In Spain the papal Inquisition could gai_Encyclopaedia Britannica, 11th Edition, "Indole" to "Insanity" Volume 14, Slice 5

ages. Spain had been, in turn or simultaneously, Arian under the

Visigoths, Catholic under the Hispano-Romans, Mussulman by conquest, and

under a régime of religious peace Judaism had developed there. After the

reconquest, and even at the height of the influence of the Cathari its

heresies had been of quite minor importance. At the end of the 12th

century Alphonso II. and Peter II. had on principle promulgated cruel

edicts against heresy, but the persecution seemed to be dormant. By the

bull _Declinante_ of the 26th of May 1232 inquisitors were sent to

Aragon by Gregory IX. on the request of Raymond of Penaforte, and by

1237-1238 the Inquisition was practically founded. But as early as 1233

King James I. had promulgated an edict against the heretics which quite

openly put the Inquisition in a subaltern position, and secularized a

great part of its activities. The people, moreover, showed great

hostility towards it. The inquisitor Fray Pedro de Cadrayta was murdered

by the mob, and in 1235 the Cortes, with the consent of King James,

prohibited the use of inquisitorial procedure and of the torture, as

constituting a violation of the Fueros, though they made no attempt to

give effect to their prohibition. In Castile Alphonso the Wise had, by

establishing in his _Fuero Real_ and his _Siete Partidas_ an entirely

independent secular legislation with regard to heretics (1255), removed

his kingdom from all papal interference. At the opening of the 14th

century Castile and Portugal had still no Inquisition. But at that time

in Spain orthodoxy was generally threatened only by a few Fraticelli and

Waldenses, who were not numerous enough to call for active repression.

The Spanish inquisitor Nicholas Eymerich, the author of the famous

_Directorium Inquisitorum_, had rarely to exercise his functions during

the whole of his long career (end of 14th century). It was not against

heresy that the church had to direct its vigilance. A mutual tolerance

between the different religions had in fact sprung up, even after the

conquest; the Christians in the north recognized the Mahommedan and

Jewish religions, and Alphonso VI. of Castile took the title of

_imperador de los dos cultos_. But for a long time past both the

decisions of councils and papal briefs had proclaimed their surprise and

indignation at this ominous indifference. As early as 1077 the third

council of Rome, and in 1081 Gregory VII., protested against the

admission of Jews to public offices in Spain. Clement IV., in a brief of

1266, exhorted James I. of Aragon to expel the Moors from his dominions.

In 1278 Nicholas III. blamed Peter III. for having made a truce with

them. One of the canons of the council of Vienne (1311-1312) denounces

as intolerable the fact that Mahommedan prayers were still proclaimed

from the top of the mosques, and under the influence of this council the

Spanish councils of Zamora (1313) and Valladolid (1322) came to

decisions which soon led to violent measures against the Mudegares

(Mussulmans of the old Christian provinces). Already in 1210 massacres

of Jews had taken place under the inspiration of Arnold of Narbonne, the

papal legate; in 1276 fresh disturbances took place as a result of James

I.'s refusal to obey the order of Clement IV., who had called upon him

to expel the Jews from his dominions. In 1278 Nicholas IV. commanded the

general of the Dominicans to send friars into all parts of the kingdom

to work for the conversion of the Jews, and draw up lists of those who

should refuse to be baptized. It was in vain that a few princes such as

Peter III. or Ferdinand of Castile interfered; the Spanish clergy

directed the persecution with ever increasing zeal. In the 14th century

the massacres increased, and during the year 1391 whole towns were

destroyed by fire and sword, while at Valencia eleven thousand forced

baptisms took place. In the 15th century the persecution continued in

the same way; it can only be said that the years 1449, 1462, 1470, 1473

were marked by the greatest bloodshed. Moreover, the Mudegares were also

subjected to these baptisms and massacres _en masse_. From those, or the

children of those who had escaped death by baptism, was formed the class

of _Conversos_ or _Marranos_, the latter name being confined to the

converted Jews. This class was still further increased after the

conquest of the kingdom of Granada and the completion of the conquest

by Ferdinand and Isabella, and after the pacification of the kingdoms of

Aragon and Valencia by Charles V. The Mahommedans and Jews in these

parts were given the choice between conversion and exile. Being of an

active nature, and desiring some immediate powers as a recompense for

their moral sufferings, the Jewish or Mussulman _Conversos_ soon became

rich and powerful. In addition to the hatred of the church, which feared

that it might quickly become Islamized or Judaized in this country which

had so little love for theology, hatred and jealousy arose also among

laymen and especially in the rich and noble classes. _Limpieza_, i.e.

purity of blood, and the fact of being an "old Christian" were made the

conditions of holding offices. It is true, this mistrust had assumed a

theological form even before the Mahommedan conquest. As early as 633

the council of Toledo had declared heretics such converts, forced or

voluntary, as returned to their old religion. When this principle was

revived and, whether through secular jealousy, religious dislike or

national pride, was applied to the _Conversos_, an essentially national

Inquisition, directed against local heretics, was founded in Spain, and

founded without the help of the papacy. It was created in 1480 by

Ferdinand and Isabella. Sixtus IV. had wished the papal Inquisition to

be established after the form and spirit of the middle ages; but

Ferdinand, in his desire for centralization (his efforts in this

direction had already led to the creation of the Holy Hermandad and the

extension of the royal jurisdiction) wished to establish an inquisition

which should be entirely Spanish, and entirely royal. Rome resisted, but

at last gave way. Sixtus IV., Alexander VI., Innocent VIII., Julius II.

and after them all the popes of the 16th century, saw in this secular

attempt a great power in favour of orthodoxy, and approved it when

established, and on seeing its constant activity. The Inquisition took

advantage of this to claim an almost complete autonomy. The decisions of

the Roman Congregation of the Index were only valid for Spain if the

Holy Office of Madrid thought good to countersign them; consequently

there were some books approved at Rome and proscribed in the peninsula,

such as the _Historia pelagiana_ of Cardinal Nores, and some which were

forbidden at Rome and approved in the peninsula, such as the writings of

Fathers Mateo Moya and Juan Bautista Poza. The Spanish Holy Office

perceived long before Rome the dangers of mysticism, and already

persecuted the mystics, the _Alumbrados_ while Rome (impervious to

Molinism) still favoured them. "During the last few centuries the church

of Spain was at once the most orthodox and the most independent of the

national churches" (Ch. V. Langlois). There was even a financial dispute

between the Inquisition and the papacy, in which the Inquisition had the

better of the argument; the Roman Penitentiary sold exemptions from

penalties (involving loss of civil rights), such as prison, the galleys

and wearing the _sanbenito_, and dispensations from the crime of

_Marrania_ (secret Judaism). The inquisitors tried to gain control of

this sale, and at a much higher price, and were seconded in this by the

kings of Spain, who saw that it was to their own interest. At first they

tried a compromise; the unfortunate victims had to pay twice, to the

pope and to the Inquisition. But the payment to the pope was held by the

Inquisition to reduce too much its own share of the confiscated

property, and the struggle continued throughout the first half of the

16th century, the Curia finally triumphing, thanks to the energy of Paul

III. Since, however, the Inquisition continued to threaten the holders

of papal dispensations, most of them found it prudent to demand a

definite rehabilitation, in return for payments both to the king and the

Inquisition. As a national institution the Inquisition had first of all

the advantage of a very strong centralization and very rapid procedure,

consisting as it did of an organization of local tribunals with a

supreme council at Madrid, the _Suprema_. The grand inquisitor was _ex

officio_ president for life of the royal council of the Inquisition. It

was the grand inquisitor, General Jimenez de Cisneros, who set in motion

the inquisitorial tribunals of Seville, Cordova, Jaen, Toledo, Murcia,

Valladolid and Calahorra. There was no such tribunal at Madrid till the

time of Philip IV. The inquisitor-general of Aragon established

inquisitors at Saragossa, Barcelona, Valencia, Majorca, Sardinia, Sicily

and Pampeluna (moved later to Calahorra). From the very beginning the

papacy strengthened this organization by depriving the Spanish

metropolitans, by the bull of the 25th of September 1487, of the right

of receiving appeals from the decisions given jointly by the bishops of

the various dioceses, their suffragans and the apostolic inquisitors,

and by investing the inquisitor-general with this right. And, more than

this, Torquemada actually took proceedings against bishops, for example,

the accusation of heresy against Don Pedro Aranda, bishop of Calahorra

(1498); while the inquisitor Lucero prosecuted the first archbishop of

Granada, Don Ferdinando de Talavera. Further, when once the Inquisition

was closely allied to the crown, no Spaniard, whether clerk or layman,

could escape its power. Even the Jesuits, though not till after 1660,

were put under the authority of the Suprema. The highest nobles were

kept constantly under observation; during the reigns of Charles III. and

Charles IV. the duke of Almodovar, the count of Aranda, the great writer

Campomanes, and the two ministers Melchior de Jovellanos and the count

of Florida-Alanca, were attacked by the Suprema. But the descendants of

Moors and Jews, though they were good Christians, or even nobles, were

most held in suspicion. Even during the middle ages the descendants of

the Paterenes were known, observed and denounced. In the eyes of the

Inquisition the taint of heresy was even more indelible. A family into

which a forced conversion or a mixed marriage had introduced Moorish or

Jewish blood was almost entirely deprived of any chance of public

office, and was bound, in order to disarm suspicion, to furnish agents

or spies to the Holy Office. The Spaniards were very quick to accept the

idea of the Inquisition to such an extent as to look upon heresy as a

national scourge to be destroyed at all costs, and they consequently

considered the Inquisition as a powerful and indispensable agent of

public protection; it would be going too far to state that this

conception is unknown to orthodox present-day historians of the

Inquisition, and especially certain Spanish historians (cf. the preface

to Menendez y Pelayo's _Heterodoxos españoles_). As had happened among

the Albigenses, commerce and industry were rapidly paralysed in Spain by

this odious régime of suspicion, especially as the _Conversos_, who

inherited the industrial and commercial capacity of the Moors and Jews,

represented one of the most active elements of the population. Besides,

this system of wholesale confiscations might reduce a family to beggary

in a single day, so that all transactions were liable to extraordinary

risks. It was in vain that the counsellors of Charles V., and on several

occasions the Cortes, demanded that the inquisitors and their countless

agents should be appointed on a fixed system by the state; the state,

and above all the Inquisition, refused to make any such change. The

Inquisition preferred to draw its revenues from heresy, and this is not

surprising if we think of the economic aspect of the Albigensian

Inquisition; the system of _encours_ was simply made general in Spain,

and managed to exist there for three centuries. In the case of the

Inquisition in Languedoc, there still remained the possibility of an

appeal to the king, the inquisitors, or more rarely the pope, against

these extortions; but there was nothing of the kind in Spain. The

Inquisition and the Crown could refuse each other nothing, and appeals

to the pope met with their united resistance. As early as the reign of

Ferdinand certain rich _Conversos_ who had bought letters of indulgence

from the Holy See were nevertheless prosecuted by Ferdinand and

Torquemada, in spite of the protests of Sixtus IV. The papacy met with

the most serious checks under the Bourbons. Philip V. forbade all his

subjects to carry appeals to Rome, or to make public any papal briefs

without the royal _exequatur_.

The political aspect of the work and character of the Inquisition has

been very diversely estimated; it is a serious error to attribute to it,

as has too often been done, extreme ideas of equality, or even to

represent it as having favoured centralization and a royal absolutism to

the same extent as the Inquisition of the 13th and 14th centuries in

Languedoc. "It was a mere coincidence," says H. C. Lea, "that the

Inquisition and absolutism developed side by side in Spain." The Suprema

did not attack all nobles as nobles; it attacked certain of them as

_Conversos_, and the Spanish feudal nobles were sure enough of their

_limpieza_ to have nothing to fear from it. But it is undeniable that it

frequently tended to constitute a state within the state. At the time of

their greatest power, the inquisitors paid no taxes, and gave no account

of the confiscations which they effected; they claimed for themselves

and their agents the right of bearing arms, and it is well known that

their declared adversaries, or even those who blamed them in some

respects, were without fail prosecuted for heresy. But that was not the

limit to their pretensions. In 1574, under Philip II., there was an idea

of instituting a military order, that of Santa Maria de la Espada

Blanca, having as its head the grand inquisitor, and to him all the

members of the order, i.e. all Spaniards distinguished by _limpieza_ of

blood, were to swear obedience in peace and in war. Moreover, they were

to recognize his jurisdiction and give up to him the reversion of their

property. Nine provinces had already consented, when Philip II. put a

stop to this theocratic movement, which threatened his authority. It

was, however, only the Bourbons, who had imbibed Gallican ideas, who by

dint of perseverance managed to make the Inquisition subservient to the

Crown, and Charles III., "the philosopher king," openly set limits to

the privileges of the inquisitors. Napoleon, on his entry into Madrid

(December 1808), at once suppressed the Inquisition, and the

extraordinary general Cortes on the 12th of February 1813 declared it to

be incompatible with the constitution, in spite of the protests of Rome.

Ferdinand VII. restored it (July 21, 1814) on his return from exile, but

it was impoverished and almost powerless. It was again abolished as a

result of the Liberal revolution of 1820, was restored temporarily in

1823 after the French military intervention under the duc d'Angoulême,

and finally disappeared on the 15th of July 1834, when Queen Christina

allied herself with the Liberals. "It was not, however, till the 8th of

May 1869 that the principle of religious liberty was proclaimed in the

peninsula; and even since then it has been limited by the constitution

of 1876, which forbids the public celebration of dissident religions"

(S. Reinach). In 1816 the pope abolished torture in all the tribunals of

the Inquisition. It is a too frequent practice to represent as peculiar

to the Spanish Inquisition modes of procedure in use for a long time in

the inquisitorial tribunals of the rest of Europe. There are no special

manuals, or _practica_, for the inquisitorial procedure in Spain; but

the few distinctive characteristics of this procedure may be mentioned.

The Suprema allowed the accused an advocate chosen from among the

members or familiars of the Holy Office; this privilege was obviously

illusory, for the advocate was chosen and paid by the tribunal, and

could only interview the accused in presence of an inquisitor and a

secretary. The theological examination was a delicate and minute

proceeding; the "qualificators of the Holy Office," special

functionaries, whose equivalent can, however, easily be found in the

medieval Inquisition, charged those books or speeches which had incurred

"theological censures," with "slight, severe or violent" suspicion.

There was no challenging of witnesses; on the contrary, witnesses who

were objected to were allowed to give evidence on the most important

points of the case. The torture, to the practice of which the Spanish

Inquisition certainly added new refinements, was originally very much

objected to by the Spaniards, and Alphonso X. prohibited it in Aragon;

later, especially in the 15th, 16th and 17th centuries it was applied

quite shamelessly on the least suspicion. But by the end of the 18th

century, according to Llorente, it had not been employed for a long

time; the _fiscal_, however, habitually demanded it, and the accused

always went in dread of it. The punishment of death by burning was much

more often employed by the Spanish than by the medieval Inquisition;

about 2000 persons were burnt in Torquemada's day. Penitents were not

always reconciled, as they were in the middle ages, but those condemned

to be burnt were as a rule strangled previously.

Spanish and Portuguese Colonies.

With the extension of the Spanish colonial empire the Inquisition

spread throughout it almost contemporaneously with the Catholic faith.

Ferdinand IV. decreed the establishment of the Inquisition in America,

and Jimenes in 1516 appointed Juan Quevedo, bishop of Cuba,

inquisitor-general delegate with discretionary powers. Excesses having

been committed by the agents of the Holy Office, Charles V. decreed

(October 15, 1538) that only the European colonists should be subject to

the jurisdiction of the Inquisition; but Philip II. increased the powers

of the inquisitors' delegate and, in 1541, established on a permanent

basis three new provinces of the Inquisition at Lima, Mexico and

Cartagena. The first _auto-da-fé_ took place at Mexico in 1574, the year

in which Hernando Cortez died. The Inquisition of Portugal was no less

careful to ensure the orthodoxy of the Portuguese colonies. An

Inquisition of the East Indies was established at Goa, with jurisdiction

over all the dominions of the king of Portugal beyond the Cape of Good

Hope. Finally Philip II. even wished to establish an itinerant

Inquisition, and at his request the pope created, by a brief of the 21st

of July 1571, the "Inquisition of the galleys," or "of fleets and

armies."

Other activities of the Spanish Inquisition.

After the expulsion of the Jews under Isabella the Catholic (1492),

followed under Philip III. by that of the Moriscoes (1609), the

Inquisition attacked especially Catholics descended from infidels, the

_Marranes_ and _Conversos_, who were, not without reason, suspected of

often practising in secret the rites of their ancestral religions. As

late as 1715 a secret association was discovered at Madrid, consisting

of twenty families, having a rabbi and a synagogue. In 1727 a whole

community of Moriscoes was denounced at Granada, and prosecuted with the

utmost rigour. Again, a great number of people were denounced, sent to

the galleys, or burnt, for having returned to their ancestral religion,

on the flimsiest of evidence, such as making ablutions during the day

time, abstaining from swine's flesh or wine, using henna, singing

Moorish songs, or possessing Arabic manuscripts. During the 16th and

17th centuries the Inquisition in Spain was directed against

Protestantism. The inquisitor-general, Fernando de Valdés, archbishop of

Seville, asked the pope to condemn the Lutherans to be burnt even if

they were not backsliders, or wished to be reconciled, while in 1560

three foreign Protestants, two Englishmen and a Frenchman were burnt in

defiance of all international law. But the Reformation never had enough

supporters in Spain to occupy the attention of the Inquisition for long.

After the _Marranes_ the mystics of all kinds furnished the greatest

number of victims to the terrible tribunal. Here again we should not

lose sight of the tradition of the medieval Inquisition; the mysticism

of the Beghards, the Brethren of the Free Spirit and the innumerable

pantheist sects had been pitilessly persecuted by the inquisitors of

Germany and France during the 14th and 15th centuries. The Illuminati

(_alumbrados_), who were very much akin to the medieval sectaries, and

the mystics of Castile and Aragon were ruthlessly examined, judged and

executed. Not even the most famous persons could escape the suspicious

zeal of the inquisitors Valdés and Melchior Cano. The writings of Luis

de Granada were censured as containing _cosas de alumbrados_. St

Ignatius de Loyola was twice imprisoned at the beginning of his career;

St Theresa was accused of misconduct, and several times denounced; one

of her works, _Conceptos del amor divino_, was prohibited by the

Inquisition, and she was only saved by the personal influence of Philip

II. Countless numbers of obscure visionaries, devotees both men and

women, clerks and laymen, were accused of Illuminism and perished in the

fires or the dungeons of the Inquisition. From its earliest appearance

Molinosism was persecuted with almost equal rigour. Molinos himself was

arrested and condemned to perpetual imprisonment (1685-1687), and during

the 18th century, till 1781, several Molinosists were burnt. The

Inquisition also attacked Jansenism, freemasonry (from 1738 onwards; cf.

the bull _In eminenti_) and "philosophism," the learned naturalist José

Clavigo y Faxarcho (1730-1806), the mathematician Benito Bails

(1730-1797), the poet Tomas de Iriarte, the ministers Clavigo Ricla,

Aranda and others being prosecuted as "philosophers." Subject also to

the tribunal of the Holy Office were bigamists, blasphemers, usurers,

sodomites, priests who had married or broken the secrecy of the

confessional, laymen who assumed ecclesiastical costume, &c. "In all

these matters, though the Inquisition may have been indiscreet in

meddling with affairs which did not concern it, it must be confessed

that it was not cruel, and that it was always preferable to fall into

the hands of the Inquisition rather than those of the secular judges, or

even the Roman inquisitors" (S. Reinach). Apart from certain exceptional

cruelties such as those of the Inquisition of Calahorra, perhaps the

greatest number of executions of sorcerers took place in the colonies,

in the Philippines and Mexico. In Spain the persecution was only

moderate; at certain times it disappeared almost completely, especially

in the time of the clear-sighted inquisitor Salazar.

Two features of the Spanish Inquisition are especially noteworthy: the

prosecutions for "speeches suspected of heresy" and the censure of

books. The great scholar Pedro de Lerma, who after fifty years at Paris

(where he was dean of the faculty of theology) had returned to Spain as

abbot of Compluto, was called upon in 1537 to abjure eleven "Erasmian"

propositions, and was forced to return to Paris to die. Juan de Vergara

and his brother were summoned before the Inquisition for favouring

Erasmus and his writings, and detained several years before they were

acquitted. Fray Alonso de Virues, chaplain to Charles V., was imprisoned

on an absurd charge of depreciating the monastic state, and was only

released by the pope at the instance of the emperor. Mateo Pascual,

professor of theology at Alcala, who had in a public lecture expressed a

doubt as to purgatory, suffered imprisonment and the confiscation of his

goods. A similar fate befell Montemayor, Las Brozas and Luis de la

Cadena.

The censure of books was established in 1502 by Ferdinand and Isabella

as a state institution. All books had to pass through the hands of the

bishops; in 1521 the Inquisition took upon itself the examination of

books suspected of Lutheran heresy. In 1554 Charles V. divided the

responsibility for the censorship between the Royal Council, whose duty

it was to grant or refuse the _imprimatur_ to manuscripts and the

Inquisition, which retained the right of prohibiting books which it

judged to be pernicious; but after 1527 it also gave the licence to

print. In 1547 the Suprema produced an Index of prohibited books, drawn

up in 1546 by the university of Louvain; it was completed especially as

regards Spanish books, in 1551, and several later editions were

published. Moreover, the _revisores de libros_ might present themselves

in the name of the Holy Office in any private library or bookshop and

confiscate prohibited books. In 1558 the penalty of death and

confiscation of property was decreed against any bookseller or

individual who should keep in his possession condemned books. The

censure of books was eventually abolished in 1812.

BIBLIOGRAPHY.--A critical bibliography was drawn up by P. Fredericq in

the preface to the French translation (1900) of H. C. Lea's important

standard work: _History of the Inquisition in the Middle Ages_ (3

vols., London, 1888). See also J. Havet, _L'Hérésie et le bras

séculier au moyen âge jusqu'au XIII^e siècle_ in the _Oeuvres

complètes_, vol. ii. (Paris, 1896); Ch. V. Langlois, _L'Inquisition

d'après des travaux récents_ (Paris, 1901); Douais, _L'Inquisition_

(Paris, 1907); E. Vacandard, _L'Inquisition_ (Paris, 1907); Douais,

_Documents pour servir à l'histoire de l'inquisition dans le

Languedoc_ (2 vols., Paris, 1900); Döllinger, _Beiträge zur

Sektengeschichte des Mittelalters_ (2 vols., Munich, 1890. The second

volume is composed of documents); Molinier, _L'Inquisition dans le

midi de la France au XIII^e et au XIV^e siècle. Étude sur les sources

de son histoire_ (Paris, 1880); P. Fredericq, _Corpus documentorum

inquisitionis haereticae pravitatis neerlandicae_ (1205-1525) (4

vols., Ghent, 1889-1900); Tanon, _Histoire des tribunaux de

l'inquisition en France_ (Paris, 1893); Hansen, _Inquisition,

Hexenwahn und Hexenverfolgung_ (Munich, 1900); Llorente, _Histoire

critique de l'inquisition d'Espagne_ (4 vols., Paris, 1818); H. C.

Lea, _History of the Inquisition of Spain_ (5 vols., London,

1905-1908); S. Reinach, articles on Lea's _History of the Inquisition

of Spain_ in the _Revue critique_ (1906, 1907, 1908) and _Cultes,

mythes et religions_ (Paris, 1908), tome iii. (P. A.)

FOOTNOTES:

[1] Pierre de Beauvoisis (?), choir-master (_grand-chantre_) of the

university of Paris (1184), bishop of Tournai (1191), of Paris

(1196); died as a Cistercian in 1197. He was beatified.

[2] He was born c. 1261, was a Dominican at Limoges in 1279,

successively prior of Albi (1294), Carcassonne (1297), Castres (1301)

and Limoges (1305), inquisitor at Toulouse (1307), bishop of Tuy

(1323) and of Lodève (1325). He died in 1331.

[3] Peter, a Dominican, born at Verona, was murdered near Milan in

1252 and canonized in 1253.

[4] Guillaume de St Amour (d. 1272), named after his birthplace in

the Jura, was canon of Beauvais and rector of the university of

Paris. He was conspicuous as the mouthpiece of the secular clergy in

their attacks on the mendicant orders, the Dominicans in particular.

[5] The name of _vauderie_, i.e. the Vaudois or Waldensian heresy,

had come to be used of witchcraft.

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_ ([Greek: psychê], mind, and [Greek:

iatreia], treatment) is applied to the study and treatment of the

condition.

I. MEDICAL AND GENERAL

Definition.

There are many diseases of the general system productive of disturbance

of the mental faculties, which, either on account of their transient

nature, from their being associated with the course of a particular

disease, or from their slight intensity, are not included under the head

of insanity proper. From a strictly scientific point of view it cannot

be doubted that the fever patient in his delirium, or the drunkard in

his excitement or stupor, is 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.

Classification.

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 healthy but has suffered from

morbid processes affecting it primarily, or from diseased states of the

general system implicating it secondarily. In studying the causation of

these two great classes, it will be found that certain remote influences

exist which are believed to be commonly predisposing; these will be

considered as such, leaving the proximate or exciting causes until each

class with its subdivisions comes under review.

Causation.

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, 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, [Greek:

streptos]); (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.

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.

Forms of Insanity.

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.).

Idiocy.

IDIOCY (from Gr. [Greek: idiôtês], 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 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 |

| | | | | |

| Scotland | 3,246 | 3,377 | 6,623 | 148 |

| | | | | |

| Ireland | 2,946 | 2,270 | 5,216 | 117 |

| | | | | |

| France (including | 20,456 | 14,677 | 35,133 | 97 |

| | | | | |

| Germany (1871) | -- | -- | 33,739 | 82 |

| | | | | |

| Sweden (1870) | -- | -- | 1,632 | 38 |

| | | | | |

| Norway (1891) | 1,357 | 1,074 | 2,431 | 121 |

| | | | | |

| Denmark (1888-89) | 2,106 | 1,751 | 3,857 | 200 |

+-------------------|--------|---------|--------|------------+

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:--

Prussia 158 | France 66

Bavaria 154 | Denmark 58

Saxony 162 | Sweden 22

Austria 53 | Norway 65

Hungary 140 | England and Wales 74

Canton of Bern 117 | Scotland 68

America 79 | Ireland 69

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.

Acquired Insanity.

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 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:--

Melancholia.

Mania.

Delusional Insanity.

Katatonia.

Hebephrenia.

Traumatic Insanity.

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.

Senile Insanity.

The general symptoms of acquired insanity group themselves naturally

under two heads, the physical and the mental.

General symptoms.

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 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.--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 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.

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. 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.

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 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.

Encyclopaedia Britannica, 11th Edition, "Indole" to "Insanity" Volume 14, Slice 5 · 第 9 / 10 章

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