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 impulsive cases are more uncontrollable, the cases of stupor more 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, 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 with 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 nineteen, 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 these 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, two-thirds 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 ond 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 hallucinations 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 these circumstances aggravate the mental symptoms, 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 marked and immediate as in J. R.'s case. It will be observed that some amount of improvement took place in her mental state as the bodily nutrition improved before menstruation returned.

The melancholic cases, of which this of J. R. is the type, nearly all recover, in my experience. Out of twenty-four of very typical form which we have had in the Royal Asylum in the past nine years, eighteen have recovered.

About one-third of the amenorrhoeal cases were maniacal, with no melancholic tendency. Such cases were by no means so clearly connected with the absent menstruation as even the melancholic ones, nor did they show the same tendency to recover in mind coincidently with its restoration. In fact, I was by no means so sure of the same kind of direct connection between the amenorrhoea and the mental symptoms in most of them as in the melancholic cases.

It is commonly supposed that the sudden suppression of menstruation in a young, full-blooded, healthy woman of nervous heredity, through chill or shock, is very liable to cause an outburst of acute delirious mania. Some authors speak of this as if it were one of the common causes of insanity. No doubt it occurs, but I have not met with more than two cases in all my experience. One was that of J. S., a girl of eighteen. stout, florid, and healthy, who got wet through and chilled while men

struating. The flow suddenly stopped, and at once a fearful headache came on, with maniacal delirium, a temperature of 103°, sleeplessness, and very great violence. A hot bath, with cold to the head, and with enormous doses of bromide of potassium, borax, and ammoniated tincture of valerian, frequently repeated, had the effect of diminishing the delirium and reducing the temperature. A condition of semi-stupor and confusion, inactivity and listlessness succeeded, and lasted for two months, when the usual mental health was regained, but it was several months before menstruation was restored. I should say that stupor is a more common mental result of suppressed menstruation in young women with a nervous heredity than acute mania.

OVARIAN INSANITY- "OLD MAID'S INSANITY."

There is a somewhat ludicrous form of insanity that Dr. Skae called "Ovarian," or more familiarly and more correctly, I think, "Old Maid's Insanity." There is really no definite proof that the ovaries are either disturbed in function or diseased in structure in those cases, but it consists no doubt of a morbid transformation of the normal affectiveness of

woman towards the opposite sex. The disease usually occurs in unprepossessing old maids, often of a religious life, who have been severely virtuous in thought, word, and deed, and on whom nature, just before the climacteric, takes revenge for too severe a repression of all the manifestations of sex, by arousing a grotesque and baseless passion for some casual acquaintance of the other sex whom the victim believes to be deeply in love with her, dying to marry her, or aflame with sexual passion towards her, or who has actually ravished her after having given her chloroform. Usually her clergyman is the subject of this false belief. Out of ten such cases which I can recall, seven have had clergymen as their supposed wooers or seducers. In no case was there the very slightest possible ground for the notion. In two cases the ladies had never even spoken to their supposed lovers. Certain gestures, or, as in one case, the contents of the agony columns of the newspapers, were sufficient proof to them of their beliefs. The annoyance to which unfortunate men are subjected in this way is often extreme. Lately a lady, J. T., now a patient of mine, went to a grocer's shop and ordered her supply of groceries in the name of a clerical acquaintance, saying she was his wife, telling the shopman to send the bill to him, and this as the culmination of a series of weekly letters to him of forty pages each. I have known grave accusations made to ecclesiastical authorities, and the be ginnings of most injurious famas started by such insane women. Such patients are all of them between thirty-five and forty-three, and the reverse of sensuous in appearance. Some of them were most estimable ladies, whom it was impossible not to pity, the whole thing was so contrary to the tenor of their lives, and so like a trick played on that higher being which they had always cultivated, by a lower and more animal nature which they had sedulously repressed None of them recovered from this sort of delusion, but in two of the cases, as they passed into the senile period, and after the climacteric, the notion became so theoretica! that they almost ceased to allude to it.

HYSTERICAL INSANITY.

That form of mental disease which is complicated with some of the protean symptoms of hysteria should really be called ovarian insanity, if that name were used in any correct sense, for there is but little doubt that undue excitation or disturbance of the functions of the ovaries has more to do with hysteria than anything else. But perhaps it is more convenient to retain the name of hysterical insanity. Typical hysteria, pure and simple, always has a mental complication. The volition, or the feelings, or the morals, are always affected along with the purely bodily symptoms. But these mental symptoms, not forming the chief features of the disease, or not being of such a nature as to make the patient irresponsible or unmanageable, are not reckoned as being of the nature of technical insanity, at least among the rich. Among the poor, with no one to look after them, hysterical young women are often enough sent to asylums. And I have seen most admirable results from this. The principles of asylum life and treatment are the very best principles of treatment for hysteria too. To put the patient under control, to give her no harmful sympathy, to make her work and walk out regularly, to improve her bodily health, are always very good for a hysterical girl. We have had three cases of almost typical hystero-epilepsy, with a suicidal tendency in two of them, and general unmanageability at home in the third, in addition to the purely motor and other symptoms, sent to this asylum within the past few years, and I have not seen or heard of any home or hospital treatment so effective as the asylum treatment proved to be in these girls.' But such patients are rare in asylums. The usual type of case classified as hysterical insanity consists of mania or melancholia in a young woman with one or more of the following characteristics well marked, viz., a morbid ostentation of sexual and uterine symptoms, feigned bodily illness to attract attention and secure sympathy, marked erotic symptoms cloaked by something else, a morbid concentration of mind on the performance of the female functions, semivolitional retention of urine, hysterical convulsions, a morbid waywardness, ostentatious and unreal attempts at suicide. The fasting girls, the girls with stigmata, those who see visions of the Saviour and the saints and receive special messages in that way, the girls who give birth to mice and frogs, and those who live on lime and hair, are all cases of this disease.

Hysterical symptoms are exceedingly apt to occur in the insanities of puberty and adolescence, and along with those symptoms the habit of masturbation is common. It is sometimes difficult, therefore, to know whether to classify such cases as adolescent, hysterical, or masturbational insanity. All one can do is to ascertain if the hysterical symptoms are the most marked and prominent features of the case before we call it hysterical insanity.

The following case of hysterical insanity fairly illustrates the general features of the disease.

1 Two of these are recorded by Mr. T. Inglis in the Edinburgh Medical Journal, December, 1878.

J. U., æt. 21, of a nervous and excitable temperament; habits correct. An aunt epileptic. Had on one occasion at home a mild attack of what must have been subacute maniacal excitement. The cause of the present attack, which has lasted for four days, was a fright which first produced ordinary hysterical symptoms, and then maniacal symptoms engrafted on them. She shouted and screamed, spoke of hearing God speaking to her, and would rush to the window to jump out. She imagined she was a most important person, attitudinized and did everything to attract at tention to herself. Attention and sympathy were craved by her, and if she could not get them in one way she tried another. She refused her food, saying it was poisoned, but took it rather than be fed with the stomach-pump. She had menorrhagia, and was most minute and circumstantial in the details as to her female health. She was tried with hyoscyamine, valerian, and mono-bromide of camphor with apparent benefit; but I considered the greatest improvement was produced in her case by discipline, work, open-air exercise, tonics, and good plain food in abundance. She improved at first, and once or twice relapsed, but in two months she recovered and was discharged. I do not like to keep hysterical cases too long in the asylum after convalescence as a general rule, for they sometimes get too fond of the place, preferring the dances, amusements, and general liveliness of asylum life, even with its restrictions, to the humdrum and hard work of poor homes.

The following very characteristic letter of a maniacal hysterical girl, J. V., very well illustrates the trains of thought in such a case:1

"MY DEAR MAMMA.-It is time that I leave to return home. I have been tremendously changed for the better. I think papa will be able to get me a commission under Garibaldi before long. There are three to whom I am especially indebted-one Mr C., the modeller, the other the doctor, a Eunuch, who modelled me at the fire, and attended on me and bathed me. He is I am sure a gentleman, a splendid doctor. Could not papa get him into a regiment abroad? And there is the nurse. Could not papa get him any situation away from Morningside Asylum where I am at present? I should like papa to come for me as soon as possible. Do you remember the verse, "There are," &c. (12th verse 19th chapter of Matthew). About Eunuchs? Then I beg to inform you that according to Scripture and my conscience, Jessy, your cook, is a man; and Janet, the mad devil is a man; and D. and H., boys who can have children. Aunt I. is a man, and yourself also, both made of men, and I am a boy, made of Dr C. and Dr Z. Mrs T. is a man, made of men. They are very ignorant on this subject here; but as for me it is certain that at least the spirits have showed me, which Christ sent when I was under drugs; they showed me this. I have at times since I came here passed the shadow of death, and therefore am authorised to speak in opposition to all men and women, gentlemen and ladies who oppose me. I am, I can I swear, as you want to know what sex I belong to, a mixture of a nymph and a half-man, half-woman, and a boy, and a dwarf, and a fairy. I know more than my fellow mortals, having expired eleven times before the time.-I am, &c."

Our statistics of hysterical insanity show a good proportion of recoveries. In the nine years, 1874-82, there were thirty-four female patients so classified, and of those who were treated to the termination of their malady sixty per cent. recovered.

1 "Morisonian Lectures" for 1873, by Drs Skae and Clouston, Journal of Mental Science, vol. xix. p. 500.