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MEDICAL AND GENERAL]
599
INSANITY


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 Forms of Insanity. are Idiocy (with its modification, Imbecility) and Cretinism (q.v.).

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, Idiocy. in whatever degree it may exist, we have to deal with a brain condition fixed by the pathological circumstances under which its possessor came into the world or by such as had been present before full cerebral activity could be developed, and the symptoms of which are not dependent on the 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