CHAPTER XIV.

THE FORMS OF INSANITY (Continued).

Exaltation.

THE Second alteration of self-consciousness occurs when the tension of the energy that circulates in the visceral and nutritive moiety of the nervous system, is not diminished, but increased. Under such circumstances the symptoms will be in all respects the contrary of those described in the last chapter. Exaltation will be substituted for depression, and exaggeration for diminution.

When the tension of the nervous energy is reduced, the reduction in the tension is not usually confined to the visceral moiety of the nervous system, although it often affects this moiety with preponderant severity; and the same is the case when the tension is increased. The heightened tension is not usually confined to this part of the nervous system, but it does usually affect one part more prominently than the other. So that in some cases the main symptom is exaggerated activity in the conduct, while in other cases the main symptom is exaggerated activity of the nutritive processes; but whichever symptom is the more prominent, some degree of the other usually accompanies it.

Exaggeration of the tension of nerve energy to a morbid entent occurs in practically only two conditions-in drunkenness and in general paralysis of the insane; which latter has all the appearance of a permanent, progressive, and incurable drunkenness. While defect in the tension may exist without appreciable loss of function in any local area, and hence a

simple depression of mind may exist without the accompaniment of any delusion, or even of any appreciable impairment of the integrity of the other mental processes; exaggeration of the nervous tension, as a clinical fact, occurs seldom, and then briefly, without some impairment of intelligence. It may be, in the very early stage of drunkenness, when as yet there is only an increased flow of blood to the higher nerve regions, and before the benumbing effect of the alcohol has had time to make itself felt, that the increase of blood supply causes an increased emission of nerve energy, and so a heightened tension in the regions affected, without any appreciable loss of function in even the highest regions. When this occurs, there is for the time, and usually it is for but a short time, not only an exaltation of the sense of wellbeing, but an actual increase of intellectual power. The individual is not only jovial and companionable, self-satisfied and happy, but he is then even witty; his conversational powers are exalted. The hesitating man becomes fluent, the dull man bright, the slow man quick, the serious man sees a joke with an unwonted readiness of appreciation. So, too, in the earliest stages of general paralysis it occasionally happens that the patient gives evidence, not only of enhanced self-complacency and increased vigour, but of actual increase of ability over his usual standard.

Such periods of simple exaltation are not, however, of long duration. Soon the very increase in the blood supply which produces the heightened cerebral activity of the man who is elevated by drink, provides additional facility for the action of the alcohol, which is present in the blood, to act on the higher nerve regions; and soon the flush of blood, which is the earliest phenomenon in inflammation, is succeeded by the deterioration of tissue that inflammation produces; the highest nerve regions succumb to the damaging influence, and while the enhancement of tension and the exaggeration of action continue, they are conducted on lower levels, and result in manifestations of increased vigour, it is true, but of vigour misapplied and misdirected,

The way in which the enhancement of tension manifests itself depends on its extent and on its seat. When it preponderates in the visceral circulation of nerve energy there results an enhancement of the vigour with which the bodily processes are carried on. Digestion, secretion, assimilation, nutrition, are all conducted with increased efficiency. The improvement in digestion, which is brought about by the consumption of wine with dinner, is well known. Many persons of weak digestion are unable to digest their food unless it is accompanied with wine; and in such cases the wine acts by enhancing the tension of the nerve energy going to the abdominal viscera.

Nothing is more remarkable in the state of the general paralytic than his splendid muscular condition. Although, owing to the defect in his highest nerve regions, his conduct may have deteriorated so much as to be almost abolished; although, owing to defect of his middle nerve regions, his movements may be so much impaired that he cannot lift his food to his mouth without spilling it, nor stand without support; yet, from the continuous flow of high tension currents into his muscles, they are maintained in as high a state of nutrition, as hard, as firm, and as vigorous as if he were in training for a race.

With this enhancement of tension of the energy in the higher regions of the visceral circulation, goes a corresponding enhancement of the feeling of well-being, which is the mental accompaniment of the action of that portion of the nervous system. After a few glasses of wine, the bashful man loses his diffidence and becomes self-confident. His self-confidence is based upon the enhancement of his appreciation of his own qualities, consequent on the increase in his nervous tension. The braggadocio in which so many tipsy men indulge has its root in the same circumstance. Feeling an enhanced consciousness of their own abilities, and having lost, by the removal of the highest layers of their external circulation, the due appreciation of the fitness of expressing themselves modestly and with reticence, they give

full expression to their enhanced self-appreciation, and brag to excess. That their self-laudation is the honest expression of their own belief in their own powers, appears from the fact that they will back themselves to perform prodigious feats, and will even attempt them. At such a time a man will offer to jump over the table, to fight overwhelming odds, or to write a poem.

In general paralysis, as the enhancement of the nervous tension is so much more exaggerated, so the vagaries of selfconsciousness are much more extravagant. While the tipsy man will content himself with the claim to be considered the strongest man in the room, the general paralytic considers himself the strongest man on earth. While he is lying bedridden, helpless, incapable of dressing, feeding, or helping himself, he will boast of his prodigious muscular power and ability that he can lift a house, drink the sea dry, beget a hundred children in a night, and that his arms and legs are miles in length.

As in the case of defect, excessive nervous tension is seldom confined to one system of nervous circulation, and is usually combined with local losses of function in both. Hence, in conditions of exaltation, we usually find delusions of self combined with delusions of the relation of self to surroundings. The general paralytic believes not only, in spite of his manifest infirmities, that he is "all right," in splendid health, and capable of boundless activity; but also, in spite of the sordid surroundings of a workhouse, he believes himself to be in a palace, that he is the possessor of untold wealth, that he owns "millions and millions and millions," that he can "pave the streets of London seventeen feet thick with diamonds," and so forth.

Of course it is not every case of general paralysis which presents delusions so exaggerated as these, and there are many cases in which no actual delusions can be elicited; but in even the least exaggerated case there is a quiet contentment, a buoyancy of mind, a general state of happiness and feeling of well-being, which are in striking contrast with the utter

wreck of bodily and mental faculty, and which render this malady one of the saddest to witness, as it is undoubtedly the least painful of all to endure.

The increased vigour of the nutritive processes, and the corresponding enhancement of the feeling of well-being, are, as might be expected, not the sole evidences of increase in the tension of the nerve energy. When, as usually happens, this increase of tension obtains in the outer, as well as in the inner, circulation of nerve energy, there follows an increase in the vigour of the action of the individual upon his surroundings, which is great or little according to the amount of increase in the nervous tension, but which is usually considerable. Nothing, not even the marked selfcomplacency and arrogance of the incipient general paralytic, is more strikingly conspicuous than his eager, restless activity. His hours of sleep are abbreviated, and his waking hours, longer though they are, are more fully employed, are more crowded with activity than ever before. His bearing and demeanour are eager and restless. He is constantly in motion, and his walk is rapid and hurried. He meddles with everything that he comes across; he writes dozens of unnecessary letters; he talks with undue vehemence, rapidity, and frequency, and at undue length. He laughs immoderately and on insufficient provocation. There is an entire absence of repose about him. The manifestations of the heightened tension of the nervous energy are of endless variety, depending as they do for their form upon the amount and distribution of the areas of the higher nerve regions which are left uncontrolled and unco-ordinated by loss of the regions above them.

The peculiarity of all these cases is that, as a rule, the character and degree of the delusions have a general relation with the other evidences of heightened tension. The greater the activity of the visceral nervous processes, the higher the self-appreciation; and when we are able to reduce the one, a corresponding reduction takes place in the other. Thus to a patient with a glorious exaltation, of