Insanity. No good definition of insanity has ever been given in any language, nor is it possible. Any definition that would have accurately fitted what was understood as insanity in Shakespeare's time would be quite inadequate now, for we count men insane who would have passed muster well enough in the 16th century. Another difficulty of definition consists in this, that the very same mental symptoms may exist in two people, and in one they may constitute true insanity, while in the other they may only be one of the brain symptoms of a fever. And if there is one thing better understood about insanity now than formerly, it is that there is no exact line of demarcation between insanity and sanity any more than there is between light and darkness. There is an undefined borderland through which most cases of insanity pass, between technical and legal sanity and insanity. But while this is true, there is no truth and little sense in the common saying that 'all are more or less insane on some point.' Such a statement entirely mistakes the real significance of insanity as a disease, and is a pernicious fallacy begotten of ignorance. Insanity may be reasonably described, according to the scientific ideas of our time, as 'such an alteration in any or all of the mental functions of the brain as makes a man unfit from this cause to do his work or manage his affairs, or mingle in the society of his fellow-men, or which makes him unsafe to himself or others or to society, this alteration not being solely the result of fever, but being the result of disease or disorder in the working of, or imperfection in the development of that portion of the brain through which mind is manifested.' In defining or describing insanity we wish to exclude the delirium of fevers, comatose conditions, somnambulism, mere eccentricity, hysteria, transitory brain excitements due to religious or other strong emotions, or due to other adequate causes. A mother who loses control over herself when she hears suddenly that a child is dead may be more sane than another who shows no outward sign of emotion on such an occasion.
Tests.—There is or can be no absolute test of insanity—or of sanity, for that matter. Sanity is best proved by normal self-control, and insanity by the loss of it from disease. The presence of one or more insane delusions was at one time the legal test, but it is not a true or scientific one. The 'knowledge of right and wrong' was at one time a legal test of responsibility, in other words of sanity, by the law, but it has long been given up. Half the lunatics know right from wrong in some degree or other.
Mind and Brain.—Insanity cannot be properly studied or in any degree understood except by reference to the mental functions of the brain. A physiological view of mind can alone throw light on the complicated and wondrous phenomena of this disease. No merely metaphysical or subjective view or study of mind seems to help us in the least as to it; the facts are inexplicable on any such view of mind. Looked at from the human and social point of view, no other disease approaches it in the terror it inspires, the sense of helplessness it causes, the deep distress to relatives, and the disruption of all normal social conditions. A scientific view of it alone brings us into the mental and emotional attitude with which civilised humanity now regards disease in general. No progress was made in its study or treatment till physicians came to look at it in precisely the same way as they do ordinary disease. Mind must be regarded by all students of insanity practically as being a 'brain function' which is found in all animals in varying degrees; which in man does not at one time of life exist at all, then is seen to arise in small beginnings like any other function, then gradually to develop, attain maturity, and then fail and eventually disappear—all these conditions of mind being absolutely correlated with the structural development and decay of the mental organ in the brain. It is thus studied and looked on as sensation and motion are studied. The latest physiological and evolutionary studies of mind in relation to brain seem to lead to the conclusion on scientific and not merely a priori grounds that it is to the mental organ or centres in the brain that all higher evolution tends. In it are 'represented' every other organ and function of the body, and so they are all in intimate and organic connection with it and its highest function of mind, and so with each other as to make of the organism an organic unity. If the evolutionists are right, everything that lives tends towards mentalisation, and all the nervous organs of all the types of animal life find their acme in the mental centres of the human brain. The whole of the human brain is not a mental organ. There are centres for motion and sensation and regulation of function, but they are all represented in, and correlated and largely controlled by the mental organ. It clearly resides in the convolutions of the brain. This dominant organ has necessarily become what it is in man through the hereditary influences that have gradually upbuilt it since the beginning of life. This heredity has been largely influenced by external conditions. These have been good and bad throughout the ages, and the bad have left many bad mental results, in so far as natural selection and the struggle for existence have not eradicated them. The mental organ in the human brain has thus become the most complicated, the most delicate, and yet the most potent thing in nature, impressionable to all stimuli from within the body and outside it; reactive in due amount, and yet not unduly if healthy, to all these impressions and stimuli; containing within itself, in a way that yet we are not even able to realise, hereditary qualities, bad and good, from thousands of ancestors. If this is so one is prepared to believe that through evil hereditary influences, and from evil conditions outside it, this organ may often be upset in its normal working. The most important form of such upset is insanity, because it touches the highest brain function. The student of mind physiologically finds on the threshold of his studies that every form of mental energy is just as hereditary as the colour of the hair or the shape of the nose; he finds that volitional power, reasoning acuteness, emotional keenness, moral sensitiveness, good social instincts, retentive memory, and mental resistiveness of all kinds are all transmitted hereditarily. He is therefore prepared to believe that these same laws of heredity have determined the volitional paralysis, the reasoning and the emotional perversions, the losses of memory, and the mental instability which he finds among the insane, and to believe that it is probably the most hereditary of all diseases.
General Symptoms.—The symptoms of insanity are best studied as mental and bodily symptoms. It is only since the disease was studied from the physician's point of view that the bodily symptoms have been specially noticed. Nothing in medicine was ever seen till it was looked for. Nowadays every physician knows that the bodily symptoms and the general condition of the body and its organs are often the most important matters for him to observe and attend to in a case of insanity. He finds few cases of recent insanity without such bodily symptoms. The most common mental symptoms are morbid emotional depression and mental pain, which is the dominant symptom in melancholia. It is an essential law of life that in health the performance of all function yields pleasure. The law is that to live is to energise, and to energise is to enjoy life. Except this is so there is abnormality or disease. In many cases of insanity to energise mentally is to suffer pain. The essential relationship between emotion and action is thus reversed. Another symptom in other cases is an undue emotional exaltation; this is commonly associated with a loss of the great controlling or inhibitory functions of the brain, and occurs in mania. There is morbid brain excitement, commonly exhibited in restless motions or shouting. Such cases may go on to complete loss of any consciousness of all the former brain impressions and mental life. The patient remembers nothing, and does not know his nearest friends. Another most common symptom is a diminution or loss in the power of attention. This is common to nearly all forms of insanity. Then we have perversion of the reasoning power, as seen most frequently in insane delusions. Like insanity, an insane delusion cannot be defined. It may be said to be 'a belief in something that would be incredible to ordinary people of the same class, education, or race as the person who expresses it, this resulting from some morbid state of the brain.' Insane delusions are common in most cases and varieties of insanity. They are divided into fixed delusions and changing delusions, the former being the most serious and incurable. Some delusions are held by patients in a sort of slack theoretical way, not influencing conduct; others again are keenly held and lead to their logical results in conduct. There may be two 'prophets of the Lord' in an asylum, one of whom will insist on delivering his 'message' on every opportunity to all with whom he comes into contact, will not employ himself in ordinary occupations, and refrains from all amusement; the other will only speak of his delusion when asked about it, will be a capital blacksmith or scrubber of floors, and enjoy thoroughly a dance or a comic song. The origin of insane delusions is one of the most interesting, and often the most obscure of psychological problems. In some cases the process can be clearly traced, being analogous to the process of 'day dreaming' in children. Imagination and fancy are vivid, the reasoning and comparing power is in abeyance, and so the subjective is taken for the objective. Every time a fancy is so looked on it gets more and more 'organised' into a real delusion. Sometimes delusions result from the accentuation of the natural mental temperament by outward circumstances—e.g. when a hunchback of a naturally sensitive, suspicious disposition is in his boyhood annoyed by his fellow-boys at school, the consciousness of his deformity being thus ever brought before him, and when weak health and lack of physical power make him irritable and misanthropic and he then takes a fever, during which he is delirious, and fancies all the time that he hears the old boy-voices of opprobrium—it seems intelligible in such a case that after recovery, but with still a bloodless and weakened brain, he should still hear the voices saying 'hunchback, hunchback.' The hearing of voices when no such exist is an example of a hallucination, which is used to denote special sense impressions that have no outward causes. Hallucinations may be of hearing, which are the most common and the most serious as a symptom of incurability if long continued; of sight, the next most common and more likely to be recovered from; of smell and taste, which are rare, and not favourable. Hallucinations and delusions are often connected with and arise out of real sensations, which are misinterpreted by the weakened brain—e.g. a man has been drinking, and has so disordered his stomach, and irritated its lining membrane, that he feels a constant pain there and a bad taste in his mouth, and he concludes that poison has been put into his food, adducing these real sensations as proof of his delusion. His mental centre had been disturbed in its working by the drink, so that he could no longer reason clearly and put the true interpretation on the facts.
A distinctive character of an insane delusion is that it cannot be in any way changed or dispelled by the clearest demonstration that it is false. A man thinks he is ruined and a pauper; you bring his bank-book and show him that he has £1000 to his account; and you bring the banker with the actual money to him, but you cannot by such means eradicate the false belief. A sane man may have a hallucination (see HALLUCINATIONS), but he knows his 'brain is playing him a trick,' when ordinary means are taken to demonstrate the unreality of his impression. Another very important and most dangerous symptom in insanity is the tendency towards suicide. This is commonly a symptom in melancholia, and usually goes with a depressed emotional state. But sometimes it exists by itself as a morbid impulse, unreasoning, unaccounted for, unexplainable. Sometimes patients attempt their lives when unconscious of what they are doing, and do not remember what they have done. Patients say that ideas of suicide come into their minds unsuggested in the midst of work and even of enjoyment. A desire to put an end to one's own life is physiologically the furthest away from health of any morbid mental symptom that can possibly occur, for it is a perversion of the primary instinct of all living beings—viz. the love of life, and the desire and effort to protect and preserve it. Without this instinct life would soon end on the earth. It is not any reasoning as to the desirability of life that keeps men and animals alive and drives to unceasing efforts to preserve it, nor is it the pleasure of eating, nor the fear of pain in death. It is the simple innate organic instinct to live which no reasoning can impair in most men. When a man attempts his life, apparently as a calm reasoning conclusion from facts which seem to prove that this is the best thing he can do, in ninety-nine cases out of a hundred the process of reasoning is not the real motive for the act, but the loss of the life instinct which started the reasoning and made the act possible. No doubt the strength of the instinct and of the love of life is much less in some persons and in some races apparently than in others. But such a lessened instinct means a bad heredity and lessened capacity for the struggle for existence. It is twin-brother to a heredity towards ordinary insanity. There may be motives that with civilised men are stronger even than the love of life, and a man with a strong will or under the impulsion of a strong emotion or in a state of despair may certainly take his own life though sane. Suicide is frequently suggested by the sight of the means of self-destruction. There are many persons not insane who cannot see a sharp weapon or go near a precipice without the suggestion of suicide, while many of the insane are entirely unable to resist attempts on their own lives when such means are seen. Some patients will use the utmost cunning to conceal their intention of committing suicide, whilst others will do it most openly. The natural courage of the person comes in very strongly in estimating the actual risk in any case; but the most timid, the most conscientious, who intellectually know it to be wrong, and see that every rational motive goes against it, the most affectionate, who know the terrible anguish it will cause to those they love, the most religious, who fear eternal damnation as its consequence, all equally commit suicide when suffering from insanity with the suicidal impulse. About 1700 persons actually take away their own lives every year in England, the proportion being much higher in some other countries. Alcohol is responsible for very many suicides every year. The same patient very often sticks to the same methods of committing suicide. He will again and again try to hang or poison himself when he has plenty of better chances of cutting his throat. The following are the common methods of suicide in Great Britain in their order of frequency—viz. drowning, hanging, starvation, wounds by firearms, poisoning, precipitation, and choking. But some patients prepare elaborate means and apparatus for the purpose. An American killed himself with a complicated apparatus worked by clockwork, which first put him under chloroform and then decapitated him; this apparatus having taken him over two years to construct. Suicidal feeling or impulse is often recovered from, and is not a specially bad symptom except as requiring the watching of the patient.
Another mental symptom of insanity very common is impulsiveness, or action in an automatic unreasoning way, sometimes without any conscious intention on the patient's part, and without power of control by the will. A man sees a large plate-glass window, and he hurls a stone through it impulsively. Another cannot resist the impulse to tear his clothes, a third cannot resist the impulse to set a haystack on fire. Uncontrollable impulse naturally goes with diminished volition in insanity. What would be the conduct of most sane men if their wills did not stand between impulse and action? If the will is paralysed, as it is in many cases from disease, their impulse is uncontrolled. Patients may be fully conscious of morbid impulses, may intellectually see their danger or absurdity, and morally may deplore their 'wickedness' in yielding to them, yet have no power to control them; or they may be in a condition of unconsciousness, or false consciousness, during which impulsive acts are done and not remembered afterwards at all. When consciousness returns such people are surprised and incredulous when told that they have smashed furniture or tried to kill their children. A patient once attempted her own life, suddenly smashed a picture, and nearly strangled her attendant, and was amazed when told what she had done. She was a gentle, religious lady of the highest principle. Whenever she passed into this condition of false consciousness during which such impulsive acts were done she would glare at one particular picture on the wall, and would spring at it, so that it had to be removed from the room. She had no particular feeling about it when in her ordinary state of consciousness.
One of the most common and most painful symptoms of insanity is a change of natural affection towards relatives. The 'mother forgets her sucking child;' the sister ceases to love the brother; and the husband dislikes or suspects his wedded wife. This is not universal, but in nearly half the cases of insanity the affective condition is thus perverted or reversed. The memory is not necessarily affected in insanity. In many patients it is exaggerated: things come back with unnatural vividness. A man during simple mania could repeat most of the Psalms and many of Shakespeare's plays, which he never could when well. In some cases the memory brings back only the unpleasantnesses of past life, in others only the pleasant events, and in others there is no memory of past events at all during the attack. It is a constant source of anxiety to relatives whether patients remember the events that have taken place during their attack or their own sayings, feelings, or thoughts then. No rule can be laid down as to this. It depends on the nature of the attack, and especially on whether the power of attention is affected during its continuance. It is certain the memory of events that happened during the attack is usually blurred or distorted or hazy, even though as in some cases the patients affirm they 'can remember everything.' It is frequent that after recovery they speak of the events during the attack and their own feelings then 'as if it were a dream.' Sometimes the affective nature gets changed during an attack not only in regard to persons, but to books, scenery, and food. The appetites become perverted and changed; the social instincts are commonly altered. In a few cases these are intensified, but their usual discrimination is lost. Commonly, a lunatic is unsocial, and some cases are entirely asocial. The imaginative faculty is usually perverted, this being generally connected with the delusions present. In some cases an attack of insanity is a prolonged 'day-dream,' the condition being one rather of disjointed fancy than of coherent or constructive imagination. The normal law of association of ideas is usually altered. The same ideas do not suggest each other in sanity and insanity. The tendency is in insanity for ideas to suggest grotesque and incongruous things or trains of thought. The habits of life are notably changed in most cases, men and women becoming literally 'not themselves' in their ways and modes of living. The cleanly becomes uncleanly; the orderly man disorderly.
The chief bodily symptoms in insanity are the following. There is scarcely any symptom more common before and in the early stages of attacks than sleeplessness. 'Tired nature's sweet restorer, balmy sleep,' certainly departs when the terrible brain disturbance occurs, or is about to occur. It does not follow that because a man is sleepless he is going to be insane, but almost every kind of insanity is sleepless in its early stages. Nor does it by any means follow that sleeplessness is always the cause of the attack. It is rather in most cases an early symptom. The next bodily symptom in importance is morbidnesses of speech. On the patient's speech we chiefly depend for our diagnosis of most cases. Through it delusions are given expression to; it may be incoherent or partially coherent; it may be over rapid, slow, or entirely absent. A patient at Morningside Asylum never uttered a word for seventeen years, though he could speak quite well but for a delusion he has, and he works well, writes to express his wishes, goes out every Saturday and sees the sights of the town, and behaves mostly like a sane man, save in this particular. Often the conventionalities of speech are lost or dropped in insanity. The articulation of words is often changed. Next in importance to the speech is the expression of the face and eyes. This is given by the most delicate combined muscular and nervous apparatus that exists in nature, being in the most intimate connection with the mental part of the brain, and acting as its chief expositor and interpreter. It would be impossible to describe all the changes that take place in the expression of the eyes and faces of the insane. In the depressed and demented cases the eye loses its lustre and brilliancy; in maniacal cases it has abnormal feverish brilliancy; the pupil enlarging and the eyelids being drawn too far apart produce staring, the whole of the cornea being seen. In regard to the expression of the face, we see how the 'mind muscles' alter the man when in action and repose, in health and sickness. The natural expression is greatly changed, and little beauty of feature survives during acute attacks. The conventional control over the outward expression of the emotions is lost, and the face accurately shows the state of the melancholic, the maniacal, or the demented patient. Often too the fixed delusion shows in the patient's face. Indeed there are many cases where the expression caused by changed emotion during the first part of an attack gets fixed, and remains so after the patient has really ceased to feel the morbid emotion at all. A lady who had been intensely melancholy in feeling for five years then sank into incurable weakness of mind, and completely lost her keen feeling and memory, but for the next twenty years, till her death, the muscles of her face and her attitude expressed the melancholy which she did not feel. She constantly wrung her hands, and could not tell why she did so. There was in fact an automatic 'muscular misery.' There are important indications of certain kinds of insanity in the state of the pupils too.
In the muscular movements of the body an insane patient will often indicate his emotions far more than a sane man would do.
The skin, the hair, the perspiration, the liver, the heart, and the kidneys are often changed in working, and the temperature of the body altered during an acute or recent attack of insanity. Before an attack there are often pains or uneasy feelings in the head, which disappear when it comes on. The bodily sensations are notably dulled in most acute attacks. Patients will often cut or bruise themselves or undergo operations without feelings of pain. The body weight is rapidly lost, and the general nutrition almost invariably suffers. Thus it is seen that disease cannot attack the highest organ and function without affecting also almost every other organ and function of the body. The higher brain centres and the peripheral organs act and react on each other, so that when the one is disturbed in action the others suffer.
Forms, Varieties, and Classification of Insanity.—One case of insanity may differ from another in all its symptoms, mental and bodily, so that the two may have almost nothing in common except that in both the mind is affected from brain disorder. One case may be so near sanity that it needs an expert to say there is anything wrong; while another is 'raving mad' to any eye. One case is conscious that his mind is affected; another, much worse, believes he was never so well in his life. One case needs no control, and can do some work; another needs the control of others in all respects, and cannot do anything. One is perfectly safe to himself and others, while another is as dangerous as the popular 'madman' is supposed to be—as a matter of fact, half the insane are not dangerous at all, and very few of them are as dangerous as they are popularly supposed to be. The popular idea that the insane are all much alike is utterly wrong. Nothing is more common than for the doctor of an asylum to be asked such questions as—'Do your patients know where they are?' 'Are they the better for the visits of friends?' 'Do they enjoy each other's society?' 'Are they happy?' 'Do they like or dislike you?' 'Are they nice to do with?' To one and all of such questions the answer has to be—'They differ entirely from each other in all these respects.' Where there are differences it is the business of science to classify. Insanity has been classified most variously, but at the present time only two of the classifications can be said to hold the field. The one is that in which the prevailing mental symptoms are taken as the basis of classification, the cases with similar mental symptoms being thrown together into each group. This was first done by Philippe Pinel, who was born in 1745 and died in 1826, was the physician to the great hospital for the insane at Paris, the Bicêtre, and who during the revolutionary period asked and got permission to remove the chains and manacles from his patients there. It is the 'mental classification,' and is used more or less by all physicians. The other classification was that devised by David Skae, who was born in 1814 and died in 1873, and was physician to the Royal Edinburgh Asylum for twenty-seven years, exercising during that time an enormous influence on the growth of the mental department of medicine, which is called 'alienism' in France, 'psychiatrie' in Germany, and commonly medico-psychology in Britain. The 'clinical classification' goes on the principle of selecting a more real, natural, and lasting relationship between the cases than mere mental symptoms. The weak point of the mental classification is that it is one of symptoms only; and a case may change entirely in its symptoms in the course of the same attack. The weak point in the clinical classification is that it does not cover the whole ground, many cases not being as yet classifiable under any of its divisions. The classification of the future will be a pathological one, which will supersede the two others, but our knowledge of the pathology of the various forms of insanity is not as yet sufficiently accurate to enable such a classification to be made. The forms of insanity under the mental classification, as found in Clouston's Clinical Lectures on Mental Diseases (1887), are as follows:
Melancholia, comprising all states of depression.—This has emotional depression, or mental pain and sense of ill-being, as its leading and dominant symptom. There may in addition be loss of self-control, insane delusions, which are usually suggested by the depression or impulses towards suicide, as well as incapacity to follow ordinary avocations in melancholia. These distinguish it from sane melancholy. Suicide is the great risk in such cases; four-fifths of melancholics being suicidal. The chief of the bodily symptoms are apt to be thinness, weakness, a low nervous and nutritive tone, and stomach, bowel, and liver derangements. Melancholia forms about 30 per cent. of the insanity sent to asylums; but if the cases not sent to such institutions, but treated at home, are taken into account, it forms probably half the total number. It is by far the most conscious and the most manageable form of recent insanity on the whole, being the form next to sanity. Most other kinds of mental disease begin by some amount of mental depression. Of melancholic patients sent to asylums 54 per cent. recover; but a larger percentage than this recovers if the cases treated at home are also included, because, of course, it is the worst class that require asylum treatment. The recoveries from melancholia are the most complete of all forms of insanity. It would seem to be caused by a more entirely functional and dynamical brain disturbance than any other form of insanity that may leave no trace whatever behind it after recovery.
Mania, comprising all states of mental exaltation.—The chief emotional forms of such mental exaltation are joyousness and rage, and are commonly accompanied by muscular excitement, restlessness, sleeplessness; the speech tends to become incoherent, the conduct violent or uncontrolled; there are commonly delusions of many kinds. The symptoms range from a joyous elevation with talkativeness and merely want of common sense and foolish conduct up to complete incoherence, delirium, and 'raving madness' or 'acute mania.' In such acute cases the temperature of the body is raised as in a fever; often there is such rapid loss of body weight that 28 lb. are lost in a week, and the patients even die of the disease in about 8 per cent. of such acute cases; while on the other hand 60 per cent. recover and 30 per cent. become incurable. The brain is very congested and hyperactive in acute mania, but this does not result from inflammation.
Folie Circulaire, or states of regular alternation between melancholia and mania, forms a small but distinct variety of insanity. More or less periodicity and tendency to recurrence and relapse is unfortunately a very common symptom in most attacks of insanity, and the period between each aggravation is often about four weeks: hence the name 'lunacy.' It is hardly necessary to say that the moon has nothing whatever to do with insanity. Nothing is more discouraging to those in charge of cases than this relapsing tendency; but it should not lead to despair of ultimate recovery, unless such relapses become regular and frequent for years. When this is the case the prospects of recovery are bad. Patients suffering from alternating insanity lead three lives—one when they are in the melancholy stage, another when in the joyous, elevated stage, and another when nearly sane.
Monomania, or delusional insanity, is that form where insane delusions are the chief signs of the mental aberration. A man may have such insane beliefs of all kinds, utterly unfounded in fact and utterly unchangeable by the plainest demonstration of fact that they are false, without any general depression of mind or exaltation. The intellect is chiefly affected rather than the affective nature in such a case. There are almost no cases of a literal monomania or a morbid false belief on one subject alone. The delusions are morbid in a particular direction, the chief forms being monomania of grandeur or pride, of unseen agencies, and of unfounded suspicions. Electricity, mesmerism, telephones, gases, noises made by imaginary persecutors are the common subjects of the second form; while utterly perverse interpretations of the conduct of friends or strangers is the common form of the latter. The two together are sometimes classed as monomania of persecution. Hallucinations of the senses—i.e. imaginary sights, sounds, smells, and tastes—are very common in this form of insanity. It is not very curable when the delusions get fixed; but in the early stage, and when dependent on derangements of the bodily health, it is often recovered from. This form of insanity, and delusion generally, is of great importance from a legal point of view, but not so much from the medical side.
Dementia, or conditions of general mental enfeeblement, is the state of mind where the memory is impaired, the reasoning weakened, the feeling diminished, the will especially lacking, the attention and curiosity far below normal, these changes having occurred in a person who had at one time been normally constituted. It is in fact silliness, want of mental force, imbecility not congenital but acquired. This does not usually occur as the first symptom of an attack of insanity, but as the sequel to mania—or, more rarely, melancholia—when it is not recovered from; hence it is commonly called secondary dementia. It is in fact the incurable stage in which these diseases end. The demented patients live on for many years sometimes. The most complete form of dementia occurs after mania that has not been recovered from in adolescence. Dementia is in fact a premature mental death with persisting bodily life.
Stupor embraces those cases where there is mental torpor, in which impressions on the senses produce no effect, the patient neither speaking nor taking notice of anything, and having no volition except to resist, but being able to stand, and walk, and eat. Trance and catalepsy are forms of stupor. The bodily functions are all lethargic in stupor, the heart's action low, the body cold, and the muscles flabby. Stupor commonly occurs in young people of both sexes, and is very curable, 50 per cent. recovering. It sometimes attracts popular wonder and attention, which is very bad for the patient. In some cases it results from profound and terrible shocks which paralyse mind and body. In some cases patients remember all that occurred when they appeared to be taking no notice whatever, and in others the time during which the stupor lasted was a blank to them afterwards.
Impulsive Insanity, or states of defective control, is the last or most recently invented division of the mental classification. In some ways it is the most interesting of all, inasmuch as will is the highest and most essential of all the mental faculties, and volitional disturbances have a closer relationship to morals, law, social life, and conduct than any other aspect of insanity. It is often seen that the children of insane or drunken parents are lacking in the normal power of control and in their perception of the sense of right and wrong, their conduct being apt to be impulsive and not guided by reasonable motives. Evolutionally the highest of all qualities is thus lessened in amount, this tending towards a disruption and destruction of organised society. If lack of control, criminality, and action from impulse became hereditary and general, society would fall to pieces. All forms of insanity are more or less distinguished by lessened control, but there are persons without general depression or excitement, without insane delusions, without enfeeblement of mind, who will suddenly, and not in obedience to any sane motive, smash furniture, tear clothing, steal, set things on fire, obey gross animal impulses, or kill themselves or others, having no power of control to prevent themselves from doing these things. We now know that certain regions of the brain and nervous centres have as their function the control of other portions, quickening the pace of action or stopping it. In the very highest regions of the brain we find the function of mental inhibition. This controls mental action in other portions of the brain convolutions. In this form of insanity it is supposed that the inhibitory controlling portions or 'centres of mental inhibition' have lost their power. It is as if one's power of controlling the act of coughing on very inadequate irritation was lost. Every minutest point of dust entering the larynx would set up coughing, which would go on independently of the will altogether, as an automatic 'reflex' act. In many of the cases of impulsive insanity the mental portions of the brain act automatically without any controlling action by the inhibiting centres. It is a pitiful and most suggestive thing to see a human being who knows right from wrong, and earnestly desires to do the one and avoid the other, compelled by morbid impulses to act wrongly, all the while bewailing the diseased necessity that is thus laid upon him. The physician frequently sees such a case. Especially is this sight pathetic when the morbid impulse is to take away his own life or that of some one dearer to him than life itself. Such impulsive insanity is often set up in hereditarily unstable brains by weak health and by alcohol. They are often curable. The so-called 'moral insanity' is just one variety of this form of mental disease where the moral sense is absent from disease, and the power of doing right nonexistent, while the impulses are all towards immorality.
The clinical varieties of insanity are headed by general paralysis, a specific disease of those portions of the brain that subserve mind and motion. It is always incurable, getting progressively worse, gradually impairing and at length destroying speech, motion, mind, and, usually in about three years' time, life itself. In this form of insanity patients commonly have extravagant delusions of wealth and power. It is found chiefly in the male sex, in large cities and manufacturing places, and as yet is almost unknown in the Highlands and the country districts of Ireland. It is a disease of modern life, and is proved to be increasing. Paralytic insanity is that connected with apoplexies, softenings and tumors of the brain, which cause ordinary paralysis first, and one form of dementia afterwards. Epileptic insanity is that accompanying epilepsy in so many cases. It is often attended by great violence and irritability, and by danger to those around the patient. Many murders are committed by insane epileptics. It is now much more manageable than formerly under modern medical treatment, but is apt to recur after apparent recovery. It prevails most variously in different parts of the country. In Scotland only 7 per cent. of the insanity is epileptic; in some southern and midland counties of England 25 per cent. is of this character. The true cause of this difference is unknown. Syphilitic insanity is the result of brain-poisoning by this terrible scourge of humanity. Alcoholic insanity is a very frequent form indeed. Alcohol is the exciting cause of from 15 to 20 per cent. of all insanity; but all the mental disease caused by alcohol is not alcoholic insanity. There can be no doubt that some brains are so prone by heredity to be upset in their mental function that it takes little to do it. If it is not a quarrel with a friend, it is a spree on bad liquor. True alcoholic insanity always has motor symptoms, such as tremblings, convulsions, impaired speech, &c., except dipsomania, one variety where the insanity consists in the craving for excessive use of liquor, and lack of control over this craving. Alcoholic insanity may be intensely acute or very mild, very short in duration or very long continued, or incurable. That caused by prolonged steady soaking is the worst. Rheumatic and gouty insanities are very rare.
Phthisical insanity, or that connected with consumption, is a very interesting variety. The patients are suspicious and unsocial, and often have no cough or spit or other outward sign of consumption, which may not be discovered till the chest is examined. In some cases it is curable. The tendency to consumption and to insanity are often found in different members of the same family. There are various forms of insanity connected with derangement of the reproductive functions. Uterine, amenorrhœal, ovarian, hysterical, and masturbational insanities; while pregnancy, childbirth, and nursing are the causes of the insanity of pregnancy, puerperal insanity, and lactational insanity. These form 10 per cent. of mental disease in the female sex. They are the most curable of all forms, recovering in over 80 per cent. of the cases. Puerperal insanity occurs commonly within a fortnight of childbirth, and is the most acute and one of the most dangerous to life of all insanities, while the most curable, and is attended by the highest temperatures, sometimes reaching 105°. The different periods of life have each their own form of insanity. Pubescent and adolescent insanity is always hereditary, is commonly acute and maniacal, usually has remissions and exacerbations, and recovers in over 60 per cent. of the cases, those not recovering commonly passing into the most typical form of secondary dementia. This form of insanity should be treated chiefly by milk diet and exercise. It is one of numerous diseases to which the period of development is subject. Climacteric insanity occurs at the period of the 'change of life.' It is usually melancholic in character, and recovers in 53 per cent. of the cases, under proper treatment and conditions of life. Senile insanity is typically seen in the senile dementia of extreme old age, when the memory and all the faculties have faded away. But spurts of mental excitement and mental depression, with sleeplessness and unmanageability at home, often occur before final dotage. These are often recovered from. They are a half-way house to dotage or a quick road to it.
A number of rarer and less important clinical varieties of insanity have been described. Traumatic insanity, from injuries to head; anæmic insanity, from thinness of blood; diabetic insanity; insanity from Bright's disease; post-febrile insanity, following all kinds of fevers, especially scarlatina; the insanity of lead-poisoning; and myxœdematous insanity.
Causes of Insanity.—There can be no question whatever that a hereditary tendency is the chief predisposing cause of insanity. All sorts of disturbing influences to the brain bring out this pre- disposition into actual disease. No doubt 70 per cent. of all cases have an insane or neurotic heredity. Epilepsy, drunkenness, all nervous diseases, consumption, too exciting or depressing or exhausting employments, or unfavourable conditions of life in ancestry may cause insanity in the offspring. Marriage of near relatives causes it if the stock is bad; not if it is good. The physical causes of insanity, affecting the body, such as alcohol in excess, produce insanity in four times the proportion which mental and moral causes, such as affliction, losses, love-affairs, and religious excitement, do. For the production of a case of insanity there may be, and there usually is, more than one cause—e.g. (1) a man has a heredity; (2) he is at a critical time of life, or is run down in general health, or takes alcohol in excess; (3) he has a money loss, or domestic affliction just before his attack. A heredity to insanity does not mean a bad brain or a weak mind before the insanity comes on. Often it is quite the contrary. It is not the fools that go off their heads.
Nature of Insanity.—No one now doubts that it is due to disorder of function of a certain portion of the brain—viz. that part of the cortex which is the vehicle of all mental function. This bodily aspect of it should never be lost sight of by physicians and relations. Essentially it in no way differs from many ordinary diseases: it begins, runs a definite course, and ends like many common ailments. It may be brought on by disorder in many other parts of the body, upsetting the brain; but with a sound brain there must be a sound mind. The exact pathology of many forms of insanity has not yet been ascertained; but in 80 or 90 per cent. of the cases that die some abnormality can be found in the brain.
Treatment of Insanity—Asylums for the Insane.—The general principles of modern treatment may be divided into bodily and mental or moral. The bodily treatment may be generally said to be to put all the organs and functions right if wrong; to get up the strength and fat of the body—the writer preaches the 'gospel of fatness' for all his insane and nervous patients; to restore the tone and right working of the nervous system; to restore the sleep; to give medicines that determine more blood to the brain in cases where there is too little, and to give those that diminish the brain's blood-supply in those where there is too much; to use suitable baths that soothe nervous irritation, and mineral waters; to invigorate and soothe by life in the open air; and to let off undue and morbid nervous energy by much exercise, gymnastics, and massage in some cases, and to secure complete brain and body rest for others. The mental treatment consists chiefly in careful observation, companionship, control, distraction of the mind from morbid thought and feeling by suitable occupations and amusements, and guarding against the dangers of suicide, homicide, and self-neglect. The whole nursing of insanity is a most difficult task, for which the best bodily, moral, and mental qualifications are needed. In old times, and even up to a very recent date, cruelty, neglect, stripes, and tortures without number were the ordinary means of 'treatment.' Cullen, and all the great authors of his time, prescribe so many 'lashes' as a doctor now does so many drops of physic. Even the very medical means used were made terrifying on purpose—'surprise baths' in which patients were without warning plunged and kept till they were nearly drowned, and 'chairs' in which they were 'rotated' till they fainted. The early Christian theory of an evil spirit having entered into an insane man, which must be 'got out of him,' was at the bottom of much of this treatment, and accounted for the utter want of sympathy shown towards this class of sufferers. Pinel in France, and William Tuke, a York Quaker, in 1792 simultaneously began the new era of humanity, skill, and science for the insane. The next great landmark of progress was when mechanical restraint, in the shape of strait-jackets, &c., was disused, and the 'non-restraint system' of treatment was adopted. This was between 1825 and 1840, and was the work of Charlesworth and Gairdner Hill of Lincoln Asylum, and Conolly at Hanwell. The next advance was made by imitation of Belgian experience at Gheel, where the insane are largely boarded in private families. If not applicable to all, or even to many in Britain, it showed that the insane were not so dangerous as they had been considered. The next advance took place in Scotland, from 1857, through employing the insane more, classifying them better in asylums, making asylums more 'homes' with 'open-door' departments in them, almost abolishing the use of high-walled, enclosed 'airing courts' in asylums for the exercise of patients, sending them out into the open grounds and on the farms instead, and setting up fully-equipped 'hospital' wards with trained nursing for the special medical treatment of the sick and of the recent acute cases, while quiet incurable cases are boarded in cottages in the country under regular inspection and supervision. We are now fully in the scientific era when we hope by careful study of the brain and its disorders to understand the real nature of the disease and apply our remedies with the certainty and exactitude of science in each case. To secure such treatment for most of the poor, and also for many of the rich, asylums for the insane are needful.
Every country in Europe has now provision more or less adequate for the care and treatment of its insane. In Germany and Austria asylums are commonly of two classes: the one for the cure of the curable, near large cities, where the patients only stay for a limited time; and the other for the incurable, larger in size, less costly, and further in the country. The same idea is carried out in France (farm colonies), in Belgium, Holland, and in Great Britain; it will certainly be extended, for it enables economy of management to come in where cost is of no avail for cure, and it enables the curative idea to be realised, however costly, among the smaller numbers and individualised patients who are curable. In England the two great establishments at Caterham and Leavesden, each with over 2000 inmates, are the best examples of establishments for the incurable. That at Darenth, Dartfort, is for congenital imbeciles and idiots. All three were built to supply the wants of London. The largest asylum in England is Colney Hatch, which contains 2250 patients. This is far too many to be in one institution if it is for curable patients. One of the best known for its scientific work and practical success is that at Wakefield, containing 1400 patients. The English 'registered hospitals' for private patients fulfil a most important philanthropic function. One of them, that at Cheadle, near Manchester, under Mr Mould's most able and original management, leads the way by treating half its patients (150 out of 280) in real homes in the country; such homes being ordinary villas, farmhouses, country mansions, and seaside residences leased for the purpose. Scotland is honourably distinguished by its early care for the insane. Either in the end of the 18th century or the beginning of the 19th, every considerable town in the country (Edinburgh, Glasgow, Dundee, Aberdeen, Perth, and Dumfries) had erected a 'royal chartered asylum' for itself, through the benevolent efforts of individual citizens or of corporate bodies. These made provision for all their insane, poor and rich alike, each helping the other.
Commonly each royal asylum has two houses or departments, one for the poorer and the other for the richer patients. The system has worked well, and by means of it far more complete provision has been made for the insane of moderate means than in England. The largest institution in Scotland is the Royal Edinburgh Asylum at Morningside and Craiglockhart, which has large accommodation for private patients, paying either the higher or lower rates, as well as for pauper patients.
The United States of America have spent enormous sums to make the best provision possible for the mentally afflicted. As much as £600 a bed has been there spent on several 'state asylums' in New York, New Jersey, and Massachusetts. In most of the states all citizens, rich and poor alike, have the privilege of using the state asylums. The members of the Society of Friends in the state of Pennsylvania were the first to make philanthropic efforts to provide 'hospital' accommodation for the insane, their efforts following at a very short interval the work of Pinel and Tuke. The institutions in the United States are now growing to be as large in size as those in the United Kingdom. One of the most original asylums in the world, in its plan, is that at Kankakee, Illinois. It has 1600 patients, and consists of about twenty houses laid out on the two sides of a 'street,' forming in fact an insane town, all of whose inhabitants resort four times a day to a central dining-room or restaurant for their meals, and where a central ward for the sick and the administration buildings are also situated. The provision for the insane in the southern states, however, is backward and defective; and on the whole, it is generally admitted, even by Americans who have seen its asylums, that Great Britain has led the way in its provisions for the treatment of the insane, and that it is still unsurpassed in the world.
There are 135 public asylums and 117 private asylums now in the United Kingdom. The principles of construction of such buildings have become much more domestic and hospital-like and less prison-like than formerly. Each one should be a hospital-home, and the different wards in it should be arranged to suit different classes of patients in different states of mind. In fact the careful 'adaptation of the house to its inhabitants' in every stage of their disease should be carried out. There should be in each one hospital wards for special mental and bodily nursing, convalescent wards just like homes, wards where the most acute and violent and dangerous can be safely and properly treated without annoying the quiet and convalescent. Every means for suitable companionship and for varied occupation and amusement should be provided. A good asylum should in fact be a series of special model dwellings suited to men and women who need a somewhat different mode of life from ordinary mankind. Good asylums for the richer classes have seaside and country houses where the patients go for change in small parties.
The Lunacy Laws.—For the protection of the property of the insane, laws had to be made at a very early period. The first statute on the subject for England was passed in the reign of Edward II., and for Scotland in the beginning of the 14th century. Both had the same end in view. Property then meant land, and the primary duties of land were to the king and the country. If the man who held it from the king was unfit from mental incapacity to perform these duties, then the king had to resume possession or appoint another to take his place and do them. But the man's state could not be ascertained without a formal inquiry by a responsible official—the Chancellor—and the chief object of the early statutes was to provide for such an inquiry. If the man was found to be idiotic or furious, he along with his property passed into the care of his nearest male relative, and there was an end of him so far as the law went. In time some little care was bestowed on him as a human being, apart from his being an owner of land. The principle was afterwards adopted that the inquiry was to be held before a jury, the issue being determined by them, and the consequences of the verdict being carried out under the direction of the Chancellor. Between 1300 and 1889 at least forty statutes were passed in England relating to the insane, and something like eight or ten in Scotland. The most important of them all was the great English Lunacy Act of 1845, passed through the exertions of Lord Shaftesbury, the philanthropist. Its objects were entirely in the interests of the insane, and its effects have been most beneficial in England, while throughout the civilised world its influence for good has been felt. Under its provisions asylums have been erected for every county in England. A Board of Commissioners was appointed who inspect and report on every asylum, and see every insane person whether in or out of an institution; and every precaution was taken that the insane should be well treated, ill-treatment of them being severely punishable. At least £10,000,000 of capital has been laid out in building asylums, and over £1,500,000 a year besides is expended for the maintenance of their inmates. A new statute in 1889 made certain changes which experience had suggested. The Scotch statute of 1857 was founded on the English Act of 1845. Under it a Board of Commissioners in Lunacy was appointed for Scotland, and provision made for the insane of the counties that had no existing royal asylums. Ireland has a very good asylum system, with inspectors in lunacy. Scotland has much the advantage of England in the ease and economy with which the property of an insane person can be taken care of temporarily or permanently under the charge of a Curator Bonis, strictly responsible to the Court of Session. England holds to the old, cumbrous and expensive, but very efficient system of a formal inquiry (de lunatico inquirendo) by a 'Master in Lunacy' in each case. If the patient is found incapable of managing his affairs (non compos mentis), the Lord Chancellor appoints a 'committee of the person' to see to his comfort and proper treatment, and a 'committee of the estate' to manage his property. In addition to the statutes that regulate the care of the property and the persons of the insane, there are acts that provide for the protection of the public and the safe custody of insane persons who have committed crimes or are specially dangerous—the Criminal Lunacy Statutes—and there are three great establishments for criminal lunatics, one at Broadmoor for England, one at Dundrum for Ireland, and one in connection with Perth Penitentiary for Scotland. About three-fourths of the obviously insane are now in asylums or under committees or curators, the others being boarded under supervision in families, or placed in workhouses. And yet, with the great facility for treating the insane in asylums, such precautions are taken by the law and by the boards of lunacy against their abuse that no case of illegal detention of a sane person on the ground of insanity in a public or private asylum was proved in the exhaustive inquiry into the subject by the select committee of the House of Commons in 1877.
Curability of Insanity.—Taking all the cases now technically reckoned as insanity and sent to asylums, 40 per cent. recover; but many of these are subject to relapses—from which, however, they often recover again, just as people have relapses in rheumatism and bronchitis. But if the slight mental disturbances not sent to asylums at all, and the cases sent to asylums in which there is no organic brain disease nor very advanced senility, are alone taken, the rate of recovery is at least 70 per cent.
Mortality.—The rate is from 80 to 100 per 1000 of the insane living, or about five times the death-rate among the general population. Insanity is in fact a disease of the brain, from which people die as from other diseases.
Ages at which Insanity occurs most frequently.—Taking the number of persons living at the different ages, and the proportion of persons of the same ages who become insane during each period, we find that insanity occurs most frequently in men from thirty to thirty-five, and in women from fifty to fifty-five. But perhaps a more instructive mode of looking at the ages most liable to insanity is to point out that there are periods specially liable to it—viz. at the end of adolescence, from eighteen to twenty-four, when the organism is just attaining reproductive, that is, organic, perfection, heredity being then the chief cause; at mid-life, from thirty to fifty-five, the worries and strains of life, and the climacteric in women being then the chief causes; and after seventy, the general failure of old age, and especially the deficiency of blood to the brain then resulting from its diseased arteries being the cause.
Is Insanity increasing?—In England the number of the insane known to exist has risen from 36,762 in 1859 to 84,345 in 1889, or from 18.67 to 29.07 to every 10,000 of the population; and in Scotland from 6413 to 11,954, or from 19.8 to 28.9 per 10,000 of the population in the same time. But this increase does not prove a real increase of lunacy. For if we take the newly-registered cases of the disease each year, and compare their numbers with the population, we find it has only risen from 4.5 to 6 per 10,000 of the population in Great Britain in thirty years. It is clear, therefore, that there is an accumulation of the insane from the following causes—viz. (1) through their being taken better care of; (2) the abundance of good institutions, where all the insane poor can be gratuitously treated; (3) the operation of the lunacy laws; (4) the increasing sensitiveness of public opinion as to the neglect or ill-treatment of insane people; and (5) the widening area of the mental disturbances that are reckoned technical insanity requiring treatment in asylums, all these tending to increase the numbers of the recognised and registered insane. There is in fact no proof that insanity as a whole is increasing: certain forms are no doubt increasing, and presumably other forms are diminishing in amount.
Medico-legal and Social Relations of Insanity.—Few persons have studied carefully the mental state of our criminal population but have come to the conclusion that crime is most closely related to mental defect in very many cases. Could we abolish the latter the former would shrink to small proportions. This does not assume that many or most criminals are technically insane persons. They are merely blood-relations of the insane. The law has been gradually altering its tests as to the amount of insanity that absolves from punishment for crime. Of old a man accused of crime had to be totally delirious or fatuous to be absolved from punishment. Now the power of controlling his actions is being gradually made the test. The law has thus approached, and at last coincides with, the scientific views of insanity. Society should have the keenest interest in the mental condition of its members. Soundness of mind is the most precious possession of a people, for there are innumerable degrees and kinds of mental and moral defects that fall far short of insanity, yet are intimately related to it, hereditarily and psychologically—defects that weaken a people's power of work, diminish its moral force, and impair its social stability. It is one of the most deeply saddening and terrible of the facts in human history that of the men of genius who have raised and glorified mankind few have been without mental disease in their families, and many have themselves fallen victims to it. If it is true that as yet the mode of human development has been such that to get one man of genius nature had to sacrifice mentally many of his kindred, the world should pay some of the debt it owes to its poets and thinkers by an ungrudging care of such victims. To produce in the human brain the greatest mental strength without running the risk of liability to mental disease must be one of the essential problems of the future for the educationist, the sociologist, the politician, and the physician. Insanity is commonly the final breakdown which shows that many previous generations had broken the laws of nature in their lives. It is the outcome of a civilisation in which the true principles of evolution for human beings had not been understood and assisted.
The chief modern authorities are: Blandford's Insanity; Bucknill and Hack Tuke's Psychological Medicine; Clouston's Mental Diseases; Griesinger's Mental Pathology; Bevan Lewis's Mental Diseases; Maudsley's Pathology of Mind; Sankey's Mental Disease; Savage's Insanity; Spitzka's Insanity; Ball's Maladies Mentales; Esquirol's Maladies Mentales; Guislain's Phrenopathies; Luy's Maladies Mentales; Morel's Maladies Mentales; Von Krafft-Ebing's Psychiatrie; Kraepelin's Psychiatrie; V. Ziemssen and Schule's Psychiatrie.