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Rh stimulants. The general bodily condition has a great deal to do with the onset of the attack, that is to say, the patient is more liable to an attack when the bodily condition is low than when the health is good. The attacks may be frequent or recur at very long intervals. They generally last for a few weeks, and may be complicated by symptoms of excitement, delusions or hallucinations.

Treatment consists in attention to the general health between attacks, with the use of such tonics as arsenic and strychnine. During the attack the patient should be confined to bed and treated with sedatives.

Morphinism.—The morphia habit is most commonly contracted by persons of a neurotic constitution. The mental symptoms associated with the disease may arise either as the result of an overdose, when the patient suffers from hallucinations, confusion and mild delirium, frequently associated with vomiting. On the other hand, mental symptoms very similar to those of delirium tremens may occur as the result of suddenly cutting off the supply of morphia in a patient addicted to the habit. Finally, chronic morphia intoxication produces mental symptoms very similar to those of chronic alcoholism. This latter condition, characterized by delusions of persecution, mental enfeeblement and loss of memory, is hopelessly incurable. The patient is always thin and anaemic on account of digestive disturbances. There is weakness or slight paralysis of the lower limbs, and the skeletal muscles are tremulous.

Treatment.—The quantity of the drug used must be gradually reduced until it is finally discontinued, and during treatment the patient must be confined to bed.

—States of mental enfeeblement are always the result of failure of development or of structural changes in the cortical grey matter of the brain. If the enfeeblement is due to failure of development or brain damage

occurring in early life, it is spoken of as idiocy or imbecility. Every form of insanity which occurs after a certain period of life is apt to be regarded by some observers as senile, but although the failing mental power may colour the character of the symptoms it cannot be regarded as correct to designate, for instance, a recurrent form of mania as senile merely because it necessarily manifests itself in a subject who has lived into the senile period. On the other hand, many persons first suffer from mental derangement at an advanced period of life without at the same time manifesting any marked failure of mental power, while others only manifest their insanity as a result of the decay of their mental faculties.

From this statement it will be seen that senile insanity is a complex of different conditions, some of them accompanied by dementia, others without dementia.

Senile Dementia is distinguished occasionally into “senile” properly so called, and “presenile” dementia, which supervenes at middle age or even earlier.

The occurrence of dementia is sometimes preceded by an acute hallucinatory phase, accompanied by mania or melancholia; but as a general rule, in the presenile cases, by neurasthenia, indifference, and mental apathy which extends to a disregard for the ordinary conventions and the means of subsistence.

It has pithily been remarked that the age of a man is the age of his blood-vessels. The two conditions of senile and presenile dementia cannot therefore be separated scientifically. From a clinical point of view, however, the two are distinguishable in so far as their symptoms are concerned, for the presenile cases are more complete and the process of dementia achieves its consummation earlier and quicker, while in the senile the gradual disease of the arteries and the slow decay of the mental faculties offer a different background for the manifestation of mental symptoms. Moreover, the senile patients more frequently present symptoms of recurrent attacks of acute insanity, a more pronounced emotionalism, and a greater tendency to restlessness at night. The presenile cases, on the other hand, except at the commencement of their malady, are usually free from acute and troublesome symptoms and present chiefly an apathetic indifference and irresponsiveness on the mental side, and on the physical side a neurasthenic and enfeebled bodily state. In both conditions memory is greatly impaired.

Added to senile dementia there is often found a condition of mania or melancholia or even of systematized delusional insanity. The chief symptoms of the maniacal attacks are the great motor restlessness and excitement, which are worst during the night time. Sleep is almost always seriously disturbed, and the patients rapidly become exhausted unless carefully nursed and tended. The actions of senile maniacs are often puerile and foolish, and they may exhibit impulses of a homicidal, suicidal or sexual character. The melancholic cases are also extremely restless, and their emotion is loudly expressed in an uncontrollable manner. They often have delusions of persecution. Their cries and groans have an automatic character, as if the patient, though compelled to utter them, did not experience the mental pain which he expressed. They also, many of them, eat their food ravenously, although a few obstinately refuse it. The senile delusional cases may manifest any of the classical forms of paranoia described above, but their delusions are of a rudimentary and unfinished type. The most common of all senile delusions is that they are being robbed. They therefore often hide their small valuables in corners and out-of-the-way places, and as their memories are very defective they are afterwards unable to find them. Others, who live alone, barricade their doors and try to prevent any one entering for fear of thieves. Delusions of ambition in senile subjects are usually of a very improbable and childish character. Hallucinations are generally present in the senile delusional cases.

The treatment of senile insanity is from the medical point of view not hopeful; it resolves itself largely into instructions for careful nursing, suitable feeding, and the protection of the patient from all the physical dangers to which he may be exposed.

Statistics.—The statistics of lunacy are merely of interest from a sociological point of view; for under that term are comprised all forms of insanity. It is needless to produce tables illustrative of the relative numbers of lunatics in the various countries of Europe, the systems of registration being so unequal in their working as to afford no trustworthy basis of comparison.

Even in Great Britain, where the systems are more perfect than in any other country, the tables published in the Blue Books of the three countries can only be regarded as approximately correct, the difficulty of registering all cases of lunacy being insuperable. On the 1st of January 1907, according to the returns made to the offices of the Commissioners in Lunacy, the numbers of lunatics stood thus on the registers:—

These figures show the ratio of lunatics to 100,000 of the population to be 354 in England and Wales, 312 in Scotland, and 538 in Ireland. Numbers of Lunatics on the 1st of January of the years 1857–1907 inclusive, according to Returns made to the Offices of the Commissioners in Lunacy for England and Wales, Scotland and Ireland.