CHAPTER V.

GENERAL SYMPTOMATOLOGY (Continued).

THE bodily symptoms associated with insanity are naturally exceedingly numerous, and many of them are so incidental and non-characteristic as to only require mention most appropriately in connection with the special type of mental disease in which they occur. Others, however, are so important, or so characteristic, that they well deserve a chapter on general symptomatology for their description.

We will take up, mainly in the order of their importance, the most prominent of these, without regard to their direct relations to each other or to pathologic processes.

Disorders of Sleep.-The disturbances of sleep take first rank in the physical phenomena of mental disorders. They are, (1) insomnia, which is a characteristic symptom in by far the larger proportion of cases of acute insanity. It is met with especially in maniacal conditions, hardly less frequently in melancholic states, and is a specially characteristic feature of the excited period of the circular insanities. The insomnia may be due to the irritability of these conditions, and thus afford a valuable therapeutic indication, but inasmuch as we do not know very perfectly the exact physiology of sleep, it is impossible to say what the mechanism of the symptom is in some of these disorders. It is very common in the prodromal periods of acute insanity, and may be considered a threatening symptom, especially in those who are predisposed, by heredity or otherwise, to mental disorders. It is remarkable to what extent sleeplessness is sometimes

endured by the insane. In acutely maniacal conditions they sometimes pass a number of days without any apparent sleep whatever, and in certain circular cases it is hard to say when the patient sleeps at all during the excited stage. In one particular case the patient was constantly active for nearly six weeks, and in another, which came under the observation of one of the writers, about ten days of apparent complete sleeplessness alternated with an equal period of stupor. There are probably in such extreme cases momentary relapses into slumber, which are overlooked, but the amount of sleep obtained must be exceedingly small.

With lack of sleep there seems to be little comparative deterioration of the general physical condition; the patients often keep well nourished, and show no serious symptoms of exhaustion. In fact, they seem to become accustomed, or acclimated, to this condition, and to make up, at least in some cases, by a prolonged period of stupor, or somnolence, for the lack of slumber which they have experienced.

2. Somnolence.-A tendency to sleep, aside from the cases just described, is often noticed in some conditions of general paralysis, and occasionally in other forms of insanity. Its diagnostic or pathologic importance is, however, very much less prominent, and it need not be further mentioned here.

3. Disturbances of sleep, in the way of restlessness, dreams, and somnambulism, are frequently met with. Many patients especially have frightful or alarming dreams, which are often the basis of a delusion. Others are readily affected in their sleep by external conditions of which they are apparently not aware. Thunderstorms, changes of the weather, etc., sometimes are causes of later disturbance, when they have occurred during the patient's slumber. We have known a number of insane patients who were decidedly worse after a thunder-storm which occurred during the night,

of which they were unconscious, probably through some disturbance of their sleep, without its having been completely destroyed.

Disorders of Nutrition.-Nutrition generally suffers in acute insanity, but not always to the extent that might be looked for. The absence of the instinct of nutrition has already been mentioned, but besides this there are many other ways in which it is disturbed. In conditions of great excitement, intellectual and motor, the waste is necessarily large, and is rarely fully made up for by the assimilation. There is, therefore, in such conditions a decrease of weight, and sooner or later a gradual failure of the vital powers, which, if long enough continued, must lead to the final exhaustion of the patient. With convalescence there is generally an increase in nutrition. The patient takes on flesh to make up for what he has lost. When this occurs, however, without corresponding mental improvement, it is an indication that the case is passing into the chronic stage, therefore an unhopeful sign. Patients refuse food not only from a lack of the instinct of nutrition, but from a complete loss of appetite, and often from delusions, fears of poisoning, etc.

In connection with this should be mentioned the disorders of digestion, which are very common, especially in depressed conditions, and the very general and exceedingly important symptom of constipation, which is one of the most serious of the conditions, and goes to an extent which would hardly be realized by those unacquainted with these cases. This reacts badly on the nervous system, not only through the mechanical overloading and sympathetic disturbance that is induced, as suggested by Schroeder van der Kolk, but also through the reabsorption of intestinal poisons and ptomains. The relief of this condition has often a vital effect on the mental condition, which will be more fully described in the chapter on general therapeutics.

Secretions. The secretions are liable to be more or less extensively altered in mental diseases, and in some of them the changes are rather characteristic. The perspiration is apt to be suppressed in many forms of insanity; a hard, dry skin in many cases of melancholia is especially noticeable. It is apt to be excessive in certain other forms, like acute rheumatic insanity. It is said that the insane have often a peculiar sour smell, which is distinctly recognized as a symptom of the condition, but this is not so true as is generally supposed. Personal neglect and dirty habits have more to do with the odor of the insane than any special character of the secretions, in most cases. In acute melancholia the lachrymal secretion is often lacking, the patients are not able to weep, and its reappearance is sometimes a sign of improvement. The salivary secretion is apparently very much affected in many forms of insanity. The patients sit and drool from the mouth a continuous stream of saliva, so that sometimes in inactive cases a large quantity could be collected in a short time. This is especially true in some forms of dementia, and in certain types of chronic insanity. Whether there is an actual increase to the extent that is apparent is not always beyond question, for the natural flow of saliva is large; but that it is very markedly increased in some cases is certainly undeniable, and this forms a very striking symptom, though not particularly important in regard to its significance in very many

cases.

Menstruation is usually disordered in insanity, and quite commonly suppressed. This is particularly true in the acute cases; in chronic insanity it may not be affected.

The condition of the blood, the urine, and other fluids of the body have been more or less studied in the insane, but the importance of the changes observed is

not altogether satisfactorily determined. Many of them are clearly symptomatic of the condition, and would occur with equal states of motor activity and nutrition. The epileptics have possibly been the most carefully studied in this regard, the toxicity of the urine and perspiration, condition of the blood, etc.

The conditions of the urine should always be investigated in cases of insanity, as this excretion is so apt to be an index of bodily disorders that may have an influence on the mental disease. The changes it shows may be entirely secondary and unimportant, but, on the other hand, one may at times be able to obtain important indications for treatment. Klein* found in some two hundred insane, six cases with depressed symptoms with excess of oxalates in the urine, and treatment directed to this symptom appeared to be in two the starting-point of recovery. As a rule, the changes from the normal will be unimportant, but in some cases they may be usefully significant. Albumin is not often found in ordinary cases of insanity, notwithstanding the fact that some degree or form of kidney derangement is almost the rule.

The study of the blood is also of value, as it may also reveal metabolic conditions calling for or guiding treatment. The exact relation between the blood changes observed-solvent resistance of red globules (isotony), reductions of hemoglobin, alkalinity, etc.— and the insanity is not always clear; but anemic and chlorotic conditions may have a practical significance.

Reflexes. The condition of the reflexes in insanity largely depends on coarse organic disease accompanying or causing it, or upon a general hyperexcitability that may exist. Thus we have the various alterations of the ocular muscular reflexes in general paralysis of the insane, and in organic insanity from various causes. We have exaggerated reflexes in certain neurasthenic

*N. Y. Med. Jour.," Mar. 18, 1899.