the affected side, atrophied or not developed. I have never been able to understand why cerebral apoplexies occur in infancy. I am inclined to think that they are often not effusions of blood, but vaso-motor spasms from neurotic causes affecting certain of the cerebral vessels, and resulting in trophic damage to the parts of the brain deprived of blood.

The inflammatory idiocy results from the inflammations and sloughings that affect the throat and ears in scarlet fever spreading inwards and damaging the brain. Certain portions of the organ are usually found to be hypertrophic in those cases. It is a very unfavorable variety.

The traumatic variety is much like the inflammatory, or sometimes like the paralytic form, and results from falls and blows on the head.

The microcephalic is a very interesting variety of idiocy. On the whole, the heads of idiots are smaller than those of sane persons, but there are many exceptions to this rule, and, as a matter of fact, the average sizes of the heads of idiots are as large as the minimum sizes of perfectly sane persons. Ireland says: "The size of the head gives no estimate of the comparative intelligence of the (idiotic) children.' There is, however, a certain minimum size below which a head is incompatible with average intelligence. I believe a circumference of below eighteen inches means idiocy. Very typical microcephalics are rare, but, when seen, they make a strong impression. They look so impish and unearthly. They are usually active, alert, mischievous, imitative, intractable. I have no really good specimen, but E. H., with a head of eighteen inches in circumference, a small face, a small but perfectly wellformed body, an active, imitative way, and a restless manner, gives an idea of one. Her only deformity is a cleft and acutely arched palate. She just looks like a small dried-up woman, with small features and a most singular expression of face, and she smiles as if a baby was imitating the features of an old woman. Microcephalics should always be sent to training schools. They are often educable up to a certain point, and, if not educated, they are often little demons. Their muscular activity must find an outlet.

The hydrocephalic variety of idiocy is very common, but I need hardly say to you that hydrocephalus with even enormous enlargement and great deformity of the head is perfectly compatible with sanity. It usually has a dwarfing and, often, a deforming effect on the body. A small head is no proof that there has not been hydrocephalus.

Her

E. I. is a good example of a hydrocephalic idiot. She is now ten, and is slow in her movements, very gentle and patient, sometimes cries and moans, as if she had an organic sensation of discomfort in her head. Her head is globular, the fontanelles raised, the temples projected. She looks unhealthy, has scrofulous glands, and a feeble constitution. temper is good. She is educable, and worth educating. I am going to have her sent from this to an imbecile training institution. Drs. Batty Tuke and Campbell Clark described very fully the condition of the brain in hydrocephalic idiocy. The former found enormous hypertrophy of the neuroglia, and the latter found a floating lobe or portion of brain, unattached to any other nerve tissue, which could never, therefore, have exercised nerve functions, yet it had nerve cells and fibres in a primitive form.

Idiocy may occur by deprivation of the senses only. The famous case of Laura Bridgman, who was blind, deaf, and dumb, and with an indistinct sense of smell, but with common sensation, through which Dr. Howe educated her brain, developed intelligence and emotion, and raised her from a condition of absolute idiocy to one of great mental capacity, is and will always be the classical case of idiocy by deprivation. She differed essentially from most other forms and cases of idiocy in having a brain well developed and apparently normal in all respects, except that its inlets and outlets were obstructed. Ordinary deaf-mutism is closely allied to idiocy, and is one of the hereditary neuroses. To me it is a physiological sin that marriages between such persons should be legal.

Cretinism is an endemic disease occurring in connection with goitre in some valleys of mountain chains, such as the Alps, Cordilleras, and Himalayas, and not found here, so I need say nothing about it. It is very interesting from an etiological and pathological point of view, and has quite a literature of its own on the Continent.

LECTURE VIII.

STATES OF MENTAL STUPOR (PSYCHOCOMA).

You will not find stupor put among the ordinary symptomatological varieties of mental diseases, along with mania, melancholia, etc. This I think is a mistake. The only objections to its being so placed are twothat it is not commonly a primary disease; and that the word stupor does not imply to the lay or even to the medical mind any necessary mental disease at all, as they understand it. But these objections should not prevent us using the word to express in a correct scientific sense a morbid mental condition, which is different psychologically and clinically from all other morbid mental symptoms, which, while it lasts, demands different treatment from them in many cases, and has a different course and termination. Stupor used in this strict medico-psychological sense may be thus defined: "A morbid condition in which there are mental and nervous lethargy and torpor, in which impressions on the senses produce no outward present effect, in which the faculty of attention is or seems perfectly paralyzed, in which there is no sign of originating mental power, in which the higher reflex functions of the brain are paralyzed, and in which the voluntary motions are almost suspended for want of convolutional stimulus, but where the patients usually retain the power of standing, walking, masticating, and swallowing.'

I look on mental stupor as essentially the expression of an exhausted, lowered, and devitalized brain.

A typical case of this condition stands for hours where he is placed in the same attitude, when spoken to he takes no notice, he shows no active desires or affections, he does not speak or move, or show any interest in anything. His expression of face is vacuous, his vaso-motor power is usually much below normal so that his extremities look blue and are cold, he does not obey the calls of nature, or take any notice of them at all. Loud sounds make no impression, pleasant or terrible sights that would in others produce motion and emotion fail to do so. A woman once committed suicide by hanging herself in a dormitory at Morningside in the presence of another woman in a condition of stupor, who took no notice whatever of this frightful sight.

Looking at the condition of stupor from the point of view of the physiology of the brain, we see that its power of receiving impressions from without is in abeyance, and its higher reflex functions are suspended. The mental and motor irritation of a full bladder or loaded rectum is not felt by the higher brain centres; and when through the action of the lower centres, evacuations take place, there is either no consciousness on the part of the higher centres, or, if there is, it does not result in the volition that prepares suitably for them, or in the vexation that would be

felt in health, if they took place over the body. Even the ordinary skin and spinal reflexes are much diminished or abolished. The appetites for food and drink are paralyzed, or if felt are not followed by any exertion to satisfy them.

A striking exception, and the only material exception to the passivity or suspension of brain function in stupor is regard to the reproductive instinct in a low morbid form. In the first place, most of the typical cases of stupor occur in the actively reproductive period of life. Most of them, in fact, are under thirty. Dr. Hack Tuke1 found that twentyseven was the average age in twenty cases. In my experience all the very typical cases are nearer twenty than thirty. In by far the majority of the cases, the commencement of the disease had been connected with or accompanied by a sexual excitation in some form or other. Many of them had indulged in the habit of masturbation to a very morbid extent indeed, and had exhausted the brain energy thereby, had "stupefied " themselves, in fact, by this. Most of them indulged in this habit long after they had entered into a condition of mental stupor, doing it automatically rather than volitionally, and many of them have sexual delusions at the expiration of the attack.

Many of these girls had been hysterical, and showed during their disease marked hysterical symptoms. The aspect, expression of eyes, and behavior before the other sex, while consciousness existed, were markedly erotic, this being so in some of the cases, even after speech and all outward mental manifestations had ceased. Many of them have cataleptic, trance, and hystero-epileptic symptoms, all these affections being most strongly, in my opinion, connected with the function of reproduction, its disorders, or its perversions. The direct connection of stupor in most cases with the reproductive and sexual functions has not been sufficiently considered hitherto. I look on those functions as the dominant vital activities from adolescence to thirty-five in many persons of the neurotic diathesis. If the inherent brain stability is hereditarily weak, with the . inhibitory powers poorly developed, and if under those circumstances there is much intense sexual excitement or a constant sexual drain through masturbation or sexual intercourse, stupor, in some form or degree, is, in my opinion, the natural expression of the exhaustion of the higher nerve force that follows. We shall see examples to prove this presently.

When I thus bring out strongly the connection of stupor with the reproductive function, it must be remembered that I am referring particularly to that form which is attended by unconsciousness, though this may have a distinctly melancholic stage or tinge throughout (mental depression too being a symptom of brain exhaustion); and it must be kept in mind that there are cases of stupor of the melancholic type resulting from other causes, such as mental or nervous shocks, frights, losses, or bodily diseases, which have no reproductive or sexual complication at all.

The voluntary motor system is found, on examination, to be in three conditions in different cases or in different stages of the same case, viz.,

1 International Medical Congress, 1881, Transactions, vol. iii. p. 638.

(1) quite passive, unresistive, and having no tendency to keep fixed positions; (2) cataleptic, with decided tendencies to keep fixed attitudes and positions, but with no resistance to external force used in changing the muscular positions; (3) resistive, showing a more or less strong resistance to external efforts to change the position. The first is commonly found in the anergic form of stupor, especially when it is caused by a previous acute attack by masturbation, general paralysis, or alcohol; the second, also, in some of the anergic reproductive cases; and the last in the melancholic form alone.

Looked at from the purely mental point of view, conditions of stupor are divisible into three varieties, viz., the unconscious-the anergicwhere consciousness and memory are gone; and the conscious-the melancholic-where they are both present, and where there is a delusion present, these facts being ascertained and tested afterwards by the patient's own account; and the half-conscious or confused, where there is some consciousness, but by no means a keen or a correct subjective realization of events, and where the recollection of them afterwards is confused or delusional. Some cases pass through all these conditions in different stages. Conditions of mental stupor have excited much interest, and have an extensive literature, especially in France, to which of course I have no time to refer. Mr. Hayes Newington, when assistant physician at Morningside in 1874, studied them carefully, and wrote a capital description' of them, with which I in the main agree; indeed, all must agree with him, for he sticks closely to clinical fact. He gave us the admirable word "anergic" to describe the passive, unconscious, nondepressed cases. This should take the place of the older term Acute Dementia, still commonly applied to such cases. It should certainly be discontinued, for it is confusing and incorrect. If you take a typical case of either the melancholic or the anergic, each undoubtedly corresponds to his descriptions; but an extended clinical experience has shown me that the same case may begin by being in the condition of melancholic and conscious stupor, and may end by being in the anergic and unconscious. Then I find that by far the greater number of the cases that were anergic during the greater part of their course had a short melancholic stage to begin with. As for stupor being a primary affection I call to mind very few cases where it was entirely so. It scarcely ever begins as stupor. There is a stage of mental depression or of mania, very short, it may be, but still present. The stupor may have been the disease for all practical and clinical purposes, but still the initiatory stage of another condition was there. The cases which we shall see, or to which I shall refer, will illustrate those various points of causation and symptoms.

The best clinical division of stupor would be, I think, into the following kinds; which, in the order of their frequency or importance, are:

a. Melancholic stupor.

b. Anergic stupor.

c. Secondary stupor (transitory after acute mental disease).

d. General paralytic stupor.

e. Epileptic stupor.

1 Journal of Mental Science, October, 1874.