly heard voices telling her she was the worst person alive. She would have refused food had she been allowed to do so. In about two months she began to improve in body and mind, especially in bodily looks and weight. For three months longer she remained depressed, and then menstruated after a series of hot baths and mustard to her feet. She brightened up from the first day of menstruation as if a cloud had been lifted off her mind, and she kept well ever after. In such a case I do not think it was the amenorrhoea alone which caused the melancholia. Both were in reality the result of a running down in health and vitality, but no doubt the mental symptoms were greatly aggravated by the suspended menstrual function. I do not think the melancholia would have been cured by a restoration of menstruation, had that been possible, before the blood had become richer and the nutrition improved. In fact, I have seen the coming on of the menses under those circumstances aggravate the mental symp toms, the case assuming during menstruation a maniacal form. The treatment of such cases should therefore be directed at first towards improving the general health more than towards restoring menstruation merely; at all events, until the nutrition of the body is improved. Then the usual means for restoring the menstrual function should be resorted to, and when they are successful, or when, as most frequently happens, nature restores the function, the mental improvement is often as |