IN 83 OF THE LAST 100 cases in my case book for the asylum, whose disease was under six months’ duration, there were symptoms of bodily disorder that could be directly connected with the psychical symptoms. One bodily disorder accompanying insanity I call ‘general debility’(13 of the 100 cases). There is great emaciation, no vigour or ability for bodily exertion, languor, and a sense of prostration. The mental symptoms in these cases are generally those of melancholy and depression of mind. There is often a sluggishness in the performance of even the organic bodily functions – a slow pulse, costive bowels, a weak circulation in the extremities, with cold feet, blue hands, and pinched features. This is without organic disease of any kind.

Treatment of general debility in insanity

The treatment of such cases of debility resolves itself into the two indications of stimulating the nervous system to a more energetic action, and supplying a sufficient quantity of tempting, easily digested, and easily assimilable food. The nervous system should be stimulated by mental as well as bodily stimulants. To rouse, amuse, employ, and distract the attention must all be tried. To this end change of scene and circumstances, powerful means of excitement, and the control exercised by surrounding circumstances or by a stronger will, are often useful. All the culinary and medical aids to digestion must be employed. Alcoholic stimulants in moderate quantity, nervine stimulants, and ethereal stimulants are all useful in different cases, or in the same case in succession. It is almost impossible to predict that any particular case will recover. It often depends on the stage of the malady at which appropriate treatment is begun.

Here is a case of this kind. The mental derangement, consisting chiefly of a monomania of suspicion of poisoning, with hallucinations of hearing, is, ordinarily, one of the most hopelessly incurable forms of insanity in existence. It is only by being taken in time that such a case ever recovers. It is only by attending to the bodily disorders present that either a right prognosis or a right treatment can be arrived at.

Clerk with suspicion that his wife is poisoning him

X.Y., aged 57, male, married, good education, a clerk; had never been insane; had been an intelligent active man, sober, and naturally of a suspicious disposition. His mother had been insane. No cause could be assigned for the coming on of his symptoms, which were at first a feeling of bodily weakness, want of appetite, sleeplessness, inability to follow his ordinary occupation; and, mentally,  an utterly unfounded suspicion of his wife’s fidelity to him, and a delusion that she poisoned his food. He was quite rational on all other points, and at first seemed only to have a half-belief in these delusions. He got worse in body and mind, took less food, lost weight; was very restless, and yet felt as if he could not walk any distance or do anything; began to have hallucinations of hearing and sight, and his delusions got more fixed in his mind. He took emetics and purges to get rid of the poison. A change was tried, but failed on account of want of occupation and companionship.

At his own request he was admitted into the Carlisle Asylum two months after his symptoms commenced. On admission he was mentally slightly depressed, memory quite good, quite coherent, could answer questions, and discourse rationally on any subject except that on which he had delusions, which were strong in his mind. He gave a most circumstantial account of seeing the poison his wife gave him, and put on his clothes, and said he heard confused voices and a humming like that of bees in the roof of the room, and he smelt bad smells.

Bodily, he was a thin, anxious, suspicious-looking man, with grey eyes, a little fat and flabby muscles, pupils equal and contractile, reflex action normal, nervous system atonic Indisposed to exertion, and excitable; his hand was so shaky he could not write; lungs and heart normal; pulse 76; tongue clean, appetite capricious, temperature 99 degrees; height five foot eight, weight 125 lbs.

He slept ill, and said he could not help brooding over his ideas. He was put on a nutritious diet, cod liver oil, two glasses of wine per diem, and a mixture of citrate and quinine and iron, and spirit of chloroform. He was induced to employ himself, read the newspapers, play draughts, and be much in the open air.

He rapidly improved in body and mind, until in a few weeks he was gaining several pounds a week; at first he began to suspect his delusions to have been mere fantasies, was soon able to see his wife and converse pleasantly with her, and when she began to sound him on his delusions he at once changed the subject, saying afterwards that he thought it better to avoid “dubious matters.” He ceased to have the hallucinations; soon he slept well all night, was able to employ himself in reading and writing continuously, and in about five weeks completely lost belief in his delusions, laughing and saying what a “fool” he had been to believe such things. He was discharged quite well in two months, having gained 18 lbs in weight, with an excellent appetite and digestion, his temperature normal, and able to attend to his usual employment.