A patient presented to you with maniacal symptoms occurring suddenly, you would ask, then, if the case is one of secondary attack. To separate cases of general paresis with melancholic symptoms from insanity proper, a slight delay for further examination may be necessary; but the symptoms in either case would be sufficient for a certificate, by which you could place a patient in an asylum for further observation, and in a few weeks the characteristic mental state would be developed. Lastly, there remain the cases of maniacal violence connected with epilepsy; these occur without melancholy, but they follow after a lengthened liability to epileptic seizures; so no difficulty of diagnosis could occur. There is, also, the so-called epilepsia larvalis; this forms a more difficult case in mental character; it resembles somewhat closely the phenomena of recurrent mania with very lucid intervals. The cases, which I have seen, exhibited also a degree of idiotic disposition in a mild form. Your opinion, however, may be sought in a case in which the person could not justly be considered to be labouring under disease, but rather under weakness of intellect. I pointed out to you that the mental functions are found in a condition of imbecility from three causes: First, naturally, i. c. (A) in childhood, before full development; and (B) in old age, from natural decay. In both these conditions the mental change is gradual, but occasionally irregular, especially in age, when it is at times accompanied with delusions and general intellectual disturbance. More rarely there is intellectual disturbance in the development in childhood. Secondly, from abnormal development, as in true idiocy. The mind is found, by original organization of the brain, variously defective for the performance of its functions. There may be deficient intellectual control or excessive animal passions, and all shades of these conditions. Cases of legal inquiry connected with this state of the organ present great difficulty. The condition, however, is readily distinguishable from alteration of character from disease. Your opinion may be sought, however, as to the existence of such a degree of mental deficiency as to render the subject irresponsible for his acts. Where there is obvious cranial defect the case will be rendered the more easy. In cases which have been neglected as to education, and have at the same time deficient intellect, mere feebleness of control over the passions appears to characterise the individual, and the question of responsibility becomes a very difficult one; in fact, it is from the con fines of this class that the larger portion of criminals are drawn. The third class are the imbeciles from disease; imbecility forms the last stage of all cases of insanity and of epilepsy, as well as other cerebral affections. These are the forms in which permanent alteration of the mental functions are met with. I say permanent, because in all acute diseases nearly, there is a transient lesion of mind, which we call delirium. If a case is brought before you for an opinion it will be found to belong to one of the states described. I have again only to guard you against judging too hastily and from reported facts. The unfortunate instances which have. occurred to medical practitioners of actions being brought against them for giving certificates of lunacy have not been few; but where the result has been against them there has certainly been, in many of them, a want of due care in investigating facts, and the diagnosis of insanity has been made too hastily and without regard to the rule which I have laid down and would now repeat. In all your diagnosis remember one symptom, one insane act, cannot constitute the whole phenomena of the disease; there must be a series of morbid phenomena; this series must begin, and progress in a given and known order. Lastly, as you cannot examine by oath, whenever it is possible always see the patient, and have the evidence of your own special senses. With these remarks of caution and advice I terminate my course. I have to thank you for your attention to my endeavours to lay before you the phenomena of a very important disease. I trust that you will find that the digest which I have been able to make in the somewhat limited space of these lectures will be a mental support to you in your professional career. The practice of medicine is frequently attended with much anxiety, and that anxiety is greatly enhanced when we are conscious of an obscurity in our views upon a particular disease. Let me add that I shall be at all times happy to assist |