INSANITY is a generic term applied to certain morbid mental conditions produced by defect or disease of the brain. The synonyms in more or less frequent use are mental disease, alienation, derangement or aberration, mad-ness, unsoundness of mind. There are many diseases of the general system productive of disturbance of the mental faculties which, either on account of their transient nature, from their being associated with the course of a particular disease, or from their slight intensity, are not included under the head of insanity proper. From a strictly scientific point of view it cannot be doubted that the fever patient in his delirium, or the drunkard in his excitement or stupor, is insanethat, the brain of either being under the influence of a morbific agent or of a poison, the mental faculties are deranged ; yet such derangements are regarded sis functional disturbances, i.e., disturbances produced by agencies which experience tells will, in the majority of cases, pass off within a given period without permanent results on the tissues of the organ, The comprehensive scientific view of the position is, that all diseases of the nervous system, whether primary or secondary, congenital or acquired, should, in the words of Griesinger, be regarded as one inseparable whole, of which the so-called mental diseases comprise only a moderate proportion. However important it may be for the physician to keep this principle before him, it may be freely admitted that it cannot be carried out fully in practice, and that social considerations compel the medical profession and the public at large to draw an arbitrary line between such functional diseases of the nervous system as hysteria, hypochondriasis, and delirium on the one hand, and such conditions as mania, melancholia, and dementia on the other.
All attempts at a short definition of the term insanity hive proved unsatisfactory; perhaps the nearest approach to accuracy is attained by the rough statement that it is a dironic disease of the brain inducing chronic disordered mental symptomsthe term disease being used in its widest acceptation. But even this definition is at once too comprehensive, as under it might be included certain of the functional disturbances alluded to, and too exclusive, as it does not comprehend certain rare trausitory forms. Still, taken over all, this may be accepted as the least defective short definition; and moreover it possesses the great practical advantage of keeping before the student the primary fact that insanity is the result of disease of the brain, that it is not a mere immaterial disorder of the intellect. In the earliest epochs of medicine the corporeal character of insanity was generally admitted, and it was not until the superstitious ignorance of the Middle Ages had obliterated the scientific, though by no means always accurate, deductions of the early writers that any theory of its purely psychical character arose. At the present day it is unnecessary to combat such a theory, as it is universally accepted that the brain is the organ through which mental phenomena are manifested, and therefore that it is im-possible to conceive of the existence of an insane mind in a healthy brain. On this basis insanity may be de-fined as consisting in morbid conditions of the brain, the results of defective formation or altered nutrition of its substance induced by local or general morbid processes, and characterized especially by non-development, obliteration, impairment, or perversion of one or more of its psychical functions. Thus insanity is not a simple condition; it comprises a large number of diseased states of the brain, which have been gathered under one popular term on account of mental defect or aberration being the predominant symptom.
The insanities are sharply divided into two great classes _the Congenital and the Acquired. Under the head of Congenital Insanity fall to be considered all cases in which, from whatever cause, brain development lias been arrested, with consequent impotentiality of development of the mental faculties; under that of Acquired Insanity all those in which the brain has been born healthy, but has suffered from morbid processes affecting it primarily, or from diseased states of the general system implicating it secondarily. In studying the causation of these two great classes, it will be found that certain remote influences exist which are believed to be commonly predisposing; these will be considered as such, leaving the proximate or excit-ing causes until each class with its genera conies under review.
In most treatises on the subject will be found discussed the bearing which civilization, nationality, occupation, education, kc, have, or are supposed to have, on the production of insanity. Such discussions are generally eminently unsatisfactory, founded as they are on common observation, broad generalizations, and very imperfect statistics. As they are for the most part negative in result, at the best almost entirely irrelevant to the present purpose, it is proposed merely to shortly summarize the general outcome of what has been arrived at by those authorities who have sought to assess the value to be attached to the influence exercised by such factors, without entering in any detail on the theories involved. (1) Civilization.Although insanity is by no means unknown amongst savage races, there can be no reasonable doubt that it is much more frequently developed in civilized communities; also that, as the former come under the influence of civilization, the percentage of lunacy is increased. This is in consonance with the observation of disease of whatever nature, and is dependent in the case of insanity on the wear and tear of nerve tissue involved in the struggle for existence, the physically depressing effects of pauperism, and on the abuse of alcoholic stimulants; each of which morbid factors falls to be considered separately as a proximate cause. (2) Nationality.In the face of the imperfect social statistics afforded by most European and American nations, and in their total absence or inacces-sibility amongst the rest of mankind, it is impossible to adduce any trustworthy statement under this head. (3) Occupation.There is nothing to prove that insanity is in any way connected with the prosecution of any trade or profession per se. Even if statistics existed (which they do not) showing the proportion of lunatics belonging to different occupations to the 1000 of the population, it is obvious that no accurate deduction quoad the influence of occupation could be drawn. (4) Education.There is no evidence to show that education has any influence over either the production or the prevention of insanity. The general result of discussions on the above subjects has been the production of a series of arithmetical statements, which have either a misleading bearing or no bearing at all on the question. In the study of insanity statistics are of slight value from the scientific point of view, and are only valuable in its financial aspects.
Of much greater importance is the question of hereditary predisposition to nervous disease. There is a general and warrantable position taken up by the medical profession, founded on the observation of ages, that a constitutional condition may be generated in a family, which, although it may never manifest itself in a concrete form of disease, may materially influence development, or may make itself felt in a more subtle manner by a mere tendency to degenerative changes. In this wise hereditary predisposi-tion may be regarded as a common factor in all insanities in the congenital class as an arrester of brain develop-ment, in the acquired as the producer of the nervous diathesis. How the constitutional condition is generated, and in what its pathological nature consists, is beyond the ken of science; it may in fact be freely admitted that the proof of its existence hangs more on popular observation than on scientific evidence. The observation is not con-fined to the nervous system; it extends itself to others, as is shown by hereditary predisposition to gout, consumption, cancer, and other diseases.
It has been strongly asserted that consanguineous marriage is a prolific source of nervous instability. There is considerable diversity of opinion on this subject; the general outcome of the investigations of many careful inquirers appears to be that the offspring of healthy cousins of a healthy stock is not more liable to nervous disease than that of unrelated parents, but that where there is a family history of diathesis of any kind there is a strong tendency in the children of cousins to degeneration, not only it the direction of the original diathesis, but also towards instability of the nervous system.1 The objection to the marriage of blood relations does not rise from the bare fact of their relationship, but has its ground in the fear of their having similar vitiations in their constitution, which, in their children, are prone to become intensified. There is sufficient evidence adducible to prove that close breeding is productive of degeneration; and when the multiform functions of the nervous system are taken into account, it may almost be assumed not only that it suffers concomitantly with other organs, but that it may also be the first to suffer independently.
Of the other causes affecting the parents which appear to have an influence in engendering a predisposition to insanity in the offspring, the abuse of alcoholic stimulants and opiates, over-exertion of the mental faculties, ad-vanced age, and weak health may be cited. Great stress has been laid on the influence exercised by the first of these conditions, and many extreme statements have been made regarding it. Such must be accepted with reserve, for, although there is reason for attaching considerable weight to the history of ancestral intemperance as a probable causating influence, it has been generally assumed as the proved cause by those who have treated of the subject, without reference to other agencies which may have acted in common with it, or quite independently of it. The question has not as yet been fairly worked out. However unsatisfactory from a scientific point of view it may appear, the general statement must standthat whatever tends to lower the nervous energy of a parent may modify the development of the progeny. It is merely a matter of probabilities in a given case.
Constitutional tendency to nervous instability once established in a family may make itself felt in various directions,epilepsy, hysteria, hypochondriasis, neuralgia, certain forms of paralysis, insanity, eccentricity. It is asserted that exceptional genius in an individual member is a phenomenal indication.
Confined to the question of insanity, this morbid inherit-ance may manifest itself in two directions,in defective brain organization manifest from birth, or from the age at which its faculties are potential, i.e., congenital insanity; or in the neurotic diathesis, which may be present in a brain to all appearance congenitally perfect, and may present itself merely by a tendency to break down under circumstances which would not affect a person of originally healthy constitution.
In systematic works and in asylum reports, it has been too much the fashion to accept the evidence of the existence of insanity in a relative as a proof of hereditary predisposi-tion in a given case. In estimating the value to be attached to such histories, two things must be taken into account, first, the amount and quality of proved ancestral nervous disease, and, secondly, the period of life at which it appeared in the alleged insane ancestor. Take, for instance, the case of a lunatic whose father or mother is reported to have died insane; this may be true in fact, but may still have no bearing on the causation of the patient's insanity; for the parent may have been the subject of mental disease at a period subsequent to the birth of the child, he may have drunk himself into alcoholic mania late in life, or disease of the cerebral arteries in old age may have produced senile insanity. It is difficult to limit the remoteness of relationship in tracing hereditary predisposition, mainly from the fact that it frequently skips a generation. As a rule it does not confine itself to a single individual of i a family, but makes itself felt in one form or another in several members. According to Esquirol and Baillarger, it is more frequently transmitted through the female than . through the male branch, but this opinion is called in j question by Koch of Wiirtemberg, whose statistics show j that hereditary tendency to insanity acts more strongly through the father than through the mother.
The morbid mental conditions which fall to be considered under this head are Idiocy (with its modification Imbecility) and Cretinism.
Idiocy.In treating of idiocy it must be carefully borne in mind that we are dealing with mental phenomena dis-associated from active bodily disease, and that, in whatever degree it may exist, we have to deal with a brain condition fixed by the pathological circumstances under which its possessor came into the world, or by such as had been present before full cerebral activity could be developed, and the symptoms of which are not dependent on the interven-tion of any subsequent morbid process. From the earliest ages the term Amentia has been applied to this condition, in contradistinction to Dementia, the mental weakness following on acquired insanity.
The causes of congenital idiocy may be divided into four classes:(1) hereditary predisposition, (2) constitutional conditions of one or both parents affecting the constitution of the infant, (3) injuries of the infant head prior to or at birth, and (4) injuries or diseases affecting the infant head during infancy. All these classes of causes may act in two directions : they may produce either non-development or abnormal development of the cranial bones, as evidenced by microcephalism, or by deformity of the head; or they may induce a more subtle morbid condition of the con-stituent elements of the brain. As a rule, the patho-logical process is more easily traceable in the case of the last three classes than in the first. For instance, in the case of constitutional conditions of the parents we may have a history of syphilis, a disease which often leaves its traces on the bones of the skull; and in the third case con-genital malformation of the brain may be produced by mechanical causes acting on the child in utero, such as attempts to procure abortion, and deformities of the ma-ternal pelvis rendering labour difficult and instrumental interference necessary. In such cases the bones of the skull may be injured; it is only fair, however, to say that more brains are saved than injured by instrumental interference. With regard to the fourth class, it is evident that the term congenital is not strictly applicable; but, as the period of life implicated is that prior to the potentiality of the manifestation of the intellectual powers, and as the result is identical with that of the other classes of causes, it is warrantable to connect it with them, on pathological principles more than as a mere matter of convenience.
Dr Ireland, in his work On Idiocy and Imbecility, classi-fies idiots from the standpoint of pathology as follows : (1) Genetous idiocy : in this form, which he holds to be complete before birth, he believes the presumption of here-dity to be stronger than in other forms ; the vitality of the general system is stated to be lower than normal; the palate is vaulted and narrow, the teeth misshapen, wrongly placed, and prone to decay, and the patient dwarfish in appear-ance ; the head is generally unsymmetrical, and the com-missures occasionally atrophied ; (2) Microcephalic idiocy, a term which explains itself ; (3) Eclampsic idiocy, due to the effects of infantile convulsions; (4) Epileptic idiocy; (5) Hydrocephalic idiocy, due to water on the brain; (6) Paralytic idiocy, a rare form, due to the brain injury causing the paralysis; (7) Traumatic idiocy, a form pro-duced by the third class of causes above mentioned; (8) Inflammatory idiocy; (9) Idiocy by deprivation of one or more of the special senses. Dr Ireland's wide experience has enabled him to differentiate these groups further by describing the general characteristics, mental and physical, of each.
The general conformation of the idiot is often very imper-fect ; he is sometimes deformed, but more frequently ihe frame is merely awkwardly put together, and he is geuerally of short stature. Only about one-fourth of all idiots have heads smaller than common. Many cases are on record in which the cranial measurements exceed the average. It is the irregularity of development of the bones of the skull, especially at the base, which marks the condition. Cases, however, often present themselves in which the skull is perfect in form and size. In such the mischief has begun in the brain matter. The palate is very often highly arched, in some cleft; hare-lip is not uncommon; in fact congenital defect or malformation of other organs than the brain is more commonly met with amongst idiots than in the general community. Of the special senses, hearing is most frequently absent. Sight is good, although coordina-tion may be defective. Many are mute. On account of the mental dulness it is difficult to determine whether the senses of touch, taste, and smell suffer impairment; but the impression is that their acuteness is below the average. It is needless to attempt a description of the mental phenomena of idiots, which range between utter want of intelligence and mere weakness of intellect.
The term Imbecility has been conventionally employed to indicate the less profound degrees of idiocy, but in point of fact no distinct line of demarcation can be drawn; the application of either term to a given case depends more on the opinion of the observer than on the condition of the observed. As the scale of imbeciles ascends, it is found that the condition is evidenced not so much by low obtuse-ness as by irregularity of intellectual development. This serves to mark the difference between the extreme stupidity of the lowest of the healthy and the highest form of the morbidly deprived type. The two conditions do not merge gradually one into the other. Extreme stupidity and sottish ness mark many cases of idiocy, but only in the lowest types, where no dubiety of opinion can exist as to their nature, and in a manner which can never be mistaken for the dulness of the man who is less talented than the average of mankind. Where in theory the morbid (morbid in the sense of deprivation) and the healthy types might be supposed to approach each other, in practice we find that, in fact, no debatable ground exists. The uniformity of dulness of the former stands in marked opposition to the irregularity of mental conformation in the latter. Comparatively speaking, there are few idiots or imbeciles who are uniformly deprived of mental power; some may be utterly sottish, living a mere vegetable existence, but every one must at least have heard of the quaint and crafty sayings of manifest idiots indicating the presence of no mean power of applied observation. In institutions for the treatment of idiots and imbeciles, children are found not ! only able to read and write, but even capable of applying the simpler rules of arithmetic. A man may possess a very i considerable meed of receptive faculty and yet be idiotic in i respect of the power of application; he may be physically ! disabled from relation, and so be manifestly a deprived person, unfit to take a position in the world on the same j platform as his fellows.
Dr lreland subdivides idiots, for thepurposes of education, ! into five grades,the first comprising those who can neither speak nor understand speech, the second those who can understand a few easy words, the third those who can speak and can be taught to work, the fourth those who can be taught to read and write, and the fifth those who can read books for themselves. The treatment of idiocy and imbecility consists almost entirely of attention to hygiene, and the building up of the enfeebled constitution, along with endeavours to develop what small amount of faculty exists by patiently applied educational influences. The success which has attended this line of treatment in many of our public and private institutions has been very con-siderable. It may be safely stated that all idiotic or im-becile children have a far better chance of amelioration in asylums devoted to them than by any amount of care and teaching lavished upon them at home.
In the class of idiots just spoken of imperfect develop-ment of the intellectual faculties is the prominent feature, so prominent that it masks the arrest of potentiality of development of the moral sense, the absence of which, even if noticed, is regarded as relatively unimportant; but, in conducting the practical study of congenital idiots, a class presents itself in which the moral sense is wanting or deficient, whilst the intellectual powers are .apparently up to the average. It is the custom of writers on the subject to speak of "intellectual" and "moral" idiots. The terms are convenient for clinical purposes, but the two con-ditions cannot be disassociated, and the terms therefore severally only imply a specially marked deprivation of intellect or moral sense in a given case. The everyday observer has no difficulty in recognizing as a fact that deficiency in re-ceptive capacity is evidence of imperfect cerebral develop-ment ; but it is not so patent to him that the perception of right and wrong can be compromised through the same cause, or to comprehend that loss of moral sense may result from disease. The same difficulty does not present itself to the pathologist; for, in the case of a child born under circumstances adverse to brain development, and in whom no process of education can develop an appreciation of what is right or wrong, although the intellectual faculties appear to be but slightly blunted or not blunted at all, he cannot avoid connecting the psychical peculiarity with the pathological evidence. The world is apt enough to refer any fault in intellectual development, manifested by imper-fect receptivity, to a definite physical cause, and is willing to base opinion on comparatively slight data; but it is not so ready to accept the theory of a pathological implication of the intellectual attributes concerned in the perception of the difference between right and wrong. Were, however, two cases pitted one against anotherthe first, one of so-called intellectual, the second, one of so-called moral idiocy it would be found that, except as regards the psychical manifestations, the cases might be identical. In both there might be a family history of tendency to degeneration of the nervous system, a peculiar cranial conformation, a history of nervous symptoms during infancy, and of a series of indications of mental incapacities during adoles-cence, differing only in this, that in the first the promi-nent indication of mental weakness was inability to add two and two together, in the second the prominent feature was incapacity to distinguish right from wrong. What complicates the question of moral idiocy is, that many of its subjects can, when an abstract proposition is placed be-fore them, answer according to the dictates of morality, which they may have learnt by memory. If asked whether it is right or wrong to lie or steal they will say it is wrong; still, when they themselves are detected in either offence, there is an evident non-recognition of its concrete nature. The question of moral idiocy will always be a moot one between the casuist and the pathologist; but, when the svholo natural history of such cases is compared, there are points of differentiation between them and mere moral depravity which, must appeal to even biased observers. Family history, individual peculiarities, the manifest im-becility of the acts committed, the general bizarre nature of the phenomena, remove such cases from the ordinary category of crime.
Statistics.According to the census returns of 1871 the total number of persons described as Idiots and Imbeciles in England and Wales was 29,452, the equality of the sexes being remarkable namely, 14,728 males and 14,724 females. Compared with the entire population, the ratio is one idiot or imbecile to 771 persons, or 13 per 10,000 persons living. Whether the returns are defec-tive, owing to the natural sensitiveness of persons who would desire to conceal the occurrence of idiocy in their families, we have no means of knowing ; but such a feeling is no doubt likely to exist among those who look upon mental infirmity as humiliating, rather than as one of the many physical evils which afflict humanity. According to Ireland, this number (29,452) is 25 per cent, below the mark. The following table shows the number of idiots accord-ing to official returns of the various countries ; probably they are subject to the same criticism as the census returns for England.
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It is difficult to understand the wide divergence of these figures, except it be that in certain states, such as Prussia and Bavaria, dements have been taken along with aments, and in others cretins. This cannot, however, apply to the case of France, which is stated to have only 66 idiots to every 100 lunatics. In many districts of France cretinism is very common ; it is practically unknown in England, where the proportion of idiots is stated as higher than in France ; and it is rare in Prussia, which stands at 158 idiots to 100 lunatics. Manifestly imperfect as this table is, it shows how im-portant an element idiocy is in social statistics ; few are aware that the number of idiots and that of lunatics approach so nearly.
Cretinism.Crétin probably comes from Chretien, either from the idea that the person was innocent in the sense in which that word is employed occasionally to imply a person who cannot sin, or from the religious respect in which cretins were held. Cretinism is a form of congenital insanity in-asmuch as the cretino-genetic miasma acts before birth ; it is endemic in many mountainous countries, and is said to occur most frequently on niagnesian limestone formations, but never at an elevation above 3000 feet. Although all cretins have not goitre, and all goitrous persons are not cretins, there is a very intimate relationship between the two conditions. The districts in Europe in which it is most common are the departments of Hautes-Pyrénées, Haute-Savoie, and Hautes-Alpes ; Styria, Upper Austria, the province of Aosta, and Sardinia. It is found more sparsely in other parts of Europe, and also among the Himalayas and Andes. It occasionally presents itself in flat countries,a remarkable instance being the island of Niederwerth below Coblentz, where out of 750 inhabitants there are 131 cretins (Dr Ireland). Notwithstanding the circumscribed area in which this disease exists, affording, it might be supposed, data founded on the conditions of life common to their inhabitants for arriving at conclusions as to its cause, nothing has been definitely determined. Cretinism has occupied the attention of many eminent observers, but the various theories they have advanced have been in succession overturned. It has been suggested that the condition is due to the constant use of snow water, or to the presence of sulphate of iron or of lime in water, but none of these theories admit of universal application. That the disease is due to some geological or climatic cause appears certain from the fact, stated by Baillarger, that it disappears from a family in one or two generations after removal to a healthy climate, and may even be prevented by the gravid mother leaving a valley where it is rife for localities where cretinism is unknown. The physical and mental symptoms of cretinism are so closely allied in essentials to those of congenital idiocy as not to demand a separate description. The marked features of the disease are its endemic nature and its intimate connexion with goitre. See CRETINISM.
Bibliography. Rapport de la Commission de S. M. le Roi de Sar-daigne, pour étudier le Crétinisme, Turin, 1848 ; B. Nièpee, Traité du Goitre et du Crétinisme, Paris, 1851 ; Beobachtungen iibcr den Crétinismus, published by the physicians of the hospital at Maria-berg, Tubingen, 1850, 1851, and 1852 ; Guggenbiihl, Die Cretinen-Heilanstalt auf dem Abendbcrg, Bern and St Gall, 1853 ; Virchow, Untersuchungen iiber die Entioiclcelung des Schddelgrundes im gesunclen und krankhaften Zustaiulc unci iiber den Einftuss derselbcn auf Schadelform, Gesichtsbildung, und Gehirnbau (Berlin, 1857), and Gesammte Abhandlunfjen zur wissenscJutftliclicn Medicin (Frankfort, 1856) ; Saint Lager, Études sitr les Causes du Crétinisme et du Goitre endémique, Paris, 1867, and Deuxième Série d'Etudes sur les Causes du Crétinisme, Lyon, 1868 ; Baillarger, Enquête sur le Goitre et le Crétinisme, Paris, 1873 : Max Parchappe, Études sur le Goître et le Crétinisme, edited and annotated by L. Lunier, Paris, 1874 ; Lombrosa, Rivista Clinicadi Bologna, pt. 7, July 1873, andpt. 11, November 1873 ; Ireland, Edinburgh Medical Journal for August and September 1875, and On Idiocy and Imbecility, 1877. The last-named is the standard work on idiocy.
ACQUIRED INSANITY. Pathology.
It is predicated in treating of Acquired Insanity that we have to deal with brains congenitally perfect, the exercise of whose functions has been normal until the incidence of disease. A full description of the tissues of the healthy brain will be found in the article ANATOMY (vol. i. pp. 869-880), a careful perusal of which will very materially assist the reader in following the present remarks on pathology. A short resapitulation of certain anatomical facts is, how-ever, necessary. The purely nervous structures of the brain consist of very delicate fibres and cells, the latter occurring only in the grey matter. It is richly supplied with blood vessels, the supply being six times greater to the grey matter than to the white. These tissues are supported and separated one from the other by a connective tissue, or interstitial matter, the neuroglia ; the whole organ is enveloped in membranes which separate it from the skull. By one system of independent fibres (the expansion system) communication is maintained between the spinal cord, the central ganglia, and the cortical grey matter ; by a second system of fibres (the commissural), corresponding and identical regions of the grey matter of the two opposite hemispheres are united ; and by a third system (the hori-zontal) communication is maintained between parts of the same hemisphere. The cells communicate one with the other by means of processes or poles, fine projections from the body of the cell. The observations of Cleland and Boll show that the apical processes become connected with the fibres as they go to the periphery ; the basal processes loop with the horizontal fibres, and also, by means _of their recurrent poles, with those of the expansion series. But it is of great importance to observe that we have no evidence of fibre communicating directly with fibre, or no certain proof that one series of fibres communicates directly with others; in fact, all anatomical demonstration goes to prove the individuality and isolation of fibre, the processes of the cells being the connecting link. It is universally accepted that the cerebral cells possess the vital property of generating, receiving, and transmitting nervous influences, and that the fibres are the organs by means of which these influences are received and communicated. In the words of Herman, " in a part of the central organs (the cortical cells) certain material processes are accompanied in an inexplicable manner with wholly undefinable phenomena which characterize what we term consciousness.''1 The term mind may be applied to the combination of all the actual and possible states of consciousness of the organism. "We have a right to presuppose that in the brain, as in othei organs of the body, the normal exercise of function is dependent on a perfect maintenance of the anatomical relations of the component structures, and conversely that morbid conditions of these structures must affect the whole economy more or less seriously" (Bucknill and Tuke). In studying brain pathology it must be kept in view that, the brain cannot, like the lungs, liver, and kidneys, cast any of its functions on other organs ; it must do its own work, rid itself of its effete matter, and of the products of injury or disease, and provide within itself for the resump-tion of functions, fjhe exercise of which has become impaired from whatever cause.
Solutions of continuity, preventing perfect maintenance of the component cerebral tissues, may arise from(1) idiopathic causes, i.e., causes originating primarily in the brain; (2) traumatic causes (injury to the head); (3) the effects of other neuroses (morbid nerve conditions); (4) ad-ventitious products (tumours, &c.) ; (5) morbid conditions of the general system secondarily implicating the brain ; (6) evolutional conditions of the system concurrently affecting the brain; (7) toxic agents (poisons). In the case of insanity the results of morbid action are confined to the convolutions of the superior surface of the brain, and to the upper part of its lateral aspects ; for the most part its base and inferior lateral aspects and the cerebellum are un-affected. It is true that in old standing cases the central ganglia present lesions, but these are for the most part secondary, and are due to the action of disease in the superior convolutions.
1. Idiopathic changes occur from disease affecting the tissues, the cause of which it may be impossible to trace, as, for instance, acute inflammation, which, however, is not a frequent cause of insanity. Diffused subacute inflammation is held to be a much more fruitful cause, producing increase (sclerosis) of the neuroglia, degeneration of the cells, destruction (atrophy) and dis-placement of fibres, and aneurism, distortion, and oblitera-tion of vessels.
A large and important class of causes of idiopathic morbid action is due to over-excitation of the brain. The causes of over-excitation of the brain functions are those which, in most works on insanity, are spoken of as " moral " (grief, anxiety, domestic complications, disappointment, terror, sorrow or joy, religious or political excitement, the exercise of the mental faculties by study unduly prolonged or conducted under adverse circumstances) in contradistinction to "'physical" causes,a distinction ; which implies some material difference in their method of I operation. To the most superficial observer, the deformed '_ head of the idiot, and the paralysis of mind and body which follows on the rupture of a cerebral vessel, are coarsely material conditions; but when mental aberration follows on mental excitement, men are prone to regard it more as a derangement of function than as an evidence of deterioration of brain structure. If, however, we give due weight to the results of physiological research, the matter is not quite so obscure. Arguing from the analogies of other organs and from direct observation, there is reason to believe that when the brain functions are being actively exerted there is a dilatation of the vessels and an increased blood supply (hyperemia) to its superior and lateral surfaces. This functional hypersemia is caused by the direct action of the cerebral cells, which, along with the sympathetic system of nerves, exercise control over the muscular coats of the arteries, the immediate regulators of bl»od supply to any given part. Control over muscular tissue implies, of course, control in two directions, dilatation and contraction. Functional hyperemia is in every respect a healthy condition, one necessary for the provision of temporary nutriment during temporary action, ceasing with the withdrawal of stimulus, when the calibre of the vessels is reduced to its original dimensions through the contracting influence of the cells. But if the excitement is unduly prolonged a new result appears; the cells themselves become exhausted, and therefore, even if the stimulus is withdrawn, they are unable to assert their ordinary control over the arterial muscular coats in the direction of con-traction, so that the increased blood supply continues although the stimulus which caused it has been removed. Instead of functional hyperemia we have a hyperemia caused, not by functional excitement, but by exhaustion of the controlling organs. In a minor degree the results of this condition are matters of everyday observation; over-taxation of the brain functions, by study for instance, is very generally followed by sensations of fulness and aching of the head, loss of sleep, and general exhaustion,a condition which is recovered from when the primary irritation is withdrawn, i.e., when the arteries reacquire healthy tone. But if relief from, the causes of irritation is not obtained, a sequence of events ensues tending to deterioration of tissue. In the first place, sleep, the condi-tion necessary for rest and recuperation of the cells, becomes unattainable. Physiological research has shown that during sleep the supply of blood to the brain is diminished (anaemia), that anaemia is necessary for, and hyperemia is inimical to, its production. Further deterioration of cell activity follows on non-recuperation, and concomitant diminished control over the vessels tends to the establish-ment of morbid hyperemia and more or less blood stagna-tion (stasis). It would be far beyond the compass of this article to follow out in detail the various pathological processes which ensue on paralysis of vaso-motor action; two only need be alluded to(1) the various changes which take place in the behaviour of the constituents of the blood, producing congestion and greater or less obstruction to its normal distribution, and (2) the effects which congestion produces on the lymphatic system of the brain, the system by which effete matter is largely removed from it. It is now generally recognized that the lymphatics of the brain are perivascular, i.e., that they are tubes sur-rounding the arteries, patent under ordinary conditions; when, however, the arteries are distended, it is easy to comprehend that the lymphatic system becomes occluded hj the artery filling up the space provided for it, and therefore that the removal of waste products becomes difficult or impossible. It is a pathological axiom that the structural integrity of a part is dependent on the main-tenance of its vascular unity, in other words, on the regular supply and withdrawal of blood by its regular channels. This if impaired or destroyed is necessarily followed by histological changes and by disturbance of function.
By this exposition of a probable sequence of pathological events it is desired to indicate that disturbance of function directly referable to over-excitation of the brain is not a mere functional derangement, not a mere morbid increase of a normal emotion, but that it is the manifestation of a pathological condition,that, in effect, so-called moral causes may be the producers of physical cerebral disease. This meets with support from the clinical observation that, with very rare exceptions, a considerable period of time elapses between the incidence of the moral cause and the first indication of mental alienation,an interval during which sleep has been absent in consequence of continued hyperemia. Instances of melancholy or mania being suddenly produced by mental shock must be searched for in works of fiction. Sudden fright, more especially, is stated to produce immediate convulsion, epilepsy, and catalepsy, but not insanity; except in certain comparatively rare instances, in which it appears to induce with great rapidity a cataleptic mental state, presently to be spoken of as acute primary dementia. Over-exercise of the intellectual function is not by any means such a prolific cause of brain disease as undue emotion. It is not work but worry that kills the brain. When both are combined the result is often rapid.
On the removal or persistence of congestion depends the issue of a caserecovery, or further and permanent solution of continuity. Unless relief is soon obtained, the changes in the cells are followed by lesions of other brain structures which are productive of important pathological conditions affecting the general system; these in their turn render recovery more difficatt or impossible, or may even cause death. (For a full account of the various lesions found in the brains of the insane, consult Bucknill and Tuke, Manual of Psychological Medicine, 4th ed., cap. vi.; Fox's Patho-logical Anatomy of the Nervous Centres, London, 1874 ; J. Batty Tuke, " On the Morbid Histology of the Brain and Spinal Cord as observed in the Insane," Brit, and For. Medico-Chirurgical Review, 1873-74.)
2. The second class comprises all accidents and injuries affecting the brain, and is most conveniently termed traumatic. Violence to the head may produce fracture of the skull with or without depression, extravasation of blood in or on the brain, or concussion. There is no relation between the apparent extent of the injury and the results in insanity; extensive fractures of the frontal, lateral, and superior surfaces of the skull, even when complicated with rupture of the envelopes and loss of brain matter, are not, taken over all, more productive of insanity, if so much so, as the apparently less serious condition of concussion. The reason of this is not far to seek; by the open wound free egress is afforded for extravasated blood and the products of inflammation, whereas in concussion, which may also involve extravasation of blood in or on the brain, foreign substances have no means of escape, and so may set up morbid action of a grave nature. Occasionally insanity follows rapidly on the injury, but much more frequently weeks or even months elapse before development of mental symptoms amounting to insanity. During this period morbid action is proceeding on the inner surface of the skull, in the membranes, or in the brain itself. On the inner table of the skull bony growths may be in process of formation, subacute inflammation of the membranes may be going on, and from the same cause the brain may be undergoing progressive changes generally in the direction of sclerosis, i.e., increase of connective tissue.
3. The nervous diseases in the train of which insanity occasionally follows are Epilepsy, Hysteria, and Locomotor Ataxy. In the case of Epilepsy the brain lesions are doubt-less the result of the frequently asphyxiated condition of the patient and of the blood poisoning due to the retention of carbonic acid gas (see EPILEPSY). AS might be expected, lesions of the arteries in the form of hypertrophy of their coats is frequently observed. The canals in the brain matter through which the vessels pass are very frequently found dilated to from two to six times their normal dimensions. If the richness of the blood supply to the grey matter is considered, this condition of dilatation must imply an immense loss of brain tissue; moreover, the cells are frequently found suffering degeneration. In dealing with the subject of Hysteria, we have, as stated in the article especially bearing on the subject (HYSTERIA), to do with a disease which, although marked by very prominent symptoms, possesses no anatomical seat, and thus when the disease amounts to insanity we are equally in the dark as to the cerebral con-ditions. The insanity following or accompanying hysteria is not a fatal one in its earlier stages, and there is no report extant of an autopsy on a recent case of this disease. Locomotor Ataxy is a disease of the spinal cord, sclerosis of its posterior columns (see ATAXY). It implicates other parts of the nervous system,for instance, the optic tracts and nerves. Insanity occasionally is concurrent with, and probably, if not certainly, is produced by an extension of the sclerosis to the cerebral convolutions. This theory meets support from the fact that the mental symptoms associated with locomotor ataxy resemble very closely those of general paralysis, in which hypertrophy of the connective tissue of the superior convolutions has been demonstrated.
4. By the term adventitious products it is meant to indicate all forms of tumours of the brain, skull-cap, and membranes. Such foreign bodies have three distinct effects on the brain structure:" 1st, They create an irritation tending to ramollissement in the nerve substance, with which they are in contact from their first appearance. 2d, They cause pressure on distant parts, which in its turn causes an alteration of the structure and nutrition. 3d, They set up progressive disease and degeneration of certain parts of the nerve structure, the true nature of which is as yet not very well known; but it seems to be in some way directly connected with the essential nature and constitution of all sorts of nerve substance, whether cells or fibres. Its results pathologically are an increase of the connective tissue in the form of granules, and enlargement and thicken-ing of the coats of the blood-vessels; but all these seem to be secondary changes" (Clouston, " On Tumours of the Brain," Journal of Mental Science, vol. xviii.). Apoplectic clots are practically tumours.
5. Morbid conditions of the general system secondarily implicating the brain. It is of great interest from an etiological point of view to note that insanity is seldom if ever the immediate result of diseases of individual organs, but that it is more or less intimately associated with those forms of disease which result from a general constitutional instability, such as tuberculosis, rheumatism, gout, and syphilis. There are many diseases painful in character and very depressing to the nervous system, such as stone, fistula (in fact all the so-called surgical diseases of the rectum and bladder), cancer of the uterus, &c, which might be presupposed to be probable causes of insanity, yet in point of fact are not inimical to mental health. They may be so indirectly, inasmuch as they prevent sleep, but even in this wise their effect is very slight. Nor does there appear sufficient reason to connect diseases of the heart, liver, kidneys, directly with insanity. Much stress has been laid on diseases of the uterus ana ovaries, and more especially on tumours of these organs, being the primary factors in the production of insanity. Skae laid down as a special form ovario- or utero-mania; and Wergt of Illnau has described the various morbid conditions of the female organs of generation found on post-mortem examination, and has connected with them mental symptoms. But authors on gynaecology make no mention of insanity being a sequela of uterine disease, except in so far as the mental depression which in most women follows on the knowledge that they are affected by serious, perhaps fatal, disease, and the pain and anxiety inseparable therefrom, may produce sleeplessness, and consequent melancholy; and there is no proof of such tumours exercising an extensive influence on causation by peripheral irritation. The fallacy has in the great majority of instances probably arisen from the observation often made in asylums that insanity arising from whatever cause is conditioned by the presence of uterine growths, and that delusions of a sexual character may arise from the sensations thereby produced. Of the very few instances on record in which a direct connexion between uterine disease and insanity has been traced may be cited a case reported by Van der Kolk, in which deep melancholy and prolapsus uteri coexisted; the mental symptoms were at once relieved by the organ being restored to its normal position. Such cases are very rare.
It is still a moot point whether a true tubercular or phthisical insanity exists; if it does, it certainly does not arise from tubercular deposits in the braina very rare condition in the insane. Those authorities who deny the existence of phthisical insanity hold that, although mental symptoms do frequently present themselves in cases of con-sumption, and although consumption is very frequent amongst the insane, the insanity is not directly dependent on the diathesis, but more probably results from the general lowering of the system, and at most is only conditioned by the primary disease, In the case of rheumatism and gout there are strong reasons for believing*that an actual trans-lation (metastasis) of the materies morbi occasionally takes place from affected joints to the connective tissue of the brain and cord,the evidence being choreic movements of the limbs (St Vitus's Dance) accompanied by acute mental symptoms, both of which disappear contemporane-ously with the return of inflammatory swellings of the joints. Syphilis may act on the brain by the production of tumours (which, however, do not differ in their effects from those of other adventitious products), and by specific changes in the coats of the arteries, which become thickened and even occluded. As a consequence the tissues in their neighbourhood suffer deterioration.
The pathological relation between sun-stroke (insolation) and brain disease has not been ascertained. A certain amount of brain congestion has been observed, but not invariably. The cerebral lesion is more probably due to the extreme depression of the whole nervous system; but the modus operandi is unknown.
The morbid condition of the general system which most frequently implicates the brain is anaemia, not itself a disease, but the result of many diseases, such as fever, and of such drains on the constitution as lactation (suckling) and imperfect nourishment. The operativeness of these drains may be assisted by over-work under unhealthy conditions. As a typical example may be cited the dress-maker, poorly paid, poorly fed, working for many hours daily in an ill-ventilated room, and sleeping in an unhealthy garret. The term anaemia is not used here to indicate a condition antithetical to hyperaemiait does not imply any mechanical deprivation of blood supply; on the contrary, the amount of blood, such as it is, is not reduced in quantity. The temporary mechanical anaemia which results from extreme cold produces its effects rapidly,'short delirium and profound sleep. But it is qualitative anaemia, an impoverished state of the blood, which produces more or less permanent results on cerebral health. Inanition acts rapidly on the brain: in the case of those cast away at sea on rafts or in boats the general story is that of short delirious mania, suicide, or death from nervous exhaustion, before emaciation (i.e., before the reserve food of the system is consumed) takes place. So in cases where inanition is more slowly produced, the nervous system is first depressed. And here the position becomes somewhat complicated ; for not only is, under such circumstances, the relative- amount of the blood constituents different from the normal standard, but its corpuscular elements change in quality; they acquire a degree of viscidity which tends to cause the red corpuscles to coalesce and hang together, and the white to lag and wander into surrounding tissues; and further, this unphysiological behaviour of the corpuscles is apt to become aggravated in regions whose nervous energy is depressed. Anaemia thus acts and reacts in procuring a condition of stasis.
6. The effects of evolutional periorls concurrently affect-ing the brain : puberty, adolescence, utero-gestation, the climacteric period, and old age. " Although from the time when the human being comes into the world to the final cessation of his corporeal existence the various functional operations of organic life are carried on with ceaseless activity, whilst those of animal life are only suspended by the intervals of repose which are needed for the renovation of their organs, yet there are very marked differences, not | only in the degree of their invited activity, but also in the I relative degrees of energy which they severally manifest at different epochs" (Carpenter's Principles of Human i Physiology, chap, xviii.). These differences in degree imply physiological modifications of nutrition, and the observation of ages has caused it to be accepted as a fact in the etiology of disease that numerous and various degenerations occur contemporaneously with such modifications, more especially in the subjects of diathetic conditions. The development of phthisis during adolescence, and of cancer amongst persons at the climacteric period, may be cited as instances, i It may be freely admitted that the nexus between the physiological and the pathological position is, as regards certain of the periods, obscure, and that it is dependent \ more on induction than on demonstration; but it may be pleaded that it is not more obscure in respect of insanity than of other diseases. The pathological difficulty obtains mostly in the relation of the earlier evolutional periods, puberty and adolescence, to insanity: in the others a physiologico-pathological nexus may be traced; but in regard to the former there is nothing to take hold of except the purely physiological process of development of the sexual function, the expansion of the intellectual powers, and rapid increase of the bulk of the body. Although in thoroughly stable subjects due provision is made for these evolutional processes, it is not difficult to conceive that in the nervously unstable a considerable risk is run by the brain in consequence of the strain laid on it. Other adju-vant influences may be at work tending to excite the system which will be spoken of when the insanity occurring at these periods is described. Between the adolescent and climacteric periods the constitution of the nervous, as of the )ther systems, becomes established, and disturbance is not liable to occur, except from some accidental circumstance apart from evolution. In the most healthily constituted individuals the " change of life " expresses itself by some loss of vigour. The nourishing (trophesial) function becomes less active, and either various degrees of wasting occur, or there is a tendency towards restitution in bulk of tissues by a less highly organized material. The most important instance of the latter tendency is fatty degenera-tion of muscle, to which the muscle of the arterial system is very liable. In the mass of mankind those changes assume no pathological importance : the man or woman of middle life passes into advanced age without serious con-stitutional disturbance; on the other hand, there may be a break down of the system due to climacteric disease of special organs, as, for instance, fatty degeneration of the heart. In all probability the insanity of the climacteric period may be referred to two pathological conditions : it may depend on structural changes in the brain due to fatty degeneration of its arteries and cells, or it may be a secondary result of general systemic disturbance, due to j cessation of menstruation in the female, and, possibly, to some analogous modification of the sexual function in men. ! The senile period brings with it further reduction of j formative activity; all the tissues waste, and are liable to fatty and calcareous degeneration. Here again the arteries ] of the brain are very generally implicated: atheroma in some degree is almost always present, but is by no means always followed by insanity. Whewell retained his faculties to the last, notwithstanding that his cerebral arteries were much diseased. Still this condition must be taken into account in studying the causation of senile insanity, as it necessarily implicates the nutrition of the brain. It must assist in preventing recuperation of the cells ; it may in cer-tain instances diminish suddenly the blood supply to a par-ticular area; but the stronger probability is that senile mental decay lies at the door of senile degeneration of the cells.
The various and profound modifications of the system which attend the periods of utero-gestation, pregnancy, and child-bearing do not leave the nervous centres unaffected. Most women are liable to slight changes of disposition and temper, morbid longings, strange likes and dislikes during pregnancy, more especially during the earlier months ; but these are universally accepted as accompaniments of the condition not involving any doubt as to sanity. But there are various factors at work in the system during pregnancy which have grave influence on the nervous system, more especially in those hereditarily predisposed, and in those gravid for the first time. There is modification of direction of the blood towards a new focus, and its quality is changed, as is shown by an increase of fibrin and water and a decrease of albumen. How much these changes structurally affect the encephalon may be deduced from the fact of the presence of bony plates (osteophyte) on the surface of the dura mater and the inner table of the skull, and how much functionally, by constant congestions and flushings. To such physical influences are superadded the discomfort and uneasiness of the situation, mental anxiety and anticipation of danger, and in the unmarried the horror of disgrace. In the puerperal (recently delivered) woman j there are to be taken into pathological account the various i depressing influences of child-bed, its various accidents | reducing vitality, the sudden return to ordinary physio-1 logical conditions, the cessation of the occasional physio-logical condition, the rapid call for anew focus of nutrition, the translation as it were of the blood supply from the \ uterus to the mammae,all physical influences liable to affect the brain. These influences may act independently of moral shock; but, where this is coincident, there is a condition of the nervous system unprepared to resist, or, it may rather be said, prepared to succumb.
7. Among the toxic agents which affect the brain, alcohol holds the foremost place. On the action of this poison the article DRUNKENNESS supplies full information. Consider-able difficulty exists as to the estimation of the importance i to be attached to alcohol in the production of brain disease . from the fact that excess in the use of stimulants is very frequently a symptom of incipient insanity, and that the symptom is often mistaken for the cause. The habitual use of opium and Indian hemp (Cannabis indica), which first stimulate and then paralyse the action of the cerebral cells, is a frequent cause of lesion.
Difficulties may arise in individual cases in establishing a theory of causation from the presence of what are generally spoken of in systematic works on insanity as | " mixed " causes, i.e., the presence of two morbid factors in | one individual. So long as these consist in variety in character of excited psychical action, such as grief and anxiety of business, over-prolonged study and domestic affliction, the combination does not affect the position ; but when we have a history of one or more of such psychical influences being associated with a depraved condition of the general system, with poverty, with excess in alcoholic stimulants, or with hereditary predisposition, it appears at the first glance difficult to assess the value to be attached to each in the production of brain disease. This complica-tion is, however, more apparent than real; weakness of the system, whether produced by disease or by malnutrition, only implies a condition in which cerebral degeneration is more likely to occur, but where there is no reason to believe it would have occurred if the brain, weakened along with the other organs of the body, had not been subjected to over-excitation. It may be argued that the brain excitation would not have produced the lesion if the tone of the general system had not been lowered : that is as it maybe, _it is a proposition which cannot be accepted or denied positively in the absence of positive data. But negative data obtain which warrant its refusal. These are twofold : ^-a depraved condition of the general system is a frequent result of over-excitation of the brain, the result being liable to be mistaken for the efficient cause; and the history and symptoms of insanity resulting from special morbid con-ditions of the system differ materially from those produced by over-excitation.
The action of all these varied morbid factors is in the direction of solution of continuity of cerebral elements, and consequently of perversion of psychical function. And here a wide gap opens itself in the study of brain pathology in its relation to morbid psychology. No adequate theory has been advanced to account for the sequence of a parti-cular type or train of morbid mental symptoms on a parti-cular morbid condition of the brain. In the most definite forms of insanity, those of which the morbid anatomy is pretty definitely determined, there is not the slightest suggestion afforded of the causation of the peculiar type of mental symptoms which symptomatize them, or for the alternation of symptoms in an individual case, or for diversity of symptoms apparently starting from the same cause. All that is known is that when the hemispherical ganglia are diseased we may have excitement or depression of feeling, delusion, or obfuscation of the intellectual and moral qualities ; but why in one case excitement, in another delusion, and in a third both, is an utter mystery.
The mental symptoms of acquired insanity have been classified from the time of Pinelit might, save from some slight difference in the application of the terms, be said from the time of Hippocratesas mania, melancholia, and dementia, according as exaltation or depression of feel-ing or weakness of intellect presents itself most prominently in a given case. To these has been added delusional insanity, spoken of by certain authors as monomania. Numberless classifications founded on psychological con-siderations have been advanced, involving, however, more variety in terminology than in principle; all such, when analysed, are reducible to the primitive mania, melancholia, and dementia. Pritchard asserted that mental symptoms were divisible into two great classes, according as the intellectual and moral faculties were implicated. This principle falls to the ground from the simple but most important fact that the primary symptom in all insanities is perversion of the moral sense, and that this perversion pervades all cases of mental disease to their termination. This change of morale amounts to various degrees of per-version of the ordinary character and disposition of the individual. He becomes indifferent to social considerations, apathetic and neglectful of the personal and family duties, evinces dislike and suspicion of friends and relatives, and may betake himself to excess in alcoholic stimulants and other forms of dissipation. There is a general concentration of his ideas on himself, which is often spoken of as the selfishness of the insane. According to the direction in action in which perversion of the moral sense is manifested such so-called forms of insanity have been constructed as dipsomania, kleptomania, erotomania, &c, which, however, are to be regarded as merely accidental phenomena. Moral insanity may appear to exist alone at certain times in certain cases, but it is greatly to be doubted whether it really ever exists apart from intellectual perversion. The mere fact that a person cannot appreciate the change in himself, cannot, as it were, disapprove of his own actions, is evidence that the moral faculties are not alone implicated. The converse proposition may be stated even more strongly intellectual insanity never exists without moral perversion.
Moral perversion is, however, only one of the initial symptoms. In most insanities a " period of incubation " is observed, generally spoken of as the prodromal or initial period. Sudden and violent outbursts of insanity are occa-sionally reported, but, when these are carefully examined into, a train of prodromal symptoms, physical as well as psychical, can almost invariably be traced. These symptom? are for the most part insidious in character. Founding on the statements of-patients suffering from premonitory symptoms, on those made by others, who, having recovered, are able to carry back their recollection to the incidence of the prodromal stage, and on the direct observation of the physician, physical indications are the first to present them-selves. These consist in a feeling of fulness in thé head, throbbing of the forehead and eyeballs, flashes of light before the eyes, and general malaise. The mental symptoms follow closely, and consist, in addition to the change in morale already spoken of, in restlessness, irritability, inability to apply the mind to the everyday affairs of life, and sleeplessness. o In certain forms this description of the prodromal symptoms requires some slight modification. They are very generally accompanied by impairment of general health.
The classification of the insanities according to the predominant mental symptom is adopted in almost all treatises on the subject ; but there is a growing convic-tion that this basis is neither so scientific nor so con-venient as a classification based on pathology. Mania, melancholia, and dementia are merely symptoms of brain disease. If these symptoms were constant in even a considerable majority of all cases, there would be better warrant for employing them as a basis of nosology ; but they vary so widely in kind and degree, they run so closely one into the other, they may all appear in an individual case within so very short a space of time, that their use is generally misleading, even as indicating the mental condi-tion of a patient. In many cases of insanity mania may present itself to-day, melancholia to-morrow, and dementia the day after, being, in fact, indications of the course of the complaint. It is undoubtedly true that in a proportion of the insane there is a general predominance of one or other of these conditions, but it is equally true that there is an equal proportion in which the application of any one of these terms is open to question. Thus we may have a melancholic mania or a maniacal melancholia. Moreover, there are many forms of insanity of which the connexion with the causation is so intimate that even those authors who adhere to the archaic classification cannot refuse to acknowledge them as pathological classes, and are com-pelled to treat of them under their pathological designa-tions ; puerperal insanity, epileptic insanity, senile insanity, and general paralysis may be cited as prominent examples.
To say of a man that he is maniacal is not saying more than to say of one who has lost power over his limbs that he suffers from palsy, a diagnosis which no scientific physician of the present day would be content with, as it conveys no definite idea as to the pathological character or cause of impairment of mobility. It may be freely admitted that medical science is not yet able to base a nosology of the in-sanities on the highest pathological platform, that of morbid anatomy. Considerable advances have been made in this direction, but the observations of pathologists, with the exception of those bearing on three or four classes of brain disease, are vague and quite insufficient for the purpose. Clinical observation, however, has served to relate symptoms with cause to such an extent as to enable the observer of mental disease to fall back on the second pathological positionetiology, and has enabled him to assert, in a very large proportion of cases, causation as a scientific and con-venient standpoint for classification. After all, classifica-tions are matters of convenience. It is not asserted that the classification adopted in this article is more than provisional; but it is asserted that it is more convenient to study the insanities in connexion with the bodily conditions of their subjects than to rely on a general description of mental symptoms which are inconstant in kind and degree, and often so complex as to render analysis impossible.
dementia. General paralysis of the insane
Epileptic insanity. Hysterical insanity. Hypochondriacal insanity.
When Esquirofs definition of the mental conditions is quoted, little more need be added, for further descrip-tion would merely involve an amplified account of psycho-logical peculiarities. Esquirol thus describes the con-ditions:(1) Melancholia, or, as he terms it, Lypemania, disorder of the faculties with respect to one or a small number of objects, with predominance of a sorrowful and depressing passion ; (2) Monomania, in which the disorder of the faculties is limited to one or a small number of objects, with excitement, and predominance of a gay and expansive passion; (3) Mania, in which the insanity extends to all kinds of objects, and is accompanied by excitement; (4) Dementia, in which the insensate utter folly, because the organs of thought have lost their energy and the strength requisite for their functions. In 1852 Schroeder van der Kolk and in 1860 Morel laid the foundation of a classification more in accordance with pathological science. The former included the different form3 of the disease under two great classes :" idiopathic insanity," comprising all cases produced by primary affec-tions of the brain; and "sympathetic insanity," including those due to morbid conditions of the general system. Morel divided the insanities into six groups :(1) heredi-tary insanity ; (2) toxic insanity ; (3) insanity produced by the transformation of other diseases ; (4) idiopathic insanity; (5) sympathetic insanity; (6) dementia, a terminative stage. Notwithstanding faults of detail, it may be fairly said that these propositions marked a great advance in the study of insanity, and that all later classifi-cations based on the same principles have been derived from study of them. The following system admittedly is so.
I. Idiopathic insanities.
II. Traumatic insanity.
Phthisical insanity. Rheumatic insanity. Gouty insanity. Syphilitic insanity. Insanity from sunstroke. Anaemic insanity.
III. The insanities associated with other o neuroses.
IV. Insanity resulting from the presence of adventitious products.
V. Insanities resulting from morbid conditions of the general system.
(Insanity of pubescence and adolescence,
VI. Insanities occur- Climacteric insanity,
ring at evolutional -j Senile insanity,
periods. Insanity of pregnancy.
I Puerperal insanity.
VII. Toxic insanity.
I. IDIOPATHIC MANIA AND MELANCHOLIA.It is pro-posed to consider under the head of idiopathic mania and melancholia the large and important class of cases which re-sult from over-excitation of the brain due to so-called moral causes. In considering this form of insanity, a difficulty arises in reconciling the dependence of two such apparently widely divergent morbid psychical states as mania and melancholia on one common pathological condition. That they are so is maintained by the following clinical observa-tions1st, that during the prodromal period, i.e., the period during which over-excitation is using its influence on the brain tissues, the symptoms of excitement and depression generally alternate; 2d, that in certain acute cases mania and melancholia coexist, that is to say, it is impossible for the observer to say whether they are cases of maniacal melancholia or melancholic mania; 3d, that, as many cases run their course towards recovery, the symptoms are con-secutively mania,*melancholia, and dementia ; 4th, that the effects of irritating poisons applied to the brain, alcohol markedly, produce these symptoms in some individuals in a very short space of time. These observations point, not to a difference of pathological causation, but to variation in symptoms in conformity with the progress of pathological processes. It must be borne in mind that congestion is not a condition constant in quality or in quantity, and, further, that it is an inconstant condition acting on an inconstant subject, and therefore productive of cumulative inconstant results. Brain congestion, due to over-excita-tion, produces functional excitement of that organ. It must be remembered that although mania is accompanied by exaltation, and melancholia by depression of feeling, they are both manifestations of excitement of feeling. Given this common psychological condition of excitement, a reason must be sought for the variety of its manifestation either in some peculiarity of the irritating cause or in some idiosyncracy of the affected individual. In either case no material assistance is gained from psychological considera-tions, for there is no necessary connexion between depress-ing emotions and melancholia; intense grief often produces acute mania, and the insanity of the man of saturnine mind is as often as not characterized by mania. The peculiarity of the irritating cause appears to be, not its psychological characteristic, but its intensity. The more rapidly excitement of feeling is produced, the more likely is mania to be the symptom of the insanity. That melancholia often supervenes on depressing emotions gradual in their incidence does not imply a psychological nexus, but that, as their irritating influence is slowly applied, so the results of the irritation are slowly produced, and (as in the case of every tissue of the body) there is variety of degree of symptoms in conformity with the rapidity of the progress of pathological events. There are also various underlying conditions difficult to treat of in the mass, any one of which may have considerable bearing on an individual case. Constitutional predisposition (diathesis) may render a person more prone to the sub-acute forms of disease, and the condition of the body at the time of irrita-tion may influence the nature of the symptoms in either direction. In the absence of the possibility of applying to the brain the mechanical aids which have given the physician an insight into the sequence of pathological events occurring in other organs, the pathologist has nothing to depend on save clinical observation. He has presented to him a diseased organ, complex in function, of the physiology of which he is, as regards its psychical action, profoundly ignorant; all he can say is that, when its histological integrity is impaired, he has reason to believe that " some functions become torpid and oppressed, while others are excited into preternatural activity" (Bucknill and Tuke). It must be stated, however, that in a considerable propor-tion of cases the nature of the ultimate condition is fore-shadowed from the very commencement by the character of the initial symptoms. Simple depression of feeling may be the first and last symptom of insanity, or it may gradu-ally increase in intensity till it attains the extreme and most complicated form of melancholia, In like manner simple excitement and exaltation of feeling may characterize a case from beginning to end, or it may culminate more or less rapidly in active mania, without the intervention of other psychical symptoms.
As to the duration of the prodromal period, in the mass of cases nothing can be stated with certainty; it can only be said that, as a general rule, the incidence of melancholia is more slow than that of mania. Putting aside exceptional cases, it may be stated that, whereas the former is a matter of mouths or weeks, the latter is a matter of weeks or days.
The initial mental symptoms having been already de-scribed, it remains only to say that the general system becomes coincidentally affected; functional disturbances of the digestive organs soon manifest themselves, and the nutrition of the body becomes defective. To this implica-tion of other systems consequent on impairment of the trophesial (nourishment-regulating) function of the brain can be traced a large amount of the errors which exist as to the causation of idiopathic melancholia and mania. Very frequently this secondary condition is set down as the primary cause; the insanity is referred to derangements of the stomach or bowels, when in fact these are, concomitantly with the mental disturbance, results of the cerebral mischief. Doubtless these functional derangements exercise considerable influence on the progress of the case by assisting to deprave the general economy, and by producing depressing sensations in the region of the stomach. To them may probably be attributed, together with the apprehension of impending insanity, that phase of the disease spoken of by the older writers as the stadium, melancholicum, which so frequently presents itself in incipient idiopathic cases. ' During the earlier stages of the prodromal period it is impossible, in the majority of cases, for the physician to predict, with anything like certainty, whether the case may culminate in acute melancholia or acute mania. But as it progresses the irritability and restlessness which ushered in the malady become intensified ; sleep is either irregular or may be lost for nights together; further degeneration of the brain constituents necessarily follows, and the loss of controlling power over ideas is manifested in excitement in one of two ways(1) by the domination of one set of ideas, which are for the most part of a depressed character, or (2) by a tendency to follow lines of thought suggested by accidental external circumstances. Although in the one case there is a concentration and in the other a diffusion of ideas, there is the common result of occlusion of the individual from a normal process of thought, inconsequence of his inability to review external circumstances correctly.
1. Acute Idiopathic Melancholia presents itself in three degrees of intensity:(1) simple depression of feeling, (2) depression of feeling with delusion, (3) depression of feeling with mania or delirium. The second and third of these conditions may supervene on the first, or any one of them may singly characterize the case.
Simple Depression of Feeling.In no form of insanity is the sane mind more prone to project a psychological scheme of causation than in that of which simple depression of feeling is the predominant symptom. The restlessness and irritability which accompany anxiety, grief, and worry, and the consequent exhaustion and depression, suggest a psychological continuity. There is, however, a very dis-tinct difference between depression of feeling within the limits of health and the depression of feeling resulting from morbid processes going on in the brain, and in symptoms there is a distinct line of demarcation. A mere fit of depression, from whatever cause, does not prevent a man from using his intellectual faculties; circumstances influence him, and he can review his position; but where the limit of health is passed the normal influence of external circum-stances is lost. This indication is accompanied by a gloomy apathy; the memory of the past is misery, the present is unendurable, and there is no hope in the future; everything is black within and without, every incident feeds the melancholy, every suggestion of hope is parried, and every appeal to the reason falls dead on the ear of the sufferer. This latter symptomthe inoperativeness of appeals to the reasonis a feature of all forms of insanity, and it is therefore well to notice it particularly when treating of the simplest. What to the sane mind is the simplest proposi-tion, to the insane appears either utterly false in itself, or to have no bearing on the position. The power of comparing idea with idea, the faculty of discriminating their differences, or the perception of agreement in the midst of difference is lostin a word, the judgment is impaired or utterly in abeyance. The common everyday expression " out of his judgment," employed to indicate that a man is insane, is psychologically accurate, and logically applicable in all forms of insanity. A strong tendency to suicide frequently presents itself; the utmost ingenuity is exercised to accomplish this object, the whole mental energies being concentrated upon it. It is impos-sible to render in terms the general as well as facial expression of the melancholic ; it cannot be simulated with success before any one conversant with the condition.
Depression of Feeling with Delusion.-Idiopathic melancholia symptomatized by simple depression of feeling may become gradually complicated with delusion and hallucination, or this complicated condition may follow immediately on the initial symptoms. The delusions and hallucinations of idiopathic melancholia may be divided into three classes :_(1) those traceable to perverted sensation produced by implication of the functions of the general system; (2) those apparently dependent on the nature of the primary causating train of emotion; and (3) those which it is impossible to connect with any particular influ-ence, either psychical or somatic. The first class contains the delusional symptoms resultant on atony of the alimentary canal, which, by producing obstinate constipation, catarrhal affections of the stomach and bowels, and dyspepsia, cause sensations which are referred by the insane mind to supernatural influences: he believes that he has serpents or worms inside him, that his gullet is closed, or that his bowels are so obstructed as to render relief by the natural passage impossible. As a direct result of this delusion food is systematically refused, and it often becomes necessary to resort to artificial feeding by the stomach-pump or some allied apparatus. Hallucinations and illusions of smell and taste may be referred to the same causes as the delusions just spoken of : the foetor of the breath due to dyspepsia may suggest to the melancholic that he is surrounded by a poisonous atmosphere, and that everything near him stinks; and the foul tongue of the same condition may be productive of hallucinations of taste, and may even lead up to the very common delusion that his food is poisoned. Such distinct objective starting points, however, do not suggest themselves for hallucinations of vision and hearing ; these can only be regarded as incidental results of the morbid cerebral con-dition of which the process of production is unknown. Hallucinations of sight are comparatively rare ; when they do occur it is generally in the form of spectres, which prompt to suicide, self-mutilation, or homicide. Hallu-cinations of hearing are more common, and are believed to be of graver import. As a rule the hallucination takes the form of words emanating from a something or some one of whose personality the patient has no conception. That an apparent connexion can often be traced between the character of the delusion and that of the primary causating emotion is particularly true of the melancholic delusions which follow on religious emotionalism, so much so that many writers regard religious melancholia as a distinct form of insanity. This is a term, however, very loosely employed, and it is, in fact, by no means easy to ascertain what it implies ; by one section of authors it is regarded as that form of melancholia in which the insanity centres upon religious ideas, by another as the form of insanity produced by depressing religious emotion. The latter position is tenable on purely clinical considerations, if the insanity retains the character of the causating emotion, which it very frequently does not; the former is open to the objection that the delusions may be mere accidents in a case, and may bear no relation whatever to the exciting psychical cause. One reason why the term is so strongly impressed on the mind of the public is, that it may appear as pseudo-epidemic. The waves of religious emotionalism, which almost periodi-cally disturb society in the form of " revivals," are apt to produce explosion of psychical action in those members of the community predisposed to nervous degradation. The public never considers, in fact does not know, that any other equally potent cause of emotion might be as effectual, and therefore sets down such accidental congeries of cases as " religious melancholia," accepting that term as representing all the abnormal psychical conditions which may result from "revivals." It is better to consider religious influences in the common category of emotions producing over-excitation of the brain. The deep despondency which follows on religious emotionalism may be productive of such pre-dominating ideas as that the soul is irretrievably lost, that the unpardonable sin has been committed, and that there is no hope of salvation. Although in the abstract it is open to question whether such predominating ideas are strictly delusions, inasmuch as they may be considered as morbid exacerbations of fears and anxieties suggested by certain schools of religious thought, still in the concrete they amount to delusion; for, even supposing they have been arrived at by a normal process of reasoningwhich in most cases is extremely doubtfulthey are maintained at the expense of all other religious considerations, and by the exclusion of all arguments founded on the experience of others.
The delusions which it is impossible to connect with any particular physical or psychical influence are for the most part characterized by suspicion and fear, and take such forms in the mind of the patient as that spies surround him, that all his actions are watched, that all connected with him are plotting against him, that conspiracies are being organized with a view to deprive him of his estate, procure his ruin, or do him some evil of which he can give no definite explanation. Occasionally delusions of fear and suspicion are connected with persons whom the patient has never seen, or with sections of society, such as political parties or religious communions. Self-accusation of serious crime is a frequent result of delusion. This idea of crime may be entirely unsubstantial, or it may possess some very slight foundation in fact, one which has no rational bearing on the existing position. When insane self-accusations are critically examined, it is found that remorse is very rarely connected with the real or imaginary crimes, from the consequences of which others have or might have suffered. The poetic stories of insanity produced by remorse of con-science for crimes involving the ruin or disgrace of others than the actual offenders may be set down as in the main apocryphal.
The delusions of the melancholic are often fearfully intense, and produce very serious results in action; they are apt to extend beyond himself. By a process of reason-ing which the sane mind cannot appreciate, he may argue himself into the belief that his misery is also the misery oi his friends and family, that his relatives are cognizant of or implicated in his imaginary crimes, and that they must suffer the consequences along with him. As death offers to him the only chance of relief, so he believes it best that those nearest and dearest to him should die also. From this state of feeling follow those fearful acts of homicide which occasionally startle societya parent destroys several of his children, a lover his mistress, or a husband his wife, before committing self-destruction. It is as well to attract attention here to the appearance of a tendency to homicide and suicide as an incident in a case, as the subject will have to be recurred to when adverting to the question of homicidal and suicidal insanity.
Depression of Feeling associated with Delirium or Mania.In this class of cases it is impossible to say whether they should be called melancholic mania or maniacal melancholia. The wildest delirious excitement coexists with the deepest depression of feeling; delusions of fear and horror are given expression to in the most extravagant manner, and relief from them is sought in frantic attempts at suicide; the patient dashes his head against the floor or wall, tries to cast himself down stairs, holds his breath in the hope that he may suffocate. In this condition there is a strong tendency towards death, which not unfrequently occurs within a few days of the develop-ment of the graver symptoms, and which is generally produced by congestion of the lungs as a direct result of the cerebral condition, i.e., by a true cerebral pneumonia.
2. Acute Idiopathic Mania presents itself in three forms (1) simple exaltation of feeling, (2) exaltation of feeling with delusion, (3) acute delirious mania. The second and third of these psychical conditions may supervene on the first, or any one of them may singly characterize a case ; in all, the period of transition from the prodromal stage is much more rapid than in acute idiopathic melancholia.
Simple exaltation of feeling manifests itself in all de-grees of intensity between mild general excitement and the extreme forms of maniacal furor; in kind it may not amount to more than a decided increase of the initial symptoms of restlessness, irritability, and change of dis-position ; in degree it is characterized by greater or less excitement of thought, word, and action. The general vague restlessness and irritability of the prodromal period not only become exacerbated, but manifest a tendency to produce results in action. Excited action may show itself either in a general exaltation or in the suspension of normal trains of thought. A prominent example of the first psychical condition is found in the naturally devout mind under certain conditions of excitement: the habitually religious man may have meditated on schemes for self-conduct, the good of mankind, or the spread of religion, schemes which, so long as mental action was under control, were mere projects, things to be hoped for, but which under morbid excitement assert themselves so powerfully as to be regarded by the unbalanced mind as immediate necessities, to be procured at the expense of all considerations. The real distinction of religious mania from religious enthusiastic excitement consists, not in the form of the ideas, for which parallel cases might be found in sanity and insanity, but in the per saltum manner in which it is sought to carry them into action, in the leaving out of those links which the sane mind uses to decide on the adoption or rejection of a scheme, but the omission of which transfers the scheme suddenly from the region of imagina-tion and hope to one of present reality. There is an absence of religious totality; the patient is bound up in some scheme for the advancement of religious knowledge, in some project for the building of a church, the founding of a school, the establishing of a mission, or, more probably, for all at once; for this he neglects his family, all social considerations, and those duties which are the precepts of his faith. Whether the apparently efficient cause be religion, politics, or the prominent social question of the day, the results are identical, being only conditioned by the nature of the original idea. The ordinary behaviour of the man is changed ; he is ever on the move ; his gestures, loud tone of voice, volubility of talk, and general manner are such as to cause his friends distinctly to mark the change. A large proportion of such cases recover under appropriate treat-ment, but they not unfrequently pass into acute delirious mania. When the disease is manifested by the suspension of the ordinary trains of thought, the symptoms consist, for the most part, in recklessness of action and conversation; there is a sort of exalted joyousness, a strong tendency to dissipation, loud and wild though not necessarily incoherent talk, extreme restlessness, and utter want of respect for all conventionalities. Such patients (reputable members of society, be it remembered, a month or a week before) outrage all sense of decency; they may walk the street with strumpets, and appear drunk in public, forcing their be-haviour on the notice of the police. They care nothing for the feelings of friends or the prospects of their families. The intellectual faculties may be active; thus wit and humour, uncontrolled by any feelings of consideration for others, may stand out all the more prominently. The condition, taken over all, is very closely allied to that stage of intoxication in which the poison of alcohol sets free all controlling influences. When the restraining power of association is lost, there is no difficulty in comprehending that the uncon-trolled brain may act in any direction. This class of cases is specially emphasized, because they are apt to be mistaken by the public for instances of mere moral obliquity.
The relation of amount of mental disturbance to the degree of excitement is not definable; mania may be extreme, and the disturbance of ideas apparently slight, and vice versa. It is of great importance that the two following facts should be insisted on(1) that mania of an extreme description can exist without delusion; and (2) that mania of a dangerous nature may exist without furious excitement. It is in this class of mania that cases of so-called folie raisonnante are for the most part met witha class strongly insisted on by many Continental authorities as of great pathological importance. By one section of foreign writers it is spoken of as folie raisonnante, by another under the original name suggested by Pinel mania sine delirio, while by a third both are used promiscuously to indicate a class of cases in which, although considerable disturbance and excitement may exist, the sufferer is able to justify his course of action by a line of reasoning not illogical in itself, although founded on false premises.
Exaltation of feeling with delusion or delusional mania, whether it follows on a period of simple exaltation of feel-ing, or is coexistent with the first symptoms of excitement, is not to be connected with the originating psychical cause ; indeed the intellectual confusion is so great and of such a kind as to render any analysis impossible. It is well to mark here the psychological difference between maniacal and melancholic delusions; the latter are persistent in character and appear to proceed from within, the former are changeful and are readily acted on from without. The general expansiveness of ideas, the rapidity with which they are produced and influenced by external objects, along with the inability to correlate idea with idea, are productive of incoherence in thought, word, and action. For instance, a man may imagine and state that he is the king of the universe, at the same time that he enters no remonstrance against herding and eating with his fellow paupers ; he may assert his superiority, but may not object to obey the behests of a common keeper.
Aeide delirious mania is a condition often rapidly produced and not unfrequently fatal. It may be the culmination of a case which has passed through the stages of simple exaltation of feeling and mania with delusiono the latter rarely; or it may appear in a few days or even a few hours as the result of some severe mental shock. It may persist for only a short time, and is then spoken of as acute transitory mania. The symptoms are very definite, the wildest yells and screams, a frenzied rushing to and fro, a reckless casting of the body on the ground or against the walls and furniture, smashing everything that comes in the way without any definite purpose save smashing, flushed features, clammy sweat, and a high bounding rapid pulse; nothing can control the patient but physical force, for his fury renders him blind to all influences.
3. Acute Primary Dementia.This disease is of rapid incidence. It may result from sudden psychical disturbance, especially fright; occasionally no cause can be traced. After a few days or hours, during which the patient is somewhat stupid and apathetic, these symptoms increase to such a degree as to cause him to be, to all outward appearance, utterly demented; he sits unaffected by anything that goes on around him; he is completely helpless, cannot take off or put on his clothes nor feed himself, and passes urine and faeces where he sits or stands ; he is speechless, and cannot be roused to action by any appeal; his movements are slow, when he can be got to move at all; but the chief motor symijtorn is a degree of catalepsy. It may be said with truth that the condition is one of mental and bodily catalepsy. Such cases to the ordinary observer appear utterly hopeless. There is a strong tendency towards death; but, when this is overcome, it often happens that the sufferer gradually emerges from the condi-tion, and can give an account of the sensations experienced during his illness. It may terminate in dementia of a very low type. Post-mortem examination of recent cases fre-quently reveals dropsy of the brain, or changes in inter-stitial tissues producing pressure. (See Blandford, Insanity and its Treatment; Bucknill and Tuke, Psychological Medicine; Griesinger, On Mental Diseases.)
4. General Paralysis of the Insane.General paresis, progressive paralytic dementia, or, as it is more frequently spoken of, general paralysis, is a disease of the superior and lateral convolutions of the brain, which gradually extends over the whole nervous system, producing a peculiar impairment of motor power, and invariably accompanied by insanity. It is marked by well-defined series of physical and psychical symptoms, and terminates in a peculiar manner within a definite period.
General paralysis was first recognized as a special disease in France; it was indicated by Esquirol, and its history was fairly elucidated by Bayle, Delaye, and Calmeil, the latter giving it the name of paralysie generale des alienes. General paralysis is a common disease, and is generally spoken of as " softening of the brain," a term diametrically opposed to its pathological anatomy. The condition is essentially a chronic diffuse subinflammatory overgrowth of the connective tissue of the cerebral hemispheres, leading to destruction of the true nerve elements, and principally affecting that region of the brain in which recent observers have localized the cortical motor centres. General paralysis is said to be a disease of middle life; this is to a certain extent true, for, in the large majority of cases, its incidence occurs between the ages of thirty-five and fifty; ft is, however, met with prior to the first-mentioned age, less frequently after the latter period of life. Statistics show that the decade between forty and fifty is the one during which the disease is most likely to occur. Men are more subject to it than women, in the proportion of, at least, eight to one; in women the symptoms are less strongly pronounced, and the disease runs its course more slowly. Although the relative frequency of the disease appears to be equal in the higher and lower classes of society, statistics show that the town artisan is more liable to it than the agricultural labourer. In the lower grades of society general paralysis is much more common in England than in Scotland or Ireland ; in certain English asylums general paralytics constitute from a sixth to an eighth of the inmates, whilst in Scotch and Irish district asylums the proportion does not amount to more then 2 or 3 per cent.
The progressive character of the disease is marked by three stages, termed the prodromal, the acute, and the ter-minative. The prodromal stage is marked by a somewhat incongruous congeries of mental symptoms, consisting of total change in the habits and disposition, general restless-ness and irritability, impairment of memory, extravagance in thought and action, and a peculiar facility closely followed by, or intercurrent with, the bodily symptoms of impaired mobility of the face and tongue. For the purposes of diagnosis the physical are more important than the mental phenomena. As a rule the bouleversement of disposition is peculiarly well marked; the impairment of memory consists, not only in the blurring and confusion of past events, but in the forgetting of the occurrence of one minute in the next,purposes formed and intentions expressed are forgotten almost as soon as formed and expressed. This want of fixity is also shown by the non-recognition of the lapse of time, and by the manner in which violent passion is suddenly changed into amiability. To the same cause may probably be traced the peculiar facility of disposition of the general paralytic ; even at this early stage there are indications of the optimism which, as the case progresses, affords the characteristic psychical symptom. In the prodromal period it is manifested by a degree of morbid vanity, general exaltation, and a tendency to regard all things in the brightest possible light. The physical symptoms consist in a finely fibrillar action of the muscles of the tongue, twitching of the upper lip, hesitancy of speech, and a loss of facial expression; the tongue symptom consists of a rapid agitation of its surface, the voluntary movements of the whole organ not being entirely under control, e.g., it is protruded with a jerk; the upper lip hangs and trembles before utterance like that of one struggling against weeping; the hesitancy of speech can best be illustrated by saying that it is identical with the slurring of words in the first stage of intoxication,the patient "speaks thick;" the face assumes a mask-like want of expressionthe muscular power being impaired to such a degree as to cause change of expression to be a compara-tively slow process. As the disease advances there is greater excitability, and the general exaltation of ideas becomes so great as to lead the patient to the commission of insanely extravagant actions, such as purchases of large numbers of useless articles, or of lands and houses far beyond his means, numerous indiscriminate proposals of marriage, the suggestion of utterly absurd commercial schemes, or attempts at feats utterly beyond his physical powers. Not unfrequently he is found committing theftuous acts. The acute period is frequently ushered in by maniacal symptoms which generally assume the type of what is termed by French writers d'elire ambitieux. Delu-sion of the wildest character may now present itself; the patient may believe himself to be in possession of millions of money, to be unsurpassed in strength and agility, to be a great and overruling genius, and the recipient of the highest honours. Every idea is expanded and exalted, whether it relates to time, space, or personal attributes. Although grandiose and extravagant delusion is very frequent, existing as it does in about one-half of all cases, it is by no means such a persistent symptom as the bien être, which condition is the diagnostic of the disease in that it is invariably present. This is shown by perfect contentment with himself and all things around him, by the constant use of superlatives and such expressions as "all right," "splendid," "first rate"; he speaks of his health as robust, "never better in my life," even when there is grave constitutional disturbance ; he is unaffected by the death of child, or wife, or nearest friend. He is utterly unsuspicious, lost to all appreciation of social relations, and facile in the extreme. Synchronously with this condition, the physical symptoms become exacerbated ; the tongue and facial symptoms already spoken of increase in intensity, and in addition impairments of the motor powers of the extremities present themselves, consisting in a loss of co-ordinating power, not in a loss of muscular strength. Thus the gait becomes straddled and uncertain ; there is a widening of the basis of support ; he has to pick his steps as he goes up and down stairs, and is apt to trip over small obstacles ; the action of walking resembles that of a half-drunk man. Later on the arms become involved. The pupils are often irregular. The third or terminative stage is marked by " epileptiform " or more properly apoplectiform attacks, the general condition becoming more and more degraded. By this time the patient is almost bedridden ; actual palsy often occurs. Towards the end certain of the semivoluntary muscles are affected ; bed-sores may form ; and he may die slowly of exhaustion or suddenly during an apoplectiform attack. General paralysis runs its course in from one to four years ; more rapid and more protracted cases are on record, but, taken over all, eighteen months may be stated as its average duration. The disease is incurable.
II. TRAUMATIC INSANITY.Generally speaking, insanity is not developed for some months or even years after receipt of the injury, but in the interval the patient suffers from headache, more especially after mental effort, irascibility of temper, confusion of thought, and consequent inaptitude for business, weakened memory, and a constant feeling of fatigue. If this condition is not overcome, a progressive dementia sets in, of which the special character is violence of temper, and a tendency to impulsive action. This dementia is generally complicated with maniacal attacks intervening at uncertain periods and marked by furor or violence. Dipsomania or insane drinking is a not very uncommon result, apart from all other indications of aberration. Prognosis is unfavourable.
III. INSANITY ASSOCIATED WITH OTHER NEUROSES.Epileptic Insanity.In the intervals between the fits the patient is generally stupid and dull of apprehension. Immediately before or after fits, or, as some believe, occasionally taking their place, mania of a violent and furious, of a subacute, or of an ecstatic character presents itself. All authorities recognize epileptic insanity as the form most dangerous to the public. Prognosis is unfavourable. Hysterical Insanity.The symptoms described in the article HYSTERIA may become so exacerbated as to amount to insanity. Superadded to these may be delusions of a sexual nature. The most extreme form of mental disturbance supervening on hysteria is acute mania of a very violent character ; it is generally of a delirious nature, but does not usually continue for any great length of time. It is open to question whether the " fasting girls " and women with " stigmata " should not be included among the hysterically insane. Men, although very rarely, are liable to this form of insanity. In a sense the prognosis is favourable, inasmuch as prolonged treatment procures great abatement of symptoms, if not actual recovery. Insanity occurring with locomotor ataxy strongly resembles general paralysis. Taken over all, it may be stated that the symptoms differ more in degree than in kind, not being so intense. There is not the same extravagance of delusion or violence of mania.
IV. INSANITY FROM THE PRESENCE OF ADVENTITIOUS PRODUCTS is marked by progressive dementia of a dull heavy character and the absence of delusion. Prognosis is unfavourable.
V. INSANITIES ASSOCIATED WITH MORBID CONDITIONS OF THE GENERAL SYSTEM.-Phthisical insanity is stated to be characterized by a short period of mania, melancholia, or delusion, which soon passes into a mixture of subacute mania and dementia. The symptom, according to Clouston, is a tendency to be suspicious. (Consult Clouston, "Tuberculosis and Insanity," Journ. of Mental Science, April 1863.) Rheumatic insanity is characterized by hallucinations of sight, touch, and taste, loss of memory, acute delirium succeeded by confusion of ideas and sluggishness of mind, accompanied by choreic movements of the limbs, deadening of reflex action, and even paralysis. These symptoms appear as the articular affection diminishes or disappears; they are, as it were, one vicarious of the other. Prognosis is favourable. (See Griesinger On Mental Diseases, p. 189 ; Clouston, Journ. of Mental Science, July 1870; Sibson, in Reynold's System of Medicine, vol. iv. p. 286.) In gouty insanity the alternation of the joint and head symptoms is also well marked. The latter are general mania with delusions of suspicion. Prognosis favourable. (Vide Berthier, Annates Medico-Psychologiques, 1869. Sydenham also alludes to the condition.) Syphilitic insanity frequently commences with acutely maniacal symptoms, shortly followed'by hypochondriasis of marked character, paralysis of energy, and rapid progressive dementia. Extravagant delusions often present themselves
so strongly as to render the diagnosis between this condition and general paralysis difficult. Prognosis unfavourable. (The most important paper on this form of insanity is by Mickle, Brit, and 'For. Medico-Chirnrgical Review, July and October 1876.) In ansemic insanity, however produced, the general train of symptoms is violent mania of short continuance followed by melancholic dementia. Prognosis favourable.
VI. INSANITIES OCCURRING AT EVOLUTIONAL PERIODS OF LIFE.Insanity of pubescence and adolescence is manifested by various trains of symptoms. Acute mania is on the whole the most common : it is characterized by motor restlessness; the patient walks, talks, smokes, drinks, must ever be on the move. Where self-abuse comes in as a factor, the sufferer is melancholic and suspicious, self-accusing. Dipsomania is a not unfrequent symptom. But whatever may be the general symptoms of these three sets of patients, they have one common symptom, a perversion or increase of the sexual instinct. Prognosis is favourable as regards the attack present, unfavourable as to the probability of recurrence. Climacteric insanity, which is nearly as common in men as in women, is marked by pretty constant symptoms of a melancholic character. Prognosis generally favourable. Senile insanity is symptomatized by dementia with frequent intercurrent attacks of mania. Prognosis unfavourable. The most frequent symptoms of the insanity of pregnancy are melancholy and moral perversion, the latter taking the form of dipsomania. Puerperal insanity shows itself during the first seventeen days after labour, and is of sudden incidence ; the mental symptom is acute delirious mania. Prognosis is favourable in this, as in the insanity of pregnancy. (Vide J. Batty Tuke, " On Puer-peral Insanity," Edin. Med. Journ., May 1865 and June 1867.)
VII. TOXIC INSANITY.Insanity of alcoholism in the acute form may be marked by acute mania of a transient nature, mania a potu; by melancholia, frequently accom-panied by delusions and hallucinations of a frightful character; in the chronic, by a type of dementia frequently simulating general paralysis. Prognosis of the acute form favourable, in the chronic the reverse.
In employing the above classification it must be clearly borne in mind that the term of the symptom should, whenever possible, be appended to the pathogenetic term ; thus, puerperal mania, climacteric melancholia, senile dementia, acute idiopathic mania, epileptic mania, &c. If the terms are combined, the nature of the disease and its general psychical characteristics are expressed in terse language.
It will be noted that no separate notice has been taken of such popular terms as homicidal or suicidal insanity. They in no wise indicate a class of the insane; they are symptoms common to many insanities, especially to epi-leptic, traumatic, puerperal, and idiopathic insanity, and as such must be regarded as incidents in a given case-
Terminations of Acquired Insanity.
Insanity terminates in recovery, in death, or in chronic mania or chronic dementia. Accurate statistics of the two first-named terminations are unattainable, as a large number of patients are treated at home ; and asylum statistics do not therefore show the result overhead, only that of the more aggravated cases. The result of treatment in lunatic hospitals gives about 40 per cent., calculated on the admis-sions, which, however, include idiocy, chronic terminative insanity, and such acknowledged incurable forms of the disease as general paralysis. This figure does not of course represent the results of treatment of all the insanities, which, although there are no figures at command to support the assertion, may be fairly estimated at not less than 70 per cent., excluding idiocy. There is a general tendency of all insanities to shorten life; as already noted, some are in themselves fatal, or render their subjects less able to withstand disease. Asylum statistics show from 7 to 8 per cent, per annum as the average mortality calculated on the numbers resident.
It is needless to attempt a description of the various phases of chronic terminative dementia and mania. De-lusion may continue, or the patient may become more or less sottish and degraded in habits; or, on the other hand, he may retain a considerable amount of mental power, still not sufficient to render him a responsible member of society. The great mass of the inmates of asylums belong to this class of lunatics, mostly harmless, yet precluded from mixing with the world as much for the convenience and safety of society as for their own benefit. A small proportion are detained on account of their liability to suffer from recurrence of attacks of insanity, although they are not actually insane during the intervals. To this condition foreign authorities have applied the term folie circulaire, and some have asserted that it is the characteristic of certain cases db initio. It is mostly confined to persons strongly hereditarily predisposed. The term explains itself : after intervals of comparative sanity, the patient manifests symptoms which run their course through the prodromal, the acute, and the demented stages, on again to recovery, in manner similar to a recent case.
In speaking of the treatment of the insanities, it will simplify matters to eliminate, in the first place, those forms of the disease which are not amenable to remedial agents in the present state of medical knowledge. Medicine, whether hygienic or therapeutic, cannot touch general paralysis, the insanity produced by adventitious products, or senile insanity, except in the reduction of intensity of symptoms. Traumatic insanity is for the most part hopeless ; it is probable that sufficient attention has not been directed to surgical measures in such cases.
In the insanities due to morbid conditions of the general system, in those associated with other neuroses, and in toxic insanity, the physician attacks the head symptoms through treatment of the causating factor. It is true that in these forms symptoms have to be attacked directly, but ultimate cure is to be looked for through treatment of the diathetic condition. It is rare, and then only in the earlier stages of the initial symptoms, that the progress of these diseases is cut short by therapeutic measures, inasmuch as they seldom come under the cognizance of the physician at that period. The exception to this statement is to be found in the case of puerperal insanity, where the patient is very generally under immediate medical supervision; in her case, therefore, the prodromal indications are often observed, and the disease arrested by the timely administration of drugs. But in the great mass of cases the last idea which occurs to the minds of friends is the possibility of impend-ing insanity, and it is not till the disease has considerably advanced that the fact is recognized and the physician called in. When he has the opportunity of applying his art during the initial stages, he directs his attention to the procuring of sleep by means of opium and other narcotics, the bromides of potash and ammonium and chloral hydrate, and by rectifying the disorders of the digestive system. But when the disease has reached the congestive stage the treat-ment becomes for the most part expectant, as it does in analogous complaiuts of other systems. " Change of scene " is often adopted, and properly so in the very earliest stages ; but when the disease is confirmed it is much more apt to aggravate the condition, fatigue and excitement only fan-ning the flame; it is much the same as if a man with a congested lung were asked to walk a mile uphill, in the hope that he would breathe more freely at the top. Till within the last few years treatment by bleeding, cupping, and blistering, shaving the head, and cold applications, was much in vogue. In asylums of the present day a shaved head is never seen. It was likewise the custom to administer large doses of sedatives. The system of treat-ment which now generally obtains is almost purely hygienic. Opiates are much less used, and are to be deprecated in those forms characterized by excitement; in idiopathic and climacteric melancholia, however, they often produce good results. General constitutional treatment is what is usually adopted. In such forms as idiopathic mania and melan-cholia, the mania of adolescence, puerperal mania, and climacteric melancholia, the disease, like many others, runs its course, not very materially affected by remedial agents apart from those applied to the maintenance of the system, and its cure is similarly dependent on rest and nursing. And the main question concerning treatment is, Where are these best to be obtained 1 In the case of the poor there is no alternative, even in comparatively mild cases, but to send the patient to an asylum. In the case of the rich it resolves itself very much into a question of convenience, for, with plenty of money at command, the physician can convert any house into an asylum. But under ordinary circumstances, when the patient is violent, noisy, suicidal, homicidal, or offensive to society, it becomes necessary to seclude him, both for the purposes of cure and for the safety and comfort of the family. Except amongst the very affluent, treatment at home is for the most part unsatisfactory; it is very generally tried, but breaks down under the constant strain to which the friends are sub-jected. In a well-ordered hospital for the insane there is every possible appliance for treatment, with trained nurses who are under constant supervision; and it therefore affords the best chance of recovery.
History.The history of the treatment of insanity has been stated to be divisible into three epochsthe barbaric, the humane, and the remedial. But this does not take into account the very highly humane and probably highly remedial system of treatment which obtained in very ancient times. In Egypt the temples of Saturn, and in Greece the Asclepia, were resorted to by lunatics, and the treatment there adopted was identical in principle with that of the present day. The directions given by all the classical medical authors, and especially Hippocrates and Galen, are of the soundest character. How long their influence existed it is difficult to say, but in the Middle Ages, and up to the middle of the last century, little attention was paid to the care or cure of the insane. A small proportion were received into monastic houses or immured in common jails. In 1537 a house in Bishopsgate Street, London, fell into the possession of the corporation, and was appropriated for the reception of fifty lunatics. This, the first Bethlehem Hospital or Bedlam, was removed in 1675 to Moorfields, and in 1814 the present hospital in St George's Fields was erected. St Luke's was instituted in 1751. Bedlams or houses of detention for lunatics appear to have existed in other cities, but, with these exceptions, no provision was made for the insane, who were allowed to wander at large. There is good reason for believing that many were executed as criminals or witches. About 1750 the condition of the insane at-tracted some amount of public attention, and the incarceration in madhouses of a considerably larger number than formerly followed, not on account of any philanthropic sympathy with their condition, but as a measure demanded for the public safety and comfort. But this measure by no means brought about the termination of the barbaric period. The houses, misnamed asylums, were in the hands of private parties, under little or no supervision, and were in fact merely prisons of the very worst description. The unhappy inmates were immured in cells, chained to the walls, flogged, starved, and not unfrequently killed. It is almost impossible to believe that this condition of matters existed far on into the present century. According to Conolly, "there is clear proof of the continued existence of these abuses in 1827 ; and it cannot be denied that not a few of them survived in some public and private asylums in 1850." Matters were no better in France when Pinel was appointed in 1792 to the charge of the Bicetre, the great hospital of Paris for male lunatics. In that establish-ment, and in the Salpetriere, the condition of the inmates was as degraded as in the British madhouses. This great philanthropist adopted the bold step of striking off the chains and other engines of restraint from those under his care. About the same time, the most gross abuses having been brought to light in connexion with the management of the city of York asylum, William Tuke, a member of the Society of Friends, was mainly active in instituting the York Retreat for the care and cure of insane members of that sect. This real asylum was conducted on non-restraint principles. The names of Pinel and Tuke are indissolubly connected with the history of the humane treatment of the insane, and to their efforts must be ascribed the awakening not only of the public but of the medical profession to the true principles of management. It took, however, many years before the principles laid down by these men were universally adopted. In 1815 a committee of the House of Commons brought to light many gross abuses in Bethlehem Hospital, and it was not till 1836 that mechanical restraint was entirely abolished in an English public asylum. This took place at Lincoln, where Dr Gardiner Hill did away with all engines of restraint. Shortly afterwards Conolly adopted the same line of treatment at Hanwell, near London, and through the influence of his example and precept the measure extended over the whole of Great Britain. Experience has shown that, as restraint of all forms is abandoned, the management of lunatics becomes easier. Walled-in airing-courts, barred windows, and strong dark rooms have almost entirely disappeared, and in some Scotch asylums it is found practicable to discontinue the use of lock and key. It has been said that the type of insanity has changed within the last forty years ; it would be more true to say that the type of treatment has changed. It is much less common nowadays to meet with those extremely violent forms of madness which entered into the descriptions of many authors. With the reduction of restraint a higher order of supervision on the part of attendants is demanded, and as they are trained to rely more and more on the moral influence they can exercise over their charges, and less on mechanical apparatus, the patient is not so apt to resent control, and therefore a greater calm and contentment pervades the atmosphere of our asylum wards. This has been mistaken for a change in the type of the disease.
Statistics.The statistics of lunacy are merely of interest from a sociological point of view ; for under that term are comprised all forms of insanity. It is needless to produce tables illustrative of the relative numbers of lunatics in the various countries of Europe, the systems of registration being so unequal in their working as to afford no trustworthy basis of comparison. Even in Great Britain, where the systems are more perfect than in any other country, the tables published in the Blue Books of the three countries can only be regarded as approximately correct, the difficulty of registering all cases of lunacy being insuperable.
On the 1st January 1880, according to the returns made to the offices of the Commissioners in Lunacy, the numbers of lunatics stood thus on the registers :
== TABLE ==
These figures show the ratio of lunatics to 100,000 of the popula-tion to be 279 in England and Wales, 217 in Scotland, and 236 in Ireland.
The next table is of interest as bearing on the question of the alleged increase of lunacy as a disease. Similar returns are not available for Ireland.
Numbers of Lunatics on the 1st January of the Years 1858-80, inclusive, according to Returns made to the Offices of the Commis-sioners in Lunacy for England and Wales and Scotland.
== TABLE ==
There is thus an increased ratio in England and Wales of lunatics to the population (which in 1859 was 19,686,701, and in 1880 was estimated at 25,480,000) of 1867 per 100,000 as against 279'4, and in Scotland of 157 as against 217 per 100,000. The publication of these figures has naturally given rise to the question whether lunacy has actually become more prevalent during the last twenty years, whether there is real increase of the disease. There is a pretty general consent of all authorities that if there has been an increase it is but very slight, and that the apparent increase is due, first to the improved systems of registration instituted by the boards of lunacy, which have brought under their cognizance a mass of cases which were formerly neglected, '' who would not have been dealt with as paupers in 1858, but who are now dealt with as such, so as to obtain for them the advantage of accommodation in pauper asylums." Secondly, a further and far more powerful reason is to be found in the increasing tendency among all classes, and especially among the poorer class, to recognize the less pronounced forms of mental disorder as being of the nature of insanity, and requiring to be dealt with as such. Thirdly, the grant of four shillings per week which in 1876 was made by parliament from imperial sources for the maintenance of pauper lunatics has induced parochial authori-ties to regard as lunatics a large number of weak-minded paupers, and to force them into asylums in order to obtain the benefit of the grant and to relieve the rates. These views receive support from the fact that the increase of private patients, i.e., patients who are provided for out of their own funds or those of the family, ha? advanced in a vastly smaller ratio. In their case the increase, small as it is, can be accounted for by the growing disinclination on the part of the community to tolerate irregularities of conduct due to mental disease, and the consequent relegation of its victims to asylums for the sake of family convenience. And again, careful inquiry has failed to show a proportional increase of admissions into asylums of such well-marked forms as general paralysis, puerperal mania, &c. The main cause of the registered increase of lunatics is thus to be sought for in improved registration, and parochial and family convenience. If there is an actual increase, and there is reason for believing that there is a slight actual increase, it is due to the tendency of the population to gravitate towards towns and cities, where the conditions of health are inferior to those of rural life, and where there is therefore a greater disposition to disease of all kinds.
Bibliography.The following are systematic works :Bucknill and Tuke, Psychological Medicine, 4th edition, 1879 ; Blandford, Insanity and its Treatment, 1877 ; Griesinger, On Mental Diseases, New Sydenham Society, 1867 ; Maudsley, The Pathology of Mind, 1879. Conolly, On the Treatment of the Insane, 1856, bears chiefly on asylum management. Every question connected with lunacy will be found discussed in the Journal of Mental Science, to the first twenty-four volumes of which a general index has been prepared by Dr Fielding Blandford, 1879. The works of Pinel and Esquirol are well worthy of attention. Consult also Krafft-Ebing, Lehrbuch der Psychiatrie, Stuttgart, 1879, and Dr Heinrich Schüle, Hand-
buch der Geisteskrankheitcn, the latter being the sixteenth volume of Von Ziemssen's Handbuch der speciellen Pathologie und Therapie, Leipsic, 1878. (J. B. T.)
The effect of insanity upon responsibility and civil capacity has been recognized at an early period in every system of law. In the Roman jurisprudence its con-sequences were very fully developed, and the provisions and terminology of that system have largely affected the subsequent legal treatment of the subject. Its leading principles were simple and well marked. The insane person having no intelligent will, and being thus incapable of consent or voluntary action, could acquire no right and incur no responsibility by his own acts; his person and property were placed after inquiry by the magistrate under the control of a curator. The different terms by which the insane were known, such as clemens, furiosus, fatuus, although no doubt signifying different types of insanity, did not infer any difference of legal treatment. They were popular names which were used somewhat indifferently, but which all denoted the complete deprivation of reason. During the Middle Ages the insane were but little protected or regarded by law. Their legal acts were annulled, and their property placed under control, but little or no attempt was made to supervise their personal treatment. In England the wardship of idiots and lunatics, which was annexed before the reign of Edward II. to the king's prerogative, had regard chiefly to the control of their lands and estates, and was only gradually elaborated into the systematic control of their person and property now exercised in chancery. Those whose means were insignifi-cant were left to the care of their relations or to charity. In criminal law the plea of insanity was unavailing except in extreme cases. About the beginning of this century a very considerable change commenced. The public attention was very strongly attracted to the miserable condition of the insane who were incarcerated in asylums without any efficient check or inspection; and at the same time the medical knowledge of insanity entered on a new phase. The possibility and advantages of a better treatment of insanity were illustrated by eminent physicians both in France and England ; its physical origin became generally accepted-, its mental phenomena were more carefully observed, and its relation was established to other mental conditions which had not hitherto been regarded as insane in the proper sense of the word. From this period we date the commencement of legislation such as that known in England as the Lunacy Acts, which aimed at the regulation and control of all constraint applied to the insane. And at the same time we find the commencement of a new state of matters in the courts. Hitherto, the criteria of insanity had been very rude, and the evidence was generally of a loose and popular character; but, whenever it was fully recognized that insanity was a disease with which physicians who had studied the subject were peculiarly conversant, expert evidence obtained increased importance, and from this time became prominent in every case. The newer medical views of insanity were thus brought into contact with the old narrow conception of the law courts, and a controversy arose in the field of criminal law which in England, at least, is not yet settled.
The fact of insanity may operate in law(1) by exclud-ing responsibility for crime; (2) by invalidating legal acts ; (3) by affording ground for depriving the insane person by a iegal process of the control of his person and property ; or (4) by affording ground for putting him under restraint.
1. Responsibility for crime may be destroyed by insanity. The theory of the limitations under which this plea is recognized by English law is first clearly stated by Hale (Pleas of the Crown, i. c. 2) in these terms : " When there is no will to commit an offence there can be no transgression, and, because the choice of the will presupposes an act of the understanding, it follows that when there is a total defect of the understanding there is no free act of the will in the choice of things or actions." This doctrine was closely followed by the courts, and in the subsequent cases we find nothing admitted in defence short of a total defect of the understanding. In later times, however, frequent attempts were made on the part of the defence to break through this stringent rule, and in 1843 the case of Macnaughten, which resulted in an acquittal, attracted so much public attention, and seemed to cast so much doubt on the law as previously understood, that a series of questions were put by the House of Lords to the judges with the view of determining conclusively how the law really stood. These answers practically affirmed the old law. They decided that, in order to establish a defence on the ground of insanity, " it must be clearly proved that at the time of the committing of the act the party accused was labouring under such a defect of reason from disease of the mind as not to know the nature and quality of the act he was doing, or if he did know it he did not know that he was doing wrong." These answers are now the ruling authority both in England and Scotland, although there have been undoubtedly many instances in which the defence of insanity has been sustained either through the judge abstaining from pressing the law very strictly or from the jury taking a wider view of the case. Frequently, also, a more lenient view has practically been given effect to by the intervention of the home secretary, many of the most puzzling cases having been disposed of in this way. When the prisoner is unable to plead or has been acquitted on the ground of insanity, the jury are obliged to state whether they find the prisoner to be insane, and in that case he is ordered to be detained during her majesty's pleasure ; and the home secretary has power to order him to be detained at such place as he may direct. Prisoners who become insane while in prison upon any form of legal process may also be removed by warrant of the home secretary to whatever asylum he thinks fit. All these are known technically as criminal lunatics, and an asylum has been provided for their detention at Broad-moor, from which they can only be discharged by warrant of the home secretary. (39 & 40 Geo. III. c. 94 ; 3 & 4 Vict. c. 54 ; 23 & 24 Vict. c. 65 ; 27 & 28 Vict. c. 29 ; 30 & 31 Vict. c. 12.)
The law thus clearly laid down by the courts has been strongly condemned by most medical authorities, who maintain that it is founded upon an ignorant and imperfect view of insanity. There can be no doubt that insanity does not wholly or even chiefly affect the will through the intellectual faculties. The disturbance of emotion and feeling is at least of equal consequence. We have cases where a criminal act seems to spring entirely from this source, and very many others where we have a complex of morbid intelligence and feeling which it is impossible to disentangle. In cases like those it is impossible by any analysis to separate the intellectual from the emotional phenomena, and to assess the amount of intelligence which, although morbid or defective, ought to be sufficient to restrain the equally morbid emotional condition. It seems clear that in judging of responsibility we ought to take the mental condition of the insane as a whole ; and the present view of the law seems to have originated partly from ignorance of the more obscure phenomena of insanity, and partly from the metaphysical conception of a will whose freedom is only limited by its intelligence. It must, however, be remembered, on the other hand, that the courts have had serious difficulties to encounter. The views of insanity and consequent irresponsibility presented to them in medical evidence were often so vague that they seemed capable of indefinite extension, and there is no subject on which the experts have appeared so much at variance with each other. But these difficulties, however much they may call for the watchfulness of the courts, seem no sufficient ground for limiting the effect of insanity in relation to responsibility to the intellectual faculties. Such a limitation seems opposed, not merely to our present knowledge of insanity, but to the experience of ordinary psychology. These controversies are not confined to England. In the United States the law may generally be said to be the same as that of England, but, as the judges have been by no means so tightly bound down as the English judges have been by the opinions in Macnaughten's considerable tendency has been shown in many (or indeed most) States to take a more liberal view of the question. In France the provision of the Code Napoléon, " il n'y a ni crime ni délit lorsque le prévenu était en état de démence," depends for its effect upon the interpretation given to the word démence, and for some time the tribunals were inclined to interpret it in such a manner as to make the law very much the same as that of England ; but the view of the physicians is now generally prevalent. In Germany the matter is dealt with in a section (§ 51,7?. 67.-3.) of the criminal code, which was the result of very careful discussion both by physicians and lawyers. It runs thus : " There is no criminal act when the actor at the time of the offence is in a state of unconsciousness or morbid dis-turbance of the mind, through which the free determination of his will is excluded."
2. In the case of all civil acts, the general rule is that capacity must be measured in relation to the act. The mere fact of insanity will not in itself make void a will, for example, if it appears that the testator had a fairly clear conception of the nature of his property and the objects of his bounty. But it is needless to say that the least appearance of insanity in the deed itself, or any appearance of fraud or undue persuasion on the part of any one, is immediately fatal to the deed. In the case of contracts an additional element is knowledge of the insanity by the other party. When the contract was entered into bona fide, and the insanity of the one party was not known to the other, the contract may not be set aside unless the parties can be exactly restored to their previous condition.
3. Both the property and person of the insane may be placed under control by a legal process. In England this right was early annexed to the prerogative of the crown, and is even yet in consequence not exercised by the ordinary courts, but by the lord chancellor and such other judges as may be entrusted with it by the sign manual. The procedure is now governed by the Lunacy Regulation Acts (16 & 17 Vict. c. 70; 18 Vict. c. 13; 25 & 26 Vict. c. 86). The question of insanity is tried before one of the masters in lunacy, either with or without a jury, according to circumstances. The terms of the inquiry arewhether the party is of unsound mind and incapable of managing himself and his affairs ; and on this being found his person and property are placed in charge of one or more persons called committees, whose administration is subject to the masters in lunacy, and through them to the chancellor. Persons thus found insane (technically known from the old form of procedure as lunatics so found by inquisition) are under the inspection of the board of chancery visitors, consisting of two medical men and a barrister, who are appointed to visit them at intervals. They are not subject to the provisions of the Lunacy Acts.
In Scotland the old procedure is by a brieve or writ from chancery, formerly tried before the judge ordinary and now before the lord president of the court of session. The nearest male agnate of twenty-five years of age is appointed tutor, but, latterly at least, is not entrusted with the per-sonal custody, the court, if necessary, selecting some one for the purpose, generally the nearest cognate. The procedure by brieves is now becoming infrequent. More generally application is made to the court of session to appoint a curator bonis to take charge of the estate, This procedure is in many ways simpler and more convenient, especially in the numerous cases which are unopposed, as the. court when they are satisfied that every person con-, cernerl has had due notice will grant the application on the certificate of two medical men. In America and on the Continent similar forms of procedure exist, which cannot be gone into in detail. In the United States the law is mostly, as is natural, derived from the English sources, but the procedure is regulated by statute in the different States. In many other countries, where the common law is based on Roman jurisprudence, the procedure seems to differ in many points from the English forms, but in substance the law on the subject has in nearly all countries reached very much the same results.
4. Insane persons (although not lunatics so found by inquisition) may be placed under personal restraint. At common law this power is limited to cases where the insane person is dangerous to himself or others, but in practice it used frequently to be exercised with little discretion and often with great barbarity. The care and restraint of the insane (other than that exercised by their friends and relatives in their own homes) is now strictly controlled by the Lunacy Acts (8 & 9 Vict. c. 100 ; 16 & 17 Vict. c. 96 ; 16 & 17 Vict. c. 97; 25 & 26 Vict. c. Ill), the general nature of whose provisions may be thus briefly described. The chief supervision of the insane is vested in a body called the Commissioners of Lunacy. No insane person can be received for profit, or detained in any house or asylum except upon an order by a person who becomes responsible for his detention, accompanied by certificates of two qualified medical practitioners that he is insane, and a proper person to be taken charge of and detained under care and treatment. Every such case must at once be reported to the commissioners, who must also be informed of the patient's death, discharge, change of residence, and similar circumstances. Not more than one insane person can be received into a house unless a licence has been previously obtained. In the metropolitan districts such licences are granted after due examination by the commis-sioners, and in the provinces by the justices of peace in quarter sessions. Every house thus licensed, together with public hospitals and asylums (which are not under licence), and every patient under private treatment, are subjected to a more or less frequent inspection by the commissioners, as well as by visitors appointed in their respective districts by the quarter sessions. The private licensed houses are under especially frequent inspection; their regulations and arrangements are subject to the approval of the commis-sioners, and especial precautions are taken that the patients shall have full opportunity of having their cases examined and of communicating with the commissioners. Patients may be discharged as cured, or on the direction of the person who ordered their detention, or on the order of the commissioners, all these modes of discharge, however, being guarded by various conditions. The order for detention of a lunatic may be given by any person having an interest in him, and he is liable in damages if there prove to have been no sufficient ground for the order, his position differ-ing in this respect from that of the physicians and keeper of the asylum, who are only liable in the event of negli-gence or mala fides.
In Scotland the equivalent Acts are 20 & 21 Vict, c. 71, 25 & 26 Vict. c. 54, and 29 & 30 Vict. c. 51. The system is in its main features the same as that of England, the leading differences being that the Commis-sioners of Lunacy are the only licensing body, and that an order granted on application by the sheriff takes the place of the order by a private person.
The regulations applicable to pauper lunatics differ in some respects from the ordinary case. The provisions applicable to them are for the most part to be found in 16 & 17 Vict. c. 97, and in 20 & 21 Vict. c. 71.
The nature of the evidence, and the manner in which it is to be presented to the court, is an important question in every department of the legal treatment of insanity. In England the courts, although giving increasing prominence to expert evidence, have gone a good deal on the theory that the medical evidence is merely a part of the general evidence in the case. In most Continental countries, on the other hand, the whole evidence is presented in the shape of reports by medical men (in most instances officials) who have previously examined the case; and in this way every piece of evidence as to the state of mind of the insane person is commented on by an expert who is presumably better acquainted with its true import than an ordinary court or jury.
Literature.The most recent book on the general law and pro-cedure in insanity is A Treatise on the Law and Practice of Lunacy, by H. M. R. Pope (London, 1877); Archibald's Statutes relating to Lunacy (2d ed., London, 1877) contains the statutory law on all branches ; Bertrand, Loi sur les Alienes (Paris, 1872), presents a comparative view of English and foreign legislations. In forensic medicine the works of Taylor (Medical Jurisprudence, 2d ed., London, 1873) and of Wharton and Stille (A Treatise on Medical Jurisprudence, Philadelphia, 1873) are probably the English authorities in most common use. See also Casper and Liman, Practisches Handbuch der Gerichtlichen Medicin, Berlin, 6th ed., 1876; Tardieu, Etude medico-legale sur la Folie, Paris, 1872 ; Legrand du Saulle, La Folie devant les Tribunaux, Paris, 1864 ; and especially Krafft-Ebing, Lehrbuch der gerichtlichen Psychopathologie, Stuttgart, 1875. (A. GI.)
1 See Report of Committee appointed by New York State Medical Society, in American Journal of Insanity, 1870 ; G. H. Darwin, Statistical Society's Journal, June 1875; Dr Langdon Down, "On Marriages of Consanguinity," London Hospital Clinical Lectures and Reports, 1866 ; Dr Arthur Mitchell, " On Consanguineous Marriages," in Edin. Med. Journ., 1865 ; Maudsley, " On Hereditary Tendency," Journal of Mental Science, Jan. 1863 and Jan. 1864 ; Trousseau, Clinique Medicate de I'Hôtel de Dieu de Paris, 1868, vol. ii. pp. 129-137 ; Alfred Henry Huth, The Marriage of Near Kin, 1875.
The first part of this article was written by J. Batty Tuke, M.D., F.R.C.P.E.
The second part of this article (on the Law of Insanity) was written by Alexander Gibson.