Admitting the difficulties that one has in the classification of insanity, it seems to me, at all events, reasonable that we should recognise classes associated with definite physical changes. Symptoms may be ever changing and deceptive. A patient may to all appearances be weak-minded, but on recovery it may be found that such patient's apparent abstraction and mental weakness were merely the result of an overbearing and overpowering sense of misery, so that, in fact he was suffering distinctly from melancholia, and the mental faculties were in abeyance through the assertion of other painful sensations. A severe grief or an intense occupation of any kind may make one forgetful of his surroundings, regardless of the state of the weather, the time of day, the condition of one's general health, and so on; and so it is that in many cases of profound melancholy there is an apparent arrest of function. This by the way. We have to consider the fact that at certain periods of life there are certain special tendencies to an intellectual breakdown. Any serious affection of the brain in early childhood so affects the as yet undeveloped structure that it totters readily to its fall, and, once having suffered a severe shock, it is with difficulty restored. In the period of adolescence other functions of the body are developed, and with them many stirring sensations are aroused, which have a great tendency to upset the highly nervous and unstable neurotic patient. As life progresses some people exhibit marked tendencies to die out through their nervous systems. Certain persons develope phthisis late in life; others develop cancer, gout, chronic rheumatism, or other constitutional vices. But the thing that interests me most in this consideration is that there are definite forms of disease seen in patients dying out from exhaustion or wearing out of their nervous tissues. As has so often been said, age is purely relative. A man may be a boy at 70 or an old man at 35. Age, from the physician's side, is a relative advance towards decay and destruction of the most important of the vital tissues and organs. A man may have all his organs slowly degenerating before he has reached middle life, the degeneration being due to some constitutional disease, or to some such condition as atheroma of the vessels. In an asylum one constantly comes across patients who have inherited insanity from their parents, and who have inherited a special form of insanity, and even others who have not inherited any special form, but have inherited the tendency which produced the insanity; thus whereas one person has atheroma of the vessels and dies of apoplexy, another has atheroma of his vessels and dies of aneurism, and another patient has atheroma of his vessels and angina pectoris, so that the offspring of these patients may have not only the atheroma of the artery, but either the apoplexy, the aneurism, or the angina pectoris, according to whether the parents had the one or the other. I have seen many cases in which a parent has suffered from mental disease only when he has become 60 or 70, and the children have gone on very well until they reached a similar age, and then have broken down under similar circumstances in a very similar way. It would not be right always to say that this has no relationship to mental effects and to predispositions. One knows that suicide, for instance, is not only associated with a family disposition to nervous disease, but is in many cases also associated with a dominant idea which has from early days been before the patient's mind—that suicide has been, as it were, the evil genius of the family; and so the fact that a parent has died of nervous breakdown has been reported to a patient, or has been remembered by him, and when he comes to a like age he necessarily thinks more about the fate of his parent, and this alone, in some temperaments, might be a cause of producing insanity. In some families it is very noteworthy that a certain age is looked upon as being critical, and if that age be satisfactorily passed, the individual may live to a considerable age beyond, but immediately before this crucial period many members have begun with ailments and have certainly worried themselves into their graves. But what I would distinctly assert is that in certain families the tendency is to die of some affection of the nervous system in preference to dying by any other system; and it is interesting to note that in some of these cases the tendency is not always transmitted in exactly the same way, but that the offspring of such parents, if they have not been placed in otherwise favourable circumstances, may break down earlier in life; and although I am not in a position to assert positively that such is the case, many instances have inclined me to the belief that the offspring of those parents who have broken down, say at the climacteric or from advanced age, are more liable than other insane patients to break down at special periods, such as at adolescence and the climacteric. When one comes to consider the changes that we mean by old age, I should say that the mark I have used as the test as to atheromatous condition of the arteries is seen by the tortuous temporal arteries, and the rigid and rather high-tension in the radial pulse. Other symptoms, such as capillary congestion about the cheeks, white hair, and a tendency to leanness, have, of course, been considered, as well as the condition of the eye called arcus senilis. All the patients to whom I shall refer have the above characteristics, as well as years over 60. They suffer either from progressive dementia, with or without paralysis, or from melancholia of one form or another. As we shall see presently, they suffered from hypochondriacal symptoms, or in some cases exhibited maniacal excitement with exaltation, and I shall have to refer specially to at least one case in which these symptoms were so markedly like those of general paralysis of the insane that I was constantly asking myself in what the difference consisted between our typical cases of general paralysis of the insane and cases such as the one under consideration. We were obliged to confess that if the patient had been brought before us, and that blindfold we had been told that his age was 35, we should not have hesitated for a moment in saying that his was a typical case of the disease. General paralysis does occur in old men sometimes as well as in young men, but it is not nearly so common, and when we meet with these cases wo are obliged to consider them as a special sub-variety of the disease, or else must look upon them merely as cases of degradation of nerve tissue, having somewhat similar symptoms, to the symptoms seen in general paralysis of the insane. I am rather fond of regarding these cases as not truly those of general paralysis, but as examples of progressive nerve degeneration, and I prefer to look upon symptoms of general paralysis of the insane as symptoms that are produced solely by a steady and progressive degeneration of the highest nerve centres; and under these circumstances I would expect that any disease which produced steady, progressive degeneration of these highest centres would also produce similar symptoms, just as in the lung, whether it be a tubercle, a mass of smoke, or a piece of steel or stone that sets up irritation, inflammation, degeneration, and a cavity, the course and symptoms of the disease are the same.
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