STATES

LECTURE V.

OF ALTERNATION, PERIODICITY, AND RELAPSE IN MENTAL DISEASES (FOLIE CIRCULAIRE, PSYCHORYTHM, FOLIE A DOUBLE FORME, CIRCULAR INSANITY, PERIODIC MANIA, RECURRENT MANIA, KATATONIA).

ONE of the most fundamental of the laws that govern the higher functions of the nervous centres in all vertebrates is that of alternation and periodicity of activity and inactivity. In all the higher species of the class the periods of inactivity are marked by unconsciousness, and are often combined with the mental phenomena of dreaming and muscular expressions or equivalents of ideation; which things are quite as strange and inexplicable in their essential nature as the phenomena of mental disease. Both may be in a general way understood by reference to mentalization as a brain function. Neither are in any way comprehensible on any mere mind theory apart from brain. The sleep and waking periodicity of the higher brain functions is the foundation and type of all the other periodicities which exist in the nervous functions, and they are not a few. The yearly hibernation of many animals, the daily periodic rises and falls of body temperature, the daily increase and decrease of the pulsations of the heart and of the cardiac pressure, the periodic returns of the appetites for food and drink, and of the activities. of the glands and involuntary muscles through which food is digested and assimilated, are all examples of secondary nervous periodicities which occur in the course of the daily life of the organism. When we look at the function of reproduction of the organism, we find that every activity and process is subject to laws of periodicity of the most marked character; and there can be no doubt that these all have their origin in the brain. The period of reproductive activity is always, in both sexes, the period of greatest physiological mental exaltation. The periodic rutting season in male animals, with its courage, pride, activity, display, pugnacity, and restlessness; the young-bearing and suckling period in females, with its increased courage, skill, cunning, protective and providing instincts, show how the functions of the brain are affected by the reproductive periodicity. So much are they affected that the mental characteristics of some animals are completely changed from their natural condition and reversed, the timid becoming bold and the shy obtrusive; hereditary and natural antipathies and fears disappear for the time, the habits change, nightfeeders become day-feeders, etc. We should not approach the study of the periodicity of symptoms in nervous and mental diseases without keeping in mind these laws and facts of the physiological periodicity of normal nerve function wherever we have a higher nervous system.

Looking at the mental activities of human beings, we find them

strongly influenced by the physiological periodicities. What man is there who is not emotionally more elevated or depressed, more active or inactive in mind, at certain times, or at his periods of almost regularly recurring reproductive desire and capacity? What woman is exactly the same in mind before, during, and after menstruation, and during pregnancy or lactation? And the instant we pass from absolutely healthy brains, all those periodicities count for more in the mental life, their effect in dulling, elevating, and depressing being far greater. There are thousands of sane men and women who are regularly duller in the morning and more lively in the evening, or the reverse; or who are duller in the winter and more elevated in the summer; or who are more irritable— that is, have diminished inhibitory power-at periodic intervals, or who are subject to "moods" and "tempers" periodically. There are many persons whose mental life is one long alternation of "action" and "reaction," activity and torpor, by a natural law of their organization. When we look at diseases of the nervous system other than the mental, we find that many of them are often markedly periodic in their symptoms and times of recurrence. I need only instance neuralgia, migraine, and, above all, epilepsy, that motor analogue of many mental diseases.

Two French writers, Falret and Baillarger, were the first to describe as a special form of insanity certain cases in which there are regularly alternating and recurring periods of mental exaltation, depression, and sanity, and to call it folie circulaire. Each of these periods may vary in absolute duration from a day to several years, and in relative duration to the other conditions in the circuit in different cases; but they always recur and follow each other with more or less regularity. In some the period of exaltation is long and the depression and sanity short; in others this is reversed. But in the really typical case the periods are each about the same length in each psychological circle, and the recurring circles all about the same size. Usually there is something special about the exaltation and depression. The exaltation is very pure brain exaltation, with often hyperesthesia and exaltation of many of the nervous functions, with much reasoning power left, but little self-control or common sense; the condition described by the French as folie raissonnante, or Pritchard's moral insanity, being well marked at the early stage. There is in nearly all the cases great increase of the reproductive nisus. The phases of the exaltation, down even to small things, recur regularly in different attacks at the same time. The depression is apt to be characterized by apathy and torpor rather than by intense mental pain: there are seldom any strong suicidal feelings or impulses. And the period of sanity is apt to be a sort of stupid, inactive sanity, wanting in volitional power, full affectiveness, and spontaneity. The mental balance goes on oscillating between melancholia and mania, standing still at the happy mean of apparent sanity just long enough to raise hopes that recovery has taken place for a few times, till the nature of the disease is apparent to the physician, and as often as they occur to ever-hoping relatives. It is mostly an incurable disease, and the bad cases are usually sent to asylums rather than treated at home.

The interest of this form of mental disease is small when it is merely looked at as a rare psychosis of typical form; but it is very great indeed

to the student of psychiatry when, in the first place, we make it a means of studying the clinical differences in the whole brain and body state of the same patient in exaltation, depression, and sanity respectively; and when, in the second place, we look on it as a pathological illustration of the great physiological periodicities to which I have referred, and of the almost constant tendency there is in nearly all cases of insanity, or at least in most of those that are hereditary, towards relapse, alternation, periodicity, or sympathy with exalted physiological function..

The following are some illustrative cases:

D. A., æt. 49 on admission to asylum. He had never been placed in a hospital for the insane before, though he had had from his boyhood dull times and active times, and many slighter attacks of the kind I am about to describe for five or six years previous to his admission. In one of the periods of exaltation, while holding an important position in India, he had got two tiger cubs, and tried to drive them in harness through the streets of the Residency. His education was good, his temperament sanguine. He had been reckoned proud and retiring, and he was of an old and distinguished family. In bodily conformation, carriage, and bearing he was the type of an aristocrat. A paternal uncle, at least, had been insane, and had shown periodicity. His family had been a very artistic one, but he had never, when sane, shown any talent in that He had married and had children.

way.

Just before admission he had been spending money recklessly, proposing marriage to many suitable and unsuitable persons, getting into passions and using threats about trifles, reckless, eccentric, changeful as the winds in intention and execution. The attack was coming on, but had not come to a height till a week after a domestic loss.

When admitted he was much excited and very indignant, calling on all to witness that he was illegally imprisoned, threatening the dire vengeance of the law on all who had to do with it, but in about ten minutes he was quite jolly, and amusing himself with a game of billiards. At first he was exalted mentally, but had much self-control. His excitement consisted in a constant restlessness, a perpetual twisting movement and play of his facial muscles. He could not sit still, or read, or engage in a game for long. He talked much, but could not stick to one subject; he was boastful in a way that was to him unnatural; he spoke of his private affairs, and would indulge in very pointed questions and remarks, without much regard to your feelings. To a good billiardplayer, "I'll give you fifty points, and bet a pair of gloves I'll beat you. I don't want to hurt your feelings, but I suppose you know your style of play is not very fine.' To a man who had been in trade, "What do you think of my stockings, Mr. ? That was in your line.' He was often extremely amusing, fluent, and witty, which he had never been when well. He would rattle off Scotch to the pauper patients in the grounds, French to the ladies, and Hisdustani to himself in a way he could never do when sane. In dress he was untidy, and in habits dirty. To the ladies, of whose society he was extremely fond, he was exaggeratedly polite, with the grand air of the olden time; but if they gave him any encouragement he would soon become too familiar. He was always giving them flowers, which he had stolen, and writing them notes, or

trying to kiss the maid-servants. If he had any request to make from a lady in the drawing-room, it was no uncommon thing for him to go down on one knee, with his hand to his heart, and all this done most gracefully and amusingly, as if half in fun and much in earnest.

He smoked as much as he could get, and was always grumbling he did not get cigars and tobacco enough, and begging, borrowing, or stealing more. He ate enormously, but not nicely, of everything that came in his way. He picked up and appropriated everything belonging to others that he had a fancy for, and did this also most gracefully, as if it was the most natural thing in the world. He was irritable when controlled, contradicted, or refused requests, and he was always making innumerable and impossible requests. He slept badly, and would, if allowed, sit up all night, or get up and move about by three or four o'clock in the morning. He was not susceptible to cold, sitting with all his windows open in winter.

He passed gradually out of one stage into another. The next stage was a more maniacal one. He dressed more grotesquely, and always wanted to put on three or four coats, vests, or trousers on the top of each other. He would come in to a dance with four vests, would go behind a door or another man, and slip one and then another off as he got warm. His habits and ways got more dirty and disorderly. His irritability took violent forms, assaulting his attendants, smashing furniture, etc. His conduct became so uncontrolled that he could not go to the drawing-room. or to church. He would run after a petticoat without regard to the appearance or age of its wearer. His whole tastes as to food were the opposite to what they were in health. He liked porridge, which he could not abide when well, and if he did not feel inclined to take it, he would turn it out on to his newspaper, put it in his pocket, and eat it when he felt hungry. He would mix up soup, milk, and claret, and eat them together. Scarcely anything was incongruous or disgusting to him. He wore his hair very short, and would singe it or cut it himself if he could get no one else to do it. He would, in playing cricket, strip himself almost naked, or put on the most ridiculous things, a woman's hat or shawl, or a cap turned outside in. He turned up at morning prayers one day in buckskin tights, a red vest, a blue cap, and black swallow-tail. His bowels were always moved twice or thrice a day. During all this time he was losing or tending to lose weight is spite of all he ate. He had his better and worse days all through, usually in alternation. He used to paint and draw pictures and portraits at this stage, producing the vilest daubs, spitting on the paper to moisten his colors, and using his hand and fingers to spread his paints. These he would carry in his pocket by the dozen, showing them to any one he met and he could pass no one without speaking. He said he had never known he could paint before. So with singing: he would sing in discord, and think he was doing splendidly. Yet with all this there never left him a certain jauntiness and grace of manner. No one, at his worst, could have taken him for anybody but a high-bred gentleman.

As this brain exaltation came on and increased in every successive attack, each little phase, each little morbid way, such as smoking, eating certain kinds of food, cutting or singeing his hair and beard, painting,

putting on one coat on the top of another, would recur with the regularity of the bud, leaf, and fruit of a tree.

The next stage was the gradual subsidence of all these symptoms of maniacal exaltation, and a resumption of his former habits and ways and appearance.

man.

The first stage, corresponding to simple mania, lasted for about a month; the second, with the symptoms of mild acute mania, about two months, and his recovering stage about three months, so that the whole period of exaltation lasted six months; but he did not stop at the sane stage. He at once passed into a condition of great mental depression. To see him in that, one would scarcely have known him to be the same His hair well grown, his whiskers trim, his features and eyes dull and inexpressive, his dress most scrupulous and neat, his manner distant and nervous; in speech reticent, and never venturing a remark; in feeling depressed, fearful, and unreliant. He thought he was so wicked that he should not see any one. He now disliked most of the people he had cultivated during his exaltation, especially relying on the chief attendant, who had controlled him most, and whom he had most heartily abused. His habits were sedentary, he could scarcely be got to go for a walk; his appetite was now moderate, and his tastes very particular, not being able to bear the smell of tobacco or to look at porridge or messes of any kind, and most sensitive to dirt and bad smells. He became very penurious about money. He was always thinking he was doing wrong or giving offence, and did not like company, while he was most moral and religious in his feelings and habits. His whole intellectual and affective life was far more unlike his exalted self than one average man is unlike another. He was stationary in weight at first, but soon began to gain. He was most sensitive to cold and draughts and loud noises, in all of which he had delighted before. He was full of a morbid sorrow and regret for his previous conduct; but he was morbidly suspicious at this stage, and used to think that the things he had given away or destroyed during his excitement had been stolen. This condition lasted for about three months, gradually passing into one of complete sanity, without depression or elevation, but with some inertness at first, and without much capacity for business. This lasted about six months, and then the signs of elevation again began. Altogether this circle of elevation, depression, and sanity lasted about fifteen months. There was no marked line anywhere, though the most distinct and sudden transition was between the elevation and the depression.

The development of the exaltation next time was a slow process, taking about two months before it got so bad that he had to come back to the asylum. The sort of things he did were going out to ride at 10 o'clock P.M., never going to bed, smoking all the time, foolishly wasting his money, proposing to marry ladies and women suitable and unsuitable, sometimes two in a day, telling one, as an inducement to accept him, that if she would marry him she could put him into an asylum and enjoy his pension! He went into a shop to buy a pair of gloves, and the shop-girl taking his fancy, he went down on his knees to her, telling her he had fallen in love with her. His nisus generativus was always exalted during the excitement, but seldom assumed very gross forms. He often said