Page:Encyclopædia Britannica, Ninth Edition, v. 13.djvu/114

104 INSANITY To say of a man that lie is maniacal is not saying more than to say of one who has lost power over his limbs that he suffers from palsy, a diagnosis which no scientific physician of the present day would be content with, as it conveys no definite idea as to the pathological character or cause of impairment of mobility. It may be freely admitted that medical science is not yet able to base a nosology of the in sanities on the highest pathological platform, that of morbid anatomy. Considerable advances have been made in this direction, but the observations of pathologists, with the exception of those bearing on three or four classes of brain disease, are vague and quite insufficient for the purpose. Clinical observation, however, has served to relate symptoms with cause to such an extent as to enable the observer of mental disease to fall back on the second pathological position etiology, and has enabled him to assert, in a very large proportion of cases, causation as a scientific and con venient standpoint for classification. After all, classifica tions are matters of convenience. It is not asserted that the classification adopted in this article is more than provisional ; but it is asserted that it is more convenient to study the insanities in connexion with the bodily conditions of their subjects than to rely on a general description of mental symptoms which are inconstant in kind and degree, and often so complex as to render analysis impossible. When Esquirol s definition of the mental conditions is quoted, little more need be added, for further descrip tion would merely involve an amplified account of psycho logical peculiarities. Esquirol thus describes the con ditions : (1) Melancholia, or, as he terms it, Lypemania, disorder of the faculties with respect to one or a small number of objects, with predominance of a sorrowful and depressing passion : (2) Monomania, in which the disorder of the faculties is limited to one or a small number of objects, with excitement, and predominance of a gay and expansive passion ; (3) Mania, in which the insanity extends to all kinds of objects, and is accompanied by excitement ; (4) Dementia, in which the insensate utter folly, because the organs of thought have lost their energy and the strength requisite for their functions. In 1852 Schroeder van der Kolk and in 1860 Morel laid the foundation of a classification more in accordance with pathological science. The former included the different forms of the disease under two great classes : " idiopathic insanity," comprising all cases produced by primary affec tions of the brain; and "sympathetic insanity," including those due to morbid conditions of the general system. Morel divided the insanities into six groups : (1) heredi tary insanity ; (2) toxic insanity ; (3) insanity produced by the transformation of other diseases ; (4) idiopathic insanity ; (5) sympathetic insanity ; (6) dementia, a terminative stage. Notwithstanding faults of detail, it may be fairly said that these propositions marked a great advance in the study of insanity, and that all later classifi cations based on the same principles have been derived from study of them. The following system admittedly is so. Idiopathic mania, melancholia,, and dementia. General paralysis of the insane. L Epileptic insanity. s Hysterical insanity. ( Hypochondriacal insanity. I. Idiopathic insani ties. II. Traumatic insanity. III. The insanities asso ciated with other neuroses. IV. Insanity resulting from the presence of adventitious pro ducts. V. Insanities resulting from morbid condi tions of the general system. ( Phthisical insanity. Rheumatic insanity. Gouty insanity. , Syphilitic insanity. I Insanity from sunstroke. I Anaemic insanity. r Insanity of pubescence and adolescence. VI. Insanities occur- Climacteric insanity, ring at evolutional Senile insanity, periods. j Insanity of pregnancy. I Puerperal insanity. VII. Toxic insanity. I. IDIOPATHIC MANIA AND MELANCHOLIA. It is pro posed to consider under the head of idiopathic mania and melancholia the large and important class of cases which re sult from over-excitation of the brain due to so-called moral causes. In considering this form of insanity, a difficulty arises in reconciling the dependence of two such apparently widely divergent morbid psychical states as mania and melancholia on one common pathological condition. That they are so is maintained by the following clinical observa tions 1st, that during the prodromal period, i.e., the period during which over-excitation is using its influence on the brain tissues, the symptoms of excitement and depression generally alternate ; 2d, that in certain acute cases mania and melancholia coexist, that is to say, it is impossible for the observer to say whether they are cases of maniacal melancholia or melancholic mania ; 3d, that, as many cases run their course towards recovery, the symptoms are con secutively mania, melancholia, and dementia ; 4th, that the effects of irritating poisons applied to the brain, alcohol markedly, produce these symptoms in some individuals in a very short space of time. These observations point, not to a difference of pathological causation, but to variation in symptoms in conformity with the progress of pathological processes. It must be borne in mind that congestion is not a condition constant in quality or in quantity, and, further, that it is an inconstant condition acting on an inconstant subject, and therefore productive of cumulative inconstant results. Brain congestion, due to over-excita tion, produces functional excitement of that organ. It must be remembered that although mania is accompanied by exaltation, and melancholia by depression of feeling, they are both manifestations of excitement of feeling. Given this common psychological condition of excitement, a reason must be sought for the variety of its manifestation either in some peculiarity of the irritating cause or in some idiosyncracy of the affected individual. In either case no material assistance is gained from psychological considera tions, for there is no necessary connexion between depress ing emotions and melancholia; intense grief of ten produces acute mania, and the insanity of the man of saturnine mind is as often as not characterized by mania. The peculiarity of the irritating cause appears to be, not its psychological characteristic, but its intensity. The more rapidly excitement of feeling is produced, the more likely is mania to be the symptom of the insanity. That melancholia often supervenes on depressing emotions gradual in their incidence does not imply a psychological nexus, but that, as their irritating influence is slowly applied, so the results of the irritation are slowly produced, and (as in the case of every tissue of the body) there is variety of degree of symptoms in conformity with the rapidity of the progress of pathological events. There are also various underlying conditions difficult to treat of in the mass, any one of which may have considerable bearing on an individual case. Constitutional predisposition (diathesis) may render a person more prone to the sub-acute forms of disease, and the condition of the body at the time of irrita tion may influence the nature of the symptoms in either direction. In the absence of the possibility of applying to the brain the mechanical aids which have given the physician an insight into the sequence of pathological events occurring in other organs, the pathologist has nothing to depend on save clinical observation. He has presented to him a diseased organ, complex in function, of the physiology of which he is, as regards its psychical action, profoundly