INSANITY (from Lat. in, not, and sanus, sound), 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 lunacy (from a supposed influence of the moon), mental disease, alienation, derangement, aberration, madness, unsoundness of mind. The term Psychiatry (ψυχή, mind, and ἰατρεία, treatment) is applied to the study and treatment of the condition.
I. Medical and General
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 Definition.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 insane; 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 as 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, stupor and dementia on the other.
All attempts at a short definition of the term “insanity” have proved unsatisfactory; perhaps the nearest approach to accuracy is attained by the rough statement that it is a symptom of disease of the brain inducing disordered mental symptoms—the term disease being used in its widest acceptance. 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 transitory 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 (see Brain, and Neuropathology), and 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 impossible to conceive of the existence of an insane mind in a healthy brain. On this basis insanity may be defined 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, 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 must be considered all cases in which, from whatever cause, brain development has 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 healthyClassification. 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 exciting causes until each class with its subdivisions comes under review.
In most treatises on the subject will be found discussed the bearing which civilization, nationality, occupation, education, &c., have, or are supposed to have, on the production of insanity. Such discussions are as a rule eminently unsatisfactory, founded as they are on common observation, Causation.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 summarize shortly 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. The causes of insanity may be divided into (a) general, and (b) proximate.
(a) General Causes.—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. In considering the influence of civilization upon the production of insanity, regard must be had to the more evolved ethical attitude towards disease in general which exists in civilized communities as well as to the more perfect recognition and registration of insanity.
2. Nationality.—In the face of the imperfect social statistics afforded by most European and American nations, and in their total absence or inaccessibility 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.
5. Inheritance.—The hereditary transmission of a liability to mental disease must be reckoned as the most important among all predisposing causes of insanity. It is probably well within the mark to say that at least 50% of the insane have a direct or collateral hereditary tendency towards insanity. The true significance of this factor cannot as yet be explained or described shortly and clearly, but it cannot be too definitely stated that it is not the insanity which is inherited, but only the predisposition to the manifestation of mental symptoms in the presence of a sufficient exciting cause. The most widely and generally accepted view of the exciting cause of insanity is that the predisposed brain readily breaks down under mental stress or bodily privations. There is, however, another view which has been recently advanced to the effect that the majority of mental diseases are secondary to bodily disorders, hereditary predisposition being the equally predisposing causal factor. There is probably truth in both these views, and such an admission accentuates the complexity of the factorship of heredity. If insanity can be induced by physical disorders, which must essentially be of the nature of toxic action or of mechanical agency which can alter or influence the functional powers of the brain, then it is probable that hereditary predisposition to insanity means, not only the transmission of an unstable nervous system, but also a constitution which is either peculiarly liable to the production of such toxic or poisonous substances, or incapable of effectively dealing with the toxins or poisonous substances normally formed during metabolic processes. Such a view broadens our conception of the factorship of hereditary transmission and offers explanation as to the manner in which insanity may appear in families previously free from the taint. Very frequently we find in the history of insane patients that although there may be no insanity in the family there are undoubted indications of nervous alongside of physical instability, the parental nervous defects taking the form of extreme nervousness, vagabondage, epilepsy, want of mental balance, inequality in mental development or endowment, extreme mental brilliancy in one direction associated with marked deficiency in others, the physical defects showing themselves in the form of insanity; liability to tubercular and rheumatic infections. The failure of constitutional power which allows of the invasion of the tubercle bacillus and the micrococcus rheumaticus in certain members of a family is apparently closely allied to that which favours the development of mental symptoms in others.
6. Consanguinity.—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 evil consequences follow where there is a strong tendency in the family to degeneration, not only in the direction of the original diathesis, but also towards instability of the nervous system. The objection to the marriage of blood relations does not arise from the bare fact of their relationship, but has its ground in the fear of their having a vicious variation of constitution, which, in their children, is 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.
7. Parental Weakness.—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, advanced 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 statements 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. However unsatisfactory from a scientific point of view it may appear, the general statement must stand that whatever tends to lower the nervous energy of a parent may modify the development of the progeny. 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, the morbid inheritance 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.
8. Periodic Influence.—The evolutional periods of puberty, adolescence, utero-gestation, the climacteric period and old age exercise an effect upon the nervous system. It may be freely admitted that the nexus between physiological processes and mental disturbances is, as regards certain of the periods, obscure, and that the causal relation 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 many 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. Between the adolescent and climacteric periods the constitution of the nervous, as of the other systems, becomes established, and disturbance is not likely to occur, except from some accidental circumstances 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 degeneration of muscle, to which 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 constitutional disturbance; on the other hand, there may be a break down of the system due to involutional changes in 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, as indicated by cessation of menstruation in the female and possibly by some analogous modification of the sexual function in men. The senile period brings with it further reduction of 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 necessarily followed by insanity.
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 doubts 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. 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 there are to be taken into pathological account, in addition to the dangers of sepsis, the various depressing influences of child-bed, its various accidents reducing vitality, the sudden return to ordinary physiological conditions, the rapid call for a new 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 its action.
(b) Proximate Causes.—The proximate causes of insanity may be divided into (1) toxic agents, (2) mechanical injury to the brain, including apoplexies and tumours, and (3) arterial degeneration.
1. Toxic Agents.—The definite nature of the symptoms in the majority of the forms of acute insanity leave little reason to doubt that they result from an invasion of the system by toxins of various kinds. The symptoms referred to may be briefly indicated as follows: (i.) Pyrexia, or fever generally of an irregular type; (ii.) Hyperleucocytosis, or an increase of the white blood corpuscles, which is the chief method by which the animal organism protects itself against the noxious influence of micro-organisms and their toxins. In such cases as typhoid fever, which is caused by a bacillus, or Malta fever which is caused by a coccus, it is found that if the blood serum of the patient is mixed in vitro with a broth culture of the infecting organism in a dilution of 1 in 50, that the bacilli or the cocci, as the case may be, when examined microscopically, are seen to run into groups or clusters. The organisms are said to be agglutinated, and the substance in the serum which produces this reaction is termed an agglutinine. In many of the forms of insanity which present the symptom of hyperleucocytosis there can also be demonstrated the fact that the blood serum of the patients contains agglutinines to certain members of a group of streptococci (so called on account of their tendency to grow in the form of a chain, στρεπτός); (iii.) the rapid organic affection of the special nerve elements depending upon the virulence of the toxin, and the resistance of the individual to its influence; (iv.) the marked physical deterioration as indicated by emaciation and other changes in nutrition; (v.) the close analogy between the character of many of the mental symptoms, e.g. delirium, hallucinations or depression, and the symptoms produced artificially by the administration of certain poisonous drugs.
The toxic substances which are generally believed to be associated with the causation of mental disorders may be divided into three great classes: (a) those which arise from the morbific products of metabolism within the body itself “auto-intoxicants”; (b) those due to the invasion of the blood or tissues by micro-organisms; (c) organic or inorganic poisons introduced into the system voluntarily or accidentally.
(a) Auto-intoxication may be due to defective metabolism or to physiological instability, or to both combined. The results of defective metabolism are most clearly manifested in the mental symptoms which not infrequently accompany such diseases as gout, diabetes or obesity, all of which depend primarily upon a deficient chemical elaboration of the products of metabolism. The association of gout and rheumatism with nervous and mental diseases is historical, and the gravest forms of spinal and cerebral degeneration have been found in association with diabetes. Until the pathology of these affections is better understood we are not in a position to determine the nature of the toxins which appear to be the cause of these diseases and of their accompanying nervous symptoms. Physiological instability is usually manifested by neurotic persons under the strain of any unusual change in their environment. If, for instance, any material change in the food supply consisting either in a decrease of its quality or quantity, or in a failure to assimilate it properly, the nerve-cells become exhausted and irritable, sleep is diminished and a condition known as the delirium of collapse or exhaustion may supervene. An extreme instance of this condition is presented by the delirium occurring in shipwrecked persons, who having to take to the boats are suddenly deprived of food, water or both. Poisoning of the nervous system may also result from the defective action of special glands such as the thyroid, the liver or the kidneys. These conditions are specially exemplified in the mental disturbances which accompany exophthalmic goitre, uraemic poisoning, and the conditions of depression which are observed in jaundice and other forms of hepatic insufficiency.
The results of modern research point to a growing belief in the frequency of infection of the nervous system from the hosts of micro-organisms which infest the alimentary tract. No definite or substantiated discoveries have as yet been formulated which would justify us in treating this source of infection as more than a highly probable causative influence.
(b) When we turn, however, to the potentiality of infection by micro-organisms introduced from without into the system we are upon surer if not upon entirely definite ground. A special form of insanity called by Weber, who first described it, the delirium of collapse, was observed by him to follow certain infectious diseases such as typhus fever and pneumonia. In later years it has been frequently observed to follow attacks of influenza. Recently our views have broadened and we find that the delirium of collapse is an acute, confusional insanity which may arise without any previous febrile symptoms, and is in fact one of the common forms of acute insanity. The nature of the physical symptoms, the mental confusion and hallucinations which accompany it, as well as the fact that it frequently follows some other infective disease, leave no doubt as to its toxic origin. A similar and analogous condition is presented by incidence of general paralysis after a previous syphilitic infection. The symptoms of general paralysis coupled with the extensive and rapid degeneration of not only the nervous but of the whole of the body tissues point to a microbic disease of intense virulence which, though probably not syphilitic, is yet induced, and enhanced in its action by the previous devitalizing action of the syphilitic toxin. There is abundant evidence to show that emotions which powerfully affect the mind, if long continued, conduce towards a condition of metabolic change, which in its turn deleteriously affects the nervous system, and which may terminate in inducing a true toxic insanity.
One of the best examples of insanity arising from micro-organisms is that form which occurs after childbirth, and which is known as puerperal mania. Other insanities may, it is true, arise at this period, but those which occur within the first fourteen days after parturition are generally of infective origin. The confusional nature of the mental symptoms, the delirium and the physical symptoms are sufficient indications of the analogy of this form of mental aberration with such other toxic forms of insanity as we find arising from septic wounds and which sometimes accompany the early toxic stages of virulent infectious diseases such as typhus, diphtheria or malignant scarlet fever.
The infective origin of puerperal mania is undoubted, though, as yet, no special pathogenic organism has been isolated. Dr Douglas (Ed. Med. Journ., 1897, i. 413) found the staphylococcus pyogenes aureus present in the blood in one case; Jackman (quoted loc. cit.) found the micrococcus pneumonial crouposae in one case; while Haultain (Ed. Med. Journ., 1897, ii. 131) found only the bacillus coli communis in the blood and secretions of several cases. From our experience of similar mental and physical symptoms produced as a result of septic wounds or which succeed surgical operations there seems to be no doubt that several forms of micrococci or streptococci of a virulent character are capable by means of the toxins they exude of causing acute delirium or mania of a confusional clinical type when introduced into the body.
(c) Accidental and voluntary poisonings of the system which result in insanity are illustrated by the forms of insanity which follow phosphorus or lead poisoning and by Pellagra. The voluntary intoxication of the system by such drugs as morphia and alcohol will be treated of below.
2 and 3. Mechanical injuries to the brain arise from direct violence to the skull, from apoplectic hemorrhage or embolism, or from rapidly growing tumours, or from arterial degeneration.
The forms of insanity may be divided into (I.) Congenital Mental Defect and (II.) Acquired Insanity.
I. Congenital Mental Defect.—The morbid mental conditions which fall to be considered under this head are Idiocy (with its modification, Imbecility) and Cretinism (q.v.).Forms of Insanity.
Idiocy (from Gr. ἰδιώτης, in its secondary meaning of a deprived person). In treating of idiocy it must be carefully borne in mind that we are dealing with mental phenomena dissociated for the most part from active bodily disease, and that, in whatever degree it may exist, we have to deal with Idiocy. 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 intervention 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 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 constituent elements of the brain. As a rule, the pathological 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 congenital malformation of the brain may be produced by mechanical causes acting on the child in utero, such as an attempt to procure abortion, or deformities of the maternal 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 (1877), classifies 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 heredity to be stronger than in other forms; the vitality of the general system is stated to be lower than normal; the palate is arched and narrow, the teeth misshapen, irregular and prone to decay and the patient dwarfish in appearance; the head is generally unsymmetrical and the commissures 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, a term which explains itself; (6) Paralytic idiocy, a rare form, due to the brain injury causing the paralysis; (7) Traumatic idiocy, a form produced by the third class of causes above mentioned; (8) Inflammatory idiocy; (9) Idiocy by deprivation of one or more of the special senses.
The general conformation of the idiot is generally imperfect; he is sometimes deformed, but more frequently the frame is merely awkwardly put together, and he is usually of short stature. Only about one-fourth of all idiots have heads smaller than the average. 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 often highly arched; hare-lip is not uncommon; in fact congenital defect or malformation of other organs than the brain is more commonly met with among idiots than in the general community. Of the special senses, hearing is most frequently affected. Sight is good, although co-ordination may be defective. Many are mute. On account of the mental dullness 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 between the conditions. As the scale of imbeciles ascends it is found that the condition is evidenced not so much by obtuseness 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 forms of the morbidly deprived type. The two conditions do not merge gradually one into the other. Absolute stupidity and sottishness mark many cases of idiocy, but only in the lowest type, where no dubiety of opinion can exist as to its 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 (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 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 considerable meed of receptive faculty and yet be idiotic in 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 platform as his fellows.
Dr Ireland subdivides idiots, for the purpose 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 public and private institutions has been very considerable. It may be safely stated that most idiotic or imbecile children have a better chance of amelioration in asylums devoted to them than by any amount of care at home.
In the class of idiots just spoken of, imperfect development 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 conditions cannot be dissociated, and the terms therefore severally only imply a specially marked deprivation of intellect or of moral sense in a given case. The everyday observer has no difficulty in recognizing as a fact that deficiency in receptive capacity is evidence of imperfect cerebral development; but it is not so patent to him that the perception of right or 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 physical peculiarity with the pathological evidence. The world is apt enough to refer any fault in intellectual development, manifested by imperfect 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 another—the 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, a peculiar cranial conformation, a history of previous symptoms during infancy, and of a series of indications of mental incapacities during adolescence, differing only in this, that in the first the prominent 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 before them, answer according to the dictates of morality, which they may have learnt by rote. 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 whole natural history of such cases is studied, there are points of differentiation between their morbid depravation and mere moral depravity. Family history, individual peculiarities, the general bizarre nature of the phenomena, remove such cases from the category of crime.
Statistics.—According to the census returns of 1901 the total number of persons described as idiots and imbeciles in England and Wales was 48,882, the equality of the sexes being remarkable, namely, 24,480 males and 24,402 females. Compared with the entire population the ratio is 1 idiot or imbecile to 665 persons, or 15 per 10,000 persons living. Whether the returns are defective, owing to the 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. Dr. Ireland estimates that there is 1 idiot or imbecile to every 500 persons in countries that have a census. The following table shows the number of idiots according to official returns of the various countries:—
|England and Wales||24,480||24,402||48,882||150|
|France (including cretins) (1872)||20,456||14,677||35,133||97|
For the United States there are no later census figures than 1890 when the feeble-minded or idiotic were recorded as 95,571 (52,940 males and 42,631 females). In 1904 (Special Report of Bureau of Census, 1906) the “feeble-minded” were estimated at 150,000.
The relative frequency of congenital and acquired insanity in various countries is shown in the following table, taken from Koch’s statistics of insanity in Württemberg, which gives the number of idiots to 100 lunatics:—
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 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 important an element idiocy is in social statistics; few are aware that the number of idiots and that of lunatics approach so nearly.
II. Acquired Insanity.—So far as the mental symptoms of acquired insanity are concerned, Pinel’s ancient classification, into Mania, Melancholia and Dementia, is still applicable to every case, and although numberless classifications have been advanced they are for the most Acquired Insanity. part merely terminological variations. Classifications of the insanities based on pathology and etiology have been held out as a solution of the difficulty, but, so far, pathological observations have failed to fulfil this ideal, and no thoroughly satisfactory pathological classification has emerged from them.
Classifications are after all matters of convenience; the following system admittedly is so:—
|Insanity following upon arterial degeneration.|
|Insanities associated or caused by: General Paralysis; Epilepsy.|
|Insanities associated with or caused by Alcoholic and Drug intoxication: Delirium Tremens, Chronic Alcoholic Insanity, Dipsomania, Morphinism.|
The general symptoms of acquired insanity group themselves naturally under two heads, the physical and the mental.
The physical symptoms of mental disease generally, if not invariably, precede the onset of the mental symptoms, and the patient may complain of indefinite symptoms of malaise for weeks and months before it is suspected that the disorder is about to terminate in mental General symptoms. symptoms. The most general physical disorder common to the onset of all the insanities is the failure of nutrition, i.e. the patient rapidly and apparently without any apparent cause loses weight. Associated with this nutritional failure it is usual to have disturbances of the alimentary tract, such as loss of appetite, dyspepsia and obstinate constipation. During the prodromal stage of such conditions as mania and melancholia the digestive functions of the stomach and intestine are almost or completely in abeyance. To this implication of other systems consequent on impairment of the trophesial (nourishment-regulating) function of the brain can be traced a large number 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 cases.
The skin and its appendages—the hair and the nails—suffer in the general disorder of nutrition which accompanies all insanities. The skin may be abnormally dry and scurfy or moist and offensive. In acute insanities rashes are not uncommon, and in chronic conditions, especially conditions of depression, crops of papules occur on the face, chest and shoulders. The hair is generally dry, loses its lustre and becomes brittle. The nails become deformed and may exhibit either excessive and irregular or diminished growth.
Where there are grave nutritional disorders it is to be expected that the chief excretions of the body should show departures from the state of health. In this article it is impossible to treat this subject fully, but it may suffice to say that in many states of depression there is a great deficiency in the excretion of the solids of the urine, particularly the nitrogenous waste products of the body; while in conditions of excitement there is an excessive output of the nitrogenous waste products. It has lately been pointed out that in many forms of insanity indoxyl is present in the urine, a substance only present when putrefactive processes are taking place in the intestinal tract.
The nervous system, both on the sensory and motor side, suffers very generally in all conditions of insanity. On the sensory side the special senses are most liable to disorder of their function, whereby false sense impressions arise which the patient from impairment of judgment is unable to correct, and hence arise the psychical symptoms known as hallucinations and delusions. Common sensibility is generally impaired.
On the motor side, impairment of the muscular power is present in many cases of depression and in all cases of dementia. The incontinence of urine so frequently seen in dementia and in acute insanity complicated with the mental symptom of confusion depends partly on impairment of muscular power and partly on disorder of the sensory apparatus of the brain and spinal cord.
The outstanding mental symptom in nearly all insanities, acute and recent or chronic, is the failure of the capacity of judgment and loss of self-control. In early acute insanities, however, the two chief symptoms which are most evident and easily noted are depression on the one hand and excitement or elevation on the other. Some distinction ought to be made between these two terms, excitement and elevation, which at present are used synonymously. Excitement is a mental state which may be and generally is associated with confusion and mental impairment, while elevation is an exaltation of the mental faculties, a condition in which there is no mental confusion, but rather an unrestrained and rapid succession of fleeting mental processes.
The symptoms which most strongly appeal to the lay mind as conclusive evidence of mental disorder are hallucinations and delusions. Hallucinations are false sense impressions which occur without normal stimuli. The presence of hallucinations certainly indicates some functional disorder of the higher brain centres, but is not an evidence of insanity so long as the sufferer recognizes that the hallucinations are false sense impressions. So soon, however, as conduct is influenced by hallucinations, then the boundary line between sanity on the one hand and insanity on the other has been crossed. The most common hallucinations are those of sight and hearing.
Delusions are not infrequently the result of hallucinations. If the hallucinations of a melancholic patient consist in hearing voices which make accusatory statements, delusions of sin and unworthiness frequently follow. Hallucinations of the senses of taste and smell are almost invariably associated with the delusion that the patient’s food is being poisoned or that it consists of objectionable matter. On the other hand, many delusions are apparently the outcome of the patient’s mental state. They may be pleasant or disagreeable according as the condition is one of elevation or depression. The intensity and quality of the delusions are largely influenced by the intelligence and education of the patient. An educated man, for instance, who suffers from sensory disturbances is much more ingenious in his explanations as to how these sensory disturbances result from electricity, marconigrams, X-rays, &c., which he believes are used by his enemies to annoy him, than an ignorant man suffering from the same abnormal sensations. Loss of self-control is characteristic of all forms of insanity. Normal self-control is so much a matter of race, age, the state of health, moral and physical upbringing, that it is impossible to lay down any law whereby this mental quality can be gauged, or to determine when deficiency has passed from a normal to an abnormal state. In many cases of insanity there is no difficulty in appreciating the pathological nature of the deficiency, but there are others in which the conduct is otherwise so rational that one is apt to attribute the deficiency to physiological rather than to pathological causes. Perversion of the moral sense is common to all the insanities, but is often the only symptom to be noticed in cases of imbecility and idiocy, and it as a rule may be the earliest symptom noticed in the early stages of the excitement of manic-depressive insanity and general paralysis.
The tendency to commit suicide, which is so common among the insane and those predisposed to insanity, is especially prevalent in patients who suffer from depression, sleeplessness and delusions of persecution. Suicidal acts may be divided into accidental, impulsive and premeditated. The accidental suicides occur in patients who are partially or totally unconscious of their surroundings, and are generally the result of terrifying hallucinations, to escape from which the patient jumps through a window or runs blindly into water or some other danger. Impulsive suicides may be prompted by suddenly presented opportunities or means of self-destruction, such as the sight of water, fire, a knife, cord or poison. Premeditated suicides most frequently occur in states of long continued depression. Such patients frequently devote their attention to only one method of destruction and fail to avail themselves of others equally practicable. As a rule the more educated the patient, the more ingenious and varied are the methods adopted to attain the desired result.
The faculty of attention is variously affected in the subjects of insanity. In some the attention is entirely subjective, being occupied by sensations of misery, depression or sensory disturbances. In others the attention is objective, and attracted by every accidental sound or movement. In most of the early acute insanities the capacity of attention is wholly abolished, while in hebephrenia the stage of exhaustion which follows acute excitement, and the condition known as secondary dementia, loss of the power of attention is one of the most prominent symptoms. The memory for both recent and remote events is impaired or abolished in all acute insanities which are characterized by confusion and loss or impairment of consciousness. In the excited stage of manic-depressive insanity it is not uncommon to find that the memory is abnormally active. Loss of memory for recent but not remote events is characteristic of chronic alcoholism and senility and even the early stage of general paralysis.
Of all the functions of the brain that of sleep is the most liable to disorder in the insane. Sleeplessness is the earliest symptom in the onset of insanity; it is universally present in all the acute forms, and the return of natural sleep is generally the first symptom of recovery. The causes of sleeplessness are very numerous, but in the majority of acute cases the sleeplessness is due to a state of toxaemia. The toxins act either directly on the brain cells producing a state of irritability incompatible with sleep, or indirectly, producing physical symptoms which of themselves alone are capable of preventing the condition of sleep. These symptoms are high arterial tension and a rapid pulse-rate. The arterial tension of health ranges between 110 and 120 millimetres of mercury, and when sleep occurs the arterial tension falls and is rarely above 100 millimetres. In observations conducted by Bruce (Scottish Medical and Surgical Journal, August 1900) on cases of insanity suffering from sleeplessness the arterial tension was found to be as high as 140 and 150 millimetres. When such sleep was obtained the tension always sank at once to 110 millimetres or even lower. In a few cases suffering from sleeplessness the arterial tension was found to be below 100 millimetres, accompanied by a rapid pulse-rate. When sleep set in, in these cases, no alteration was noted in the arterial tension, but the pulse was markedly diminished.
Melancholia.—Melancholia is a general term applied to all forms of insanity in which the prevailing mental symptom is that of depression and dates back to the time of Hippocrates. Melancholic patients, however, differ Melancholia. very widely from one another in their mental symptoms, and as a consequence a perfectly unwarrantable series of subdivisions have been invented according to the prominence of one or other mental symptoms. Such terms as delusional melancholia, resistive melancholia, stuporose melancholia, suicidal melancholia, religious melancholia, &c. have so arisen; they are, however, more descriptive of individual cases than indicative of types of disease.
So far as our present knowledge goes, at least three different and distinct disease conditions can be described under the general term melancholia. These are, acute melancholia, excited melancholia and the state of depression occurring in Folie circulaire or alternating insanity, a condition in which the patient is liable to suffer from alternating attacks of excitement and depression.
Acute Melancholia is a disease of adult life and the decline of life. Women appear to be more liable to be attacked than men. Hereditary predisposition, mental worry, exhausting occupations, such as the sick-nursing of relatives, are the chief predisposing causes, while the direct exciting cause of the condition is due to the accumulation in the tissues of waste products, which so load the blood as to act in a toxic manner on the cells and fibres of the brain.
The onset of the disease is gradual and indefinite. The patient suffers from malaise, indigestion, constipation and irregular, rapid and forcible action of the heart. The urine become scanty and high coloured. The nervous symptoms are irritability, sleeplessness and a feeling of mental confusion. The actual onset of the acute mental symptoms may be sudden, and is not infrequently heralded by distressing hallucinations of hearing, together with a rise in the body temperature. In the fully developed disease the patient is flushed and the skin hot and dry; the temperature is usually raised 1° above the normal in the evening. The pulse is hard, rapid and often irregular. There is no desire for food, but dryness of the mouth and tongue promote a condition of thirst. The bowels are constipated. The urine is scanty and frequently contains large quantities of indoxyl. The blood shows no demonstrable departure from the normal. The patient is depressed, the face has a strained, anxious expression, while more or less mental confusion is always present. Typical cases suffer from distressing aural hallucinations, and the function of sleep is in abeyance.
Acute melancholia may terminate in recovery either gradually or by crises, or the condition may pass into chronicity, while in a small proportion of cases death occurs early in the attack from exhaustion and toxaemia. The acute stage of onset generally lasts for from two to three weeks, and within that period the patient may make a rapid and sudden recovery. The skin becomes moist and perspiration is often profuse. Large quantities of urine are excreted, which are laden with waste products. The pulse becomes soft and compressible, sleep returns, and the depression, mental confusion and hallucinations pass away. In the majority of untreated cases, however, recovery is much more gradual. At the end of two or three weeks from the onset cf the attack the patient gradually passes into a condition of comparative tranquillity. The skin becomes moister, the pulse less rapid, and probably the earliest symptom of improvement is return of sleep. Hallucinations accompanied by delusions persist often for weeks and months, but as the patient improves physically the mental symptoms become less and less prominent.
If the patient does not recover, the physical symptoms are those of mal-nutrition, together with chronic gastric and intestinal disorder. The skin is dull and earthy in appearance, the hair dry, the nails brittle and the heart’s action weak and feeble. Mentally there is profound depression with delusions, and persistent or recurring attacks of hallucinations of hearing. When death occurs, it is usually preceded by a condition known as the “typhoid state.” The patient rapidly passes into a state of extreme exhaustion, the tongue is dry and cracked, sordes form upon the teeth and lips, diarrhoea and congestion of the lungs rapidly supervene and terminate life.
Treatment.—The patient in the early stage of the disease must be confined to bed and nursed by night as well as day. The food to begin with should be milk, diluted with hot water or aerated water, given frequently and in small quantities. The large intestine should be thoroughly cleared out by large enemata and kept empty by large normal saline enemata administered every second day. Sleep may be secured by lowering the blood pressure with half-grain doses of erythrol-tetra-nitrate. If a hypnotic is necessary, as it will be if the patient has had no natural sleep for two nights in succession, then a full dose of paraldehyde or veronal may be given at bed-time. Under this treatment the majority of cases, if treated early, improve rapidly. As the appetite returns great care must be taken that the patient does not suddenly resume a full ordinary dietary. A sudden return to a full dietary invariably means a relapse, which is often less amenable to treatment than the original attack. Toast should first be added to the milk, and this may be followed by milk puddings and farinaceous foods in small quantities. Any rise of temperature or increase of pulse-rate or tendency to sleeplessness should be regarded as a threatened relapse and treated accordingly.
Excited Melancholia.—Excited melancholia is almost invariably a disease of old age or the decline of life, and it attacks men and women with equal frequency. Chronic gastric disorders, deficient food and sleep, unhealthy occupations and environments, together with worry and mental stress, are all more or less predisposing causes of the disease. The direct exciting cause or causes have not as yet been demonstrated, but there is no doubt that the disease is associated with, or caused by, a condition of bacterial toxaemia, analogous to the bacterial toxaemias of acute and chronic rheumatism.
The onset of the disease is always gradual and is associated with mal-nutrition, loss of body weight, nervousness, depression, loss of the capacity for work, sleeplessness and attacks of restlessness, these attacks of restlessness become more and more marked as self-control diminishes, and as the depression increases the disease passes the borderland of sanity.
In the fully developed disease the appearance of the patient is typical. The expression is drawn, depressed, anxious or apprehensive. The skin is yellow and parchment like. The hair is often dry and stands out stiffly from the head. The hands are in constant movement, twisting and untwisting, picking the skin, pulling at the hair or tearing at the clothes. The patient moans continuously, or emits cries of grief and wanders aimlessly. Mentally the patient, although depressed, miserable and self-absorbed, is not confused. There is complete consciousness except during the height of a paroxysm of restlessness and depression, and the patient can talk and answer questions clearly and intelligently, but takes no interest in the environment. Some of the patients suffer from delusions, generally a sense of impending danger, but very few suffer from hallucinations.
Physically there is loss of appetite, constipation and rapid heart action, a great increase in the number of the white blood corpuscles, particularly of the multinucleated cells which are frequently increased in bacterial infections. In the blood serum also there can be demonstrated the presence of agglutinines to certain members of the streptococci group.
The course of the disease is prolonged and chronic. The acute symptoms tend to remit at regular intervals, the patient becoming more quiet and less demonstratively depressed; but as a rule these remissions are extremely temporary. Excited melancholia is a disease characterized by repeated relapses, and recoveries are rare in cases above the age of forty.
Treatment.—There is no curative treatment for excited melancholia. The patient must be carefully nursed; kept in bed during the exacerbations of the disease and treated with graduated doses of nepenthe or tincture of opium, to secure some amelioration of the acute symptoms. Careful dieting, tonics and baths are of benefit during the remissions of the disease, and in a few cases seem to promote recovery.
Folie circulaire, or alternating insanity, was first described by Falret and Baillarger, and more recently Kraepelin has considerably widened the conception of this class of disease, which he describes under the term “manic-depressive insanity.” Of the two terms (folie circulaire and manic-depressive insanity) the latter is the more correct. Folie circulaire implies that the disease invariably passes through a complete cycle, which description is only applicable to very few of the cases. Manic-depressive insanity implies that the patient may either suffer from excitement or depression which do not necessarily succeed one another in any fixed order. As a matter of fact, the majority of patients who suffer from the disease either have marked excited attacks with little or no subsequent depression, or marked attacks of depression with a subsequent period of such slight exaltation as hardly to be distinguished from a state of health.
Depression of the manic-depressive variety, therefore, may either precede or follow upon an attack of maniacal excitement, or it may be the chief and only obvious symptom of the disease and may recur again and again. The disease attacks men and women with equal frequency, and as a rule manifests itself either late in adolescence or during the decline of life. Hereditary predisposition has been proved to exist in over 50% of cases, beyond which no definite predisposing cause is at present known. A considerable number of cases follow upon attacks of infective disease such as typhoid fever, scarlet fever or rheumatic fever. The actual exciting cause is probably an intestinal toxaemia of bacterial origin; at all events, mal-nutrition, gastric and intestinal symptoms not infrequently precede an attack, and the condition of the blood—the increase in number in the multinucleated white blood corpuscles and the presence of agglutinines to certain members of the streptococci group of bacteria—are symptoms which have been definitely demonstrated by Bruce in every case so far examined.
If the depression is the sequel to an attack of excitement, the onset may be very sudden or it may be gradual. If, on the other hand, the depression is not the sequel of excitement, the onset is very gradual and the patient complains of lassitude, incapacity for mental or physical work, loss of appetite, constipation and sleeplessness often for months before the case is recognized as one of insanity. In the fully developed disease the temperature is very rarely febrile, on the contrary it is rather subnormal in character. The stomach is disordered and the bowels confined. The urine is scanty, turbid and very liable to rapid decomposition. The heart’s action is slow and feeble and the extremities become cold, blue and livid. In extreme cases gangrene of the lower extremities may occur, but in all there is a tendency to oedema of the extremities. The skin is greasy, often offensive, and the palms of the hands and the soles of the feet are sodden.
Mentally there is simple depression, without, in the majority of cases, any implication of consciousness. Many patients pass through attack after attack without suffering from hallucinations or delusions, but in rare cases hallucinations of hearing and sight are present. Delusions of unworthiness and unpardonable sin are not uncommon, and if once expressed are liable to recur again during the course of each successive attack. The disease is prolonged and chronic in its course, and the condition of the patient varies but little from day to day. When the depression follows excitement, the patient as a rule becomes fat and flabby. On the other hand, if the illness commences with depression, the chief physical symptoms are mal-nutrition and loss of body weight, and the return to health is always preceded by a return of nutrition and a gain in body weight.
The attacks may last from six months to two or three years. The intervals between attacks may last for only a few weeks or months or may extend over several years. During the interval the patient is not only capable of good mental work but may show capacity of a high order. In other words this form of mental disorder does not tend to produce dementia; the explanation probably being that between the attacks there is no toxaemia.
Treatment.—There is no known curative treatment for the depression of manic-depressive insanity, but the depression, the sleeplessness and the gastric disorder are to some extent mitigated by common sense attention to the general health of the body. If the patient is thin and wasted, then treatment is best conducted in bed. The diet should be bland, consisting largely of milk, eggs and farinaceous food, given in small quantities and frequently. Defecation should be maintained by enemata, and the skin kept clean by daily warm baths. What is of much more importance is the fact that in some instances subsequent attacks can be prevented by impressing upon the patient the necessity for attending to the state of the bowels, and of discontinuing work when the slightest symptoms of an attack present themselves. If these symptoms are at all prominent, rest in bed is a wise precaution, butcher-meat should be discontinued from the dietary and a tonic of arsenic or quinine and acid prescribed.
Mania.—The term mania, meaning pathological elevation or excitement, has, like the term melancholia, been applied to all varieties of morbid mental conditions in which the prevailing mental symptom is excitement or elevation. Mania. As in melancholia so in mania various subdivisions have been invented, such as delusional mania, religious mania, homicidal mania, according to the special mental characteristics of each case, but such varieties are of accidental origin and cannot be held to be subdivisions.
Under the term mania two distinct diseased conditions can be described, viz. acute mania, and the elevated stage of folie circulaire or manic-depressive insanity.
Acute Mania.—Acute mania is a disease which attacks both sexes at all ages, but its onset is most prevalent during adolescence and early adult life. Hereditary predisposition, physical and mental exhaustion, epileptic seizures and childbirth are all predisposing causes. The direct exciting cause or causes are unknown, but the physical symptoms suggest that the condition is one of acute toxaemia or poisoning, and the changes in the blood are such as are consequent on bacterial toxaemia.
The onset is gradual in the large majority of cases. Histories of sudden outbursts of mania can rarely be relied on, as the illness is almost invariably preceded by loss of body weight, sleeplessness, bad dreams, headaches and symptoms of general malaise, sometimes associated with depression. The actual onset of the mental symptoms themselves, however, are frequently sudden. A typical case of the fully developed disease is not easily mistaken. The patient is usually anaemic and thin, the expression of the face is unnatural, the eyes widely opened and bright; and there is great motor restlessness, the muscular movements being purposeless and inco-ordinate. This inco-ordination of movement affects not only the muscles of the limbs and trunk but also those of expression, so that the usual aspect of the face becomes entirely altered. The temperature is generally slightly febrile. The tongue and lips are cracked and dry through excessive shouting or speaking. There is often no desire for food or drink. The heart’s action is rapid and forcible. The skin is soft and moist. The urine is scanty, turbid and loaded with urates. The white blood corpuscles per cubic millimetre of blood are markedly increased, and the blood serum contains agglutinines to certain strains of streptococci which are not present in healthy persons. Sensibility to pain is lost or much impaired. Such patients will swing and jerk a broken limb apparently unaware that it is broken. Sleep is absent or obtained in short snatches, and even when asleep the patient is often restless and talkative as if the disease processes were still active.
Mentally the patient is excited, often wildly so, quite confused and unable to recognize time or place. Answers to questions may sometimes be elicited by repeated efforts to engage the attention of the patient. The speech is incoherent, and for all practical purposes the patient is mentally inaccessible. This state of acute excitement lasts usually for two or three weeks and gradually passes into a condition of chronic restlessness and noise, in which the movements are more coordinate and purposeful. The confusion of the acute stage passes off and the attention can be more readily attracted but cannot be concentrated on any subject for any length of time. The patient will now recognize friends, but the affections are in abeyance and the memory is defective. The appetite becomes insatiable, but the patient does not necessarily gain in weight. This stage of subacute excitement may last for months, but as a rule favourable cases recover within six months from the onset of the disease. A recovering patient gradually gains weight, sleeps soundly at night and has periods of partial quiescence during the day, particularly in the morning after a good night’s sleep. These lucid intervals become more and more prolonged and finally pass into a state of sanity. Some cases on the other hand, after the acute symptoms decline, remain confused, and this state of confusion may last for months; by some alienists it is described as secondary stupor.
The symptoms detailed above are those typical of an attack such as is most frequently met with in adult cases. Acute mania, however, is a disease which presents itself in various forms. Adolescent cases, for instance, very commonly suffer from recurrent attacks, and the recurrent form of the disease is also to be met with in adults. The recurrent form at the onset does not differ in symptoms from that already described, but the course of the attack is shorter and more acute, so that the patient after one or two weeks of acute excitement rapidly improves, the mental symptoms pass off and the patient is apparently perfectly recovered. An examination of the blood, however, reveals the fact that the patient is still suffering from some disorder of the system, inasmuch as the white blood corpuscles remain increased above the average of health. Subsequent attacks of excitement come on without any obvious provocation. The pulse becomes fast and the face flushed. The patient frequently complains of fullness in the head, ringing in the ears and a loss of appetite. Sleeplessness is an invariable symptom. Self-control is generally lost suddenly, and the patient rapidly passes into a state of delirious excitement, to recover again, apparently, in the course of a few weeks. Recurrent mania might therefore be regarded as a prolonged toxaemia, complicated at intervals by outbursts of delirious excitement. Acute mania in the majority of cases ends in recovery. In the continuous attack the recovery is gradual. In the recurrent cases the intervals between attacks become longer and the attacks less severe until they finally cease. In such recovered cases very frequently a persistent increase in the number of the white blood corpuscles is found, persisting for a period of two or three years of apparently sound mental health. A few cases die, exhausted by the acuteness of the excitement and inability to obtain rest by the natural process of sleep. When death does occur in this way the patient almost invariably passes into the typhoid state.
The residue of such cases become chronic, and chronicity almost invariably means subsequent dementia. The chronic stage of acute mania may be represented by a state of continuous subacute excitement in which the patient becomes dirty and destructive in habits and liable from time to time to exacerbations of the mental symptoms. Continuous observation of the blood made in such cases over a period extending for weeks reveals the fact that the leucocytosis, if represented in chart form, shows a regular sequence of events. Just prior to the onset of an exacerbation the leucocytosis is low. As the excitement increases in severity the leucocytosis curve rises, and just before improvement sets in there may be a decided rise in the curve and then a subsequent fall; but this fall rarely reaches the normal line. In other cases, which pass into chronicity, a state of persistent delusion, rather than excitement, is the prevailing mental characteristic, and these cases may at recurrent intervals become noisy and dangerous.
Treatment.—Acute mania can only be treated on general lines. During the acute stage of onset the patient should be placed in bed. If there is difficulty in inducing the patient to take a sufficient quantity of food, this difficulty can be got over by giving food in liquid form, milk, milk-tea, eggs beaten up in milk, meat juice and thin gruel, and it is always better to feed such a patient with small quantities given frequently. Cases of mania following childbirth are those which most urgently demand careful and frequent feeding, artificially administered if necessary. If there is any tendency to exhaustion, alcoholic stimulants are indicated, and in some cases strychnine, quinine and cardiac tonics are highly beneficial. The bowels should be unloaded by large enemata or the use of saline purgatives. The continuous use of purgatives should as a rule be avoided, as they drain the system of fluids. On the other hand, the administration of one large normal saline enema by supplying the tissues with fluids, and probably thereby diluting the toxins circulating in the system, gives considerable relief. A continuous warm bath frequently produces sleep and reduces excitement. The sleeplessness of acute mania is best treated by warm baths wherever possible, and if a drug must be administered, then paraldehyde is the safest and most certain, unless the patient is also an alcoholic, when chloral and bromide is probably a better sedative.
The Elevated Stage of Folie Circulaire or Manic Depressive Insanity.—As previously mentioned in the description of the depressed stage of this mental disorder, the disease is equally prone to attack men and women, generally during late adolescence or in early adult life, and in a few cases first appears during the decline of life. Hereditary predisposition undoubtedly plays a large part as a predisposing cause, and after that is said it is difficult to assign any other definite predisposing causes and certainly no exciting causes. As in the stage of depression, so in the stage of excitement the first attack may closely follow upon typhoid fever, erysipelas or rheumatic fever. On the other hand many cases occur without any such antecedent disease. Another fact which has been commented upon is that these patients at the onset of an attack of excitement often appear to be in excellent physical health.
The earliest symptoms of onset are moral rather than physical. The patient changes in character, generally for the worse. The sober man becomes intemperate. The steady man of business enters into foolish, reckless speculation. There is a tendency for the patient to seek the society of inferiors and to ignore the recognized conventionalities of life and decency. The dress becomes extravagant and vulgar and the speech loud, boastful and obscene. These symptoms may exist for a considerable period before some accidental circumstance or some more than usually extravagant departure from the laws and customs of civilization draws public attention to the condition of the patient. The symptoms of the fully developed disease differ in degree in different cases. The face is often flushed and the expression unnatural. There is constant restlessness, steady loss of body weight, and sleeplessness. In very acute attacks there are frequently symptoms of gastric disorder, while in other cases the appetite is enormous, gross and perverted. The leucocytosis is above that usually met with in health, and the increase in the early stages is due to the relative and absolute increase in the multinucleated or polymorphonuclear leucocytes. The hyperleucocytosis is not, however, so high as it is in acute mania, and upon recovery taking place the leucocytosis always falls to normal. In the serum of over 80% of cases there are present agglutinines to certain strains of streptococci, which agglutinines are not present in the serum of healthy persons. The changes in the urine are those which one would expect to find in persons losing weight; the amount of nitrogenous output is in excess of the nitrogen ingested in the food.
Mentally there is always exaltation rather than excitement, and when excitement is present it is never of a delirious nature, that is to say, the patient is cognizant of the surroundings, and the special senses are abnormally acute, particularly those of sight and hearing. Hallucinations and delusion are sometimes present, but many cases pass through several attacks without exhibiting either of these classes of symptoms. The patient is always garrulous and delighted to make any chance acquaintance the confidant of his most private affairs. The mood is sometimes expansive and benevolent, interruption in the flow of talk may suddenly change the subject of the conversation or the patient may with equal suddenness fly into a violent rage, use foul and obscene language, ending with loud laughter and protestations of eternal friendship. In other words the mental processes are easily stimulated and as easily diverted into other channels. The train of thought is, as it were, constantly being changed by accidental associations. Although consciousness is not impaired, the power of work is abolished as the attention cannot be directed continuously to any subject, and yet the patient may be capable of writing letters in which facts and fiction are most ingeniously blended. A typical case will pass through the emotions of joy, sorrow and rage in the course of a few minutes. The memory is not impaired and is often hyper-acute. The speech may be rambling but is rarely incoherent.
The course of the attack is in some cases short, lasting for from one to three weeks, while in others the condition lasts for years. The patient remains in a state of constant restlessness, both of body and mind, untidy or absurd in dress, noisy, amorous, vindictive, boisterously happy or virulently abusive. As time passes a change sets in. The patient sleeps better, begins to lay on flesh, the sudden mental fluctuations become less marked and finally disappear. Many of these patients remember every detail of their lives during the state of elevation, and many are acutely ashamed of their actions during this period of their illness. As a sequel to the attack of elevation there is usually an attack of depression, but this is not a necessary sequel.
The majority of patients recover even after years of illness, but the attacks are always liable to recur. Even recurrent attacks, however, leave behind them little if any mental impairment.
Treatment.—General attention to the health of the body, and an abundance of nourishing food, and, where necessary, the use of sedatives such as bromide and sulphonal, sum up the treatment of the elevated stage of manic-depressive insanity. In Germany it is the custom to treat such cases in continuous warm baths, extending sometimes for weeks. The use of warm baths of several hours’ duration has not proved satisfactory.
Delusional Insanity.—Considerable confusion exists at the present day regarding the term delusional insanity. It is not correct to define the condition as a disease in which fixed delusions dominate the conduct and are the Delusional Insanity. chief mental symptom present. Such a definition would include many chronic cases of melancholia and mania. All patients who suffer from attacks of acute insanity and who do not recover tend to become delusional, and any attempt to include and describe such cases in a group by themselves and term them delusional insanity is inadmissible. The fact that delusional insanity has been described under such various terms as progressive systematized insanity, mania of persecution and grandeur, monomanias of persecution, unseen agency, grandeur and paranoia, indicates that the disease is obscure in its origin, probably passing through various stages, and in some instances having been confused with the terminal stages of mania and melancholia. If this is admitted, then probably the best description of the disease is that given by V. Magnan under the term of “systematized delusional insanity,” and it may be accepted that many cases conform very closely to Magnan’s description.
The disease occurs with equal frequency in men and women, and in the majority of cases commences during adolescence or early adult life. The universally accepted predisposing cause is hereditary predisposition. As to the exciting causes nothing is known beyond the fact that certain forms of disease, closely resembling delusional insanity, are apparently associated or caused by chronic alcoholism or occur as a sequel to syphilitic infection. In the vast majority of cases the onset is lost in obscurity, the patient only drawing attention to the diseased condition by insane conduct after the delusional state is definitely established. The friends of such persons frequently affirm that the patient has always been abnormal. However this may be, there is no doubt that in a few cases the onset is acute and closely resembles the onset of acute melancholia. The patient is depressed, confused, suffers from hallucinations of hearing and there are disturbances of the bodily health. There is generally mal-nutrition with dyspepsia and vague neuralgic pains, often referred to the heart and intestines. Even at this stage the patient may labour under delusions. These acute attacks are of short duration and the patient apparently recovers, but not uncommonly both hallucinations and delusions persist, although they may be concealed.
The second or delusional stage sets in very gradually. This is the stage in which the patient most frequently comes under medical examination. The appearance is always peculiar and unhealthy. The manner is unnatural and may suggest a state of suspicion. The nutrition of the body is below par, and the patient frequently complains of indefinite symptoms of malaise referred to the heart and abdomen. The heart’s action is often weak and irregular, but beyond these symptoms there are no special characteristic symptoms.
Mentally there may be depression when the patient is sullen and uncommunicative. It will be found, however, that he always suffers from hallucinations. At first hallucinations of hearing are the most prominent, but later all the special senses may be implicated. These hallucinations constantly annoy the patient and are always more troublesome at night. Voices make accusations through the walls, floors, roofs or door. Faces appear at the window and make grimaces. Poisonous gases are pumped into the room. Electricity, Röntgen rays and marconigrams play through the walls. The food is poisoned or consists of filth. In many cases symptoms of visceral discomfort are supposed to be the result of nightly surgical operations or sexual assaults. All these persecutions are ascribed to unknown persons or to some known person, sect or class. Under the influence of these sensory disturbances the patient may present symptoms of angry excitement, impulsive violence or of carefully-thought-out schemes of revenge; but the self-control may be such that although the symptoms are concealed the behaviour is peculiar and unreasonable. It is not uncommon to find that such patients can converse rationally and take an intelligent interest in their environments, but the implication of the capacity of judgment is at once apparent whenever the subject of the persecutions is touched upon.
All cases of delusional insanity at this stage are dangerous and their actions are not to be depended upon. Assaults are common, houses are set on fire, threatening letters are written and accusations are made which may lead to much worry and trouble before the true nature of the disease is realized.
This, the second or persecutory stage of delusional insanity, may persist through life. The patient becomes gradually accustomed to the sensory disturbances, or possibly a certain amount of mental enfeeblement sets in which reduces the mental vigour. In other cases, the disease goes on to what Magnan calls the third stage or stage of grandiose delusions. The onset of this stage is in some cases gradual. The patient, while inveighing against the persecutions, hints at a possible cause. One man is an inventor and his enemies desire to deprive him of the results of his inventions. Another is the rightful heir to a peerage, of which he is to be deprived. Women frequently believe themselves to be abducted princesses or heirs to the throne. Others of both sexes, even more ambitious, assume divine attributes and proclaim themselves Virgin Marys, Gabriels, Holy Ghosts and Messiahs. Cases are recorded in which the delusions of grandeur were of sudden onset, the patient going to bed persecuted and miserable and rising the following morning elated and grandiose. In this stage the hallucinations persist but appear to change in character and become pleasant. The king hears that arrangements are being made for his coronation and waits quietly for the event. The angel Gabriel sees visions in the heavens. The heirs and heiresses read of their prospective movements in the court columns of the daily papers and are much soothed thereby. In short, no delusion is too grotesque and absurd for such patients to believe and express.
Cases of delusional insanity never become demented in the true sense of the word, but their mental state might be described as a dream in which an imaginary existence obliterates the experiences of their past lives.
Treatment.—No treatment influences the course of the disease. During the stage of persecution such patients are a danger to themselves, as they not infrequently commit suicide, and to their supposed persecutors, whom they frequently assault or otherwise annoy.
Katatonia.—This disease, so called on account of the symptom of muscular spasm or rigidity which is present during certain of its stages, was first described and named by K. L. Kahlbaum in 1874. Many British alienists refuse to Katatonia. accept katatonia as a distinct disease, but as it has been accepted and further elaborated by such an authority as E. Kraepelin reference to it cannot be avoided.
Katatonia attacks women more frequently than men, and is essentially a disease of adolescence, but typical cases occasionally occur in adults. Hereditary predisposition is present in over 50% of the cases and is the chief predisposing cause. Childbirth, worry, physical strain and mental shocks are all advanced as secondary predisposing causes. The disease is one of gradual onset, with loss of physical and mental energy. Probably the earliest mental symptom is the onset of aural hallucinations. For convenience of description the disease may be divided into (1) the stage of onset; (2) the stage of stupor; (3) the stage of excitement.
The symptoms of the stage of onset are disorders of the alimentary tract, such as loss of appetite, vomiting after food and obstinate constipation. The pulse is rapid, irregular and intermittent. The skin varies between extreme dryness and drenching perspirations. In women the menstrual function is suppressed. At uncertain intervals the skeletal muscles are thrown into a condition of rigidity, but this symptom does not occur invariably. The instincts of cleanliness are in abeyance, owing to the mental state of the patient, and as a result these cases are inclined to be wet and dirty in their habits.
Mentally there is great confusion, vivid hallucinations, which apparently come on at intervals and are of a terrifying nature, for the patient often becomes frightened, endeavours to hide in corners or escape by a window or door. A very common history of such a case prior to admission is that the patient has attempted suicide by jumping out of a window, the attempt being in reality an unconscious effort on the part of the patient to escape from some imaginary danger. During these attacks the skin pours with perspiration. The patient is oblivious to his surroundings and is mentally inaccessible. In the intervals between these attacks the patient may be conscious and capable of answering simple questions. This acute stage, in which sleep is abolished, lasts from a few days to four or six weeks and then, generally quite suddenly, the patient passes into the state of stupor. In some cases a sharp febrile attack accompanies the onset of the stupor, while in others this symptom is absent; but in every case examined by Bruce during the acute stage there was an increase in the number of the white blood corpuscles, which, just prior to the onset of stupor, were sometimes enormously increased; the increase being entirely due to multiplication of the multinucleated or polymorphonuclear leucocytes.
In the second or stuporose stage of the disease the symptoms are characteristic. The patient lies in a state of apparent placidity, generally with the eyes shut. Consciousness is never entirely abolished, and many of the patients give unmistakable evidence that they understand what is being said in their presence. Any effort at passive movement of a limb immediately sets up muscular resistance, and throughout this stage the sternomastoid and the abdominal muscles are more or less in a state of over-tension, which is increased to a condition of rigidity if the patient is interfered with in any way. This symptom of restiveness or negativism is one of the characteristics of the disease. The patient resists while being fed, washed, dressed and undressed, and even the normal stimuli which in a healthy man indicate that the bladder or rectum require to be emptied are resisted, so that the bladder may become distended and the lower bowel has to be emptied by enemata. The temperature is low, often subnormal, the pulse is small and weak, and the extremities cold and livid. This symptom is probably due in some part to spasm of the terminal arterioles. Mentally the symptoms are negative. Though conscious, the patient cannot be got to speak and apparently is oblivious to what is passing around. Upon recovery, however, these cases can often recount incidents which occurred to them during their illness, and may also state that they laboured under some delusion. Coincidently with the onset of the stupor sleep returns, and many cases sleep for the greater part of the twenty-four hours. The duration of the stuporose state is very variable. In some cases it lasts for weeks, in others for months or years, and may be the terminal stage of the disease, the patient gradually sinking into dementia or making a recovery. The third stage or stage of excitement comes on in many cases during the stage of stupor: the stages overlap; while in others a distinct interval of convalescence may intervene between the termination of the stupor and the onset of the excitement. The excitement is characterized by sudden impulsive actions, rhythmical repetition of words and sounds (verbigeration), and by rhythmical movements of the body or limbs, such as swaying the whole frame, nodding the head, swinging the arms, or walking in circles. The patient may be absolutely mute in this stage as in the stage of stupor. Others again are very noisy, singing, shouting or abusive. The speech is staccato in character and incoherent. Physically the patient, who often gains weight in the stage of stupor, again becomes thin and haggard in appearance owing to the incessant restlessness and sleeplessness which characterize the stage of excitement. The patient may, during the stage of onset, die through exhaustion, or accidentally and unconsciously commit suicide usually by leaping from a window. During the stuporose stage symptoms of tubercular disease of the lungs may commence. All the adolescent insane are peculiarly liable to contract and die from tubercular disease. Accidental suicide is also liable to occur during this stage. The stage of excitement, if at all prolonged, invariably ends in dementia. According to Kraepelin 13% of the cases recover, 27 make partial recoveries, and 60% become more or less demented.
Treatment.—No treatment arrests or diverts the course of katatonia, and the acute symptoms of the disease as they arise must be treated on hospital principles.
Hebephrenia.—This is a disease of adolescence (Gr. ἥβη) which was first described by Hecker and Kahlbaum and more recently by Kraepelin and other foreign workers. Hebephrenia is not yet recognized by British alienists. Hebephrenia. The descriptions of the disease are indefinite and confusing, but there are some grounds for the belief that such an entity does exist, although it is probably more correct to say that as yet the symptoms are very imperfectly understood. Hebephrenia is always a disease of adolescence and never occurs during adult life. It attacks women more frequently than men, and according to Kahlbaum hereditary predisposition to insanity is present in over 50% of the cases attacked. The onset of the disease is invariably associated with two symptoms. On the physical side an arrested or delayed development and on the mental a gradual failure of the power of attention and concentrated thought. The onset of the condition is always gradual and the symptoms which first attract attention are mental. The patient becomes restless, is unable to settle to work, becomes solitary and peculiar in habits and sometimes dissolute and mischievous. As the disease advances the patient becomes more and more enfeebled, laughs and mutters to himself and wanders aimlessly and without object. There is no natural curiosity, no interest in life and no desire for occupation. Later, delusions may appear and also hallucinations of hearing, and under their influence the patient may be impulsive and violent. Physically the subjects are always badly developed. The temperature is at times slightly elevated and at intervals the white blood corpuscles are markedly increased. The menstrual function in women is suppressed and both male and female cases are addicted to masturbation. According to Kraepelin 5% of the cases recover, 15% are so far relieved as to be able to live at home, but are mentally enfeebled, the remaining 80% become hopelessly demented. The patients who recover frequently show at the onset of their disease acute symptoms, such as mild excitement, slightly febrile temperature and quick pulse-rate. When recovery does take place there is marked improvement in development. The subjects of hebephrenia are peculiarly liable to tubercular infection and many die of phthisis.
There is no special treatment for hebephrenia beyond attention to the general health.
Insanity following upon Injuries to the Brain, or Apoplexies or Tumours or Arterial Degeneration. (a) Traumatic Insanity.—Insanity following blows on the head is divided into (1) the forms in which the insanity immediately Traumatic Insanity. follows the accident; (2) the form in which there is an intermediate prodromal stage characterized by strange conduct and alteration in disposition; and (3) in which the mental symptoms occur months or years after the accident, which can have at most but a remote predisposing causal relation to the insanity. The cases which immediately succeed injuries to the head are in all respects similar to confusional insanity after operations or after fevers. There is generally a noisy incoherent delirium, accompanied by hallucinations of sight or of hearing, and fleeting unsystematized delusions. The physical symptoms present all the features of severe nervous shock.
In those cases in which there is an intervening prodromal condition, with altered character and disposition, there is usually a more or less severe accidental implication of the cortex cerebri, either by depression of bone or local hemorrhage, or meningitic sub-inflammatory local lesions. Most of the cases during the prodromal stage are sullen, morose or suspicious, and indifferent to their friends and surroundings. At the end of the prodromal stage there most usually occurs an attack of acute mania of a furious impulsive kind. The cases which for many years after injury are said to have remained sane will generally be found upon examination and inquiry to exhibit symptoms of hereditary degeneration or of acquired degeneracy, which may or may not be a consequence of the accident.
The most common site of vascular lesion is one of the branches of the middle cerebral artery within the sylvian fissure, or of one of the smaller branches of the same artery which go directly to supply the chief basal ganglia. When an artery like the middle cerebral or one of its branches becomes either through rupture or blocking of its lumen, incapable of performing its function of supplying nutrition to important cerebral areas, there ensues devitality of the nervous tissues, frequently followed by softening and chronic inflammation. It is these secondary changes which give rise to and maintain those peculiar mental aberrations known as post-apoplectic insanity.
Various characteristic physical symptoms, depending upon the seat of the cerebral lesion, are met with in the course of this form of insanity. These consist of paraplegias, hemiplegias and muscular contractures. Speech defects are very common, being due either to the enfeebled mental condition, to paralysis of the nerve supplying the muscles of the face and tongue, or to aphasia caused by implication of those parts of the cortex which are intimately associated with the faculty of speech. Mental symptoms vary considerably in different cases and in accordance with the seat and extent of the lesion. There is almost always present, however, a certain degree of mental enfeeblement, accompanied by loss of memory and of judgment, often by mental confusion. Another very general mental symptom is the presence of emotionalism which leads the patient to be affected either to tears or to laughter upon trifling and inadequate occasions.
Cerebral tumours do not necessarily produce insanity. Indeed it has been computed that not one half of the cases become insane. When insanity appears it is met with in all degrees varying from slight mental dulness up to complete dementia, and from mere moral perversion up to the most intense form of maniacal excitement. On the physical side the various symptoms of cerebral tumour such as coma, ataxia, paralysis, headache, vomiting, optic neuritis and epileptiform convulsions are met with. All forms of so-called moral changes and of changes of disposition are met with as mental symptoms and all the ordinary forms of insanity may occur in varying intensity; but by far the most common mental change occurring in connexion with cerebral tumour is a progressive enfeeblement of the intelligence, unattended with any more harmful symptoms than mental deterioration which ends in complete dementia.
(b) Arterial Degeneration.—Arterial degeneration is a common cause of mental impairment, especially of that form of mental affection known as “Early” dementia. It also predisposes to embolism and thrombosis, Insanity due to Arterial Degeneration. which often results in the paralytic and aphasic groups of nerve disturbance, and which are always accompanied by more or less marked interference with normal cerebral action.
The commonest seat for atheroma of the cerebral vessels is the arteries at the base of the brain and their main branches, especially the middle cerebral. As a general rule the other arteries of the cerebrum are not implicated to the same extent, although in a not inconsiderable number of cases of the disease all the arteries of the brain may participate in the change. When this is so, we obtain those definite symptoms of slowly advancing dementia commencing in late middle life and ending in complete dementia before the usual period for the appearance of senile dementia. The same appearances are met with in certain patients who have attained the age in which senile changes in the arteries are not unexpected. As a rule atheroma in the cerebral vessels is but a part of a general atheroma of all the arteries of the body. Atheroma is common after middle life and increases in frequency with age. The chief causes are syphilis, alcoholism, the gouty and rheumatic diatheses and above all Bright’s disease of the kidneys. Perhaps certain forms of Bright’s disease, owing to the tendency to raise the blood pressure, are of all causes the most common.
It is not easy to say to what extent, alone, the arteriosclerosis is effectual in inducing the gradual failure of the mental powers, and to what extent it is assisted in its operation by the action on the brain-cells of the general toxic substances which give rise to the arterial atheroma. In any case there can be no question that the gradual mechanical diminution of the blood-supply to the cortex caused by the occlusion of the lumen of the arteries is a factor of great importance in the production of mental incapacity.
General Paralysis of the Insane (syn. General Paralysis, dementia paralytica, progressive dementia) is a disease characterized by symptoms of progressive degeneration of the central nervous system, more particularly of the motor General Paralysis. centres. The disease is almost invariably fatal. Apparent recoveries do very occasionally occur, though this is denied by the majority of alienists. The disease is in every case associated with gradually advancing mental enfeeblement, and very frequently is complicated by attacks of mental disease.
General paralysis, which is a very common disease, was first recognized in France; it was identified by J. E. D. Esquirol, and further described and elaborated by A. L. J. Bayle, Delaye and J. L. Calmeil, the latter giving it the name of paralysie générale des aliénés.
As first described by the earlier writers the disease was regarded as being invariably associated with delusions of grandeur. At the present day this description does not apply to the majority of cases admitted into asylums. The change may be explained as being either due to an alteration in the type of the disease, or more probably the disease is better understood and more frequently diagnosed than formerly, the diagnosis being now entirely dependent on the physical and not on the mental symptoms. This latter may also be the explanation why general paralysis is much more common at the present day in British asylums than it was. The total death-rate from this disease in English and Scottish asylums rose from 1321 in 1894 to 1795 in 1904.
General paralysis attacks men much more frequently than women, and occurs between the ages of 35 and 50 years. It is essentially a disease of town life. In asylums which draw their patients from country districts in Scotland and Ireland, the disease is rare, whereas in those which draw their population from large cities the disease is extremely common.
Considerable diversity of opinion exists at present regarding the causation of general paralysis. Hereditary predisposition admittedly plays a very small part in its causation. There is, however, an almost universal agreement that the disease is essentially the result of toxaemia or poisoning, and that acquired or inherited syphilitic infection is an important predisposing factor. A history of syphilitic infection occurs in from 70 to 90% of the patients affected. At first it was held that general paralysis was a late syphilitic manifestation, but as it was found that no benefit followed the use of anti-syphilitic remedies the theory was advanced that general paralysis was a secondary auto-intoxication following upon syphilitic infection. The latest view is that the disease is a bacterial invasion, to which syphilis, alcoholism, excessive mental and physical strain, and a too exclusively nitrogenous diet, only act as predisposing causes. This latter theory has been recently advanced and elaborated by Ford Robertson and McRae of Edinburgh.
Whatever the cause of general paralysis may be, the disease is essentially progressive in character, marked by frequent remissions and so typical in its physical symptoms and pathology that we regard the bacterial theory with favour, although we are far from satisfied that the actual causative factor has as yet been discovered.
For descriptive purposes the disease is most conveniently divided into three stages,—called respectively the first, second and third,—but it must be understood that no clear line of demarcation divides these stages from one another.
The onset of general paralysis is slow and gradual, and the earliest symptoms may be either physical or mental. The disease may commence either in the brain itself or the spinal cord may be primarily the seat of lesion, the brain becoming affected secondarily. When the disease originates in the spinal cord the symptoms are similar to those of locomotor ataxia, and it is now believed that general paralysis and locomotor ataxia are one and the same disease; in the one case the cord, in the other the brain, being the primary seat of lesion. The early physical symptoms are generally motor. The patient loses energy, readily becomes tired, and the capacity for finely co-ordinated motor acts, such as are required in playing games of skill, is impaired. Transient attacks of partial paralysis of a hand, arm, leg or one side of the body, or of the speech centre are not uncommon. In a few cases the special senses are affected early and the patient may complain of attacks of dimness of vision or impairment of hearing. Or the symptoms may be purely mental and affect the highest and most recently acquired attributes of man, the moral sense and the faculty of self-control. The patient then becomes irritable, bursts into violent passions over trifles, changes in character and habits, frequently takes alcohol to excess and behaves in an extravagant, foolish manner. Theft is often committed in this stage and the thefts are characterized by an open, purposeless manner of commission. The memory is impaired and the patient is easily influenced by others, that is to say he becomes facile. In other cases a wild attack of sudden excitement, following upon a period of restlessness and sleeplessness may be the first symptom which attracts attention. Whatever the mode of onset the physical symptoms which characterize the disease come on sooner or later. The speech is slurred and the facial muscles lose their tone, giving the face a flattened expression. The muscular power is impaired, the gait is straddling and the patient sways on turning. All the muscles of the body, but particularly those of the tongue, upper lip and hands, which are most highly innervated, present the symptom of fine fibrillary tremors. The pupils become irregular in outline, often unequal in size and either one or both fail to react normally to the stimuli of light, or of accommodation for near or distant vision.
As the disease advances there is greater excitability and a tendency to emotionalism. In classical cases the general exaltation of ideas becomes so great as to lead the patient to the commission of insanely extravagant acts, 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 beyond his physical powers. The mental symptoms, in short, are very similar to those of the elevated stage of manic-depressive insanity.
Delusions of the wildest character may also be present. 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. This grandiose condition is by no means present in every case and is not in itself diagnostic of the disease. But mental facility, placid contentment, complete loss of judgment and affection for family and friends, with impaired memory, are symptoms universally present. As the disease advances the motor symptoms become more prominent. The patient has great difficulty in writing, misses letters out of words, words out of sentences, and writes in a large laboured hand. The expression becomes fatuous. The speech is difficult and the facial muscles are thrown into marked tremors whenever any attempt at speech is made. The voice changes in timbre and becomes high-pitched and monotonous. The gait is weak and uncertain and the reflexes are exaggerated. In the first stage the patient, through restlessness and sleeplessness, becomes thin and haggard. As the second stage approaches sleep returns, the patient lays on flesh and becomes puffy and unhealthy in appearance. The mental symptoms are marked by greater facility and enfeeblement, while the paralysis of all the muscles steadily advances. The patient is now peculiarly liable to what are called congestive seizures or epileptiform attacks. The temperature rises, the face becomes flushed and the skin moist. Twitchings are noticed in a hand or arm. These twitchings gradually spread until they may involve the whole body. The patient is now unconscious, bathed in perspiration, which is offensive. The bowels and bladder empty themselves reflexly or become distended, and bedsores are very liable to form over the heels, elbows and back. Congestive seizures frequently last for days and may prove fatal or, on the other hand, the patient may have recurrent attacks and finally die of exhaustion or some accidental disease, such as pneumonia. In the second stage of the disease the patient eats greedily, and as the food is frequently swallowed unmasticated, choking is not an uncommon accident. The special senses of taste and smell are also much disordered. We have seen a case of general paralysis, in the second stage drink a glass of quinine and water under the impression that he was drinking whisky.
The third stage of the disease is characterized by sleeplessness and rapid loss of body weight. Mentally the patient becomes quite demented. On the physical side the paralysis advances rapidly, so that the patient becomes bedridden and speechless. Death may occur as the result of exhaustion, or a congestive seizure, or of some intercurrent illness.
The duration of the disease is between eighteen months and three years, although it has been known to persist for seven.
No curative measures have so far proved of any avail in the treatment of general paralysis.
Insanity Associated with Epilepsy.—The term “epileptic insanity,” which has for many years been in common use, is now regarded as a misnomer. There is in short no such disease as epileptic insanity. A brain, however, Epileptic Insanity. which is so unstable as to exhibit the sudden discharges of nervous energy which are known as epileptic seizures, is prone to be attacked by insanity also, but there is no form of mental disease exclusively associated with epilepsy. Many epileptics suffer from the disease for a lifetime and never exhibit symptoms of insanity. The majority of patients, however, who suffer from epilepsy are liable to exhibit certain mental symptoms which are regarded as characteristic of the disease. Some suffer from recurrent attacks of depression, ill-humour and irritability, which may readily pass into violence under provocation. Others are emotionally fervid in religious observances, though sadly deficient in the practice of the religious life. A third class are liable to attacks of semi-consciousness which may either follow upon or take the place of a seizure, and during these attacks actions are performed automatically and without consciousness on the part of the patient.
When epileptics do become insane the insanity is generally one of the forms of mania. Either the patient suffers from sudden furious attacks of excitement in which consciousness is entirely abolished, or the mania is of the type of the elevated stage of folie circulaire (manic-depressive insanity) and alternates with periods of deep depression. In the elevated period the patient shows exaggerated self-esteem, with passionate outbursts of anger, and periods of religious emotionalism. While in the stage of depression the patient is often actively suicidal.
Epileptic patients who suffer from recurrent attacks of delirious mania are liable to certain nervous symptoms which indicate that not only are the motor centres in the brain damaged, but that the motor tracts in the spinal cord are also affected. The gait becomes awkward and laboured, the feet being lifted high off the ground and the legs thrown forward with a jerk. The tendon reflexes are at the same time exaggerated. These symptoms indicate descending degeneration of the motor tracts of the cord.
If the mental attacks partake of the character of elevation or depression the mental functions suffer more than the motor. These patients, in course of time, become delusional, enfeebled and childish, and in some cases the enfeeblement ends in complete dementia of a very degraded type.
Where insanity is superadded to epilepsy the prognosis is unfavourable.
Insanity Associated with or caused by Alcoholic and Drug Intoxication.—The true rôle of alcoholic indulgence in the production of insanity is at present very imperfectly understood. In many cases the alcoholism is merely a Toxic Insanity. symptom of the mental disease—a result, not a cause. In others, alcohol seems to act purely as a predisposing factor, breaking down the resistance of the patient and disordering the metabolism to such an extent that bodily disorders are engendered which produce well-marked and easily recognized mental symptoms. In others, again, alcohol itself may possibly act as a direct toxin, disordering the functions of the brain. In the latter class may be included the nervous phenomena of drunkenness, which commence with excitement and confusion of ideas, and terminate in stupor with partial paralysis of all the muscles. Certain brains which, either through innate weakness or as the result of direct injury, have become peculiarly liable to toxic influences, under the influence of even moderate quantities of alcohol pass into a state closely resembling delirious mania, a state commonly spoken of as mania a potu.
Delirium Tremens.—Delirium tremens is the form of mental disorder most commonly associated with alcoholic indulgence in the lay mind. Considerable doubt exists, however, as to whether the disease is directly or secondarily the result of alcoholic poisoning. Much evidence exists in favour of the latter supposition. Delirium tremens may occur in persons who have never presented the symptom of drunkenness, or it may occur weeks after the patient has ceased to drink alcohol, and in such cases the actual exciting cause of the disease may be some accidental complication, such as a severe accident, a surgical operation, or an attack of pneumonia or erysipelas.
The early symptoms are always physical. The stomach is disordered. The desire for food is absent, and there may be abdominal pain and vomiting. The hands are tremulous, and the patient is unable to sleep. At this stage the disease may be checked by the administration of an aperient and some sedative such as bromide and chloral. The mental symptoms vary greatly in their severity. In a mild case one may talk to the patient for some time before discovering any mental abnormality, and then it will be found that confusion exists regarding his position and the identity of those around him, while the memory is also impaired for recent events. Hallucinations of sight and hearing may be present. The hallucinations of sight may be readily induced by pressure upon the eyeballs. If the symptoms are more acute they usually come on suddenly, generally during the evening or night. The patient becomes excited, suffers from vivid hallucinations of sight and hearing which produce great fear, and these hallucinations may be so engrossing as to render him quite oblivious to the environment. The hallucinations of sight are characterized by the false sense impressions taking the forms of animals or insects which surround or menace the patient. Visions may also appear in the form of flames, goblins or fairies. The hallucinations of hearing rarely consist of voices, but are more of the nature of whistlings, and ringings in the ears, shouts, groans or screams which seem to fill the air, or emanate from the walls or floors of the room. All the special senses may be affected, but sight and hearing are always implicated. Delirium tremens is a short-lived disease, generally running its course in from four to five days. Recovery is always preceded by the return of the power of sleep.
The patient must be carefully nursed and constantly watched, as homicidal and suicidal impulses are liable to occur under the terrifying influence of the hallucinations. The food should be concentrated and fluid, given frequently and in small quantities.
Chronic Alcoholic Insanity.—Almost any mental disorder may be associated with chronic alcoholism, but the most characteristic mental symptoms are delusions of suspicion and persecution which resemble very closely those of the persecution stage of systematized delusional insanity. The appearance of the patient is bloated and heavy; the tongue is furred and tremulous, and symptoms of gastric and intestinal disorder are usually present. The gait is awkward and dragging, owing to the partial paralysis of the extensor muscles of the lower limbs. All the skeletal muscles are tremulous, particularly those of the tongue, lips and hands. The common sensibility of the skin is disordered so that the patient complains of sensory disturbances, such as tinglings and prickings of the skin, which may be interpreted as electric shocks. In some cases the mental symptoms may be concealed, but delusions and hallucinations, particularly hallucinations of sight and hearing, are very commonly present. The delusions are often directly the outcome of the physical state; the disordered stomach suggesting poisoning, and the disturbances of the special senses being interpreted as various forms of persecution. The patient hears voices shouting foul abuse at him; all his thoughts are read and repeated aloud; electric shocks are sent through him at night; gases are pumped into his room. Sexual delusions are very common and frequently affect marital relations by arousing suspicions regarding the fidelity of wife or husband; or the delusions may be more gross and take the form of belief in actual attempts at sexual mutilations. The memory is always impaired.
Patients who in addition to chronic alcoholism are also insane are always dangerous and liable to sudden and apparently causeless outbursts of violence.
Dipsomania.—Dipsomania is a condition characterized by recurrent or periodic attacks of an irresistible craving for stimulants. The general bodily condition has a great deal to do with the onset of the attack, that is to say, the patient is more liable to an attack when the bodily condition is low than when the health is good. The attacks may be frequent or recur at very long intervals. They generally last for a few weeks, and may be complicated by symptoms of excitement, delusions or hallucinations.
Treatment consists in attention to the general health between attacks, with the use of such tonics as arsenic and strychnine. During the attack the patient should be confined to bed and treated with sedatives.
Morphinism.—The morphia habit is most commonly contracted by persons of a neurotic constitution. The mental symptoms associated with the disease may arise either as the result of an overdose, when the patient suffers from hallucinations, confusion and mild delirium, frequently associated with vomiting. On the other hand, mental symptoms very similar to those of delirium tremens may occur as the result of suddenly cutting off the supply of morphia in a patient addicted to the habit. Finally, chronic morphia intoxication produces mentalvery similar to those of chronic alcoholism. This latter condition, characterized by delusions of persecution, mental enfeeblement and loss of memory, is hopelessly incurable. The patient is always thin and anaemic on account of digestive disturbances. There is weakness or slight paralysis of the lower limbs, and the skeletal muscles are tremulous.
Treatment.—The quantity of the drug used must be gradually reduced until it is finally discontinued, and during treatment the patient must be confined to bed.
Senile Insanity.—States of mental enfeeblement are always the result of failure of development or of structural changes in the cortical grey matter of the brain. If the enfeeblement is due to failure of development or brain damage Senile Insanity. occurring in early life, it is spoken of as idiocy or imbecility. Every form of insanity which occurs after a certain period of life is apt to be regarded by some observers as senile, but although the failing mental power may colour the character of the symptoms it cannot be regarded as correct to designate, for instance, a recurrent form of mania as senile merely because it necessarily manifests itself in a subject who has lived into the senile period. On the other hand, many persons first suffer from mental derangement at an advanced period of life without at the same time manifesting any marked failure of mental power, while others only manifest their insanity as a result of the decay of their mental faculties.
From this statement it will be seen that senile insanity is a complex of different conditions, some of them accompanied by dementia, others without dementia.
Senile Dementia is distinguished occasionally into “senile” properly so called, and “presenile” dementia, which supervenes at middle age or even earlier.
The occurrence of dementia is sometimes preceded by an acute hallucinatory phase, accompanied by mania or melancholia; but as a general rule, in the presenile cases, by neurasthenia, indifference, and mental apathy which extends to a disregard for the ordinary conventions and the means of subsistence.
It has pithily been remarked that the age of a man is the age of his blood-vessels. The two conditions of senile and presenile dementia cannot therefore be separated scientifically. From a clinical point of view, however, the two are distinguishable in so far as their symptoms are concerned, for the presenile cases are more complete and the process of dementia achieves its consummation earlier and quicker, while in the senile the gradual disease of the arteries and the slow decay of the mental faculties offer a different background for the manifestation of mental symptoms. Moreover, the senile patients more frequently present symptoms of recurrent attacks of acute insanity, a more pronounced emotionalism, and a greater tendency to restlessness at night. The presenile cases, on the other hand, except at the commencement of their malady, are usually free from acute and troublesome symptoms and present chiefly an apathetic indifference and irresponsiveness on the mental side, and on the physical side a neurasthenic and enfeebled bodily state. In both conditions memory is greatly impaired.
Added to senile dementia there is often found a condition of mania or melancholia or even of systematized delusional insanity. The chief symptoms of the maniacal attacks are the great motor restlessness and excitement, which are worst during the night time. Sleep is almost always seriously disturbed, and the patients rapidly become exhausted unless carefully nursed and tended. The actions of senile maniacs are often puerile and foolish, and they may exhibit impulses of a homicidal, suicidal or sexual character. The melancholic cases are also extremely restless, and their emotion is loudly expressed in an uncontrollable manner. They often have delusions of persecution. Their cries and groans have an automatic character, as if the patient, though compelled to utter them, did not experience the mental pain which he expressed. They also, many of them, eat their food ravenously, although a few obstinately refuse it. The senile delusional cases may manifest any of the classical forms of paranoia described above, but their delusions are of a rudimentary and unfinished type. The most common of all senile delusions is that they are being robbed. They therefore often hide their small valuables in corners and out-of-the-way places, and as their memories are very defective they are afterwards unable to find them. Others, who live alone, barricade their doors and try to prevent any one entering for fear of thieves. Delusions of ambition in senile subjects are usually of a very improbable and childish character. Hallucinations are generally present in the senile delusional cases.
The treatment of senile insanity is from the medical point of view not hopeful; it resolves itself largely into instructions for careful nursing, suitable feeding, and the protection of the patient from all the physical dangers to which he may be exposed.
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 of January 1907, according to the returns made to the offices of the Commissioners in Lunacy, the numbers of lunatics stood thus on the registers:—
|England and Wales||57,176||66,812||123,988|
These figures show the ratio of lunatics to 100,000 of the population to be 354 in England and Wales, 312 in Scotland, and 538 in Ireland.
Numbers of Lunatics on the 1st of January of the years 1857–1907 inclusive, according to Returns made to the Offices of the Commissioners in Lunacy for England and Wales, Scotland and Ireland.
There is thus an increased ratio in England and Wales of lunatics to the population (which in 1859 was 19,686,701, and in 1907 was estimated at 34,945,600) of 186.8 per 100,000 as against 354.8, and in Scotland of 157 as against 312 per 100,000. The Irish figures on the same basis have increased from 130.9 in 1862 to 538.1 in 1907. The publication of these figures has 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 very slight, and that the apparent increase is due, first to the improved systems of registration, and secondly (a far more powerful reason) to 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. 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 authorities 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, has 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 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 the 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.
The futility of seeking for accurate figures bearing on the relative number of lunatics in other countries is illustrated by the tables set forth in a report by the United States Census Bureau. They show that the number of registered lunatics in 1903 was 150,151; in 1890, 74,028; and in 1880, 40,942. An attempt was made in 1890 to estimate the number of insane persons outside of hospitals, which was stated to be 32,457. In 1903 no such attempt was made, as it was admitted that so many sources of fallacy existed as to render it useless. Thus the mere statement that of every 100,000 of the population (calculated at 80,000,000) 186.2 were registered as insane is of no value.
Bibliography.—The following are systematic works: Bucknill and Tuke, Psychological Medicine (4th edition, 1879); Griesinger, On Mental Diseases (New Sydenham Society, 1867); Maudsley, The Pathology of Mind (1895); Bevan Lewis, A Text-Book of Mental Diseases (1899); Clouston, Clinical Lectures on Mental Diseases (1892); Kraepelin, Psychiatrie (1893); Krafft-Ebing, Lehrbuch der Psychiatrie (1893); Regis, A Practical Manual of Mental Medicine (London, 1895); Magnan, Leçons cliniques sur les maladies mentales (1897); Mendil, Leitfaden der Psychiatrie (1902); Mercier, A Text-Book of Insanity (1902); Lewis C. Bruce, Studies in Clinical Psychiatry (1906); Macpherson, Mental Affections (1899); Brower-Bannister, Practical Manual of Insanity (1902); Ford Robertson, Text-Book of Pathology in Relation to Mental Diseases (1900).
II. Legal Aspects
The effect of insanity upon responsibility and civil capacity has been recognized at an early period in every system of law.
Roman Law.—In the Roman jurisprudence its consequences 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 (see Sohm’s Inst. Roman Law, 3rd ed. pp. 216, 217, 219); his person and property were placed after inquiry by the magistrate under the control of a curator, who was empowered and bound to manage the property of the lunatic on his behalf (Sohm, p. 513; Hunter, Roman Law, pp. 732-735). The different terms by which the insane were known, such as demens, furiosus, fatuus, although no doubt signifying different types of insanity, did not in Roman law infer any difference of legal treatment. They were popular names, which all denoted the complete deprivation of reason.
Medieval Law.—During the middle ages the insane were little protected. 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 persons and property now exercised under the jurisdiction in lunacy. Those whose means were insignificant 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 the 19th century a very considerable change commenced. The public attention was strongly attracted to the miserable condition of the insane 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, Philippe Pinel in France, H. Tuke in England, Bond, B. Rush and I. Ray in the United States; its physical origin became generally accepted; its mental phenomena were more carefully observed, and its relation was established to other mental conditions.
Modern Law.—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. 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, still continues.
Relations between Insanity and Law.—The fact of insanity may operate in law—(1) by excluding responsibility for crime; (2) by invalidating legal acts; (3) by affording ground for depriving the insane person by a legal process of the control of his person and property; or (4) by affording ground for putting him under restraint.
Legal Terminology.—Before proceeding, however, to deal with these matters in succession, it may be desirable to say something with regard to the chief legal terms respecting persons suffering under mental disabilities. The subject is now of less importance than formerly, because the modern tendency of the law is to determine the capacity or responsibility of a person alleged to be insane by considering it with reference to the particular matter or class of matters which brings his mental condition sub judice. But the literature of the law of lunacy cannot be clearly understood unless the distinctions between the different terms employed to describe the insane are kept in view. The term non compos mentis is as old as the statute De praerogativa regis (1325), and is used sometimes, as in that statute, to indicate a species contrasted with idiot, sometimes (e.g. in Co. Litt. 246 (b)) as a genus, and afterwards, chiefly in statutes relating to the insane, in connexion with the terms “idiot” and “lunatic” as a word ejusdem generis. The word “idiot” (Gr. ἴδιος, a private person, one who does not hold any public office, and ἰδιώτης, an ignorant and illiterate person) appears in the statute De praerogativa regis as fatuus naturalis, and it is placed in contradistinction to non compos mentis. The “idiot” is defined by Sir E. Coke (4 Rep. 124 (b)) as one who from his nativity, by a perpetual infirmity, is non compos mentis, and Sir M. Hale (Pleas of the Crown, i. 29) describes idiocy as “fatuity a nativitate vel dementia naturalis.” In early times various artificial criteria of idiocy were suggested. Fitzherbert’s test was the capacity of the alleged idiot to count twenty pence, or tell his age, or who were his father and mother (De natura brevium, 233). Swinburne proposed as a criterion of capacity, inter alia, to measure a yard of cloth or name the days in the week (Testaments, 42). Hale propounded the sounder view that “idiocy or not is a question of fact triable by jury and sometimes by inspection” (Pleas of the Crown, i. 29). The legal incidents of idiocy were at one time distinct in an important particular from those of lunacy. Under the statute De praerogativa regis the king was to have the rents and profits of an idiot’s lands to his own use during the life of the idiot, subject merely to an obligation to provide him with necessaries. In the case of the lunatic the king was a trustee, holding his lands and tenements for his benefit and that of his family. It was on account of this difference in the legal consequences of the two states that on inquisitions distinct writs, one de idiota inquirendo, the other de lunatico inquirendo, were framed for each of them. But juries avoided finding a verdict of idiocy wherever they could, and the writ de idiota inquirendo fell into desuetude. A further blow was struck at the distinction when it came to be recognized even by the legislature (see the Idiots Act 1886) that idiots are capable of being educated and trained, and it was practically abolished when the Lunacy Regulation Act 1862, in a provision reproduced in substance in the Lunacy Act 1890, limited the evidence admissible in proof of unsoundness of mind on an inquisition (without special leave of the Master trying the case) to a period of two years before the date of the inquiry, and raised a uniform issue, viz. the state of mind of the alleged lunatic at the time when the inquisition is held.
The term “lunatic,” derived from the Latin luna in consequence of the notion that the moon had an influence on mental disorders, does not appear in the statute-book till the time of Henry VIII. (1541). Coke defines a lunatic as a “person who has sometimes his understanding and sometimes not, qui gaudet lucidis intervallis, and therefore he is called non compos mentis so long as he has not understanding” (Co. Litt. 247 (a), 4 Rep. 124 (b)). Hale defines “lunacy” as “interpolated” (i.e. intermittent) dementia accidentalis vel adventitia, whether total or (a description, it will be observed, of “partial insanity”) quoad hoc vel illud (Pleas of the Crown, i. 29). In modern times, the word “lunacy” has lost its former precise signification. It is employed sometimes in the strict sense, sometimes in contradistinction to “idiocy” or “imbecility”; once at least—viz. in the Lunacy Act 1890—as including “idiot”; and frequently in conjunction with the vague terms “unsound mind” (non-sane memory) and “insane.” Section 116 of the Lunacy Act 1890 has by implication extended the meaning of the term lunacy so as to include for certain purposes the incapacity of a person to manage his affairs through mental infirmity arising from disease or age. “Imbecility” is a state of mental weakness “between the limits of absolute idiocy on the one hand and of perfect capacity on the other” (see 1 Haggard, Eccles. Rep. p. 401).
1. The Criminal Responsibility of the Insane.—The law as to the criminal responsibility of the insane has pursued in England a curious course of development. The views of Coke and Hale give the best exposition of it in the 17th century. Both were agreed that in criminal causes the act and wrong of a madman shall not be imputed to him; both distinguished, although in different language, between dementia naturalis (or a nativitate) and dementia accidentalis or adventitia; and the main points in which the writings of Hale mark an advance on those of Coke are in the elaboration by the former of the doctrine of “partial insanity,” and his adoption of the level of understanding of a child of fourteen years of age as the test of responsibility in criminal cases (Pleas of the Crown, i. 29, 30; and see Co. 4 Rep. 124 (b)). In the 18th century a test, still more unsatisfactory than this “child of fourteen” theory, with its identification of “healthy immaturity” with “diseased maturity” (Steph. Hist. Crim. Law, ii. 150), was prescribed. On the trial of Edward Arnold in 1723 for firing at and wounding Lord Onslow, Mr Justice Tracy told the jury that “a prisoner, in order to be acquitted on the ground of insanity, must be a man that is totally deprived of his understanding and memory, and doth not know what he is doing, no more than an infant, than a brute or wild beast.” In the beginning of the 19th century a fresh statement of the test of criminal responsibility in mental disease was attempted. On the trial of Hadfield for shooting at George III. in Drury Lane Theatre on 15th May 1800, Lord Chief Justice Kenyon charged the jury in the following terms: “If a man is in a deranged state of mind at the time, he is not criminally answerable for his acts; but the material part of the case is whether at the very time when the act was committed the man’s mind was sane.” The practical effect of this ruling, had it been followed, would have been to make the question of the amenability of persons alleged to be insane to the criminal law very much one of fact, to be answered by juries according to the particular circumstances of each case, and without being aided or embarrassed by any rigid external standard. But in 1812, on the trial of Bellingham for the murder of Mr Perceval, the First Lord of the Treasury, Sir James Mansfield propounded yet another criterion of criminal responsibility in mental disease, viz. whether a prisoner has, at the time of committing an offence, a sufficient degree of capacity to distinguish between good and evil. The objection to this doctrine consisted in the fact, to which the writings of Continental and American jurists soon afterwards began to give prominence, that there are very many lunatics whose general ideas on the subject of right and wrong are quite unexceptionable, but who are yet unable, in consequence of delusions, to perceive the wrongness of particular Macnaughton’s Case. acts. Sir James Mansfield’s statement of the law was discredited in the case (4 State Tri. (n.s.) 847; 10 Cl. and Fin. 200) of Daniel Macnaughton, who was tried in March 1843, before Chief Justice Tindal, Mr Justice Williams and Mr Justice Coleridge, for the murder of Mr Drummond, the private secretary of Sir Robert Peel. Mr (afterwards Lord Chief Justice) Cockburn, who defended the prisoner, used Hale’s doctrine of partial insanity as the foundation of the defence, and secured an acquittal, Chief Justice Tindal telling the jury that the question was whether Macnaughton was capable of distinguishing right from wrong with respect to the act with which he stood charged. This judicial approval of the doctrine of partial insanity formed the subject of an animated debate in the House of Lords, and in the end certain questions were put by that House to the judges, and answered by Chief Justice Tindal on behalf of all his colleagues except Mr Justice Maule, who gave independent replies. The answers to those questions are commonly called “The Rules in Macnaughton’s case,” and they still nominally contain the law of England as to the criminal responsibility of the insane. The points affirmed by the Rules that must be noted here are the propositions that knowledge of the nature and quality of the particular criminal act, at the time of its commission, is the test of criminal responsibility, and that delusion is a valid exculpatory plea, when, and only when, the fancies of the insane person, if they had been facts, would have been so. The Rules in Macnaughton’s case are open to serious criticism. They ignore, at least on a literal interpretation, those forms of mental disease which may, for the present purpose, be roughly grouped under the heading “moral insanity,” and in which the moral faculties are more obviously deranged than the mental—the affections and the will, rather than the reason, being apparently disordered. The test propounded with reference to delusions has also been strenuously attacked by medical writers, and especially by Dr Maudsley in his work on Responsibility in Mental Disease, on the ground that it first assumes a man to have a delusion in regard to a particular subject, and then expects and requires him to reason sanely upon it. It may be pointed out, however, that in thus localizing the range of the immunity which insane delusion confers, the criminal law is merely following the course which, mutatis mutandis, the civil law has, with general acceptance, adopted in questions as to the contractual and testamentary capacity of the insane.
The Rules in Macnaughton’s case have, as regards moral insanity, undergone considerable modification. Soon after they were laid down, Sir (then Mr) James Fitz-James Stephen, in an article in the Juridical Papers, i. 67, on the policy of maintaining the existing law as to the criminal responsibility of the insane, foreshadowed the view which he subsequently propounded in his History of the Criminal Law, ii. 163, that no man who was deprived by mental disease of the power of passing a fairly rational judgment on the moral character of an act could be said to “know” its nature and quality within the meaning of the Rules; and it has in recent years been found possible in practice so to manipulate the test of the criminal responsibility which they prescribed as to afford protection to the accused in the by no means infrequent cases of insanity which in its literal interpretation it would leave without excuse.
In Scotland the Rules in Macnaughton’s case are recognized, but, as in England, there is a tendency among judges to adopt a generous construction of them. Mental unsoundness insufficient to bar trial, or to exempt from punishment, may still, it is said, be present in a degree which is regarded as reducing the offence from a higher to a lower category,—a doctrine first practically applied in Scotland, it is believed, in 1867 by Lord Deas; and the fact that a prisoner is of weak or ill-regulated mind is often urged with success as a plea in mitigation of punishment. The Indian Penal Code (Act XLV. of 1860, § 84) expressly adopts the English test of criminal responsibility, but the qualifications noted in the case of Scotland have received some measure of judicial acceptance (see Mayne, Crim. Law Ind., 3rd ed., pp. 403-419; Nelson, Ind. Pen. Code, 3rd ed., pp. 135 et seq.). The Rules in Macnaughton’s case have also been adopted in substance in those colonies which have codified the criminal law. The following typical references may be given: 55 and 56 Vict. (Can.) c. 29, § 11; 57 Vict. (N.Z.), No. 56 of 1893, § 23; No. 101 of 1888 (St Lucia), § 50; No. 5 of 1876 (Gold Coast), § 49 (b); No. 2 of 1883, art. 77 (Ceylon); No. 4 of 1871, art. 84 (Straits Settlements). On the other hand, a departure towards a recognition of “moral insanity” is made by the Queensland Criminal Code (No. 9 of 1899), § 27 of which provides that “a person is not criminally responsible for an act” if at the time of doing it “he is in such a state of mental disease ... as to deprive him ... of capacity to control his actions”: and the law has been defined in the same sense in the Cape of Good Hope in the case of Queen v. Hay (1899, 16 S.C.R. 290). The Rules were rapidly reproduced in the United States, but the modern trend of American judicial opinion is adverse to them (see Clevenger, Med. Jur. of Ins. p. 125; Parsons v. State (1887) 81 Ala. 577). On the Continent of Europe moral insanity and irresistible impulse are freely recognized as exculpatory pleas (see the French Code Penal, § 64; Belgian Code Penal, § 71; German Penal Code, § 51; Italian Penal Code, §§ 46, 47).
Not only is insanity at the time of the commission of an offence a valid exculpatory plea, but supervening insanity stays the action of the criminal law at every stage from arrest up to punishment. High treason was formerly an exception, but the statute making it so (33 Hen. VIII. c. 20) was repealed in the time of Philip and Mary. The Home Secretary has power, under the Criminal Lunatics Act 1884 to order by warrant the removal of a prisoner, certified to be insane, to a lunatic asylum, before trial or after trial, whether under sentence of death or not. Prisoners dealt with under these provisions are styled “Secretary of State’s lunatics.” On the other hand, a prisoner who on arraignment appears, or is found by the jury to be unfit to plead, or who is found “guilty but insane” at the time of committing the offence—a verdict substituted by the Trial of Lunatics Act 1883 for the old verdict of “acquitted on the ground of insanity,” in the hope that the formal conviction recorded in the new finding might have a deterrent effect on the mentally unstable—is committed to a criminal lunatic asylum by the order of the judge trying the case, to be detained there “during the king’s pleasure.” Lunatics of this class are called “king’s pleasure lunatics.” There was no doubt at common law as to the power of the courts to order the detention of criminal lunatics in safe custody, but, prior to 1800, the practice was varying and uncertain. On the acquittal of Hadfield, however, in that year for the attempted murder of George III., a question arose as to the provision which was to be made for his detention, and the Criminal Lunatics Act 1800, part of which is still in force, was passed to affirm the law on the subject.
The Criminal Lunatics Act contains provisions similar to those of the Lunacy Act 1890, as to the discharge (conditional or absolute) and transfer of criminal lunatics and the detention of persons becoming pauper lunatics. The expenses of the maintenance of criminal lunatics are defrayed out of moneys provided by Parliament (Crim. Luns. Act 1884, and Hansard, 3rd series, vol. ccxc. p. 75; 139 Com. Jo. pp. 336, 340, 344). The Lunatics’ Removal (India) Act 1851 provides for the removal to a criminal lunatic asylum in Great Britain of persons found guilty of crimes and offences in India, and acquitted on the ground of insanity. Similar provisions with regard to colonial criminal lunatics are contained in the Colonial Prisoners’ Removal Act 1884; and the policy of this statute has been followed by No 5. of 1894 (New South Wales), and Ordin. No. 2 of 1895 (Falkland Islands). Indian law (see Act V. of 1898, §§ 464–475) and the laws of the colonies (the Cape Act No. 1 of 1897 is a typical example) as to the trial of lunatics are similar to the English. In Scotland all the criminal lunatics, except those who may have been removed to the ordinary asylums or have been discharged, are confined in the Criminal Asylum established at Perth in connexion with H.M.’s General Prison, and regulated by special acts (23 & 24 Vict. c. 105, and 40 & 41 Vict. c. 53). Provision similar to the English has been made for prisoners found insane as a bar to trial, or acquitted on the ground of insanity or becoming insane in confinement. In New York, Michigan and other American states there are criminal lunatic asylums. Elsewhere insane criminals are apparently detained in state prisons, &c. The statutory rules as to the maintenance of criminal lunatic asylums, the treatment of the criminal insane, and the plea of insanity in criminal courts in America, closely resemble English practice. The only special point in Continental law calling for notice is the system by which official experts report for the guidance of the tribunals on questions of alleged criminal irresponsibility (see, e.g., the German Code of Penal Procedure, § 293, and cp. § 81).
2. Insanity and Civil Capacity.—The law as to the civil capacity of the insane was for some time influenced in Great Britain by the view propounded by Lord Brougham in 1848 in the case of Waring v. Waring, and by Sir J. P. Wilde in a later case, raising the question of the validity of a marriage, that, as the mind is one and indivisible, the least disorder of its faculties was fatal to civil capacity. In the leading case of Banks v. Goodfellow in 1870, the court of queen’s bench, in an elaborate judgment delivered by Chief Justice Cockburn, disapproved of this doctrine, and in effect laid down the principle that the question of capacity must be considered with strict reference to the act which has to be or has been done. Thus a certain degree of unsoundness of mind is not now, in the absence of undue influence, a bar to the formation of a valid marriage, if the party whose capacity is in question knew at the time of the marriage the nature of the engagement entered into (but see 51 Geo. III. c. 37 as to the marriage of lunatics so found by inquisition). Again, a man whose mind is affected may make a valid will, if he possesses at the time of executing it a memory sufficiently active to recall the nature and extent of his property, the persons who have claims upon his bounty, and a judgment and will sufficiently free from the influence of morbid ideas or external control to determine the relative strength of those claims. So far has this rule been carried, that in 1893 probate was granted of the will of a lady who was a Chancery lunatic at the date of its execution, and died without the inquisition having been superseded. (Roe v. Nix, 1893, P. 55.) It is also now settled that the simple contract of a lunatic is voidable and not void, and is binding upon him, unless he can show that at the time of making it he was, to the knowledge of the other party, so insane as not to know what he was about. (Imperial Loan Co. v. Stone, 1892, 1 Q.B. 599.) The test established by Banks v. Goodfellow is applied also in a number of minor points in which civil capacity comes into question, e.g. competency of the insane as witnesses. The law implies, on the part of a lunatic, whether so found or not, an obligation to pay a reasonable price for “necessaries” supplied to him; and the term “necessaries” means goods suitable to his condition in life and to his actual requirements at the time of sale and delivery (Sale of Goods Act 1893).
The question of the liability of an insane person for tort appears still to be undecided (see Pollock on Torts, 7th ed. p. 53; Clerk and Lindsell on Torts, 2nd ed. pp. 39, 40; Law Quart. Rev. vol. xiii. p. 325). Supervening insanity is no bar to proceedings by or against a lunatic husband or wife for divorce or separation for previous matrimonial offences. It does not avoid a marriage nor constitute per se a ground either for divorce or for judicial separation. But cruelty does not cease to be a cause of suit if it proceeds from disorderly affections or want of moral control falling short of positive insanity; and possibly even cruelty springing from intermittent or recurrent insanity might be held a ground for judicial separation, since in such case the party offended against cannot obtain protection by securing the permanent confinement of the offending spouse. Whether insanity at the time when an alleged matrimonial offence was committed is a bar to a suit for divorce or separation is an open question; and in any event, in order that it may be so, the insanity must be of such a character as to have prevented the insane party from knowing the nature and consequences of the act at the time of its commission. The laws of Scotland, Ireland, India (see, e.g., Act IX. of 1872, § 12), the colonies and the United States are substantially identical with English law on the subject of the civil capacity of the insane. The German Civil Code (§ 1569) recognizes the lunacy of a spouse as a ground for divorce, but only where the malady continues during at least three years of the union, and has reached such a pitch that intellectual intercourse between the spouses is impossible, and that every prospect of a restoration of such association is excluded. If one of the spouses obtains a divorce on the ground of the lunacy of the other the former has to allow alimony, just as a husband declared to be the sole guilty party in a divorce suit would have to do (§§ 1585, 1578).
3. The Jurisdiction in Lunacy.—In order to effect a change in the status of persons alleged to be of unsound mind, and to bring their persons and property under control, the aid of the jurisdiction in lunacy must be invoked. Under the unrepealed statute De Praerogativa Regis (1325) the care and custody of lunatics belong to the Crown. But the Crown has, at least since the 16th century, exercised this branch of the prerogative by delegates, and principally through the Lord Chancellor—not as head of the Court of Chancery, but as the representative and delegate of the sovereign. Under the Lunacy Acts 1890 and 1891, the jurisdiction in lunacy is exercised first by the Lord Chancellor and such of the Lords Justices and other judges as may be invested with it by the sign-manual; and, secondly, by the two Masters in Lunacy, appointed by the Lord Chancellor, from members of the bar of at least ten years’ standing, whose duties include the holding of inquisitions and summary inquiries, and the making of most of the consequential orders dealing with the persons and estates of lunatics. County court judges may also exercise a limited jurisdiction in lunacy in the case of lunatics as to whom a reception order has been made, if their entire property is under £200 in value, and no relative or friend is willing to undertake the management of it; in partnership cases where the assets do not exceed £500; and upon application by the guardians of any union for payment of expenses incurred by them in relation to any lunatic.
Persons of unsound mind are brought under the jurisdiction in lunacy either by an inquisition de lunatico inquirendo, or, in certain cases which will be adverted to below, by proceedings instituted under § 116 of the Lunacy Act 1890, which is now the great practice section in the Lunacy Office. Prior to 1853 a special commission was issued to the Masters in each alleged case of lunacy. But by the Lunacy Regulation Act of that year a general commission was directed to the Masters, empowering them to proceed in each case in which the Lord Chancellor by order required an inquisition to be held. This procedure is still in force. A special commission would now be issued only where both Masters were personally interested in the subject of the inquiry, or for some other similar reason. An inquisition is ordered by the judge in lunacy (a term which does not, for this purpose, at present include the Masters, although this is one of the points in regard to which a change in the law has been suggested, on the petition generally of a near relative of the alleged lunatic). The inquiry is held before one of the Masters, and a jury may be summoned if the alleged lunatic, being within the jurisdiction, demands it, unless the judge is satisfied that he is not competent to form and express such a wish; and even in that case the Master has power to direct trial by jury if he thinks fit on consideration of the evidence. Where the alleged lunatic is not within the jurisdiction the trial must be by jury; and the judge in lunacy may direct this mode of trial to be adopted in any case whatever.
A few points of general interest in connexion with inquisitions must be noted. In practice thirty-four jurors are summoned by the sheriff, and not more than twenty-four are empanelled. Twelve at least must concur in the verdict. Counsel for the petitioner ought to act in the judicial spirit expected from counsel for the prosecution in criminal cases. The issue to be determined on an inquisition is “whether or not the alleged lunatic is at the time of the inquisition of unsound mind, and incapable of managing himself and his affairs” (a special verdict may, however, be found that the lunatic is capable of managing himself, although not his affairs, and that he is not dangerous to others); and without the direction of the person holding the inquisition, no evidence as to the lunatic’s conduct at any time being more than two years before the inquisition is to be receivable. This limitation, both of the issue and of the evidence, was imposed with a view to preventing the recurrence of such cases as that of Mr Windham in 1861–1862, when the inquiry ranged over the whole life of an alleged lunatic, forty-eight witnesses being examined on behalf of the petitioners and ninety-one on behalf of the respondents, while the hearing lasted for thirty-four days. For the purpose of assisting the Master or jury in arriving at a decision, provision is made for the personal examination of the alleged lunatic by them on oath or otherwise, and either in open court or in private, as may be directed. The proceedings on inquisition are open to the public. When a person has been found lunatic by inquisition he becomes subject to the jurisdiction in lunacy, and remains so (unless he succeeds in setting aside the verdict by a “traverse”—a proceeding which ultimately comes before, and is determined by, the King’s Bench Division in London or at the assizes) until his recovery, when the inquisition may be put an end to by a procedure technically known as “supersedeas,” or by his death. The results of the inquisition are worked out in the Lunacy Office. The control of the estate, and, except where he was found incapable of managing his property only, of the person of the lunatic is entrusted to committees of the estate and person, who are appointed by, and accountable to, the Master in Lunacy, and whose legal position corresponds roughly with that of the tutors and curators of the civil law. The committee of the estate in particular exercises over the property of the lunatic, with the sanction or by the order of the Master, very wide powers of management and administration, including the raising of money by sale, charge or otherwise, to pay the lunatic’s debts, or provide for his past or future maintenance, charges for permanent improvements, the sale of any property belonging to the lunatic, the execution of powers vested in him and the performance of contracts relating to property.
The alternative method of bringing a person of unsound mind under lunacy jurisdiction was created by § 116 of the Lunacy Act 1890. The effect of that section briefly is to enable the Master, on a summons being taken out in his chambers and heard before him, to apply the powers of management and administration summarized in the last preceding paragraph, without any inquisition, to the following classes of cases: lunatics not so found by inquisition, for the protection or administration of whose property any order was made under earlier acts; every person lawfully detained, within the jurisdiction of the English courts, as a lunatic, though not so found by inquisition; persons not coming within the foregoing categories who are “through mental infirmity arising from disease or age” incapable of managing their affairs; persons of unsound mind whose property does not exceed £2000 in value, or does not yield an annual income of more than £100; and criminal lunatics continuing insane and under confinement.
In Scotland the insane are brought under the jurisdiction in lunacy by alternative methods, similar to the English inquisition and summary procedure, viz. “cognition,” the trial taking place before the Lord President of the Court of Session, or any judge of that court to whom he may remit it, and a jury of twelve—see 31 & 32 Vict. c. 100, and Act of Sederunt of 3rd December 1868—and an application to the Junior Lord Ordinary of the Court of Session or (43 & 44 Vict. c. 4, § 4) to the Sheriff Court, when the estate in question does not exceed £100 a year, for the appointment of a curator bonis or judicial factor.
The powers of the Lord Chancellor of Ireland with regard to lunatics are generally similar to those of the English Chancellor (see the Lunacy Regulations (Ireland) Act 1871, 34 & 35 Vict. c. 22, and the Lunacy (Ireland) Act 1901, 1 Ed. VII. c. 17; also Colles on The Lunacy Regulation (Ireland) Act.
The main feature of the French system is the provision made by the Civil Code (arts. 489-512) for the interdiction of an insane person by the Tribunal of First Instance, with a right of appeal to the Court of Appeal, after a preliminary inquiry and a report by a family council (arts. 407, 408), consisting of six blood relatives in as near a degree of relationship to the lunatic as possible, or, in default of such relatives, of six relatives by marriage. The family council is presided over by the Juge de Paix of the district in which the lunatic is domiciled. This system is also in force in Mauritius.
There are provisions, it may be noted, in Scots law for the interdiction of lunatics, either voluntarily or judicially (see Bell’s Principles, § 2123). The German Civil Code provides for insane persons being made subject to guardianship (vormundung), on conditions similar to those of Scots and French law (see Civil Code, §§ 6, 104 (1896, 1906), 645-679). In the United States the fundamental procedure is an inquisition conducted on practically the same lines as in England. (Cf. Indiana, Rev. Stats. (1894) §§ 2715 et seq.; Missouri, Annot. Code (1892) §§ 2835 et seq.; New Mexico, General Laws (1880) c. 74 §§ 1 et seq.).
4. Asylum Administration.—Asylum administration in England is now regulated by the Lunacy Acts 1890 and 1891. Receptacles for the insane are divisible into the following classes: (i.) Institutions for lunatics, including asylums, registered hospitals and licensed houses. The asylums are provided by counties or boroughs, or by union of counties or boroughs. Registered hospitals are hospitals holding certificates of registration from the Commissioners in Lunacy, where lunatics are received and supported wholly or partially by voluntary contributions or charitable bequests, or by applying the excess of the payments of some patients towards the maintenance of others. Licensed houses are houses licensed by the Commissioners, or, beyond their immediate jurisdiction, by justices; (ii.) Workhouses—see article Poor Law; (iii.) Houses in which patients are boarded out; (iv.) Private houses (unlicensed) in which not more than a single patient may be received. A person, not being a pauper or a lunatic so found by inquisition, cannot, in ordinary cases, be received and detained as a lunatic in any institution for the insane, except under a “reception order” made by a county court judge or stipendiary magistrate or specially appointed justice of the peace. The order is made on a petition presented by a relative or friend of the alleged lunatic, and supported by two medical certificates, and after a private hearing by the judicial authority. The detention of a lunatic is, however, justifiable at common law, if necessary for his safety or that of others; and the Lunacy Act 1890, borrowing from the lunacy law of Scotland, provides for the reception of a lunatic not a pauper into an asylum, where it is expedient for his welfare or the public safety that he should be confined without delay, upon an “urgency order,” made if possible by a near relative and accompanied by one medical certificate. The urgency order only justifies detention for seven days (the curtailment of this period to four days is proposed), and before the expiration of that period the ordinary procedure must be followed. “Summary reception orders” may be made by justices otherwise than on petition. There are four classes of cases in which such orders may be made, viz.: (i.) lunatics (not paupers and not wandering at large) who are not under proper care and control, or are cruelly treated or neglected; (ii.) resident pauper lunatics; (iii.) lunatics, whether pauper or not, wandering at large; (iv.) lunatics in workhouses. (As to pauper lunatics generally, see article Poor Law.) A lunatic may also be received into an institution under an order by the Commissioners in Lunacy; and a lunatic so found by inquisition under an order signed by the committee of his person.
The chief features of English asylum administration requiring notice are these. Mechanical restraint is to be applied only when necessary for surgical or medical purposes, or in order to prevent the lunatic from injuring himself or others. The privacy of the correspondence of lunatics with the Lord Chancellor, the Commissioners in Lunacy, &c., is secured. Provision is made for regular visits to patients by their relatives and friends. The employment of males for the custody of females is, except on occasions of urgency, prohibited. Pauper lunatics may be boarded out with relatives and friends. Elaborate provision is made for the official visitation of every class of receptacle for the insane. The duties of visitation are divided between the Commissioners in Lunacy, the Chancery Visitors and various other visitors and visiting committees. There are ten Commissioners in Lunacy—four unpaid and six paid, three of the latter being barristers of not less than five years’ standing at the date of appointment, and three medical. The Commissioners in Lunacy, who are appointed by the Lord Chancellor, visit every class of lunatics except persons so found by inquisition. These are visited by the Chancery Visitors. There are three Chancery Visitors, two medical and one legal (a barrister of at least five years’ standing at the date of his appointment), who are appointed and removable by the Lord Chancellor. The Chancery Visitors (together with the Master in Lunacy) form a Board, and have offices in the Royal Courts of Justice. In addition to these two classes of visitors, every asylum has a Visiting Committee of not less than seven members, appointed by the local authority; and the justices of every county and quarter-sessions borough not within the immediate jurisdiction of the Commissioners in Lunacy annually appoint three or more of their number as visitors of licensed houses.
Provision is made for the discharge of lunatics from asylums, &c., on recovery, or by habeas corpus, or by the various visiting authorities. Any person who considers himself to have been unjustly detained is entitled on discharge to obtain, free of expense, from the secretary to the Lunacy Commissioners a copy of the documents under which he was confined.
The Irish [Lunacy Acts 1821–1890; Lunacy (Ireland) Act 1901] and Scottish [Lunacy Acts 1857 (20 & 21 Vict. c. 71), 1887 (50 & 51 Vict. c. 39)] asylum systems present no feature sufficiently different from the English to require separate notice, except that in Scotland “boarding out” is a regular, and not merely an incidental, part of asylum administration. The “boarding out” principle has, however, received its most extended and most successful application in the Gheel colony in Belgium. The patients, after a few days’ preliminary observation, are placed in families, and, except that they are under ultimate control by a superior commission, composed of the governor of the province, the Procureur du Roi and others, enjoy complete liberty indoors as well as out of doors. The patients are visited by nurses from the infirmary, to which they may be sent if they become seriously ill or unmanageable. They are encouraged to work. The accommodation provided for them is prescribed, and is to be of the same quality as that of the household in which they live. Clothing is provided by the administration.
In the French (see laws of 30th June 1838 and 18th December 1839) and German (see Journal of Comparative Legislation, n.s. vol. i. at pp. 271, 272) asylum systems the main features of English administration are also reproduced.
The lunacy laws of the British colonies have also closely followed English legislation (cf. Ontario, R.S. 1897, cc. 317, 318; Manitoba, R.S. 1902, c. 80; Victoria (No. 1113, 1890); New Zealand (No. 34 of 1882 and Amending Acts); Mauritius (No. 37 of 1858).
In America the different states of the Union have each their own lunacy legislation. The national government provides only for the insane of the army and navy, and for those residing in the District of Columbia and in Alaska. The various laws as to the reception, &c., of the insane into asylums closely resemble English procedure. But in several states the verdict of a jury finding lunacy is a necessary preliminary to the commitment of private patients (Kentucky, Act of 1883, c. 900, § 14; Maryland, R.S. 1878, c. 53, § 21; Illinois, R.S. 1874, c. 85, § 22).
Authorities.—The following works may be consulted: Collinson on the Law of Lunatics and Idiots (2 vols., London, 1812); Shelford on the Law of Lunatics and Idiots (London, 1847). On all points relating to the history and development of the law these two treatises are invaluable. Pope on Lunacy (2nd ed., London, 1890); Archbold’s Lunacy (4th ed., London, 1895); Elmer on Lunacy (7th ed., London, 1892); Wood Renton on Lunacy (London and Edinburgh, 1896); Fry’s Lunacy Laws (3rd ed., London, 1890); Pitt-Lewis, Smith and Hawke, The Insane and the Law (London, 1895); Hack-Tuke, Dictionary of Psychological Medicine (London, 1892), and the bibliographies attached to the various legal articles in that work; Clevenger, Medical Jurisprudence of Insanity (2 vols., New York, 1899); Semelaigne, Les Aliénistes français (Paris 1849); Bertrand, Loi sur les aliénés (Paris, 1872), presents a comparative view of English and foreign legislations. In forensic medicine the works of Taylor, Medical Jurisprudence (5th ed., London, 1905); Dixon Mann, Foreign Medicine and Toxicology (3rd ed., London, 1902); and Wharton and Stillé, A Treatise on Medical Jurisprudence (Philadelphia, 1873); Hamilton and Godkin, System of Legal Medicine (New York, 1895); are probably the English authorities in most common use. See also Casper and Liman, Praktisches Handbuch der gerichtlichen Medicin (Berlin, 6th ed., 1876); Tardieu, Étude médico-légale sur la folie (Paris, 1872); Legrand du Saulle, La Folie devant les tribunaux (Paris, 1864); Dubrac, Traité de jurisprudence médicale (Paris, 1894); Tourdes, Traité de médecine légale (Paris, 1897); and especially Krafft-Ebing, Lehrbuch der gerichtlichen Psychopathologie (Stuttgart, 1899). (A. W. R.)
III. Hospital Treatment
The era of real hospitals for the insane began in the 19th century. There had been established here and there in different parts of the world, it is true, certain asylums or places of restraint before the beginning of the 19th century. We find mention in history of such a place established by monks at Jerusalem in the latter part of the 5th century. There is evidence that even earlier than this in Egypt and Greece the insane were treated as individuals suffering from disease. Egyptian priests employed not only music and the beautiful in nature and art as remedial agents in insanity, but recreation and occupation as well. A Greek physician protested against mechanical restraint in the care of the insane, and advocated kindly treatment, the use of music, and of some sorts of manual labour. But these ancient beneficent teachings were lost sight of during succeeding centuries. The prevailing idea of the pathology of insanity in Europe during the middle ages was that of demoniacal possession. The insane were not sick, but possessed of devils, and these devils were only to be exorcised by moral or spiritual agencies. Medieval therapeutics in insanity adapted itself to the etiology indicated. Torture and the cruellest forms of punishment were employed. The insane were regarded with abhorrence, and were frequently cast into chains and dungeons. Milder forms of mental disease were treated by other spiritual means—such as pilgrimages to the shrines of certain saints who were reputed to have particular skill and success in the exorcism of evil spirits. The shrine of St Dymphna at Gheel, in Belgium, was one of these, and seems to have originated in the 7th century, a shrine so famed that lunatics from all over Europe were brought thither for miraculous healing. The little town became a resort for hundreds of insane persons, and as long ago as the 17th century acquired the reputation, which still exists to this day, of a unique colony for the insane. At the present time the village of Gheel and its adjacent farming hamlets (with a population of some 13,000 souls) provides homes, board and care for nearly 2000 insane persons under medical and government supervision. Numerous other shrines and holy wells in various parts of Europe were resorted to by the mentally afflicted—such as Glen-na-Galt in Ireland, the well of St Winifred, St Nun’s Pool, St Fillans, &c. At St Nun’s the treatment consisted of plunging the patient backwards into the water and dragging him to and fro until mental excitement abated. Not only throughout the middle ages, but far down into the 17th century, demonology and witchcraft were regarded as the chief causes of insanity. And the insane were frequently tortured, scourged, and even burned to death.
Until as late as the middle of the 18th century, mildly insane persons were cared for at shrines, or wandered homeless about the country. Such as were deemed a menace to the community were sent to ordinary prisons or chained in dungeons. Thus large numbers of lunatics accumulated in the prisons, and slowly there grew up a sort of distinction between them and criminals, which at length resulted in a separation of the two classes. In time many of the insane were sent to cloisters and monasteries, especially after these began to be abandoned by their former occupants. Thus “Bedlam” (Bethlehem Royal Hospital) was originally founded in 1247 as a priory for the brethren and sisters of the Order of the Star of Bethlehem. It is not known exactly when lunatics were first received into Bedlam, but some were there in 1403. Bedlam was rebuilt as an asylum for the insane in 1676. In 1815 a committee of the House of Commons, upon investigation, found it in a disgraceful condition, the medical treatment being of the most antiquated sort, and actual inhumanity practised upon the patients. Similarly the Charenton Asylum, just outside Paris, near the park of Vincennes, was an old monastery which had been given over to the insane. Numerous like instances could be cited, but the interesting point to be borne in mind is, that with a general tendency to improvement in the condition of imbeciles upon public charge, idiots and insane persons came gradually to be separated from criminals and other paupers, and to be segregated. The process of segregation was, however, very slow. Even after it had been accomplished in the larger centres of civilization, the condition of these unfortunates in provincial districts remained the same. Furthermore, the transfer to asylums provided especially for them was not followed by any immediate improvement in the patients.
Twenty-five years after Pinel had, in 1792, struck the chains from the lunatics huddled in the Salpétrière and Bicêtre of Paris, and called upon the world to realize the horrible injustice done to this wretched and suffering class of humanity, a pupil of Pinel, Esquirol, wrote of the insane in France and all Europe: “These unfortunate people are treated worse than criminals, reduced to a condition worse than that of animals. I have seen them naked, covered with rags, and having only straw to protect them against the cold moisture and the hard stones they lie upon; deprived of air, of water to quench thirst, and all the necessaries of life; given up to mere gaolers and left to their surveillance. I have seen them in their narrow and filthy cells, without light and air, fastened with chains in these dens in which one would not keep wild beasts. This I have seen in France, and the insane are everywhere in Europe treated in the same way.” It was not until 1838 that the insane in France were all transferred from small houses of detention, workhouses and prisons to asylums specially constructed for this purpose.
In Belgium, in the middle ages, the public executioner was ordered to expel from the towns, by flogging, the poor lunatics who were wandering about the streets. In 1804 the Code Napoleon “punished those who allowed the insane and mad criminals to run about free.” In 1841 an investigation showed in Belgium thirty-seven establishments for the insane, only six of which were in good order. In fourteen of them chains and irons were still being used. In Germany, England and America, in 1841, the condition of the insane was practically the same as in Belgium and France.
These facts show that no great advance in the humane and scientific care of the insane was made till towards the middle of the 19th century. Only then did the actual metamorphosis of asylums for detention into hospitals for treatment begin to take place. Hand in hand with this progress there has grown, and still is growing, a tendency to subdivision and specialization of hospitals for this purpose. There are now hospitals for the acutely insane, others for the chronic insane, asylums for the criminal insane, institutions for the feeble-minded and idiots, and colonies for epileptics. There are public institutions for the poor, and well-appointed private retreats and homes for the rich. All these are presided over by the best of medical authorities, supervised by unsalaried boards of trustees or managers, and carefully inspected by Government lunacy commissioners, or boards of charities—a contrast, indeed, to the gaols, shrines, holy wells, chains, tortures, monkish exorcisms, &c., of the past!
The statistics of insanity have been fairly well established. The ratio of insane to normal population is about 1 to 300 among civilized peoples. This proportion varies within narrow limits in different races and countries. It is probable that intemperance in the use of alcohol and drugs, the spread of venereal diseases, and the over-stimulation in many directions induced by modern social conditions, have caused an increase of insanity in the 19th as compared with past centuries. The amount of such increase is probably very small, but on superficial examination might seem to be large, owing to the accumulation of the chronic insane and the constant upbuilding of asylums in new communities. The imperfections of census-taking in the past must also be taken into account.
The modern hospital for the insane does credit to latter-day civilization. Physical restraint is no longer practised. The day of chains—even of wristlets, covered cribs and strait-jackets—is past. Neat dormitories, cosy single rooms, and sitting- and dining-rooms please the eye. In the place of bare walls and floors and curtainless windows, are pictures, plants, rugs, birds, curtains, and in many asylums even the barred windows have been abolished. Some of the wards for milder patients have unlocked doors. Many patients are trusted alone about the grounds and on visits to neighbouring towns. An air of busy occupation is observed in sewing-rooms, schools, shops, in the fields and gardens, employment contributing not only to economy in administration, but to improvement in mental and physical conditions. The general progress of medical science in all directions has been manifested in the department of psychiatry by improved methods of treatment, in the way of sleep-producing and alleviating drugs, dietetics, physical culture, hydrotherapy and the like. There are few asylums now without pathological and clinical laboratories. While it is a far cry from the prisons and monasteries of the past to the modern hospital for the insane, it is still possible to trace a resemblance in many of our older asylums to their ancient prototypes, particularly in those asylums built upon the so-called corridor plan. Though each generation contributed something new, antecedent models were more or less adhered to. Progress in asylum architecture has hence advanced more slowly in countries where monasteries and cloisters abounded than in countries where fixed models did not exist. Architects have had a freer hand in America, Australia and Germany, and even in Great Britain, than in the Catholic countries of Europe.
Germany approaches nearest to an ideal standard of provision for the insane. The highest and best idea which has yet been attained is that of small hospitals for the acutely insane in all cities of more than 50,000 inhabitants, and of colonies for the chronic insane in the rural districts adjacent to centres of population. The psychopathic hospital in the city gives easy and speedy access to persons taken suddenly ill with mental disease, aids in early diagnosis, places the patients within reach of the best specialists in all departments of medicine, and associated, as it should be, with a medical school or university, affords facilities not otherwise available for scientific research and for instruction in an important branch of medical learning. A feature of the psychopathic hospital should be the reception of patients for a reasonable period of time, as sufferers from disease, without the formality of legal commitment papers. Such papers are naturally required for the detention and restraint of the insane for long periods of time, but in the earlier stages they should be spared the stigma, delay and complicated procedure of commitment for at least ten days or two weeks, since in that time many may convalesce or recover, and in this way escape the public record of their infirmities, unavoidable by present judicial procedures.
There should be associated with such hospitals for the acutely insane in cities out-door departments or dispensaries, to which patients may be brought in still earlier stages of mental disorder, at a period when early diagnosis and preventive therapeutics may have their best opportunities to attain good results. In Germany a psychopathic hospital now exists in every university town, under the name of Psychiatrische Klinik.
Colonies for the chronic insane are established in the country, but in the neighbourhood of the cities having psychopathic hospitals, to receive the overflow of the latter when the acute stage has passed. The true colony is constructed on the principle of a farming hamlet, without barracks, corridored buildings, or pavilions. It is similar in most respects to any agricultural community. The question here is one of humane care and economical administration. Humane care includes medical supervision, agreeable home-life, recreation, and, above all things, regular manual and out-of-door occupation in garden, farm and dairy, in the quarry, clay-pit or well-ventilated shop. Employment for the patients is of immense remedial importance, and of great value from the standpoint of economical administration. In the colony system the small cottage homes of the patients are grouped about the centres of industry. The workers in the farmstead live in small families about the farmstead group of buildings; the tillers of the soil adjacent to the fields, meadows and gardens; the brickmakers, quarrymen and artizans in still other cottages in the neighbourhood of the scenes of their activities. In addition to these groups of cottages, which constitute the majority of the buildings in the village, an infirmary for bedridden, excited and crippled patients is required, and a small hospital for the sick. All the inhabitants of the colony are under medical supervision. A laboratory for scientific researches forms a highly important part of the equipment. The colony is not looked upon as a refuge for the incurable; it is still a hospital for the sick, where treatment is carried on under the most humane and most suitable conditions, and wherein the of recoveries will be larger than in asylums and hospitals as now conducted. In respect of the establishment of colonies for the insane upon the plan outlined here, Germany has, as in the case of the psychopathic hospital, led the world. It has been less difficult for that country to set the example, because she had fewer of the conditions of the past to fight, and with her the progress of medical science and of methods of instruction in all departments of medicine has been more pronounced and rapid.
Among the German colonies for the insane, that at Alt-Scherbitz, near Leipzig, is the oldest and most successful, and is pre-eminent in its close approach to the ideal village or colony system. In 1899 Professor Kraeplin of Heidelberg stated (Psychiatrie, 6th edition) that the effort was made everywhere in Germany to give the exterior of asylums, by segregation of the patients in separate home-like villas, rather the appearance of hamlets for working-people than prisons for the insane, and he said, further, that the whole question of the care of the insane had found solution in the colony system, the best and cheapest method of support. “I have myself,” he writes, “had opportunity to see patients, who had lived for years in a large closed asylum, improve in the most extraordinary manner under the influence of the freer movement and more independent occupation of colony life.”
In America the colony scheme has been successfully adopted by the state of New York at the Craig Colony for Epileptics at Sonyea and elsewhere.
That the tendency nowadays, even outside of Germany, in the direction of the ideal standard of provision for the insane is a growing one is manifested in all countries by a gradual disintegration of the former huge cloister-like abodes. More asylums are built on the pavilion plan. Many asylums have, as it were, thrown off detached cottages for the better care of certain patients. Some asylums have even established small agricultural colonies a few miles away from the parent plant, like a vine throwing out feelers. What is called the boarding-out system is an effort in a similar direction. Patients suffering from mild forms of insanity are boarded out in families in the country, either upon public or private charge. Gheel is an example of the boarding-out system practised on a large scale. But the ideal system is that of the psychopathic hospital and the colony for the insane.
Authorities.—Sir J. B. Tuke, Dictionary of Psychological Medicine, (London and Philadelphia, 1892); W. P. Letchworth, The Insane in Foreign Countries (New York, 1889); Care and Treatment of Epileptics (New York, 1900); F. Peterson, Mental Diseases (Philadelphia, 1899); “Annual Address to the American Medico-Psychological Association,” Proceedings (1899). (F. P.*)
- The word for “lunatic” in several other languages has a similar etymology. Cp. Ital. lunatico, Span. alunado, Gr. σεληνιακός (epileptic), Ger. mondsüchtig.
- It has sometimes been stated that this power, which ought clearly, in the interests alike of prisoners and of the public, to be exercised with caution, is in fact exerted in an unduly large number of cases. The following figures, taken from the respective volumes of the Criminal Judicial Statistics, show the number of criminal lunatics certified insane before trial. In 1884–1885, out of a total of 938 criminal lunatics, 169 were so certified; in 1885–1886, 149 out of 890; in 1889–1890, 108 out of 926; in 1890–1891, 95 out of 900; in 1894, 78 out of 738; in 1895, 84 out of 757; in 1896, 88 out of 769; in 1897, 85 out of 764; in 1898, 17 out of 209; in 1899, 13 out of 159; in 1900, 12 out of 185; in 1901, 15 out of 205; in 1902, 7 out of 233; in 1903, 11 out of 229.