his appetite became less, and he invariably complained of dyspepsia; he never left the hall for a walk, or even his room, unless requested to do so.

The whole round of excitement, depression, and comparative insanity, after he came to the Retreat, generally covered about one year. Whether the experiences of the many years prior to that time were limited to a like period, does not appear from the history. In this case the favorable stage generally continued nearly twice as long as the conditions of excitement and depression. The state of excitement for many years was during the summer months.

In three or more of the cases of this form of disease which have been under my care, and one of which at the present time of writing is in the Retreat, the period of excitement has been in the winter season.

Prognosis. The prognosis in cases of folie circulaire is always, or nearly always, unfavorable. This, at first view, seems to be remarkable, especially as the group of symptoms consists of a combination, in rhythmic alternation, of those present in two forms of insanity, mania and melancholia, in both of which, when uncomplicated, the prognosis is usually favorable. The explanation, however, may be found in one of the elements of its ætiology already referred to, i. e., the powerful influence of a morbid habit which has become fully established in the delicate tissues of the brain.

A similar habit, or a recurrent morbid action, affecting other sections of the brain tissues, is found in cases of epilepsy and chorea. Recoveries are exceedingly rare in both of these forms of disease when chronicity has once become established. We are unacquainted with any form or system of treatment which has thus far in the history

of the treatment of the disease proved to be of any avail in arresting its continuance and progress.

Patients not unfrequently live many years, retaining a considerable degree of their normal vigor, and do not usually pass into a condition of dementia.

LECTURE XIII.

DEMENTIA.

Dementia and Idiocy-Distinction-Definition of Dementia-Importance of Averting an Issue of Dementia in Cases of Mania-It Rarely Occurs as a Sequel of Delusional Insanity-Symptoms-The Degree of Dementia Varies Very Much in Different Cases-Prevalence Among Chronic Cases-Periods of Excitement-The Transition to a State of Dementia is Generally Gradual-Third Class of Dements-Symptoms-Delusions-Sequential to Attacks of Mania and Melancholia-Three Forms of Dementia-Tendency to Merge into Each Other-Lines of Clinical Distinction Cannot be Definitely Drawn-Cases I and 2-Prognosis in Primary DementiaIn Secondary Delusional Insanity-Treatment-Importance of State Provision for Proper Care-Two Methods-Boarding Out of Such Patients Among Farmers-Public Institutions-Advantages of the Latter Method.

From the time of Esquirol to the present a distinction between dementia and idiocy has been recognized by alienists. It is not easy in a few words to accurately define either of these mental states. They resemble each other in the presentation of similar and important features. In both there exists an enfeeblement of the mental faculties, and in extreme cases almost an extinguishment of the intellectual life. But in the idiot these faculties have never existed except in a nascent state; the brain centres upon whose activities they depend for exhibition have never become developed. Hereditary, conceptional, or pre-natal influences have crippled the structural growth before postpartum experiences began to exist.

Not so with the dement. In his case the development

of faculties, mental and physical, may have been, so far as external indications gave evidence, as perfect as in ordinary children: the unfolding of both proceeds pari passu; but after the experience of some form of mental disorder, or a long-protracted mental strain, generally during the adolescent period, there supervenes a cerebral affection which Esquirol has described, in a few words, as "ordinarily without fever, and characterized by enfeeblement of sensibility, intelligence, and the will." Another form of expression would be-impairment, of the psychical, sensory, and motor centres of the brain.

This definition, however, does not adequately differentiate dementia from idiocy-nor does it indicate the somewhat extensive range of mental conditions which it is used to cover. In one way all insanity indicates an impairment, and consequently an enfeeblement, of the mind. Certainly all legal insanity presupposes this, and, in consequence of it, the legal procedure in restricting the liberty of the individual, and assuming the care of his property, is instituted. But the term dementia is used in medicine in a more restricted sense, and is applied to mental states which generally are sequential to other forms of insanity. Indeed, there exists no doubt that in the large majority of cases it is consecutive to mania, melancholia, and alcoholic insanity. This is the issue which is to be dreaded and if possible guarded against in the management of these forms of disease. Age and inheritance are influential factors in averting its advent. After thirty or thirty-five years of age, the brain has become so developed and its cellular structure so fully invigorated that it more readily endures the experience of excitement without failure of its energizing capacity. Discipline of the mental and physical organs in early life is of the highest importance as a preventive.

In cases of primary delusional insanity and folie circulaire, dementia rarely occurs until after many years, and it is then much less pronounced in character. Instances are on record in which the latter form of disorder has existed with its alternate states of excitement and depression during twenty and even thirty years without the occurrence of pronounced indications of dementia. An instance of this kind is described on page 251. The brain which is handicapped by inheritance, or enfeebled by excesses or unfavorable hygienic influences, is the one that succumbs after the experience of an attack of insanity.

Symptoms.-The acute and active manifestations of mania, the mental pain and self-accusatory conditions of melancholia, generally subside in the course of a few weeks or months, and sometimes are succeeded by a condition of profound quiet. The patient remains for hours, if permitted to do so, by himself, with his eyes closed, or looking on the floor, with little movement of the person or with little expression of the face. The form which in health had been so active and full of bounding life, energy, and happiness, with all the possibilities of human intelligence and enjoyment before it, is now, after the storm of an acute attack of insanity has passed, an abject and pitiful sight; sometimes too indifferent to take even the requisite amount of food and drink, or to attend to the calls of nature; in a condition which has been rightly termed the "tomb of human reason." All "the pride and splendor of the intellectual life" has faded away into a darkness so profound that it seems impossible that the light of reason should ever again penetrate and

banish it.

The intensity and character of this state, however, varies very largely in different individuals. With some it is com