Next to the convulsive and organic varieties of melancholia, the delusional is the least hopeful as regards recovery.

The following are actual examples of delusions of about one hundred female melancholic patients, and they far from exhaust the list:

Delusions of general persecution.

"general suspicion.

being killed.

"being conspired against.

being defrauded.

being preached against in church.

being pregnant.

being destitute.

"being followed by the police.

being very wicked. impending death. impending calamity. "the soul being lost. having no stomach. having no inside.

having a bone in the throat.
"having lost much money.
being unfit to live.

"that she will not recover.
"that she is to be murdered.
"that she is to be boiled alive.

LECTURE III.

STATES OF MENTAL DEPRESSION-MELANCHOLIA

(PSYCHALGIA)-CONTINUED.

EXCITED (MOTOR) MELANCHOLIA.-This, like all the other varieties. of the disease, may be one stage in the complete clinical history of a case, or may be the type from beginning to end. The motor centres are evidently affected to a greater extent in this than in any of the other varieties, except the one I shall describe as the melancholia with epileptiform attacks. The patients rush about, are violent to those about them, wander ceaselessly, walking up and down like tigers in a cage, or roll about on the floor, or wring their hands, or shout, or groan, or moan, or weep loudly, or tear their clothes, or in their cries, attitudes, and motions express strongly their mental pain. In short, the muscular expression of the pervading emotion is strong and uncontrollable by volition. Some of the very worst and most incurable cases of melancholia are of this typecertainly the most troublesome to manage. The motor expressions are partly determined by the intensity with which the ideo-motor centres are affected in the brain, and partly by the amount of inhibition possessed by the individual when well. Women very frequently present the motor type of the disease. The Celtic race does so markedly. The wailing and weeping, the gesticulations and motor grief of an Irish woman are usually out of all proportion to the mental pain-that is, if we take the Teutonic type as our standard. Here is an example:

A. V., æt. 28, an Irish woman. Patient had been confined a week previous to admission. The day before her admission she suddenly became very unsettled and careless about her child; she also attempted suicide. On admission she was greatly depressed; she confessed to feeling exceedingly miserable, and could only be got to answer the simplest questions with difficulty; she had a woe-begone appearance, and her bodily health was very weak. She slept very little the first night, but seemed considerably better next day: conversed readily and cheerfully; said she felt much better, and that her strange behavior previous to admission was due to something which came over her and confused her.

In a week she got worse, being much depressed; thought she was to be killed, and that everything was going wrong with her; did not take her food well; attempted to drown herself by jumping into the asylum shallow curling pond.

In a month she was somewhat improved, but still continued much depressed in mind. She did a little work. In six weeks, after seeming to improve for a time, patient relapsed. She became the embodiment of utter misery and wretchedness, which she exhibited in a most demonstra

tive way. She wrings her hands; sways backwards and forwards, contorting her body; rushes about from place to place, and cannot settle for a minute. But the most striking things about her are her countenance and the noises she makes. She has a large mouth, and as her v.sage assumes the most doleful aspect, expressing the intensest misery, her mouth begins to open until it is a great gaping cavern, and she howls"Oh, John, dear! doctor, darlin'! and me childer! and me persecuted in this jail! oh, I'm punished! dear darlin' doctor! oh, me two brothers! oh, kilt and murdered they are! Oh! oh! oh!" All this time there is seldom a tear, and it goes on from morning till night, and sometimes all night, so that you cannot hear yourself speak within ten yards of her. Though the misery is most real to her, yet the effect is often very ludicrous, as if you were looking at the overdone misery of an Irish wake on the stage. She ate well, and her bodily health improved, though she had prolapsus uteri, for which no treatment could be adopted. Here is a chronic case of the sort that has years: A. W., æt. 45, deaf and dumb, who was educated. A relative is in

sane.

gone on for

paces

For four years now he has been in his present condition, which to all outward appearance is that of misery, as great as any painter has ever depicted as the lot of the damned in hell. He is never at rest, but about with an uneasy, nervous gait. His hands are always moving, tearing his clothes or unbuttoning them, or masturbating, which he does in the most shameless open way; indeed, he is doing it half the time. He makes a hideous noise nearly all the time between a groan and a hiss, and his expression of face is that of absolute misery and desperation. At times he rushes about, and if any one comes in his way he knocks him down; in fact, he has a distinct homicidal impulse, which makes him attack those near him. At times he tears his flesh and beats his head. He seems to feel no pain. He is the worst patient in Morningside Asylum, and, in fact, is about the worst I have ever seen, taking the long time he has been affected into account. Everything has been tried in vain for his recovery and amelioration. Nothing will interest him; scarcely anything will quiet him. I have tried hyoscyamine, and it nearly poisoned him. I gave him bromide of potassium in doses up to six drachms a day. I tried cannabis Indica with it, and he merely fell off in flesh, without being benefited. He was walked in the fresh air till two strong attendants were done up. He was tried to wheel heavy barrows of soil, but the fight to get him to do so threatened to run some risk of killing him. I only wish I could castrate him, for the constant masturbation, or attempt to masturbate, seems to show that the centres. of generation are in a state of morbid excitation, and I think it might do him good.

This is another chronic case of motor melancholia, which is very common in old age:

A. X., æt. 77. Single; gentlewoman. Disposition active, but passionate. First attack. No exciting cause known. Had a fall down stairs six months ago. Became very restless and sleepless, and lost appe

tite. This condition has lasted for three months.

On admission she was very depressed and unsettled. Could not sit

down or rest for a moment. Walked about the room the picture of despair, and took no interest in anything. Was enfeebled in mind, and behaved in a silly, miserable way. Her physical condition and general health were poor, and she was very anxious about her state of health and her soul's salvation. She had no sleep the night after admission, and was very noisy and restless. She was very depressed; begged to be sent home; wrung her hands and wept. This continued with little change. Her nights, with few exceptions, were sleepless, unless narcotics were given; and she was also very noisy, beating at her bedroom door and shouting loudly. During the day she was in a constant state of miserable unrest. She was suspicious and despondent; said she wished she were dead; refused her food; would not settle to any work. This state of unhappy restlessness and excitement became fixed and chronic, while her mind became more enfeebled. She got plenty of food, but never could be fattened. After three years she began to show distinct signs of partial hemiplegia, which was first on one side and then on the other, each attack passing off in a few days. Two of my former assistants, Drs. Hayes Newington and J. J. Brown, have described this condition and its pathology, attributing it to capillary apoplexies, as are shown in Plate VII., Fig. 2, occurring in succession. But she could never sit down for any length of time till near the very end, a year after the commencement of the paralysis, when she went to bed and soon died. She would eat her meals standing and moving. She swore and used blasphemous language to herself. She said she would "burst" if she was made to sit down. The convolutional motor excitement was unceasing, and nothing could exhaust it. It was connected with the decay and degeneration and atrophy of the brain in old age-a long-continued brain storm that ended only with life. Such old people are most difficult to treat. If we, by mechanical means, restrain their motions, my experience has been that it is no conservation of energy, but the excitement, finding no motor outlet, reacts inwards and makes the mental state much

worse.

When insanity in boys and girls takes the melancholic form, it is usually attended by much motor excitation, especially weeping-the boyish mode of expressing grief. This is an example:

A. Y., æt. 12. Disposition: old-fashioned, sedentary, excitable, thoughtful, and studious for his age. Several brothers and sisters died in infancy of head affections, and a paternal uncle had been melancholic. Mother nervous and eccentric. Father died of consumption. Had been brought up in a poor way with an old grandfather, with whom he lived alone, living on tea and coffee and no milk. Had not romped and played enough. Had been in the habit of wetting the bed. His father died a few months ago. Seemed to feel it as a man would, and has never been the same since. Of late has dreamed much, and awoke in the middle of the night. Has been at school, and did well. Last week the schoolmaster checked him for holding his pen the wrong way. He came home agitated, nervous, depressed, and confused. Talked all night in an incoherent way of holding the pen, etc. He has got worse till he is now

1 Edin. Med. Journ., August, 1874, and Journ. of Mental Science, July, 1877.