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to recovery. Such periods have existed in both the first and third cases detailed above, and it has seemed to friends as if they were nearly or quite well. But they are generally of short duration, and from some slight cause, such as a disappointment, or a failure to secure what has been expected, or some triling bodily illness, the old delusions suddenly spring into new vigor and activity. Not very unfrequently the patient succeeds in concealing his delusions and hallucinations for a considerable time, especially when by so doing he expects to gain some desired object, such as his personal liberty, or a permission to return to his home.

Treatment.-This will include a residence in some asylum or home especially designed to secure the requisite care of the case, and so far as possible shield him from those occurrences which would act as sources of irritation and increased excitement of existing hullucinations and delusions. When the exciting cause has been that of masturbation, the bromides in large doses are often of service in allaying the irritation of the sexual organs and the attendant hallucinations. Opiates may also be used to relieve the sufferings which arise in connection with the delusions of persecution, and also to allay the supersensitive state of portions of the nervous system. Out-of-door exercise in walking or some kind of light employment will prove a relief by occupying the attention and diverting the mental activities into other channels.

Those cases which come under care and treatment at an early stage of development, and which arise largely from some exciting experiences in the history of the individual, may sometimes be benefited by a systematic course of physical exercise, such as may be secured by calisthenic or gymnastic practice. This should be conducted under

the direction of a physician, or trained attendant, with great regularity and persistency, during several months. The physical improvement secured in this way may have a favorable effect upon the mental state, while the change of thought and increased power of attention will tend to correct the marked character of the concepts, ideas, etc.

LECTURE XII.

FOLIE CIRCULAIRE.

Cases of Folie Circulaire Not Numerous-Impossibility of Deciding Before

hand whether a Case of Mania will Eventuate in Folie Circulaire-Two Stages of the Disease-Ætiology-Heredity-Climatic InfluencesMore Frequent in France than in England-Symptoms – Those of Mania--Mental and Physical Faculties Become Excited - Period during which the Patient is Relieved—lle Passes into the Stage of Depression I During the Excited Period Confusion of Ideas Rarely Exists—The Meniory Good—A Moral Defect Present-Dress and General Appearance-Craving for Stimulants—Painful Emotions-ForebodingsDesire to Remain Indoors and Frequently in Bed—The Length of a Full Period of Excitement and Depression-Case-Patients May at Times Exhibit Very Little Mental Impairment-Importance of Recognizing the Character of the Disease-Case-Prognosis-Recoveries.

Less than one-fourth of one per cent of those cases which have been admitted to the Retreat and classified under the head of mania and melancholia have proved to be cases of folie circulaire, or have eventuated in a special combination of symptoms which has been properly designated by that term. When examined from a clinical point of view, it is doubtless of little importance whether this group of symptoms be regarded, as it was by most writers of the last generation, as one of the terminations of acute mania, or as a special genus of insanity. It certainly appears to be quite impracticable to determine beforehand whether a given case will prove to be one of mania with a sequel of recovery or chronicity, or one of folie circu

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laire. It does not appear that there is any pathognomonic distinction between the symptoms incident to the initial excitement of mania which eventuates in recovery and the mania of folie circulaire. It is claimed that the intensity of the excitement is less than usually exists in mania, and this doubtless is true in subsequent periods of excitement, after the first one or two, and after the regularity of the two kinds of symptoms has become fully established, but there is no evidence that such is the case during the initial maniacal attack. Indeed, there can be no standard or measure of the excitement incident to mania, but, on the contrary, the largest difference is found in different cases, and yet with no corresponding results in the way of a sequel of folie circulaire.

It has been thought more probable that a termination in folie circulaire arises not from any special element of brain character which has formerly existed, and which is peculiar alone to those cases in which it appears, but rather from an exaggerated development of that habit which is common to all brains, namely, a tendency toward reaction. Excitement invariably tends to produce an after period of depression ; unusual brain activity is followed by unusual quiet and inactivity; an excessive state of hilarity and happiness by one of dullness and depression. This physiological tendency toward action and reaction extends to all the organs of the system when in health, within certain periods or cycles, and tends to become established upon a morbid basis after experiences of mania. In a very small proportion of cases this tendency becomes converted into an actuality, and we have that special form of insanity which has been named from the peculiarity of its symptoms folie circulaire

Now whether this reasoning is based upon correct premises or not, it is unnecessary to inquire further, inasmuch as all admit that distinctive characteristics pertain to some of the symptoms, when the special character of brain action has become established. These relate, first to the development of two distinct stages, which succeed each other with some regularity; second, to an established periodicity; third, to the special character of symptoms present in both stages of progress; fourth, to an unfavorable prognosis. These several elements of character, and others to be referred to, render it appropriate to regard it as a special genus of insanity.

To Falret and Baillarger belongs the honor of first differentiating and describing this form of insanity under the term of folie circulaire or folie a double form.

Ætiology.-Hereditary tendency toward insanity has usually been regarded as the strongest factor in the causation in this special form of disease; and it is found in clinical experience that nearly all persons so affected have such an inheritance. But this element of ætiology exists in a hundred cases affected with other forms of insanity to every one with folie circulaire; there is, therefore, nothing whatever distinctive in it as a cause. And there are exceptions to the general rule, one of which has been under my own observation, this case being a well-marked one, and extending over a period of many years. It is quite possible that climatic influences are operative in rendering the system more susceptible and liable to take on such periodic changes in its mental activity. French authors refer to this group of symptoms as more frequent in their experience than do either English or American authors. Dr. Savage says he has had almost no experience at the Bethlehem Hospital in London with folie circulaire. I am, however, inclined to regard the physiological tendencies which

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