life than in the female, and is much more irregular and indefinite. There is nothing to mark it off so clearly as the menopause. Sexual power remains, but the appetite for it is not in normally constituted persons keen or pervading. There is little or no self-control needed to restrain it, as in earlier years, and indeed it is commonly dormant, except when stimulated. The common age for the "grand climacteric" in man is from fifty-five to sixty-five, a few cases occurring before and after those ages. The popular tradition puts it at sixty-three. The procreative power of man has been demonstrated by statistics to become progressively less after fifty, and to be in reality small at the latter age. The normal mental change in man is essentially the same as in woman.

The abnormal mental changes that are seen in some cases at the climacteric period in men are the same in general type, too, as in women. The spontaneity, the courage, the mental aggressiveness, the necessity to energize actively, the poetic sentiment, the keenness of feeling in all directions, all these are impaired. There is no drawing towards the other sex, and no subtile delight in its presence. The sleep is less sound and shorter. A cloud of vague depression rests on the man, who shuns society, falls off in fat, becomes restless and hypochondriacal, and feels strongly the tedium vitæ. This may go on to suicidal longings and desires, which are usually not very intense. In fact, nothing is intense with the man. His energies, his functions, and his vitality have all been lowered. With this there is no atheroma, arcus senilis, or proper senility. The following was an aggravated case of senile insanity in the male sex: K. X., æt. 56. A quiet man, of melancholic temperament, steady and industrious in his habits, and with no known heredity to insanity. Lately he had little work and not much food, and was therefore anxious and underfed. He gradually became dull, and possessed with the fear that something dreadful was going to happen to him and his family-a fear founded on realities at first, but gradually assuming a delusional character. He became taciturn and wearied of his life, ceased to take any interest in anything, and could not be roused. One morning, just before coming into the asylum, he told his wife to get up at once and conceal herself, as he had a strong desire to kill her and others. On admission he said he felt very badly, that strange and frightful ideas came into his head and preyed on his mind. One minute he was looking the picture of misery and sitting quite still, then he would lose control over himself and become restless and impulsive, and strike and bite those near him. He was thin, pale, flabby in his muscles, and his skin dark, muddy, and pigmented. He had been blistered at the back of his head before admission (blisters are good treatment for some cases of insanity, but not for a half-starved, melancholic workman at the climacteric). He had a vague, indefinite dread on him, and an absolute lack of interest in anything in life, though his memory and general intelligence were good. His tongue was foul, his bowels costive. There were no visible signs of atheroma of the arteries. He took his food fairly well at first, and was ordered extra diet, porter, and Parrish's syrup of the phosphates. He improved considerably for the first six months in body and mind, but he never got to enjoy life or to be sociable. After that time he got worse, did not take his food well, and fell off again in flesh. Everything was

done to improve his appetite, and nourishment, quinine, cod-liver oil, the phosphates and hypophosphates, garden work, and amusements were all tried, but he got steadily worse. He became more solitary and silent. His blood got so abnormal that at one time purpuric spots appeared over his legs. His delusions assumed more of a hypochondriacal character before his death, which took place two and a half years after admission. He thought all his organs were diseased, and that he had no stomach. He died suddenly at last, being then a mere skeleton from exhaustion. The brain convolutions were found to be atrophied and very anæmic; the arteries had begun to show the atheromatous degeneration; there were some granulations on the floor of the fourth ventricle, and the lateral ventricles were dilated and filled with a pink serum. There was a patch of white softening, about the size of a filbert, in the centre of the left hemisphere. The aorta was markedly atheromatous. This case had not had during life any of the distinctively senile mental characters, yet the pathology was undoubtedly like that of many senile cases.

Of a much more common type was the following less aggravated case: K. Y., æt. 57, a professional man, who had worked very hard indeed. He had a slight and distant heredity to mental disease. His professional work became a burden to him, and he lost all confidence in doing it, so that he had to give it up. He did not sleep well, became much depressed, and was very miserable, obstinate, and hypochondriacal. He had quite made up his mind that he was not to get better, and would do nothing towards his own cure. He did not lose his self-control. He simply changed his habits, avoided his friends, neglected his personal appearance, was absolutely idle, and might be said to have become morbidly "selfish." With all this there was apparently no lack of reasoning power, or general intelligence, and this made the whole thing the more trying to his friends. When a man who cannot reason acts unreasonably allowance is made for him, but when a man acts unreasonably who can reason, the natural impulse is to blame him and hold him fully responsible. Fortunately he did not give up going out into the fresh air, and this was his ultimate salvation, for he slowly improved, and in the course of about five years he got perfectly well, and resumed his business, though he never could do as much, and was never quite the same man," but was about as happy as the average of his fellow-men in their post-climacteric. No doubt if he had taken to his bed, or to staying in the house, as so many such cases do, he would never have recovered. In his case, as that of many others I have met with, the first decided symptoms of mental improvement were coincident with an eczematous skin eruption. I have seen gouty, syphilitic, and all sorts of skin eruptions come on in such cases during the disease, usually greatly to the patient's mental benefit.

66

The prognosis and other points in climacteric insanity are best brought out by a statistical study of a number of cases. In the nine years (1874-1882) I have diagnosed as such two hundred and twenty-eight cases of the thirty-one hundred and forty-five that have been admitted into the Royal Edinburgh Asylum in that time. Of these the large proportion of one hundred and ninety-six were women, and only thirty-two being men. The table below shows their ages.

We see that by far the majority of the female cases occurred between

forty and fifty, and the majority of the men between fifty-five and sixtyfive. As regards the symptomatological forms assumed by the cases, only thirteen of the men and fifty-six of the women, or eighteen per cent. of the whole, were acute in character. It is essentially, therefore, a subacute psychosis in its general character. Of the whole, only eightytwo were cases of mania, the remaining one hundred and forty-six being melancholic. One-half the patients were suicidal in intent at least, but few of them have made very serious or desperate attempts to take away their lives, though to this there were some exceptions. There was a high proportion, but a low intensity of suicidal impulse.

The results of treatment showed that one hundred and twelve cases, or fifty-three per cent. of them, recovered, the women recovering in the largest proportion. In fact, only thirty-one per cent. of the men got well, while fifty-seven per cent. of the women did so. The numbers who died, on the contrary, were greater proportionately in the men than the women, four of the former, or twelve per cent., and seventeen of the latter, or nine per cent., having died up to this time. This would seem to indicate that the disease is rarer, less curable, and more deadly in the male sex than the female; but the numbers are perhaps too few on which to base a correct generalization.

The patients who recovered had not been so long ill as I had previously imagined. Taking the time they were under treatment in the asylum (the only correct basis I have on which to estimate the duration), sixtyone of the one hundred and twenty-two who recovered, or fifty-five per cent., were discharged within three months, and eighty, or sixty-five per cent. within six months, and one hundred and eleven, or ninety-one per cent., within twelve months. There were a few patients who recovered after two years of treatment. The maniacal and the melancholic cases recovered in about equal proportion, but the maniacal in shorter time. The recoveries were much fewer in the women over fifty. only twenty-nine per cent. of these getting better. Up to fifty they recovered equally well. At the other ages, from fifty-five to sixty, the cases were the most curable in the men. Only three of the eleven over sixty got over their malady.'

1 These statistics may be profitably compared with those of Dr. Merson's admirable paper on this subject, in the West Riding Lunatic Asylum Medical Reports, vol. vi. p. 85.

SENILE INSANITY.

The psychology of normal old age has yet to be written from the purely physiological and brain point of view. Poets, dramatists, and novelists have had much to say of it from their standpoint. King Lear is beyond a doubt a truthful delineation of senility, partly normal and partly abnormal. By normal senility I mean the purely physiological abatement and decay in the mental function running pari passu with the lessening of energy in all the other functions of the organism at the latter end of life. No doubt, in an organism with no special hereditary weaknesses and that had been subjected to no special strains, all the functions except the reproductive should decline gradually and all together, and death would take place, not by disease in any proper sense, but through general physiological extinction. The great function of reproduction stands in a different position from all the other functions of the organism. It arises differently, it ceases differently, and it is more affected by the sex of the individual than any other function. It is, as a matter of fact, not entirely dependent on individual organs. It may exist as a desire and an instinct without testes, or ovaries, or sexual organs. It is really an essential, all-pervading quality of the whole organism, and to some extent of every individual organ, not one of which has entirely lost the primordial fissiparous tendency to multiply. But the physiological period of the climacteric has determined and ended it in its intensity and greatest power, though many of its adjuncts remain; and in the male sex we have to reckon with it and its abnormal transformations to some extent even in the senile period of life.

Physiological senility typically means no reproductive power, greatly lessened affective faculty, diminished power of attention and memory, diminished desire and power to energize mentally and bodily, lowered imagination and enthusiasm, lessened adaptability to change, greater slowness of mental action, slower and less vigorous speech as well as ideation, fewer blood-corpuscles red and white, lessened power of nutrition in all the tissues, a tendency to disease of the arteries, a lessening in bulk of the whole body, but notably of the brain, which alters structurally and chemically in its most essential elements, the cellular action and the nerve currents being slower, and there being more resistance along the conducting fibres.

In the young man there is an organic craving for action, which, not being gratified, there results organic discomfort; in the old man there is an organic craving for rest, and not to gratify that causes organic uneasi

ness.

The three great dangers to normal mental senility are hereditary brain. weakness, a diseased vascular system, and the after-effects of overexertion or abnormal disturbance of brain function at former periods of life which have left the convolutions weakened. The hereditary predisposition to mental disease that has not shown itself till after sixty must, no doubt, have been slight or well counteracted in the conditions of life, yet in many brains it never shows itself till then. Until the organ had begun physiologically to lose its structural perfection and its dynamical

force, the pathological phenomenon that we call mental disease was not developed. As we shall see from a statistical study of clinical cases, heredity to insanity was less common in the cases of senile insanity than in any other form of mental disease except general paralysis; but there is this fallacy, that the facts about heredity were further back and more forgotten in this than in any other form. An old man's living relatives are few, and his ancestors' history far off. We may put it down as a certain law of nervous heredity, that the stronger the predisposition the sooner it manifests itself in life, and the weaker it is the later in life it shows itself. To have survived, therefore, the changes and chances, the crises and perils of life with intact mental function till after sixty, means slight neurotic heredity or great absence of exciting causes of disease.

It is impossible to fix an age at which physiological senility begins, and therefore we cannot fix an age for senile insanity. Some men are older at fifty than others are at seventy. I believe that in some cases neurotic heredity assumes the special outcome of early senility—that is, of early wear-out or poor organic staying power. Most congenital imbeciles and idiots grow old soon. Very many races of men grow old early, like the Kalmucs and Hottentots; but, roughly speaking, in our race one cannot call a man old till he is sixty, though I have often met with senile mental symptoms between fifty and sixty, and, as we know, atheromatous arteries and consequent tissue degenerations are common enough before then. But in speaking of senile insanity, I shall include no one under sixty years of age.

It is, of course, a well-known fact that mental disease, speaking generally, is a disease of middle and advanced life rather than of youth. Of the general population under 20 a very small percentage become insane. Only 0.9 per 10,000 of the general population under that age are sent to asylums in a year in England and Wales, while 11.4 per 10,000 over 60 are so sent, or about twelve times the proportion.

The best foundation for what I have to say of senile insanity will be the chief statistical and clinical facts recorded about 203 cases (71 males and 132 females) that have been classified under that heading in the nine years' admissions to the Royal Edinburgh Asylum, 1874-82. The total number of patients admitted in that time was 3145, and they were of all classes, from the sons of peers of the realm down to the lowest beggar. Of these, 304, or 9.6 per cent., were over 60 years of age. One remembers this better by thinking that one-tenth of them were over 60. But of these 304 cases only 203 were called by me senile insanity. The other 101 were mostly epileptics, old cases of long-existing mania or dementia, or cases of climacteric insanity-that is, old age had acted as a predisposing or exciting cause of the mental disease, and the symptoms were more or less characteristic of senility in those 203 cases only. Six and a third per cent. of the whole admissions, or one-sixteenth of them, were thus cases of senile insanity. It is, therefore, a common, but not the most common, form of insanity, as compared with the other clinical varieties of mental disease.

The great predisposing cause of insanity, heredity, appeared to be, as I have said, very uncommon. Only 26 of the cases, or 13 per cent., were so affected. In estimating the frequency of heredity in mental dis