as well as the sane, such conditions of it are the frequent remote causes of other diseases; such as dropsies, gastric affections, and disorders of the bowels, which largely contribute to the mortality of lunatics.

5. Constipation.

There is an opposite condition of the bowels to that just referred to, and to which old lunatics when they become very feeble are especially liable, and that is, extreme constipation. Sometimes they will pass several weeks without a single stool, till there is such an immense accumulation of fæcal matter, that the patients, if not relieved by art, are in imminent danger. This accumulation is vulgarly called a ball-stool. I am aware it is not confined to insane persons, but is common to senility. Ordinary constipation is a frequent and troublesome symptom of insanity; but this peculiar obstruction does not present itself among lunatics, except in cases of long duration, and where the patient is reduced by the disease, rather than by years, to that general state of atony, the concomitant of extreme age.

The intestines in this case participate in the general insensibility and torpor of the whole system; hence the secretions are diminished and become indurated, the peristaltic motion is enfeebled, and the power of the rectum and abdominal muscles, by which the alvine evacuations are expelled, is diminished or lost.

When old lunatics are in this atonic state, and no stool has for a very long time passed, before drastic purgatives, or even stimulating clysters, are administered, an examination per anum should take place. If an accumulated and hardened mass be found, nothing will relieve the patient but the introduction into the rectum of some convenient instrument, such as a spoon, by which it may be broken down and brought away.

I have known dangerous consequences arise when this

obstruction has been attempted to be removed by the exhibition of repeated and strong purgatives, which, failing of the intended effect, have collected in the stomach and superior intestines; and upon the passage being freed, have induced superpurgation. If such remedies have been given, upon discovery of the real nature of the case, precautionary means should be taken to prevent the violent catharsis they may produce, after the lower intestine is relieved of the indurated colluvies. A little care, and the occasional injection of simple clysters, will prevent the recurrence of this kind of constipation.

6. Sudden Debility.

Death sometimes supervenes upon a sudden state of debility; particularly in cases of melancholia, which have continued some months, or longer. The patient may be in the usual health he has maintained since the access of insanity, and there is no alteration in any of the animal functions which indicates danger; he complains of faintness; the face is pale, the features contract, appetite is defective, pulse small and intermitting, and there is sudden prostration of strength; and most commonly, in spite of every remedy and care, in a few, perhaps in a couple of days, he succumbs.

I have met with this fatal termination by sudden debility in several patients, who, neither from age, inanition, nor from any remedial treatment, intimated the least danger. Neither have I, from the examination of their corpses, been able to detect any assignable cause for the event. A slight turgescence of the cerebral blood-vessels, and a little fluid in the ventricles, have been the only signs visible of a morbid action. In three out of five of these dissections, the brain was quite healthy.

It is principally from observing these cases of death succeeding sudden debility without any apparent cause

except mental depression, and likewise that many diseases of the insane run on to a fatal issue with greater rapidity than generally attends on similar diseases where the mind is sane, that I have been induced to conclude, that the prognosis is always most unfavourable where the principle of intelligence is degenerated or alienated.

7. Mortification of the Extremities.

Most writers on insanity mention the liability of lunatics confined in asylums to mortification of the lower extremities. This occurrence has by some been ascribed to extreme neglect, or from an improper exposure to cold; it having been a pretty general opinion, that all lunatics were insensible to atmospheric impressions and changes. Certainly, however, no conclusion can be more erroneous than that insane persons are insusceptible of the extremes of temperature. Experience proves the contrary to be the fact.

I confess it is quite wonderful to me how it could have escaped observation, as I suppose it must, that lunatics, especially melancholics, are commonly subject to an extremely languid circulation in the lower extremities; and therefore, without extraordinary care, must of course suffer greatly from cold.

Extremes of heat and cold are not only in themselves causes of insanity, but sensibly affect both the bodily and mental state of most lunatics. In whatever asylum the patients are treated under the conviction that they are insensible of cold, there, assuredly, mortification of the extremities will be common. In most of the British lunatic asylums which I have inspected since the year 1821, I found proper care taken to prevent injury from cold. Indeed, I had frequent occasion to remark, that the dayrooms were sometimes too much heated; so that when the patients went from those rooms into the galleries and airing-grounds, the atmospheric change was too

great; and hence catarrhal, ophthalmic, and rheumatic affections were induced. But in others the patients were by no means sufficiently protected from the effects of cold, and, as might be expected, I there found mortification of the extremities less rare.

But this affection is not always the simple effect of exposure to cold, or of neglect of any kind. I have met with instances of it in private practice, where an aptitude seemed to exist to this morbid condition of the system. This I have attributed to that diminution of the vital principle which I have noticed to be so often conspicuous in the constitution of persons in whom the influence of the intelligent principle is deteriorated. I will quote two examples. A gentleman, aged thirty-six, had injured one foot severely in an attempt to commit suicide by burning himself; the inflammation was great, mortification ensued, and his toes in a few weeks sloughed away. Three months after this circumstance, and in warm weather, inflammation appeared on the instep of the other foot, and soon included the toes: it proceeded exactly as in the foot which was burned; and mortification and sloughing-off of these toes followed, notwithstanding every aid the best professional advice and attention offered. Mr. Stanley, of St. Bartholomew's Hospital, and Dr. Arnould, of Peckham, attended with me in this case. In the other instance, a gentleman, aged twenty-six, a free liver, was seized with mania at Brighton, whence he was brought to town. As he was very violent, depletory measures were adopted for four or five days, and he was then removed into country lodgings. I there first visited him. I found him still violent and very incoherent, with a small, quick pulse, foul tongue, and his stomach so irritable that it would scarcely bear any. thing. A medical gentleman in the country had visited him before me, and ordered his head to be shaved, leeches to be applied, and a tartarised

antimonial warm plaster to be extended over the whole scalp. I suspect that the gastric irritation may have been owing to absorption of the antimony, for it ceased altogether next day.

In a few days, notwithstanding he was well supported, the vital powers seemed sinking; and at this juncture the whole of one foot suddenly became inflamed. It shortly put on a disposition to sphacelus. In a case where life was threatened, the delirium was of minor consideration; therefore bark, cayenne, opium, and a moderate quantity of wine, and stimulating applications to the inflamed parts, were exhibited. These means arrested the progress of mortification, and a healthy action was gradually resumed. A week afterwards, the other foot assumed exactly the same aspect, and threatened gangrene; but by persisting in the same plan, the powers of life rallied, and the second foot got well. The general health now mended fast; as that improved, the state of mind corresponded, and in about six weeks from the attack of mania he quite recovered.

In the second case, from the previous habits of the patient, and subsequent depletion and reduction, a state of sphacelus was by no means an unlikely consequence, had there been any wound or even abrasion of the skin on any part of the body; but the spontaneous inflammation, and successive proneness to mortification of the feet, support, I think, the inference I have deduced, that frequently there is an idiosyncrasy of constitution where the maniacal action exists, favourable to mortification of the extremities.

Possibly, this peculiar constitution may be analogous to that to which Pott refers, in cases of mortification of the extremities not dissimilar.*

* Chirur. Works, vol. iii.