muscular spasm or rigidity which is present during certain of its
stages, was first described and named by K. L. Kahlbaum in 1874. Many
British alienists refuse to accept katatonia as a distinct disease, but
as it has been accepted and further elaborated by such an authority as
E. Kraepelin reference to it cannot be avoided.
Katatonia attacks women more frequently than men, and is essentially a
disease of adolescence, but typical cases occasionally occur in adults.
Hereditary predisposition is present in over 50% of the cases and is the
chief predisposing cause. Childbirth, worry, physical strain and mental
shocks are all advanced as secondary predisposing causes. The disease is
one of gradual onset, with loss of physical and mental energy. Probably
the earliest mental symptom is the onset of aural hallucinations. For
convenience of description the disease may be divided into (1) the stage
of onset; (2) the stage of stupor; (3) the stage of excitement.
The symptoms of the stage of onset are disorders of the alimentary
tract, such as loss of appetite, vomiting after food and obstinate
constipation. The pulse is rapid, irregular and intermittent. The skin
varies between extreme dryness and drenching perspirations. In women the
menstrual function is suppressed. At uncertain intervals the skeletal
muscles are thrown into a condition of rigidity, but this symptom does
not occur invariably. The instincts of cleanliness are in abeyance,
owing to the mental state of the patient, and as a result these cases
are inclined to be wet and dirty in their habits.
Mentally there is great confusion, vivid hallucinations, which
apparently come on at intervals and are of a terrifying nature, for the
patient often becomes frightened, endeavours to hide in corners or
escape by a window or door. A very common history of such a case prior
to admission is that the patient has attempted suicide by jumping out of
a window, the attempt being in reality an unconscious effort on the part
of the patient to escape from some imaginary danger. During these
attacks the skin pours with perspiration. The patient is oblivious to
his surroundings and is mentally inaccessible. In the intervals between
these attacks the patient may be conscious and capable of answering
simple questions. This acute stage, in which sleep is abolished, lasts
from a few days to four or six weeks and then, generally quite suddenly,
the patient passes into the state of stupor. In some cases a sharp
febrile attack accompanies the onset of the stupor, while in others this
symptom is absent; but in every case examined by Bruce during the acute
stage there was an increase in the number of the white blood corpuscles,
which, just prior to the onset of stupor, were sometimes enormously
increased; the increase being entirely due to multiplication of the
multinucleated or polymorphonuclear leucocytes.
In the second or stuporose stage of the disease the symptoms are
characteristic. The patient lies in a state of apparent placidity,
generally with the eyes shut. Consciousness is never entirely abolished,
and many of the patients give unmistakable evidence that they understand
what is being said in their presence. Any effort at passive movement of
a limb immediately sets up muscular resistance, and throughout this
stage the sternomastoid and the abdominal muscles are more or less in a
state of over-tension, which is increased to a condition of rigidity if
the patient is interfered with in any way. This symptom of restiveness
or negativism is one of the characteristics of the disease. The patient
resists while being fed, washed, dressed and undressed, and even the
normal stimuli which in a healthy man indicate that the bladder or
rectum require to be emptied are resisted, so that the bladder may
become distended and the lower bowel has to be emptied by enemata. The
temperature is low, often subnormal, the pulse is small and weak, and
the extremities cold and livid. This symptom is probably due in some
part to spasm of the terminal arterioles. Mentally the symptoms are
negative. Though conscious, the patient cannot be got to speak and
apparently is oblivious to what is passing around. Upon recovery,
however, these cases can often recount incidents which occurred to them
during their illness, and may also state that they laboured under some
delusion. Coincidently with the onset of the stupor sleep returns, and
many cases sleep for the greater part of the twenty-four hours. The
duration of the stuporose state is very variable. In some cases it lasts
for weeks, in others for months or years, and may be the terminal stage
of the disease, the patient gradually sinking into dementia or making a
recovery. The third stage or stage of excitement comes on in many cases
during the stage of stupor: the stages overlap; while in others a
distinct interval of convalescence may intervene between the termination
of the stupor and the onset of the excitement. The excitement is
characterized by sudden impulsive actions, rhythmical repetition of
words and sounds (verbigeration), and by rhythmical movements of the
body or limbs, such as swaying the whole frame, nodding the head,
swinging the arms, or walking in circles. The patient may be absolutely
mute in this stage as in the stage of stupor. Others again are very
noisy, singing, shouting or abusive. The speech is staccato in character
and incoherent. Physically the patient, who often gains weight in the
stage of stupor, again becomes thin and haggard in appearance owing to
the incessant restlessness and sleeplessness which characterize the
stage of excitement. The patient may, during the stage of onset, die
through exhaustion, or accidentally and unconsciously commit suicide
usually by leaping from a window. During the stuporose stage symptoms of
tubercular disease of the lungs may commence. All the adolescent insane
are peculiarly liable to contract and die from tubercular disease.
Accidental suicide is also liable to occur during this stage. The stage
of excitement, if at all prolonged, invariably ends in dementia.
According to Kraepelin 13% of the cases recover, 27 make partial
recoveries, and 60% become more or less demented.
_Treatment._--No treatment arrests or diverts the course of katatonia,
and the acute symptoms of the disease as they arise must be treated on
hospital principles.
Hebephrenia.
HEBEPHRENIA.--This is a disease of adolescence (Gr. [Greek: hêbê]) which
was first described by Hecker and Kahlbaum and more recently by
Kraepelin and other foreign workers. Hebephrenia is not yet recognized
by British alienists. The descriptions of the disease are indefinite and
confusing, but there are some grounds for the belief that such an entity
does exist, although it is probably more correct to say that as yet the
symptoms are very imperfectly understood. Hebephrenia is always a
disease of adolescence and never occurs during adult life. It attacks
women more frequently than men, and according to Kahlbaum hereditary
predisposition to insanity is present in over 50% of the cases attacked.
The onset of the disease is invariably associated with two symptoms. On
the physical side an arrested or delayed development and on the mental a
gradual failure of the power of attention and concentrated thought. The
onset of the condition is always gradual and the symptoms which first
attract attention are mental. The patient becomes restless, is unable to
settle to work, becomes solitary and peculiar in habits and sometimes
dissolute and mischievous. As the disease advances the patient becomes
more and more enfeebled, laughs and mutters to himself and wanders
aimlessly and without object. There is no natural curiosity, no interest
in life and no desire for occupation. Later, delusions may appear and
also hallucinations of hearing, and under their influence the patient
may be impulsive and violent. Physically the subjects are always badly
developed. The temperature is at times slightly elevated and at
intervals the white blood corpuscles are markedly increased. The
menstrual function in women is suppressed and both male and female cases
are addicted to masturbation. According to Kraepelin 5% of the cases
recover, 15% are so far relieved as to be able to live at home, but are
mentally enfeebled, the remaining 80% become hopelessly demented. The
patients who recover frequently show at the onset of their disease acute
symptoms, such as mild excitement, slightly febrile temperature and
quick pulse-rate. When recovery does take place there is marked
improvement in development. The subjects of hebephrenia are peculiarly
liable to tubercular infection and many die of phthisis.
There is no special treatment for hebephrenia beyond attention to the
general health.
Traumatic Insanity.
INSANITY FOLLOWING UPON INJURIES TO THE BRAIN, OR APOPLEXIES OR TUMOURS
OR ARTERIAL DEGENERATION. (a) _Traumatic Insanity._--Insanity following
blows on the head is divided into (1) the forms in which the insanity
immediately follows the accident; (2) the form in which there is an
intermediate prodromal stage characterized by strange conduct and
alteration in disposition; and (3) in which the mental symptoms occur
months or years after the accident, which can have at most but a remote
predisposing causal relation to the insanity. The cases which
immediately succeed injuries to the head are in all respects similar to
confusional insanity after operations or after fevers. There is
generally a noisy incoherent delirium, accompanied by hallucinations of
sight or of hearing, and fleeting unsystematized delusions. The physical
symptoms present all the features of severe nervous shock.
In those cases in which there is an intervening prodromal condition,
with altered character and disposition, there is usually a more or less
severe accidental implication of the cortex cerebri, either by
depression of bone or local hemorrhage, or meningitic sub-inflammatory
local lesions. Most of the cases during the prodromal stage are sullen,
morose or suspicious, and indifferent to their friends and surroundings.
At the end of the prodromal stage there most usually occurs an attack of
acute mania of a furious impulsive kind. The cases which for many years
after injury are said to have remained sane will generally be found upon
examination and inquiry to exhibit symptoms of hereditary degeneration
or of acquired degeneracy, which may or may not be a consequence of the
accident.
The most common site of vascular lesion is one of the branches of the
middle cerebral artery within the sylvian fissure, or of one of the
smaller branches of the same artery which go directly to supply the
chief basal ganglia. When an artery like the middle cerebral or one of
its branches becomes either through rupture or blocking of its lumen,
incapable of performing its function of supplying nutrition to important
cerebral areas, there ensues devitality of the nervous tissues,
frequently followed by softening and chronic inflammation. It is these
secondary changes which give rise to and maintain those peculiar mental
aberrations known as post-apoplectic insanity.
Various characteristic physical symptoms, depending upon the seat of the
cerebral lesion, are met with in the course of this form of insanity.
These consist of paraplegias, hemiplegias and muscular contractures.
Speech defects are very common, being due either to the enfeebled mental
condition, to paralysis of the nerve supplying the muscles of the face
and tongue, or to aphasia caused by implication of those parts of the
cortex which are intimately associated with the faculty of speech.
Mental symptoms vary considerably in different cases and in accordance
with the seat and extent of the lesion. There is almost always present,
however, a certain degree of mental enfeeblement, accompanied by loss of
memory and of judgment, often by mental confusion. Another very general
mental symptom is the presence of emotionalism which leads the patient
to be affected either to tears or to laughter upon trifling and
inadequate occasions.
Cerebral tumours do not necessarily produce insanity. Indeed it has been
computed that not one half of the cases become insane. When insanity
appears it is met with in all degrees varying from slight mental dulness
up to complete dementia, and from mere moral perversion up to the most
intense form of maniacal excitement. On the physical side the various
symptoms of cerebral tumour such as coma, ataxia, paralysis, headache,
vomiting, optic neuritis and epileptiform convulsions are met with. All
forms of so-called moral changes and of changes of disposition are met
with as mental symptoms and all the ordinary forms of insanity may occur
in varying intensity; but by far the most common mental change occurring
in connexion with cerebral tumour is a progressive enfeeblement of the
intelligence, unattended with any more harmful symptoms than mental
deterioration which ends in complete dementia.
Insanity due to Arterial Degeneration.
(b) _Arterial Degeneration._--Arterial degeneration is a common cause of
mental impairment, especially of that form of mental affection known as
"Early" dementia. It also predisposes to embolism and thrombosis, which
often results in the paralytic and aphasic groups of nerve disturbance,
and which are always accompanied by more or less marked interference
with normal cerebral action.
The commonest seat for atheroma of the cerebral vessels is the arteries
at the base of the brain and their main branches, especially the middle
cerebral. As a general rule the other arteries of the cerebrum are not
implicated to the same extent, although in a not inconsiderable number
of cases of the disease all the arteries of the brain may participate in
the change. When this is so, we obtain those definite symptoms of slowly
advancing dementia commencing in late middle life and ending in complete
dementia before the usual period for the appearance of senile dementia.
The same appearances are met with in certain patients who have attained
the age in which senile changes in the arteries are not unexpected. As a
rule atheroma in the cerebral vessels is but a part of a general
atheroma of all the arteries of the body. Atheroma is common after
middle life and increases in frequency with age. The chief causes are
syphilis, alcoholism, the gouty and rheumatic diatheses and above all
Bright's disease of the kidneys. Perhaps certain forms of Bright's
disease, owing to the tendency to raise the blood pressure, are of all
causes the most common.
It is not easy to say to what extent, alone, the arteriosclerosis is
effectual in inducing the gradual failure of the mental powers, and to
what extent it is assisted in its operation by the action on the
brain-cells of the general toxic substances which give rise to the
arterial atheroma. In any case there can be no question that the gradual
mechanical diminution of the blood-supply to the cortex caused by the
occlusion of the lumen of the arteries is a factor of great importance
in the production of mental incapacity.
General Paralysis.
GENERAL PARALYSIS OF THE INSANE (syn. General Paralysis, _dementia
paralytica_, progressive dementia) is a disease characterized by
symptoms of progressive degeneration of the central nervous system, more
particularly of the motor centres. The disease is almost invariably
fatal. Apparent recoveries do very occasionally occur, though this is
denied by the majority of alienists. The disease is in every case
associated with gradually advancing mental enfeeblement, and very
frequently is complicated by attacks of mental disease.
General paralysis, which is a very common disease, was first recognized
in France; it was identified by J. E. D. Esquirol, and further described
and elaborated by A. L. J. Bayle, Delaye and J. L. Calmeil, the latter
giving it the name of _paralysie générale des aliénés_.
As first described by the earlier writers the disease was regarded as
being invariably associated with delusions of grandeur. At the present
day this description does not apply to the majority of cases admitted
into asylums. The change may be explained as being either due to an
alteration in the type of the disease, or more probably the disease is
better understood and more frequently diagnosed than formerly, the
diagnosis being now entirely dependent on the physical and not on the
mental symptoms. This latter may also be the explanation why general
paralysis is much more common at the present day in British asylums than
it was. The total death-rate from this disease in English and Scottish
asylums rose from 1321 in 1894 to 1795 in 1904.
General paralysis attacks men much more frequently than women, and
occurs between the ages of 35 and 50 years. It is essentially a disease
of town life. In asylums which draw their patients from country
districts in Scotland and Ireland, the disease is rare, whereas in those
which draw their population from large cities the disease is extremely
common.
Considerable diversity of opinion exists at present regarding the
causation of general paralysis. Hereditary predisposition admittedly
plays a very small part in its causation. There is, however, an almost
universal agreement that the disease is essentially the result of
toxaemia or poisoning, and that acquired or inherited syphilitic
infection is an important predisposing factor. A history of syphilitic
infection occurs in from 70 to 90% of the patients affected. At first it
was held that general paralysis was a late syphilitic manifestation, but
as it was found that no benefit followed the use of anti-syphilitic
remedies the theory was advanced that general paralysis was a secondary
auto-intoxication following upon syphilitic infection. The latest view
is that the disease is a bacterial invasion, to which syphilis,
alcoholism, excessive mental and physical strain, and a too exclusively
nitrogenous diet, only act as predisposing causes. This latter theory
has been recently advanced and elaborated by Ford Robertson and McRae of
Edinburgh.
Whatever the cause of general paralysis may be, the disease is
essentially progressive in character, marked by frequent remissions and
so typical in its physical symptoms and pathology that we regard the
bacterial theory with favour, although we are far from satisfied that
the actual causative factor has as yet been discovered.
For descriptive purposes the disease is most conveniently divided into
three stages,--called respectively the first, second and third,--but it
must be understood that no clear line of demarcation divides these
stages from one another.
The onset of general paralysis is slow and gradual, and the earliest
symptoms may be either physical or mental. The disease may commence
either in the brain itself or the spinal cord may be primarily the seat
of lesion, the brain becoming affected secondarily. When the disease
originates in the spinal cord the symptoms are similar to those of
locomotor ataxia, and it is now believed that general paralysis and
locomotor ataxia are one and the same disease; in the one case the cord,
in the other the brain, being the primary seat of lesion. The early
physical symptoms are generally motor. The patient loses energy, readily
becomes tired, and the capacity for finely co-ordinated motor acts, such
as are required in playing games of skill, is impaired. Transient
attacks of partial paralysis of a hand, arm, leg or one side of the
body, or of the speech centre are not uncommon. In a few cases the
special senses are affected early and the patient may complain of
attacks of dimness of vision or impairment of hearing. Or the symptoms
may be purely mental and affect the highest and most recently acquired
attributes of man, the moral sense and the faculty of self-control. The
patient then becomes irritable, bursts into violent passions over
trifles, changes in character and habits, frequently takes alcohol to
excess and behaves in an extravagant, foolish manner. Theft is often
committed in this stage and the thefts are characterized by an open,
purposeless manner of commission. The memory is impaired and the patient
is easily influenced by others, that is to say he becomes facile. In
other cases a wild attack of sudden excitement, following upon a period
of restlessness and sleeplessness may be the first symptom which
attracts attention. Whatever the mode of onset the physical symptoms
which characterize the disease come on sooner or later. The speech is
slurred and the facial muscles lose their tone, giving the face a
flattened expression. The muscular power is impaired, the gait is
straddling and the patient sways on turning. All the muscles of the
body, but particularly those of the tongue, upper lip and hands, which
are most highly innervated, present the symptom of fine fibrillary
tremors. The pupils become irregular in outline, often unequal in size
and either one or both fail to react normally to the stimuli of light,
or of accommodation for near or distant vision.
As the disease advances there is greater excitability and a tendency to
emotionalism. In classical cases the general exaltation of ideas becomes
so great as to lead the patient to the commission of insanely
extravagant acts, such as purchases of large numbers of useless
articles, or of lands and houses far beyond his means, numerous
indiscriminate proposals of marriage, the suggestion of utterly absurd
commercial schemes, or attempts at feats beyond his physical powers. The
mental symptoms, in short, are very similar to those of the elevated
stage of manic-depressive insanity.
Delusions of the wildest character may also be present. The patient may
believe himself to be in possession of millions of money, to be
unsurpassed in strength and agility, to be a great and overruling
genius, and the recipient of the highest honours. This grandiose
condition is by no means present in every case and is not in itself
diagnostic of the disease. But mental facility, placid contentment,
complete loss of judgment and affection for family and friends, with
impaired memory, are symptoms universally present. As the disease
advances the motor symptoms become more prominent. The patient has great
difficulty in writing, misses letters out of words, words out of
sentences, and writes in a large laboured hand. The expression becomes
fatuous. The speech is difficult and the facial muscles are thrown into
marked tremors whenever any attempt at speech is made. The voice changes
in timbre and becomes high-pitched and monotonous. The gait is weak and
uncertain and the reflexes are exaggerated. In the first stage the
patient, through restlessness and sleeplessness, becomes thin and
haggard. As the second stage approaches sleep returns, the patient lays
on flesh and becomes puffy and unhealthy in appearance. The mental
symptoms are marked by greater facility and enfeeblement, while the
paralysis of all the muscles steadily advances. The patient is now
peculiarly liable to what are called congestive seizures or epileptiform
attacks. The temperature rises, the face becomes flushed and the skin
moist. Twitchings are noticed in a hand or arm. These twitchings
gradually spread until they may involve the whole body. The patient is
now unconscious, bathed in perspiration, which is offensive. The bowels
and bladder empty themselves reflexly or become distended, and bedsores
are very liable to form over the heels, elbows and back. Congestive
seizures frequently last for days and may prove fatal or, on the other
hand, the patient may have recurrent attacks and finally die of
exhaustion or some accidental disease, such as pneumonia. In the second
stage of the disease the patient eats greedily, and as the food is
frequently swallowed unmasticated, choking is not an uncommon accident.
The special senses of taste and smell are also much disordered. We have
seen a case of general paralysis, in the second stage drink a glass of
quinine and water under the impression that he was drinking whisky.
The third stage of the disease is characterized by sleeplessness and
rapid loss of body weight. Mentally the patient becomes quite demented.
On the physical side the paralysis advances rapidly, so that the patient
becomes bedridden and speechless. Death may occur as the result of
exhaustion, or a congestive seizure, or of some intercurrent illness.
The duration of the disease is between eighteen months and three years,
although it has been known to persist for seven.
No curative measures have so far proved of any avail in the treatment
of general paralysis.
Epileptic Insanity.
INSANITY ASSOCIATED WITH EPILEPSY.--The term "epileptic insanity," which
has for many years been in common use, is now regarded as a misnomer.
There is in short no such disease as epileptic insanity. A brain,
however, which is so unstable as to exhibit the sudden discharges of
nervous energy which are known as epileptic seizures, is prone to be
attacked by insanity also, but there is no form of mental disease
exclusively associated with epilepsy. Many epileptics suffer from the
disease for a lifetime and never exhibit symptoms of insanity. The
majority of patients, however, who suffer from epilepsy are liable to
exhibit certain mental symptoms which are regarded as characteristic of
the disease. Some suffer from recurrent attacks of depression,
ill-humour and irritability, which may readily pass into violence under
provocation. Others are emotionally fervid in religious observances,
though sadly deficient in the practice of the religious life. A third
class are liable to attacks of semi-consciousness which may either
follow upon or take the place of a seizure, and during these attacks
actions are performed automatically and without consciousness on the
part of the patient.
When epileptics do become insane the insanity is generally one of the
forms of mania. Either the patient suffers from sudden furious attacks
of excitement in which consciousness is entirely abolished, or the mania
is of the type of the elevated stage of folie circulaire
(manic-depressive insanity) and alternates with periods of deep
depression. In the elevated period the patient shows exaggerated
self-esteem, with passionate outbursts of anger, and periods of
religious emotionalism. While in the stage of depression the patient is
often actively suicidal.
Epileptic patients who suffer from recurrent attacks of delirious mania
are liable to certain nervous symptoms which indicate that not only are
the motor centres in the brain damaged, but that the motor tracts in the
spinal cord are also affected. The gait becomes awkward and laboured,
the feet being lifted high off the ground and the legs thrown forward
with a jerk. The tendon reflexes are at the same time exaggerated. These
symptoms indicate descending degeneration of the motor tracts of the
cord.
If the mental attacks partake of the character of elevation or
depression the mental functions suffer more than the motor. These
patients, in course of time, become delusional, enfeebled and childish,
and in some cases the enfeeblement ends in complete dementia of a very
degraded type.
Where insanity is superadded to epilepsy the prognosis is unfavourable.
Toxic Insanity.
INSANITY ASSOCIATED WITH OR CAUSED BY ALCOHOLIC AND DRUG
INTOXICATION.--The true rôle of alcoholic indulgence in the production
of insanity is at present very imperfectly understood. In many cases the
alcoholism is merely a symptom of the mental disease--a result, not a
cause. In others, alcohol seems to act purely as a predisposing factor,
breaking down the resistance of the patient and disordering the
metabolism to such an extent that bodily disorders are engendered which
produce well-marked and easily recognized mental symptoms. In others,
again, alcohol itself may possibly act as a direct toxin, disordering
the functions of the brain. In the latter class may be included the
nervous phenomena of drunkenness, which commence with excitement and
confusion of ideas, and terminate in stupor with partial paralysis of
all the muscles. Certain brains which, either through innate weakness or
as the result of direct injury, have become peculiarly liable to toxic
influences, under the influence of even moderate quantities of alcohol
pass into a state closely resembling delirious mania, a state commonly
spoken of as _mania a potu_.
_Delirium Tremens._--Delirium tremens is the form of mental disorder
most commonly associated with alcoholic indulgence in the lay mind.
Considerable doubt exists, however, as to whether the disease is
directly or secondarily the result of alcoholic poisoning. Much
evidence exists in favour of the latter supposition. Delirium tremens
may occur in persons who have never presented the symptom of
drunkenness, or it may occur weeks after the patient has ceased to drink
alcohol, and in such cases the actual exciting cause of the disease may
be some accidental complication, such as a severe accident, a surgical
operation, or an attack of pneumonia or erysipelas.
The early symptoms are always physical. The stomach is disordered. The
desire for food is absent, and there may be abdominal pain and vomiting.
The hands are tremulous, and the patient is unable to sleep. At this
stage the disease may be checked by the administration of an aperient
and some sedative such as bromide and chloral. The mental symptoms vary
greatly in their severity. In a mild case one may talk to the patient
for some time before discovering any mental abnormality, and then it
will be found that confusion exists regarding his position and the
identity of those around him, while the memory is also impaired for
recent events. Hallucinations of sight and hearing may be present. The
hallucinations of sight may be readily induced by pressure upon the
eyeballs. If the symptoms are more acute they usually come on suddenly,
generally during the evening or night. The patient becomes excited,
suffers from vivid hallucinations of sight and hearing which produce
great fear, and these hallucinations may be so engrossing as to render
him quite oblivious to the environment. The hallucinations of sight are
characterized by the false sense impressions taking the forms of animals
or insects which surround or menace the patient. Visions may also appear
in the form of flames, goblins or fairies. The hallucinations of hearing
rarely consist of voices, but are more of the nature of whistlings, and
ringings in the ears, shouts, groans or screams which seem to fill the
air, or emanate from the walls or floors of the room. All the special
senses may be affected, but sight and hearing are always implicated.
Delirium tremens is a short-lived disease, generally running its course
in from four to five days. Recovery is always preceded by the return of
the power of sleep.
The patient must be carefully nursed and constantly watched, as
homicidal and suicidal impulses are liable to occur under the
terrifying influence of the hallucinations. The food should be
concentrated and fluid, given frequently and in small quantities.
_Chronic Alcoholic Insanity._--Almost any mental disorder may be
associated with chronic alcoholism, but the most characteristic mental
symptoms are delusions of suspicion and persecution which resemble very
closely those of the persecution stage of systematized delusional
insanity. The appearance of the patient is bloated and heavy; the tongue
is furred and tremulous, and symptoms of gastric and intestinal disorder
are usually present. The gait is awkward and dragging, owing to the
partial paralysis of the extensor muscles of the lower limbs. All the
skeletal muscles are tremulous, particularly those of the tongue, lips
and hands. The common sensibility of the skin is disordered so that the
patient complains of sensory disturbances, such as tinglings and
prickings of the skin, which may be interpreted as electric shocks. In
some cases the mental symptoms may be concealed, but delusions and
hallucinations, particularly hallucinations of sight and hearing, are
very commonly present. The delusions are often directly the outcome of
the physical state; the disordered stomach suggesting poisoning, and the
disturbances of the special senses being interpreted as various forms of
persecution. The patient hears voices shouting foul abuse at him; all
his thoughts are read and repeated aloud; electric shocks are sent
through him at night; gases are pumped into his room. Sexual delusions
are very common and frequently affect marital relations by arousing
suspicions regarding the fidelity of wife or husband; or the delusions
may be more gross and take the form of belief in actual attempts at
sexual mutilations. The memory is always impaired.
Patients who in addition to chronic alcoholism are also insane are
always dangerous and liable to sudden and apparently causeless outbursts
of violence.
_Dipsomania._--Dipsomania is a condition characterized by recurrent or
periodic attacks of an irresistible craving for stimulants. The general
bodily condition has a great deal to do with the onset of the attack,
that is to say, the patient is more liable to an attack when the bodily
condition is low than when the health is good. The attacks may be
frequent or recur at very long intervals. They generally last for a few
weeks, and may be complicated by symptoms of excitement, delusions or
hallucinations.
_Treatment_ consists in attention to the general health between
attacks, with the use of such tonics as arsenic and strychnine. During
the attack the patient should be confined to bed and treated with
sedatives.
_Morphinism._--The morphia habit is most commonly contracted by persons
of a neurotic constitution. The mental symptoms associated with the
disease may arise either as the result of an overdose, when the patient
suffers from hallucinations, confusion and mild delirium, frequently
associated with vomiting. On the other hand, mental symptoms very
similar to those of delirium tremens may occur as the result of suddenly
cutting off the supply of morphia in a patient addicted to the habit.
Finally, chronic morphia intoxication produces mental symptoms very
similar to those of chronic alcoholism. This latter condition,
characterized by delusions of persecution, mental enfeeblement and loss
of memory, is hopelessly incurable. The patient is always thin and
anaemic on account of digestive disturbances. There is weakness or
slight paralysis of the lower limbs, and the skeletal muscles are
tremulous.
_Treatment._--The quantity of the drug used must be gradually reduced
until it is finally discontinued, and during treatment the patient
must be confined to bed.
Senile Insanity.
SENILE INSANITY.--States of mental enfeeblement are always the result of
failure of development or of structural changes in the cortical grey
matter of the brain. If the enfeeblement is due to failure of
development or brain damage occurring in early life, it is spoken of as
_idiocy_ or imbecility. Every form of insanity which occurs after a
certain period of life is apt to be regarded by some observers as
senile, but although the failing mental power may colour the character
of the symptoms it cannot be regarded as correct to designate, for
instance, a recurrent form of mania as senile merely because it
necessarily manifests itself in a subject who has lived into the senile
period. On the other hand, many persons first suffer from mental
derangement at an advanced period of life without at the same time
manifesting any marked failure of mental power, while others only
manifest their insanity as a result of the decay of their mental
faculties.
From this statement it will be seen that senile insanity is a complex of
different conditions, some of them accompanied by dementia, others
without dementia.
_Senile Dementia_ is distinguished occasionally into "senile" properly
so called, and "presenile" dementia, which supervenes at middle age or
even earlier.
The occurrence of dementia is sometimes preceded by an acute
hallucinatory phase, accompanied by mania or melancholia; but as a
general rule, in the presenile cases, by neurasthenia, indifference, and
mental apathy which extends to a disregard for the ordinary conventions
and the means of subsistence.
It has pithily been remarked that the age of a man is the age of his
blood-vessels. The two conditions of senile and presenile dementia
cannot therefore be separated scientifically. From a clinical point of
view, however, the two are distinguishable in so far as their symptoms
are concerned, for the presenile cases are more complete and the process
of dementia achieves its consummation earlier and quicker, while in the
senile the gradual disease of the arteries and the slow decay of the
mental faculties offer a different background for the manifestation of
mental symptoms. Moreover, the senile patients more frequently present
symptoms of recurrent attacks of acute insanity, a more pronounced
emotionalism, and a greater tendency to restlessness at night. The
presenile cases, on the other hand, except at the commencement of their
malady, are usually free from acute and troublesome symptoms and present
chiefly an apathetic indifference and irresponsiveness on the mental
side, and on the physical side a neurasthenic and enfeebled bodily
state. In both conditions memory is greatly impaired.
Added to senile dementia there is often found a condition of mania or
melancholia or even of systematized delusional insanity. The chief
symptoms of the maniacal attacks are the great motor restlessness and
excitement, which are worst during the night time. Sleep is almost
always seriously disturbed, and the patients rapidly become exhausted
unless carefully nursed and tended. The actions of senile maniacs are
often puerile and foolish, and they may exhibit impulses of a homicidal,
suicidal or sexual character. The melancholic cases are also extremely
restless, and their emotion is loudly expressed in an uncontrollable
manner. They often have delusions of persecution. Their cries and groans
have an automatic character, as if the patient, though compelled to
utter them, did not experience the mental pain which he expressed. They
also, many of them, eat their food ravenously, although a few
obstinately refuse it. The senile delusional cases may manifest any of
the classical forms of paranoia described above, but their delusions are
of a rudimentary and unfinished type. The most common of all senile
delusions is that they are being robbed. They therefore often hide their
small valuables in corners and out-of-the-way places, and as their
memories are very defective they are afterwards unable to find them.
Others, who live alone, barricade their doors and try to prevent any one
entering for fear of thieves. Delusions of ambition in senile subjects
are usually of a very improbable and childish character. Hallucinations
are generally present in the senile delusional cases.
The _treatment_ of senile insanity is from the medical point of view
not hopeful; it resolves itself largely into instructions for careful
nursing, suitable feeding, and the protection of the patient from all
the physical dangers to which he may be exposed.
_Statistics._--The statistics of lunacy are merely of interest from a
sociological point of view; for under that term are comprised all
forms of insanity. It is needless to produce tables illustrative of
the relative numbers of lunatics in the various countries of Europe,
the systems of registration being so unequal in their working as to
afford no trustworthy basis of comparison.
Even in Great Britain, where the systems are more perfect than in any
other country, the tables published in the Blue Books of the three
countries can only be regarded as approximately correct, the
difficulty of registering all cases of lunacy being insuperable. On
the 1st of January 1907, according to the returns made to the offices
of the Commissioners in Lunacy, the numbers of lunatics stood thus on
the registers:--
+------------------+--------+----------+---------+
| | Males. | Females. | Totals. |
+------------------+--------+----------+---------+
| England and Wales| 57,176 | 66,812 | 123,988 |
| Scotland | 8,594 | 8,999 | 17,593 |
| Ireland | 12,254 | 11,300 | 23,554 |
+------------------+--------+----------+---------+
| Gross total | 78,024 | 87,111 | 165,135 |
+------------------+--------+----------+---------+
These figures show the ratio of lunatics to 100,000 of the population
to be 354 in England and Wales, 312 in Scotland, and 538 in Ireland.
_Numbers of Lunatics on the 1st of January of the years 1857-1907
inclusive, according to Returns made to the Offices of the
Commissioners in Lunacy for England and Wales, Scotland and Ireland._
+------+---------+----------+----------+
| | England | | |
|Years.| and | Scotland.| Ireland. |
| | Wales. | | |
+------+---------+----------+----------+
| 1858 | .. | 5,823 | .. |
| 1859 | 36,762 | 6,072 | .. |
| 1860 | 38,058 | 6,273 | .. |
| 1861 | 39,647 | 6,327 | .. |
| 1862 | 41,129 | 6,398 | 8,055 |
| 1863 | 43,118 | 6,386 | 7,862 |
| 1864 | 44,795 | 6,422 | 8,272 |
| 1865 | 45,950 | 6,533 | 8,845 |
| 1866 | 47,648 | 6,730 | 8,964 |
| 1867 | 49,086 | 6,888 | 8,962 |
| 1868 | 51,000 | 7,055 | 9,086 |
| 1869 | 53,177 | 7,310 | 9,454 |
| 1870 | 54,713 | 7,571 | 10,082 |
| 1871 | 56,755 | 7,729 | 10,257 |
| 1872 | 58,640 | 7,849 | 10,767 |
| 1873 | 60,296 | 7,982 | 10,958 |
| 1874 | 60,027 | 8,069 | 11,326 |
| 1875 | 63,793 | 8,225 | 11,583 |
| 1876 | 64,916 | 8,509 | 11,777 |
| 1877 | 66,636 | 8,862 | 12,123 |
| 1878 | 68,538 | 9,097 | 12,380 |
| 1879 | 69,885 | 9,386 | 12,585 |
| 1880 | 71,191 | 9,624 | 12,819 |
| 1881 | 73,113 | 10,012 | 13,062 |
| 1882 | 74,842 | 10,355 | 13,444 |
| 1883 | 76,765 | 10,510 | 13,882 |
| 1884 | 78,528 | 10,739 | 14,088 |
| 1885 | 79,704 | 10,918 | 14,279 |
| 1886 | 80,156 | 11,187 | 14,590 |
| 1887 | 80,891 | 11,309 | 14,702 |
| 1888 | 82,643 | 11,609 | 15,263 |
| 1889 | 84,340 | 11,954 | 15,685 |
| 1890 | 86,067 | 12,302 | 16,159 |
| 1891 | 86,795 | 12,595 | 16,251 |
| 1892 | 87,848 | 12,799 | 16,688 |
| 1893 | 89,822 | 13,058 | 17,124 |
| 1894 | 92,067 | 13,300 | 17,276 |
| 1895 | 94,081 | 13,852 | 17,665 |
| 1896 | 96,446 | 14,093 | 18,357 |
| 1897 | 99,365 | 14,500 | 18,966 |
| 1898 | 101,972 | 14,906 | 19,590 |
| 1899 | 105,086 | 15,399 | 20,304 |
| 1900 | 106,611 | 15,663 | 20,863 |
| 1901 | 107,944 | 15,899 | 21,169 |
| 1902 | 110,713 | 16,288 | 21,630 |
| 1903 | 113,964 | 16,658 | 22,138 |
| 1904 | 117,199 | 16,894 | 22,794 |
| 1905 | 119,829 | 17,241 | 22,996 |
| 1906 | 121,979 | 17,450 | 23,365 |
| 1907 | 123,988 | 17,593 | 23,554 |
+------+---------+----------+----------+
There is thus an increased ratio in England and Wales of lunatics to
the population (which in 1859 was 19,686,701, and in 1907 was
estimated at 34,945,600) of 186.8 per 100,000 as against 354.8, and in
Scotland of 157 as against 312 per 100,000. The Irish figures on the
same basis have increased from 130.9 in 1862 to 538.1 in 1907. The
publication of these figures has given rise to the question whether
lunacy has actually become more prevalent during the last twenty
years, whether there is real increase of the disease. There is a
pretty general consent of all authorities that if there has been an
increase it is very slight, and that the apparent increase is due,
first to the improved systems of registration, and secondly (a far
more powerful reason) to the increasing tendency among all classes,
and especially among the poorer class, to recognize the less
pronounced forms of mental disorder as being of the nature of
insanity. Thirdly, the grant of four shillings per week which in 1876
was made by parliament from imperial sources for the maintenance of
pauper lunatics has induced parochial authorities to regard as
lunatics a large number of weak-minded paupers, and to force them into
asylums in order to obtain the benefit of the grant and to relieve the
rates. These views receive support from the fact that the increase of
private patients, i.e. patients who are provided for out of their own
funds or those of the family, has advanced in a vastly smaller ratio.
In their case the increase, small as it is, can be accounted for by
the growing disinclination on the part of the community to tolerate
irregularities of conduct due to mental disease. And again, careful
inquiry has failed to show a proportional increase of admissions into
asylums of such well-marked forms as general paralysis, puerperal
mania, &c. The main cause of the registered increase of lunatics is
thus to be sought for in the improved registration, and parochial and
family convenience. If there is an actual increase, and there is
reason for believing that there is a slight actual increase, it is due
to the tendency of the population to gravitate towards towns and
cities, where the conditions of health are inferior to those of rural
life, and where there is therefore a greater disposition to disease of
all kinds.
The futility of seeking for accurate figures bearing on the relative
number of lunatics in other countries is illustrated by the tables set
forth in a report by the United States Census Bureau. They show that
the number of registered lunatics in 1903 was 150,151; in 1890,
74,028; and in 1880, 40,942. An attempt was made in 1890 to estimate
the number of insane persons outside of hospitals, which was stated to
be 32,457. In 1903 no such attempt was made, as it was admitted that
so many sources of fallacy existed as to render it useless. Thus the
mere statement that of every 100,000 of the population (calculated at
80,000,000) 186.2 were registered as insane is of no value.
BIBLIOGRAPHY.--The following are systematic works: Bucknill and Tuke,
_Psychological Medicine_ (4th edition, 1879); Griesinger, _On Mental
Diseases_ (New Sydenham Society, 1867); Maudsley, _The Pathology of
Mind_ (1895); Bevan Lewis, _A Text-Book of Mental Diseases_ (1899);
Clouston, _Clinical Lectures on Mental Diseases_ (1892); Kraepelin,
_Psychiatrie_ (1893); Krafft-Ebing, _Lehrbuch der Psychiatrie_ (1893);
Regis, _A Practical Manual of Mental Medicine_ (London, 1895); Magnan,
_Leçons cliniques sur les maladies mentales_ (1897); Mendil,
_Leitfaden der Psychiatrie_ (1902); Mercier, _A Text-Book of Insanity_
(1902); Lewis C. Bruce, _Studies in Clinical Psychiatry_ (1906);
Macpherson, _Mental Affections_ (1899); Brower-Bannister, _Practical
Manual of Insanity_ (1902); Ford Robertson, _Text-Book of Pathology in
Relation to Mental Diseases_ (1900). (J. B. T.; J. Mn.; L. C. B.)
II. LEGAL ASPECTS
The effect of insanity upon responsibility and civil capacity has been
recognized at an early period in every system of law.
_Roman Law._--In the Roman jurisprudence its consequences were very
fully developed, and the provisions and terminology of that system have
largely affected the subsequent legal treatment of the subject. Its
leading principles were simple and well marked. The insane person having
no intelligent will, and being thus incapable of consent or voluntary
action, could acquire no right and incur no responsibility by his own
acts (see Sohm's _Inst. Roman Law_, 3rd ed. pp. 216, 217, 219); his
person and property were placed after inquiry by the magistrate under
the control of a curator, who was empowered and bound to manage the
property of the lunatic on his behalf (Sohm, p. 513; Hunter, _Roman
Law_, pp. 732-735). The different terms by which the insane were known,
such as _demens_, _furiosus_, _fatuus_, although no doubt signifying
different types of insanity, did not in Roman law infer any difference
of legal treatment. They were popular names, which all denoted the
complete deprivation of reason.
_Medieval Law._--During the middle ages the insane were little
protected. Their legal acts were annulled, and their property placed
under control, but little or no attempt was made to supervise their
personal treatment. In England the wardship of idiots and lunatics,
which was annexed before the reign of Edward II. to the king's
prerogative, had regard chiefly to the control of their lands and
estates, and was only gradually elaborated into the systematic control
of their persons and property now exercised under the jurisdiction in
lunacy. Those whose means were insignificant were left to the care of
their relations or to charity. In criminal law the plea of insanity was
unavailing except in extreme cases. About the beginning of the 19th
century a very considerable change commenced. The public attention was
strongly attracted to the miserable condition of the insane incarcerated
in asylums without any efficient check or inspection; and at the same
time the medical knowledge of insanity entered on a new phase. The
possibility and advantages of a better treatment of insanity were
illustrated by eminent physicians, Philippe Pinel in France, H. Tuke in
England, Bond, B. Rush and I. Ray in the United States; its physical
origin became generally accepted; its mental phenomena were more
carefully observed, and its relation was established to other mental
conditions.
_Modern Law._--From this period we date the commencement of legislation
such as that known in England as the Lunacy Acts, which aimed at the
regulation and control of all constraint applied to the insane.
Hitherto, the criteria of insanity had been very rude, and the evidence
was generally of a loose and popular character; but, whenever it was
fully recognized that insanity was a disease with which physicians who
had studied the subject were peculiarly conversant, expert evidence
obtained increased importance, and from this time became prominent in
every case. The newer medical views of insanity were thus brought into
contact with the old narrow conception of the law courts, and a
controversy arose in the field of criminal law which in England, at
least, still continues.
_Relations between Insanity and Law._--The fact of insanity may operate
in law--(1) by excluding responsibility for crime; (2) by invalidating
legal acts; (3) by affording ground for depriving the insane person by a
legal process of the control of his person and property; or (4) by
affording ground for putting him under restraint.
_Legal Terminology._--Before proceeding, however, to deal with these
matters in succession, it may be desirable to say something with regard
to the chief legal terms respecting persons suffering under mental
disabilities. The subject is now of less importance than formerly,
because the modern tendency of the law is to determine the capacity or
responsibility of a person alleged to be insane by considering it with
reference to the particular matter or class of matters which brings his
mental condition _sub judice_. But the literature of the law of lunacy
cannot be clearly understood unless the distinctions between the
different terms employed to describe the insane are kept in view. The
term _non compos mentis_ is as old as the statute _De praerogativa
regis_ (1325), and is used sometimes, as in that statute, to indicate a
species contrasted with idiot, sometimes (e.g. in Co. Litt. 246 (b)) as
a genus, and afterwards, chiefly in statutes relating to the insane, in
connexion with the terms "idiot" and "lunatic" as a word _ejusdem
generis_. The word "idiot" (Gr. [Greek: idios], a private person, one
who does not hold any public office, and [Greek: idiôtês], an ignorant
and illiterate person) appears in the statute _De praerogativa regis as
fatuus naturalis_, and it is placed in contradistinction to _non compos
mentis_. The "idiot" is defined by Sir E. Coke (4 Rep. 124 (b)) as one
who from his nativity, by a perpetual infirmity, is non compos mentis,
and Sir M. Hale (_Pleas of the Crown_, i. 29) describes idiocy as
"fatuity a _nativitate vel dementia naturalis_." In early times various
artificial criteria of idiocy were suggested. Fitzherbert's test was the
capacity of the alleged idiot to count twenty pence, or tell his age, or
who were his father and mother (_De natura brevium_, 233). Swinburne
proposed as a criterion of capacity, inter alia, to measure a yard of
cloth or name the days in the week (_Testaments_, 42). Hale propounded
the sounder view that "idiocy or not is a question of fact triable by
jury and sometimes by inspection" (_Pleas of the Crown_, i. 29). The
legal incidents of idiocy were at one time distinct in an important
particular from those of lunacy. Under the statute _De praerogativa
regis_ the king was to have the rents and profits of an idiot's lands to
his own use during the life of the idiot, subject merely to an
obligation to provide him with necessaries. In the case of the lunatic
the king was a trustee, holding his lands and tenements for his benefit
and that of his family. It was on account of this difference in the
legal consequences of the two states that on inquisitions distinct
writs, one _de idiota inquirendo_, the other _de lunatico inquirendo_,
were framed for each of them. But juries avoided finding a verdict of
idiocy wherever they could, and the writ _de idiota inquirendo_ fell
into desuetude. A further blow was struck at the distinction when it
came to be recognized even by the legislature (see the Idiots Act 1886)
that idiots are capable of being educated and trained, and it was
practically abolished when the Lunacy Regulation Act 1862, in a
provision reproduced in substance in the Lunacy Act 1890, limited the
evidence admissible in proof of unsoundness of mind on an inquisition
(without special leave of the Master trying the case) to a period of two
years before the date of the inquiry, and raised a uniform issue, viz.
the state of mind of the alleged lunatic at the time when the
inquisition is held.
The term "lunatic," derived from the Latin _luna_ in consequence of the
notion that the moon had an influence on mental disorders,[1] does not
appear in the statute-book till the time of Henry VIII. (1541). Coke
defines a lunatic as a "person who has sometimes his understanding and
sometimes not, _qui gaudet lucidis intervallis_, and therefore he is
called _non compos mentis_ so long as he has not understanding" (Co.
Litt. 247 (a), 4 Rep. 124 (b)). Hale defines "lunacy" as "interpolated"
(i.e. intermittent) _dementia accidentalis vel adventitia_, whether
total or (a description, it will be observed, of "partial insanity")
_quoad hoc vel illud_ (_Pleas of the Crown_, i. 29). In modern times,
the word "lunacy" has lost its former precise signification. It is
employed sometimes in the strict sense, sometimes in contradistinction
to "idiocy" or "imbecility"; once at least--viz. in the Lunacy Act
1890--as including "idiot"; and frequently in conjunction with the
vague terms "unsound mind" (non-sane memory) and "insane." Section 116
of the Lunacy Act 1890 has by implication extended the meaning of the
term lunacy so as to include for certain purposes the incapacity of a
person to manage his affairs through mental infirmity arising from
disease or age. "Imbecility" is a state of mental weakness "between the
limits of absolute idiocy on the one hand and of perfect capacity on the
other" (see 1 Haggard, _Eccles. Rep._ p. 401).
Macnaughton's Case.
1. _The Criminal Responsibility of the Insane._--The law as to the
criminal responsibility of the insane has pursued in England a curious
course of development. The views of Coke and Hale give the best
exposition of it in the 17th century. Both were agreed that in criminal
causes the act and wrong of a madman shall not be imputed to him; both
distinguished, although in different language, between _dementia
naturalis_ (or a _nativitate_) and _dementia accidentalis_ or
_adventitia_; and the main points in which the writings of Hale mark an
advance on those of Coke are in the elaboration by the former of the
doctrine of "partial insanity," and his adoption of the level of
understanding of a child of fourteen years of age as the test of
responsibility in criminal cases (_Pleas of the Crown_, i. 29, 30; and
see Co. 4 _Rep._ 124 (b)). In the 18th century a test, still more
unsatisfactory than this "child of fourteen" theory, with its
identification of "healthy immaturity" with "diseased maturity" (Steph.
_Hist. Crim. Law_, ii. 150), was prescribed. On the trial of Edward
Arnold in 1723 for firing at and wounding Lord Onslow, Mr Justice Tracy
told the jury that "a prisoner, in order to be acquitted on the ground
of insanity, must be a man that is totally deprived of his understanding
and memory, and doth not know what he is doing, no more than an infant,
than a brute or wild beast." In the beginning of the 19th century a
fresh statement of the test of criminal responsibility in mental disease
was attempted. On the trial of Hadfield for shooting at George III. in
Drury Lane Theatre on 15th May 1800, Lord Chief Justice Kenyon charged
the jury in the following terms: "If a man is in a deranged state of
mind at the time, he is not criminally answerable for his acts; but the
material part of the case is whether at the very time when the act was
committed the man's mind was sane." The practical effect of this ruling,
had it been followed, would have been to make the question of the
amenability of persons alleged to be insane to the criminal law very
much one of fact, to be answered by juries according to the particular
circumstances of each case, and without being aided or embarrassed by
any rigid external standard. But in 1812, on the trial of Bellingham for
the murder of Mr Perceval, the First Lord of the Treasury, Sir James
Mansfield propounded yet another criterion of criminal responsibility in
mental disease, viz. whether a prisoner has, at the time of committing
an offence, a sufficient degree of capacity to distinguish between good
and evil. The objection to this doctrine consisted in the fact, to which
the writings of Continental and American jurists soon afterwards began
to give prominence, that there are very many lunatics whose general
ideas on the subject of right and wrong are quite unexceptionable, but
who are yet unable, in consequence of delusions, to perceive the
wrongness of particular acts. Sir James Mansfield's statement of the law
was discredited in the case (4 _State Tri._ (n.s.) 847; 10 Cl. and Fin.
200) of Daniel Macnaughton, who was tried in March 1843, before Chief
Justice Tindal, Mr Justice Williams and Mr Justice Coleridge, for the
murder of Mr Drummond, the private secretary of Sir Robert Peel. Mr
(afterwards Lord Chief Justice) Cockburn, who defended the prisoner,
used Hale's doctrine of partial insanity as the foundation of the
defence, and secured an acquittal, Chief Justice Tindal telling the jury
that the question was whether Macnaughton was capable of distinguishing
right from wrong _with respect to the act with which he stood charged_.
This judicial approval of the doctrine of partial insanity formed the
subject of an animated debate in the House of Lords, and in the end
certain questions were put by that House to the judges, and answered by
Chief Justice Tindal on behalf of all his colleagues except Mr Justice
Maule, who gave independent replies. The answers to those questions are
commonly called "The Rules in Macnaughton's case," and they still
nominally contain the law of England as to the criminal responsibility
of the insane. The points affirmed by the Rules that must be noted here
are the propositions that knowledge of the nature and quality of the
particular criminal act, at the time of its commission, is the test of
criminal responsibility, and that delusion is a valid exculpatory plea,
when, and only when, the fancies of the insane person, if they had been
facts, would have been so. The Rules in Macnaughton's case are open to
serious criticism. They ignore, at least on a literal interpretation,
those forms of mental disease which may, for the present purpose, be
roughly grouped under the heading "moral insanity," and in which the
moral faculties are more obviously deranged than the mental--the
affections and the will, rather than the reason, being apparently
disordered. The test propounded with reference to delusions has also
been strenuously attacked by medical writers, and especially by Dr
Maudsley in his work on _Responsibility in Mental Disease_, on the
ground that it first assumes a man to have a delusion in regard to a
particular subject, and then expects and requires him to reason sanely
upon it. It may be pointed out, however, that in thus localizing the
range of the immunity which insane delusion confers, the criminal law is
merely following the course which, _mutatis mutandis_, the civil law
has, with general acceptance, adopted in questions as to the contractual
and testamentary capacity of the insane.
The Rules in Macnaughton's case have, as regards moral insanity,
undergone considerable modification. Soon after they were laid down, Sir
(then Mr) James Fitz-James Stephen, in an article in the _Juridical
Papers_, i. 67, on the policy of maintaining the existing law as to the
criminal responsibility of the insane, foreshadowed the view which he
subsequently propounded in his _History of the Criminal Law_, ii. 163,
that no man who was deprived by mental disease of the power of passing a
fairly rational judgment on the moral character of an act could be said
to "know" its nature and quality within the meaning of the Rules; and it
has in recent years been found possible in practice so to manipulate the
test of the criminal responsibility which they prescribed as to afford
protection to the accused in the by no means infrequent cases of
insanity which in its literal interpretation it would leave without
excuse.
In Scotland the Rules in Macnaughton's case are recognized, but, as in
England, there is a tendency among judges to adopt a generous
construction of them. Mental unsoundness insufficient to bar trial, or
to exempt from punishment, may still, it is said, be present in a degree
which is regarded as reducing the offence from a higher to a lower
category,--a doctrine first practically applied in Scotland, it is
believed, in 1867 by Lord Deas; and the fact that a prisoner is of weak
or ill-regulated mind is often urged with success as a plea in
mitigation of punishment. The Indian Penal Code (Act XLV. of 1860, § 84)
expressly adopts the English test of criminal responsibility, but the
qualifications noted in the case of Scotland have received some measure
of judicial acceptance (see Mayne, _Crim. Law Ind._, 3rd ed., pp.
403-419; Nelson, _Ind. Pen. Code_, 3rd ed., pp. 135 et seq.). The Rules
in Macnaughton's case have also been adopted in substance in those
colonies which have codified the criminal law. The following typical
references may be given: 55 and 56 Vict. (Can.) c. 29, § 11; 57 Vict.
(N.Z.), No. 56 of 1893, § 23; No. 101 of 1888 (St Lucia), § 50; No. 5 of
1876 (Gold Coast), § 49 (b); No. 2 of 1883, art. 77 (Ceylon); No. 4 of
1871, art. 84 (Straits Settlements). On the other hand, a departure
towards a recognition of "moral insanity" is made by the Queensland
Criminal Code (No. 9 of 1899), § 27 of which provides that "a person is
not criminally responsible for an act" if at the time of doing it "he is
in such a state of mental disease ... as to deprive him ... of capacity
to control his actions": and the law has been defined in the same sense
in the Cape of Good Hope in the case of _Queen_ v. _Hay_ (1899, 16
S.C.R. 290). The Rules were rapidly reproduced in the United States, but
the modern trend of American judicial opinion is adverse to them (see
Clevenger, _Med. Jur. of Ins._ p. 125; _Parsons_ v. _State_ (1887) 81
Ala. 577). On the Continent of Europe moral insanity and irresistible
impulse are freely recognized as exculpatory pleas (see the French _Code
Penal_, § 64; Belgian _Code Penal_, § 71; German _Penal Code_, § 51;
Italian _Penal Code_, §§ 46, 47).
Not only is insanity at the time of the commission of an offence a valid
exculpatory plea, but supervening insanity stays the action of the
criminal law at every stage from arrest up to punishment. High treason
was formerly an exception, but the statute making it so (33 Hen. VIII.
c. 20) was repealed in the time of Philip and Mary. The Home Secretary
has power, under the Criminal Lunatics Act 1884 to order by warrant the
removal of a prisoner, certified to be insane, to a lunatic asylum,
before[2] trial or after trial, whether under sentence of death or not.
Prisoners dealt with under these provisions are styled "Secretary of
State's lunatics." On the other hand, a prisoner who on arraignment
appears, or is found by the jury to be unfit to plead, or who is found
"guilty but insane" at the time of committing the offence--a verdict
substituted by the Trial of Lunatics Act 1883 for the old verdict of
"acquitted on the ground of insanity," in the hope that the formal
conviction recorded in the new finding might have a deterrent effect on
the mentally unstable--is committed to a criminal lunatic asylum by the
order of the judge trying the case, to be detained there "during the
king's pleasure." Lunatics of this class are called "king's pleasure
lunatics." There was no doubt at common law as to the power of the
courts to order the detention of criminal lunatics in safe custody, but,
prior to 1800, the practice was varying and uncertain. On the acquittal
of Hadfield, however, in that year for the attempted murder of George
III., a question arose as to the provision which was to be made for his
detention, and the Criminal Lunatics Act 1800, part of which is still in
force, was passed to affirm the law on the subject.
The Criminal Lunatics Act contains provisions similar to those of the
Lunacy Act 1890, as to the discharge (conditional or absolute) and
transfer of criminal lunatics and the detention of persons becoming
pauper lunatics. The expenses of the maintenance of criminal lunatics
are defrayed out of moneys provided by Parliament (Crim. Luns. Act 1884,
and Hansard, 3rd series, vol. ccxc. p. 75; 139 Com. Jo. pp. 336, 340,
344). The Lunatics' Removal (India) Act 1851 provides for the removal to
a criminal lunatic asylum in Great Britain of persons found guilty of
crimes and offences in India, and acquitted on the ground of insanity.
Similar provisions with regard to colonial criminal lunatics are
contained in the Colonial Prisoners' Removal Act 1884; and the policy of
this statute has been followed by No 5. of 1894 (New South Wales), and
Ordin. No. 2 of 1895 (Falkland Islands). Indian law (see Act V. of 1898,
§§ 464-475) and the laws of the colonies (the Cape Act No. 1 of 1897 is
a typical example) as to the trial of lunatics are similar to the
English. In Scotland all the criminal lunatics, except those who may
have been removed to the ordinary asylums or have been discharged, are
confined in the Criminal Asylum established at Perth in connexion with
H.M.'s General Prison, and regulated by special acts (23 & 24 Vict. c.
105, and 40 & 41 Vict. c. 53). Provision similar to the English has been
made for prisoners found insane as a bar to trial, or acquitted on the
ground of insanity or becoming insane in confinement. In New York,
Michigan and other American states there are criminal lunatic asylums.
Elsewhere insane criminals are apparently detained in state prisons, &c.
The statutory rules as to the maintenance of criminal lunatic asylums,
the treatment of the criminal insane, and the plea of insanity in
criminal courts in America, closely resemble English practice. The only
special point in Continental law calling for notice is the system by
which official experts report for the guidance of the tribunals on
questions of alleged criminal irresponsibility (see, e.g., the German
_Code of Penal Procedure_, § 293, and cp. § 81).
2. _Insanity and Civil Capacity._--The law as to the civil capacity of
the insane was for some time influenced in Great Britain by the view
propounded by Lord Brougham in 1848 in the case of _Waring_ v. _Waring_,
and by Sir J. P. Wilde in a later case, raising the question of the
validity of a marriage, that, as the mind is one and indivisible, the
least disorder of its faculties was fatal to civil capacity. In the
leading case of _Banks_ v. _Goodfellow_ in 1870, the court of queen's
bench, in an elaborate judgment delivered by Chief Justice Cockburn,
disapproved of this doctrine, and in effect laid down the principle that
the question of capacity must be considered with strict reference to the
act which has to be or has been done. Thus a certain degree of
unsoundness of mind is not now, in the absence of undue influence, a bar
to the formation of a valid marriage, if the party whose capacity is in
question knew at the time of the marriage the nature of the engagement
entered into (but see 51 Geo. III. c. 37 as to the marriage of lunatics
so found by inquisition). Again, a man whose mind is affected may make a
valid will, if he possesses at the time of executing it a memory
sufficiently active to recall the nature and extent of his property, the
persons who have claims upon his bounty, and a judgment and will
sufficiently free from the influence of morbid ideas or external control
to determine the relative strength of those claims. So far has this rule
been carried, that in 1893 probate was granted of the will of a lady who
was a Chancery lunatic at the date of its execution, and died without
the inquisition having been superseded. (_Roe_ v. _Nix_, 1893, P. 55.)
It is also now settled that the simple contract of a lunatic is voidable
and not void, and is binding upon him, unless he can show that at the
time of making it he was, to the knowledge of the other party, so insane
as not to know what he was about. (_Imperial Loan Co._ v. _Stone_, 1892,
1 Q.B. 599.) The test established by _Banks_ v. _Goodfellow_ is applied
also in a number of minor points in which civil capacity comes into
question, e.g. competency of the insane as witnesses. The law implies,
on the part of a lunatic, whether so found or not, an obligation to pay
a reasonable price for "necessaries" supplied to him; and the term
"necessaries" means goods suitable to his condition in life and to his
actual requirements at the time of sale and delivery (Sale of Goods Act
1893).
The question of the liability of an insane person for tort appears still
to be undecided (see Pollock on _Torts_, 7th ed. p. 53; Clerk and
Lindsell on _Torts_, 2nd ed. pp. 39, 40; _Law Quart. Rev._ vol. xiii. p.
325). Supervening insanity is no bar to proceedings by or against a
lunatic husband or wife for divorce or separation for previous
matrimonial offences. It does not avoid a marriage nor constitute _per
se_ a ground either for divorce or for judicial separation. But cruelty
does not cease to be a cause of suit if it proceeds from disorderly
affections or want of moral control falling short of positive insanity;
and possibly even cruelty springing from intermittent or recurrent
insanity might be held a ground for judicial separation, since in such
case the party offended against cannot obtain protection by securing the
permanent confinement of the offending spouse. Whether insanity at the
time when an alleged matrimonial offence was committed is a bar to a
suit for divorce or separation is an open question; and in any event, in
order that it may be so, the insanity must be of such a character as to
have prevented the insane party from knowing the nature and consequences
of the act at the time of its commission. The laws of Scotland, Ireland,
India (see, e.g., Act IX. of 1872, § 12), the colonies and the United
States are substantially identical with English law on the subject of
the civil capacity of the insane. The German Civil Code (§ 1569)
recognizes the lunacy of a spouse as a ground for divorce, but only
where the malady continues during at least three years of the union, and
has reached such a pitch that intellectual intercourse between the
spouses is impossible, and that every prospect of a restoration of such
association is excluded. If one of the spouses obtains a divorce on the
ground of the lunacy of the other the former has to allow alimony, just
as a husband declared to be the sole guilty party in a divorce suit
would have to do (§§ 1585, 1578).
3. _The Jurisdiction in Lunacy._--In order to effect a change in the
status of persons alleged to be of unsound mind, and to bring their
persons and property under control, the aid of the jurisdiction in
lunacy must be invoked. Under the unrepealed statute _De Praerogativa
Regis_ (1325) the care and custody of lunatics belong to the Crown. But
the Crown has, at least since the 16th century, exercised this branch of
the prerogative by delegates, and principally through the Lord
Chancellor--not as head of the Court of Chancery, but as the
representative and delegate of the sovereign. Under the Lunacy Acts 1890
and 1891, the jurisdiction in lunacy is exercised first by the Lord
Chancellor and such of the Lords Justices and other judges as may be
invested with it by the sign-manual; and, secondly, by the two Masters
in Lunacy, appointed by the Lord Chancellor, from members of the bar of
at least ten years' standing, whose duties include the holding of
inquisitions and summary inquiries, and the making of most of the
consequential orders dealing with the persons and estates of lunatics.
County court judges may also exercise a limited jurisdiction in lunacy
in the case of lunatics as to whom a reception order has been made, if
their entire property is under £200 in value, and no relative or friend
is willing to undertake the management of it; in partnership cases where
the assets do not exceed £500; and upon application by the guardians of
any union for payment of expenses incurred by them in relation to any
lunatic.
Persons of unsound mind are brought under the jurisdiction in lunacy
either by an inquisition _de lunatico inquirendo_, or, in certain cases
which will be adverted to below, by proceedings instituted under § 116
of the Lunacy Act 1890, which is now the great practice section in the
Lunacy Office. Prior to 1853 a special commission was issued to the
Masters in each alleged case of lunacy. But by the Lunacy Regulation Act
of that year a general commission was directed to the Masters,
empowering them to proceed in each case in which the Lord Chancellor by
order required an inquisition to be held. This procedure is still in
force. A special commission would now be issued only where both Masters
were personally interested in the subject of the inquiry, or for some
other similar reason. An inquisition is ordered by the judge in lunacy
(a term which does not, for this purpose, at present include the
Masters, although this is one of the points in regard to which a change
in the law has been suggested, on the petition generally of a near
relative of the alleged lunatic). The inquiry is held before one of the
Masters, and a jury may be summoned if the alleged lunatic, being within
the jurisdiction, demands it, unless the judge is satisfied that he is
not competent to form and express such a wish; and even in that case the
Master has power to direct trial by jury if he thinks fit on
consideration of the evidence. Where the alleged lunatic is not within
the jurisdiction the trial must be by jury; and the judge in lunacy may
direct this mode of trial to be adopted in any case whatever.
A few points of general interest in connexion with inquisitions must be
noted. In practice thirty-four jurors are summoned by the sheriff, and
not more than twenty-four are empanelled. Twelve at least must concur in
the verdict. Counsel for the petitioner ought to act in the judicial
spirit expected from counsel for the prosecution in criminal cases. The
issue to be determined on an inquisition is "whether or not the alleged
lunatic is at the time of the inquisition of unsound mind, and incapable
of managing himself and his affairs" (a special verdict may, however, be
found that the lunatic is capable of managing himself, although not his
affairs, and that he is not dangerous to others); and without the
direction of the person holding the inquisition, no evidence as to the
lunatic's conduct at any time being more than two years before the
inquisition is to be receivable. This limitation, both of the issue and
of the evidence, was imposed with a view to preventing the recurrence of
such cases as that of Mr Windham in 1861-1862, when the inquiry ranged
over the whole life of an alleged lunatic, forty-eight witnesses being
examined on behalf of the petitioners and ninety-one on behalf of the
respondents, while the hearing lasted for thirty-four days. For the
purpose of assisting the Master or jury in arriving at a decision,
provision is made for the personal examination of the alleged lunatic by
them on oath or otherwise, and either in open court or in private, as
may be directed. The proceedings on inquisition are open to the public.
When a person has been found lunatic by inquisition he becomes subject
to the jurisdiction in lunacy, and remains so (unless he succeeds in
setting aside the verdict by a "traverse"--a proceeding which ultimately
comes before, and is determined by, the King's Bench Division in London
or at the assizes) until his recovery, when the inquisition may be put
an end to by a procedure technically known as "supersedeas," or by his
death. The results of the inquisition are worked out in the Lunacy
Office. The control of the estate, and, except where he was found
incapable of managing his property only, of the person of the lunatic is
entrusted to committees of the estate and person, who are appointed by,
and accountable to, the Master in Lunacy, and whose legal position
corresponds roughly with that of the tutors and curators of the civil
law. The committee of the estate in particular exercises over the
property of the lunatic, with the sanction or by the order of the
Master, very wide powers of management and administration, including the
raising of money by sale, charge or otherwise, to pay the lunatic's
debts, or provide for his past or future maintenance, charges for
permanent improvements, the sale of any property belonging to the
lunatic, the execution of powers vested in him and the performance of
contracts relating to property.
The alternative method of bringing a person of unsound mind under lunacy
jurisdiction was created by § 116 of the Lunacy Act 1890. The effect of
that section briefly is to enable the Master, on a summons being taken
out in his chambers and heard before him, to apply the powers of
management and administration summarized in the last preceding
paragraph, without any inquisition, to the following classes of cases:
lunatics not so found by inquisition, for the protection or
administration of whose property any order was made under earlier acts;
every person lawfully detained, within the jurisdiction of the English
courts, as a lunatic, though not so found by inquisition; persons not
coming within the foregoing categories who are "through mental infirmity
arising from disease or age" incapable of managing their affairs;
persons of unsound mind whose property does not exceed £2000 in value,
or does not yield an annual income of more than £100; and criminal
lunatics continuing insane and under confinement.
In Scotland the insane are brought under the jurisdiction in lunacy by
alternative methods, similar to the English inquisition and summary
procedure, viz. "cognition," the trial taking place before the Lord
President of the Court of Session, or any judge of that court to whom he
may remit it, and a jury of twelve--see 31 & 32 Vict. c. 100, and Act of
Sederunt of 3rd December 1868--and an application to the Junior Lord
Ordinary of the Court of Session or (43 & 44 Vict. c. 4, § 4) to the
Sheriff Court, when the estate in question does not exceed £100 a year,
for the appointment of a _curator bonis_ or judicial factor.
The powers of the Lord Chancellor of Ireland with regard to lunatics are
generally similar to those of the English Chancellor (see the Lunacy
Regulations (Ireland) Act 1871, 34 & 35 Vict. c. 22, and the Lunacy
(Ireland) Act 1901, 1 Ed. VII. c. 17; also Colles on _The Lunacy
Regulation (Ireland) Act_.
The main feature of the French system is the provision made by the Civil
Code (arts. 489-512) for the interdiction of an insane person by the
Tribunal of First Instance, with a right of appeal to the Court of
Appeal, after a preliminary inquiry and a report by a family council
(arts. 407, 408), consisting of six blood relatives in as near a degree
of relationship to the lunatic as possible, or, in default of such
relatives, of six relatives by marriage. The family council is presided
over by the _Juge de Paix_ of the district in which the lunatic is
domiciled. This system is also in force in Mauritius.
There are provisions, it may be noted, in Scots law for the interdiction
of lunatics, either voluntarily or judicially (see Bell's _Principles_,
§ 2123). The German Civil Code provides for insane persons being made
subject to guardianship (_vormundung_), on conditions similar to those
of Scots and French law (see Civil Code, §§ 6, 104 (1896, 1906),
645-679). In the United States the fundamental procedure is an
inquisition conducted on practically the same lines as in England. (Cf.
Indiana, _Rev. Stats._ (1894) §§ 2715 et seq.; Missouri, Annot. Code
(1892) §§ 2835 et seq.; New Mexico, _General Laws_ (1880) c. 74 §§ 1 et
seq.).
4. _Asylum Administration._--Asylum administration in England is now
regulated by the Lunacy Acts 1890 and 1891. Receptacles for the insane
are divisible into the following classes: (i.) Institutions for
lunatics, including asylums, registered hospitals and licensed houses.
The asylums are provided by counties or boroughs, or by union of
counties or boroughs. Registered hospitals are hospitals holding
certificates of registration from the Commissioners in Lunacy, where
lunatics are received and supported wholly or partially by voluntary
contributions or charitable bequests, or by applying the excess of the
payments of some patients towards the maintenance of others. Licensed
houses are houses licensed by the Commissioners, or, beyond their
immediate jurisdiction, by justices; (ii.) Workhouses--see article POOR
LAW; (iii.) Houses in which patients are boarded out; (iv.) Private
houses (unlicensed) in which not more than a single patient may be
received. A person, not being a pauper or a lunatic so found by
inquisition, cannot, in ordinary cases, be received and detained as a
lunatic in any institution for the insane, except under a "reception
order" made by a county court judge or stipendiary magistrate or
specially appointed justice of the peace. The order is made on a
petition presented by a relative or friend of the alleged lunatic, and
supported by two medical certificates, and after a private hearing by
the judicial authority. The detention of a lunatic is, however,
justifiable at common law, if necessary for his safety or that of
others; and the Lunacy Act 1890, borrowing from the lunacy law of
Scotland, provides for the reception of a lunatic not a pauper into an
asylum, where it is expedient for his welfare or the public safety that
he should be confined without delay, upon an "urgency order," made if
possible by a near relative and accompanied by one medical certificate.
The urgency order only justifies detention for seven days (the
curtailment of this period to four days is proposed), and before the
expiration of that period the ordinary procedure must be followed.
"Summary reception orders" may be made by justices otherwise than on
petition. There are four classes of cases in which such orders may be
made, viz.: (i.) lunatics (not paupers and not wandering at large) who
are not under proper care and control, or are cruelly treated or
neglected; (ii.) resident pauper lunatics; (iii.) lunatics, whether
pauper or not, wandering at large; (iv.) lunatics in workhouses. (As to
pauper lunatics generally, see article POOR LAW.) A lunatic may also be
received into an institution under an order by the Commissioners in
Lunacy; and a lunatic so found by inquisition under an order signed by
the committee of his person.
The chief features of English asylum administration requiring notice are
these. Mechanical restraint is to be applied only when necessary for
surgical or medical purposes, or in order to prevent the lunatic from
injuring himself or others. The privacy of the correspondence of
lunatics with the Lord Chancellor, the Commissioners in Lunacy, &c., is
secured. Provision is made for regular visits to patients by their
relatives and friends. The employment of males for the custody of
females is, except on occasions of urgency, prohibited. Pauper lunatics
may be boarded out with relatives and friends. Elaborate provision is
made for the official visitation of every class of receptacle for the
insane. The duties of visitation are divided between the Commissioners
in Lunacy, the Chancery Visitors and various other visitors and visiting
committees. There are ten Commissioners in Lunacy--four unpaid and six
paid, three of the latter being barristers of not less than five years'
standing at the date of appointment, and three medical. The
Commissioners in Lunacy, who are appointed by the Lord Chancellor, visit
every class of lunatics except persons so found by inquisition. These
are visited by the Chancery Visitors. There are three Chancery
Visitors, two medical and one legal (a barrister of at least five years'
standing at the date of his appointment), who are appointed and
removable by the Lord Chancellor. The Chancery Visitors (together with
the Master in Lunacy) form a Board, and have offices in the Royal Courts
of Justice. In addition to these two classes of visitors, every asylum
has a Visiting Committee of not less than seven members, appointed by
the local authority; and the justices of every county and
quarter-sessions borough not within the immediate jurisdiction of the
Commissioners in Lunacy annually appoint three or more of their number
as visitors of licensed houses.
Provision is made for the discharge of lunatics from asylums, &c., on
recovery, or by _habeas corpus_, or by the various visiting authorities.
Any person who considers himself to have been unjustly detained is
entitled on discharge to obtain, free of expense, from the secretary to
the Lunacy Commissioners a copy of the documents under which he was
confined.
The Irish [Lunacy Acts 1821-1890; Lunacy (Ireland) Act 1901] and
Scottish [Lunacy Acts 1857 (20 & 21 Vict. c. 71), 1887 (50 & 51 Vict. c.
39)] asylum systems present no feature sufficiently different from the
English to require separate notice, except that in Scotland "boarding
out" is a regular, and not merely an incidental, part of asylum
administration. The "boarding out" principle has, however, received its
most extended and most successful application in the Gheel colony in
Belgium. The patients, after a few days' preliminary observation, are
placed in families, and, except that they are under ultimate control by
a superior commission, composed of the governor of the province, the
Procureur du Roi and others, enjoy complete liberty indoors as well as
out of doors. The patients are visited by nurses from the infirmary, to
which they may be sent if they become seriously ill or unmanageable.
They are encouraged to work. The accommodation provided for them is
prescribed, and is to be of the same quality as that of the household in
which they live. Clothing is provided by the administration.
In the French (see laws of 30th June 1838 and 18th December 1839) and
German (see _Journal of Comparative Legislation_, n.s. vol. i. at pp.
271, 272) asylum systems the main features of English administration are
also reproduced.
The lunacy laws of the British colonies have also closely followed
English legislation (cf. Ontario, _R.S._ 1897, cc. 317, 318; Manitoba,
_R.S._ 1902, c. 80; Victoria (No. 1113, 1890); New Zealand (No. 34 of
1882 and Amending Acts); Mauritius (No. 37 of 1858).
In America the different states of the Union have each their own lunacy
legislation. The national government provides only for the insane of the
army and navy, and for those residing in the District of Columbia and in
Alaska. The various laws as to the reception, &c., of the insane into
asylums closely resemble English procedure. But in several states the
verdict of a jury finding lunacy is a necessary preliminary to the
commitment of private patients (Kentucky, Act of 1883, c. 900, § 14;
Maryland, _R.S._ 1878, c. 53, § 21; Illinois, _R.S._ 1874, c. 85, § 22).
AUTHORITIES.--The following works may be consulted: Collinson on the
_Law of Lunatics and Idiots_ (2 vols., London, 1812); Shelford on the
_Law of Lunatics and Idiots_ (London, 1847). On all points relating to
the history and development of the law these two treatises are
invaluable. Pope on _Lunacy_ (2nd ed., London, 1890); Archbold's
_Lunacy_ (4th ed., London, 1895); Elmer on _Lunacy_ (7th ed., London,
1892); Wood Renton on _Lunacy_ (London and Edinburgh, 1896); Fry's
_Lunacy Laws_ (3rd ed., London, 1890); Pitt-Lewis, Smith and Hawke,
_The Insane and the Law_ (London, 1895); Hack-Tuke, _Dictionary of
Psychological Medicine_ (London, 1892), and the bibliographies
attached to the various legal articles in that work; Clevenger,
_Medical Jurisprudence of Insanity_ (2 vols., New York, 1899);
Semelaigne, _Les Aliénistes français_ (Paris 1849); Bertrand, _Loi sur
les aliénés_ (Paris, 1872), presents a comparative view of English and
foreign legislations. In forensic medicine the works of Taylor,
_Medical Jurisprudence_ (5th ed., London, 1905); Dixon Mann, _Foreign
Medicine and Toxicology_ (3rd ed., London, 1902); and Wharton and
Stillé, _A Treatise on Medical Jurisprudence_ (Philadelphia, 1873);
Hamilton and Godkin, _System of Legal Medicine_ (New York, 1895); are
probably the English authorities in most common use. See also Casper
and Liman, _Praktisches Handbuch_ _der gerichtlichen Medicin_
(Berlin, 6th ed., 1876); Tardieu, _Étude médico-légale sur la folie_
(Paris, 1872); Legrand du Saulle, _La Folie devant les tribunaux_
(Paris, 1864); Dubrac, _Traité de jurisprudence médicale_ (Paris,
1894); Tourdes, _Traité de médecine légale_ (Paris, 1897); and
especially Krafft-Ebing, _Lehrbuch der gerichtlichen Psychopathologie_
(Stuttgart, 1899). (A. W. R.)
III. HOSPITAL TREATMENT
The era of real hospitals for the insane began in the 19th century.
There had been established here and there in different parts of the
world, it is true, certain asylums or places of restraint before the
beginning of the 19th century. We find mention in history of such a
place established by monks at Jerusalem in the latter part of the 5th
century. There is evidence that even earlier than this in Egypt and
Greece the insane were treated as individuals suffering from disease.
Egyptian priests employed not only music and the beautiful in nature and
art as remedial agents in insanity, but recreation and occupation as
well. A Greek physician protested against mechanical restraint in the
care of the insane, and advocated kindly treatment, the use of music,
and of some sorts of manual labour. But these ancient beneficent
teachings were lost sight of during succeeding centuries. The prevailing
idea of the pathology of insanity in Europe during the middle ages was
that of demoniacal possession. The insane were not sick, but possessed
of devils, and these devils were only to be exorcised by moral or
spiritual agencies. Medieval therapeutics in insanity adapted itself to
the etiology indicated. Torture and the cruellest forms of punishment
were employed. The insane were regarded with abhorrence, and were
frequently cast into chains and dungeons. Milder forms of mental disease
were treated by other spiritual means--such as pilgrimages to the
shrines of certain saints who were reputed to have particular skill and
success in the exorcism of evil spirits. The shrine of St Dymphna at
Gheel, in Belgium, was one of these, and seems to have originated in the
7th century, a shrine so famed that lunatics from all over Europe were
brought thither for miraculous healing. The little town became a resort
for hundreds of insane persons, and as long ago as the 17th century
acquired the reputation, which still exists to this day, of a unique
colony for the insane. At the present time the village of Gheel and its
adjacent farming hamlets (with a population of some 13,000 souls)
provides homes, board and care for nearly 2000 insane persons under
medical and government supervision. Numerous other shrines and holy
wells in various parts of Europe were resorted to by the mentally
afflicted--such as Glen-na-Galt in Ireland, the well of St Winifred, St
Nun's Pool, St Fillans, &c. At St Nun's the treatment consisted of
plunging the patient backwards into the water and dragging him to and
fro until mental excitement abated. Not only throughout the middle ages,
but far down into the 17th century, demonology and witchcraft were
regarded as the chief causes of insanity. And the insane were frequently
tortured, scourged, and even burned to death.
Until as late as the middle of the 18th century, mildly insane persons
were cared for at shrines, or wandered homeless about the country. Such
as were deemed a menace to the community were sent to ordinary prisons
or chained in dungeons. Thus large numbers of lunatics accumulated in
the prisons, and slowly there grew up a sort of distinction between them
and criminals, which at length resulted in a separation of the two
classes. In time many of the insane were sent to cloisters and
monasteries, especially after these began to be abandoned by their
former occupants. Thus "Bedlam" (Bethlehem Royal Hospital) was
originally founded in 1247 as a priory for the brethren and sisters of
the Order of the Star of Bethlehem. It is not known exactly when
lunatics were first received into Bedlam, but some were there in 1403.
Bedlam was rebuilt as an asylum for the insane in 1676. In 1815 a
committee of the House of Commons, upon investigation, found it in a
disgraceful condition, the medical treatment being of the most
antiquated sort, and actual inhumanity practised upon the patients.
Similarly the Charenton Asylum, just outside Paris, near the park of
Vincennes, was an old monastery which had been given over to the insane.
Numerous like instances could be cited, but the interesting point to be
borne in mind is, that with a general tendency to improvement in the
condition of imbeciles upon public charge, idiots and insane persons
came gradually to be separated from criminals and other paupers, and to
be segregated. The process of segregation was, however, very slow. Even
after it had been accomplished in the larger centres of civilization,
the condition of these unfortunates in provincial districts remained the
same. Furthermore, the transfer to asylums provided especially for them
was not followed by any immediate improvement in the patients.
Twenty-five years after Pinel had, in 1792, struck the chains from the
lunatics huddled in the Salpétrière and Bicêtre of Paris, and called
upon the world to realize the horrible injustice done to this wretched
and suffering class of humanity, a pupil of Pinel, Esquirol, wrote of
the insane in France and all Europe: "These unfortunate people are
treated worse than criminals, reduced to a condition worse than that of
animals. I have seen them naked, covered with rags, and having only
straw to protect them against the cold moisture and the hard stones they
lie upon; deprived of air, of water to quench thirst, and all the
necessaries of life; given up to mere gaolers and left to their
surveillance. I have seen them in their narrow and filthy cells, without
light and air, fastened with chains in these dens in which one would not
keep wild beasts. This I have seen in France, and _the insane are
everywhere in Europe treated in the same way_." It was not until 1838
that the insane in France were all transferred from small houses of
detention, workhouses and prisons to asylums specially constructed for
this purpose.
In Belgium, in the middle ages, the public executioner was ordered to
expel from the towns, by flogging, the poor lunatics who were wandering
about the streets. In 1804 the Code Napoleon "punished those who allowed
the insane and mad criminals to run about free." In 1841 an
investigation showed in Belgium thirty-seven establishments for the
insane, only six of which were in good order. In fourteen of them chains
and irons were still being used. In Germany, England and America, in
1841, the condition of the insane was practically the same as in Belgium
and France.
These facts show that no great advance in the humane and scientific care
of the insane was made till towards the middle of the 19th century. Only
then did the actual metamorphosis of asylums for detention into
hospitals for treatment begin to take place. Hand in hand with this
progress there has grown, and still is growing, a tendency to
subdivision and specialization of hospitals for this purpose. There are
now hospitals for the acutely insane, others for the chronic insane,
asylums for the criminal insane, institutions for the feeble-minded and
idiots, and colonies for epileptics. There are public institutions for
the poor, and well-appointed private retreats and homes for the rich.
All these are presided over by the best of medical authorities,
supervised by unsalaried boards of trustees or managers, and carefully
inspected by Government lunacy commissioners, or boards of charities--a
contrast, indeed, to the gaols, shrines, holy wells, chains, tortures,
monkish exorcisms, &c., of the past!
The statistics of insanity have been fairly well established. The ratio
of insane to normal population is about 1 to 300 among civilized
peoples. This proportion varies within narrow limits in different races
and countries. It is probable that intemperance in the use of alcohol
and drugs, the spread of venereal diseases, and the over-stimulation in
many directions induced by modern social conditions, have caused an
increase of insanity in the 19th as compared with past centuries. The
amount of such increase is probably very small, but on superficial
examination might seem to be large, owing to the accumulation of the
chronic insane and the constant upbuilding of asylums in new
communities. The imperfections of census-taking in the past must also be
taken into account.
The modern hospital for the insane does credit to latter-day
civilization. Physical restraint is no longer practised. The day of
chains--even of wristlets, covered cribs and strait-jackets--is past.
Neat dormitories, cosy single rooms, and sitting- and dining-rooms
please the eye. In the place of bare walls and floors and curtainless
windows, are pictures, plants, rugs, birds, curtains, and in many
asylums even the barred windows have been abolished. Some of the wards
for milder patients have unlocked doors. Many patients are trusted alone
about the grounds and on visits to neighbouring towns. An air of busy
occupation is observed in sewing-rooms, schools, shops, in the fields
and gardens, employment contributing not only to economy in
administration, but to improvement in mental and physical conditions.
The general progress of medical science in all directions has been
manifested in the department of psychiatry by improved methods of
treatment, in the way of sleep-producing and alleviating drugs,
dietetics, physical culture, hydrotherapy and the like. There are few
asylums now without pathological and clinical laboratories. While it is
a far cry from the prisons and monasteries of the past to the modern
hospital for the insane, it is still possible to trace a resemblance in
many of our older asylums to their ancient prototypes, particularly in
those asylums built upon the so-called corridor plan. Though each
generation contributed something new, antecedent models were more or
less adhered to. Progress in asylum architecture has hence advanced more
slowly in countries where monasteries and cloisters abounded than in
countries where fixed models did not exist. Architects have had a freer
hand in America, Australia and Germany, and even in Great Britain, than
in the Catholic countries of Europe.
Germany approaches nearest to an ideal standard of provision for the
insane. The highest and best idea which has yet been attained is that of
small hospitals for the acutely insane in all cities of more than 50,000
inhabitants, and of colonies for the chronic insane in the rural
districts adjacent to centres of population. The psychopathic hospital
in the city gives easy and speedy access to persons taken suddenly ill
with mental disease, aids in early diagnosis, places the patients within
reach of the best specialists in all departments of medicine, and
associated, as it should be, with a medical school or university,
affords facilities not otherwise available for scientific research and
for instruction in an important branch of medical learning. A feature of
the psychopathic hospital should be the reception of patients for a
reasonable period of time, as sufferers from disease, without the
formality of legal commitment papers. Such papers are naturally required
for the detention and restraint of the insane for long periods of time,
but in the earlier stages they should be spared the stigma, delay and
complicated procedure of commitment for at least ten days or two weeks,
since in that time many may convalesce or recover, and in this way
escape the public record of their infirmities, unavoidable by present
judicial procedures.
There should be associated with such hospitals for the acutely insane in
cities out-door departments or dispensaries, to which patients may be
brought in still earlier stages of mental disorder, at a period when
early diagnosis and preventive therapeutics may have their best
opportunities to attain good results. In Germany a psychopathic hospital
now exists in every university town, under the name of Psychiatrische
Klinik.
Colonies for the chronic insane are established in the country, but in
the neighbourhood of the cities having psychopathic hospitals, to
receive the overflow of the latter when the acute stage has passed. The
true colony is constructed on the principle of a farming hamlet, without
barracks, corridored buildings, or pavilions. It is similar in most
respects to any agricultural community. The question here is one of
humane care and economical administration. Humane care includes medical
supervision, agreeable home-life, recreation, and, above all things,
regular manual and out-of-door occupation in garden, farm and dairy, in
the quarry, clay-pit or well-ventilated shop. Employment for the
patients is of immense remedial importance, and of great value from the
standpoint of economical administration. In the colony system the small
cottage homes of the patients are grouped about the centres of industry.
The workers in the farmstead live in small families about the farmstead
group of buildings; the tillers of the soil adjacent to the fields,
meadows and gardens; the brickmakers, quarrymen and artizans in still
other cottages in the neighbourhood of the scenes of their activities.
In addition to these groups of cottages, which constitute the majority
of the buildings in the village, an infirmary for bedridden, excited and
crippled patients is required, and a small hospital for the sick. All
the inhabitants of the colony are under medical supervision. A
laboratory for scientific researches forms a highly important part of
the equipment. The colony is not looked upon as a refuge for the
incurable; it is still a hospital for the sick, where treatment is
carried on under the most humane and most suitable conditions, and
wherein the percentage of recoveries will be larger than in asylums and
hospitals as now conducted. In respect of the establishment of colonies
for the insane upon the plan outlined here, Germany has, as in the case
of the psychopathic hospital, led the world. It has been less difficult
for that country to set the example, because she had fewer of the
conditions of the past to fight, and with her the progress of medical
science and of methods of instruction in all departments of medicine has
been more pronounced and rapid.
Among the German colonies for the insane, that at Alt-Scherbitz, near
Leipzig, is the oldest and most successful, and is pre-eminent in its
close approach to the ideal village or colony system. In 1899 Professor
Kraeplin of Heidelberg stated (_Psychiatrie_, 6th edition) that the
effort was made everywhere in Germany to give the exterior of asylums,
by segregation of the patients in separate home-like villas, rather the
appearance of hamlets for working-people than prisons for the insane,
and he said, further, that the whole question of the care of the insane
had found solution in the colony system, the best and cheapest method of
support. "I have myself," he writes, "had opportunity to see patients,
who had lived for years in a large closed asylum, improve in the most
extraordinary manner under the influence of the freer movement and more
independent occupation of colony life."
In America the colony scheme has been successfully adopted by the state
of New York at the Craig Colony for Epileptics at Sonyea and elsewhere.
That the tendency nowadays, even outside of Germany, in the direction of
the ideal standard of provision for the insane is a growing one is
manifested in all countries by a gradual disintegration of the former
huge cloister-like abodes. More asylums are built on the pavilion plan.
Many asylums have, as it were, thrown off detached cottages for the
better care of certain patients. Some asylums have even established
small agricultural colonies a few miles away from the parent plant, like
a vine throwing out feelers. What is called the boarding-out system is
an effort in a similar direction. Patients suffering from mild forms of
insanity are boarded out in families in the country, either upon public
or private charge. Gheel is an example of the boarding-out system
practised on a large scale. But the ideal system is that of the
psychopathic hospital and the colony for the insane.
AUTHORITIES.--Sir J. B. Tuke, _Dictionary of Psychological Medicine_,
(London and Philadelphia, 1892); W. P. Letchworth, _The Insane in
Foreign Countries_ (New York, 1889); _Care and Treatment of
Epileptics_ (New York, 1900); F. Peterson, _Mental Diseases_
(Philadelphia, 1899); "Annual Address to the American
Medico-Psychological Association," _Proceedings_ (1899). (F. P.*)
FOOTNOTES:
[1] The word for "lunatic" in several other languages has a similar
etymology. Cp. Ital. _lunatico_, Span. _alunado_, Gr. [Greek:
selêniakos] (epileptic), Ger. _mondsüchtig_.
[2] It has sometimes been stated that this power, which ought
clearly, in the interests alike of prisoners and of the public, to be
exercised with caution, is in fact exerted in an unduly large number
of cases. The following figures, taken from the respective volumes of
the _Criminal Judicial Statistics_, show the number of criminal
lunatics certified insane before trial. In 1884-1885, out of a total
of 938 criminal lunatics, 169 were so certified; in 1885-1886, 149
out of 890; in 1889-1890, 108 out of 926; in 1890-1891, 95 out of
900; in 1894, 78 out of 738; in 1895, 84 out of 757; in 1896, 88 out
of 769; in 1897, 85 out of 764; in 1898, 17 out of 209; in 1899, 13
out of 159; in 1900, 12 out of 185; in 1901, 15 out of 205; in 1902,
7 out of 233; in 1903, 11 out of 229.