A text-book of insanity and other mental diseases

Front matter

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Part II Forms, Types, And Kinds Of Insanity

IV. The Classification of Insanity . . .115 V. Forms of Insanity . . . . 126

"VI. Types of Insanity . . . .174

Acut« and Chronic Insanity VII. Kinds of Insanity . . . . 209

Insanity of Involution VIII. Kinds of Insanity . . . . 232

Insanity of Dissolution Symptomatic Insanity IX. Insanity of Dissolution . " . . . 243

Symptomatic Insanity General Paralysis X. Symptomatic Insanity . ... 269

Traumatic Insanity . ... 269

Insanity of Epilepsy . . . . 271

XV

XVI

CHAPTER

XL Idiopathic Insanity

PAGE

. 278

Cyclical Insanity

. 278

Fixed Delusion .

. 280

. 292

XII. Idiopathic Insanity

. 298

Alcoholic Insanity

. 299

Sequelar Insanity

. 305

Insanity of Times of Life

. 305

Insanity of Keproduction

. 311

Part III The Legal Relations Of Insanity XIII

The Legal Relations of Insanity

. 317

Certifiability

. 319

Placing and Keeping under Care .

. 323

Testamentary and Contracting Capacity

. 339

Criminal Responsibility .

. 340

APPENDICES

A.

—Model Certificate

. 342

—Letters of Insane Persons .

. 345

Index

.

. 347

Introduction

When the student of medicine passes to the study of insanity, he crosses a scientific frontier, and enters an entirely new province of knowledge. Hitherto his purview has been limited to the processes that go on within the body, and whatever references he had to make beyond that field were indirect and of secondary import. He needs to know the structure and functions of the several organs of the body, and, when any function is disordered, his calling is to take measures to readjust the bodily processes to one another so that they may work in harmony again. He has, in short, to maintain the organism in a fit state to do its work, whatever that may be, but with the doing of the work he has no concern. What the work may be, and with what efficiency it may be performed, is no concern of his, except in as far as these things may afiect the general capability of the organism to continue its existence. His position towards the patient is the position of the shipwright and the engineer towards the vessel on which they are engaged. Like them, he must be thoroughly acquainted with the structure and function of every part, and, like them, he must be upon the watch to repair the structure and correct the function, when the one is damaged or the other is at fault ; but with the ship's course he has nothing to do. That is a matter altogether beyond his province. When the student oversteps the bounds of medicine to enter upon the study of insanity, he leaves

xvii xviii A TEXT-BOOK OF INSANITY

the engine-room for the quarter-deck. He is no longer directly concerned with the integrity of the structure or the efficiency of the engines. His function now is to set the ship's course, to note the way in which she comports herself in wind and weather, to study charts and tides, stars and clouds, to watch the barometer and to sound the lead, and generally to relinquish the observation of the ship herself, and to take up that of her relations to the world in which she moves. This is the function of the student of insanity — to study the individual, not per se, or simpliciter, but in relation to the world in which he exists, and in which he has to maintain his existence.

Insanity is often called disorder of mind, and this it is, but it is much more than this. Were it disorder of mind alone, we should not be called upon to treat it ; for we should know nothing about it unless we happened to be subject to it ourselves. What goes on in the minds of other people we can never know, unless and until it is revealed to us by their conduct. Only by disorder of conduct can we infer the existence of disorder of mind, and when conduct is disordered, we may safely and immediately infer, we are irresistibly compelled to infer, the existence of insanity, without stopping to investigate the condition of the mind. If a general officer goes on parade in flannels and practising the banjo ; if a parson goes into the pulpit and plays cup and ball before the congregation ; if a hostess comes down to a dinner party in her nightdress and curl-papers ; if a smith pulls a glowing horse-shoe out of the fire with his naked hand ; if a navvy tries to break up the road with a saucepan ; we do not need to sit down and investigate the state of their minds before we pronounce them insane ; the

INTRODUCTION xix

state of the mind is left on one side and does not enter into our consideration. We say at once that such conduct is itself insane, and needs no further evidence to establish the insanity. It is true that there are cases, many cases, in which we do investigate the state of mind, and in which we should not pronounce an opinion on the sanity or insanity of the patient until his mental condition has been investigated ; but these are cases in which a portion, it may be a very large portion, of the conduct exhibits no disorder ; in which the disorder of conduct is only occasional, and afiects only a small, though it may be an important, department of conduct ; and in which we have, perhaps, no opportunity of witnessing any disorder of conduct. In such cases we investigate the state of mind in order to discover whether conduct is likely to exhibit disorder ; and it is an index to the Likelihood of disorder of conduct, not as in itself exhibiting disorder, that disorder of mind is important. If we discover a disorder of mind that has no influence upon conduct, we cannot regard it as an indication of insanity.

Mind and conduct are not the only things disordered in insanity. The former is a sign, the latter is a symptom, of disorder of the highest nerve processes, whose function it is to actuate conduct, and whose activity is the condition under which mental states arise. These highest nerve processes have a double function. Not only do they actuate conduct, and thereby regulate the whole of the commerce between the organism as a whole and the universe which environs it, but they regulate also the whole of the internal processes of the body with respect to one another, harmonise and balance and preserve due relations amongst them. When the highest nerve processes are disordered, therefore, there is disorder

XX A TEXT-BOOK OF INSANITY

among these bodily processes — disorder which is often inconspicuous, but which, in the deeper degrees of insanity, is often very pronounced, and exhibits itself in anomalies of skin, hair, nails, sweat, etc. — superficial and conspicuous examples of a disordered metabolism which is doubtless present in the deeper tissues also.

Conduct, however, is the main thing that is disordered in insanity. It is disorder of conduct that gives to insanity its whole significance. Disorder of mind without disorder of conduct, if it were possible, would be unimportant, if it were important, would be unrecognisable ; and thus the first essential to a knowledge of insanity is an enumeration of the main features of conduct, and of the ways in which conduct may be disordered.

Chapter I The Causes Of Insanity

Whenever a meclianism fails to perform the duty demanded of it, the reason must be either that the work is too heavy for the mechanism or that the mechanism is not strong enough for the work ; and the two things are not exactly the same. When a human organism breaks doT;vTi under the stress of life, in a way that the majority of men do not break down, it is because either the person who fails is weaker than his fellows, or the stress brought to bear on him is greater. For every person, as for every beam and every rope, there is a breaking strain. Load a beam or a rope with sufficient weight, and, whatever its strength, it will break at last. Subject a man to sufficient stress, and however well he may be constituted, he will become insane. In estimating the factors that go to produce insanity in any case, we have to consider, first, the person who becomes insane, and, second, the stresses to which he is subject.

The fact that the majority of people are sane, indicates that they possess a nervous organisation of sufficient stability and strength to withstand the stresses to which it is subject ; and if here and there one becomes insane, it is because either his nervous organisation was not strong enough to withstand ordinary stresses, or he has been subjected to stresses of extraordinary severity. The great majority of cases of ordinary insanity belong to the former class ; cases of insanity of drunkenness, and of general paralysis, belong to the latter.

We have no means of gauging the efl&ciency of a person to withstand stresses, except by observation of his behaviour under their incidence ; but, since every person is the outcome and product of his ancestry, we may make a rough guess at his efficiency by investigating his heredity. That heredity has a very important part in the production of insanity is proved, not less by clinical experience than by the considerations just dealt with ; but what it is that is inherited in cases in which insanity " runs in the family " it is difficult to say. Insanity is manifested in conduct, and it is evidently absurd to speak of what a man is now doing as an inheritance from his forefathers. The only thing that can be clearly conceived as transmitted by inheritance is structure ; and if a son " inherits insanity " from his father, what is transmitted from father to son must be some structural peculiarity of nerve tissue. There are several such peculiarities that may conceivably be derived by inheritance. In the first place, the process of development may be deficient in impetus ; it may come to a premature close ; and in that case the part of the body which will remain undeveloped will be the part which is the last to be completed — that is to say, the highest regions of the brain. The degree of development which is reached by these regions varies much in difierent persons, according to the strength and persistence of the developmental impetus. When these are exceptionally great, the highest nerve regions become exceptionally well developed, and the person attains to a high level of intellectual development. When the process of development is feeble, and comes

INHERITANCE OF INSANITY 5

to a premature close, the brain never attains full development, and the person never reaches the normal intellectual standard.

But there are other forms of insanity than idiocy and imbecility, and many of the insane whose insanity " runs in the family " are of average, and even of more than average, ability. How can we suppose that, in such cases, the insanity is " transmitted " ? Or rather, what is it that is transmitted by inheritance in such cases ? The analogous case of tubercle may help us to understand. That inheritance has a large share in the production of phthisis is as indisputable at the present day, when the tuberculous process is known to be due to the invasion of a micro-organism, as it was before bacilli were discovered ; but, though it is known that phthisis is influenced by heredity, it is known also that the bacillus is not inherited. What is inherited is a " delicacy of constitution," a " vulnerability," a " feebleness of resistance," such that, when the organism is invaded by bacilli, it has less power to attack and destroy them, they more easily efiect a lodgment, establish themselves and multiply, than they do in the tissues of a person of stronger constitution. And some cases, at any rate, of insanity are closely analogous. Among the stresses that do unquestionably produce insanity is that of poison circulating in the blood, and supplied in the pabulum presented to the nerve tissue. There is indisputable evidence with respect to some of these poisons that the nerve tissue of different people has different power of exclusion or of counteraction. No observation is more trite than the amount of alcohol, for instance, which will make one man beastly drunk, will leave another but slightly elevated, and have no appreciable effect upon a third. And these differences in the power of the nerve tissue to exclude or to neutralise the alcohol that is supplied to it are derived from inheritance. They are part of the innate constitution which the person derives from his ancestry. There is therefore nothing inconsistent with experience in supposing that similar innate and inherited differences exist in the power of the nerve tissue to exclude or neutralise other poisons ; and if, as is probable, many cases of insanity are due to the action of poisons upon the nerve tissue, the influence of inherited quality of nerve tissue is easy to understand in such cases.

But although poisons are among the most powerful stresses that the higher nerve regions have to withstand, and among the most frequent, they are not the only ones. As we shall presently see, there are many other stresses that are provocative of insanity ; but the way in which inherited incapacity renders the person obnoxious to the action of poisons helps us to understand the way in which incapacity, similarly inborn, may facilitate the occurrence of insanity on other provocation than that of poisonous food. We see similar differences in the power of the nervous system to resist disturbing agents, and to maintain equable action, in other respects. We see that the disaster which will reduce one man to despairing impotence will stimulate another to energetic activity. We see that the same insult which will provoke one man to uncontrollable rage will be treated by another with contemptuous indifference. And these differences, again, are innate, and are derived from inheritance ; so that we can dimly understand how it is that a set of circumstances which will produce insanity in one man will have no such effect upon another.

^0 widely spread and so strong is the belief in the

INHERITANCE OF INSANITY 7

hereditariness of insanity, that proposals are frequently made to limit by law the marriage, not merely of persons who have been insane, but of those who have insanity " in the family " ; and the expediency of such marriages is a matter on which medical practitioners are frequently consulted. Such proposals are impracticable. If marriage is to be prohibited in all cases in which a clean bill of health cannot be shown for all the individuals in, say, three generations, the practical result would be to prohibit marriage altogether ; and although the offspring of those who have been insane are more likely to be insane, and to have children who become insane, than are the offspring of normal persons, yet it by no means necessarily follows that such ill results will accrue. The children of any individual who errs from the general standard of the race in any respect exhibit, in the great majority of cases, a return towards the standard. The children of giants are not so tall, nor are the children of dwarfs so short, as their respective parents ; and very many of the children of the insane are as sound in mind as they are vigorous in body. Even when insanity is strongly prepotent in a race, and when four or five brothers or sisters are insane, there is usually at least one brother or sister who never shows a sign of insanity. The influence of inheritance in producing insanity is great, but it should not be exaggerated ; and it would be a gross exaggeration to suppose that the children of an insane person must necessarily be insane.

There is a widespread opinion that the children of cousins german are more prone to insanity, and especially to weakness of mind, than other people. The very thorough investigations of Mr. Huth into the marriage of near kin have not sufficed to dispel this opinion, in the face of the occasional occurrence of idiocy or insanity in the offspring of persons so related. That such cases do occur is indisputable, but that in very many cases the offspring of cousins german are as normal and as well endowed as other people, shows beyond question that it is not the mere existence of blood relationship between the parents that produces this effect. The truth seems to be that if there is any heritable disposition in the common family, whether this disposition be to phthisis, gout, cancer, insanity, or what not, the inheritance in the child is intensified by its derivation from both parents. The same intensification would be produced even were the common grandparents destitute of any such heritable disposition, if such disposition existed in both of the unrelated parents of the cousins. Whether the person gets his morbid inheritance from the common ancestor of his parents or from unrelated ancestors makes little difference. The important consideration is whether he gets the same kind of inheritance — inheritance of the same disposition or defect — from both his parents. In such a case the gravity of the inheritance is more than doubled.

The stresses that produce insanity are of three kinds. The first consists of those in which a disturbing agent acts directly upon the nerve tissue of the highest regions of the brain ; in which they are bruised by violence, compressed by tumours, damaged by inflammation, or vitiated by the supply of a poison in the blood. These we will call " direct stresses."*

* It should be mentioned that the term " stress " has of late years been used in a sense diiferent from that in the text, which was first applied by me in 1890 to the agents that provoke insanity. It is used to mean exercise, fatigue, exhaustion of nervous tissue. The former meaning has been restored in the text.

DIRECT STRESSES 9

Gross lesions of the brain, in their active stage, are seldom attended by insanity in the clinical sense. Meningitis, cerebral abscess, cerebral tumour, concussion, fracture of the skull, wounds, lacerations of the hemispheres, are attended, not by active insanity, but by various depths of coma ; and coma, though scientifically it is a form of insanity, and though it is the form which all insanities assume at last, if they go on to the end, yet, since it is not clinically regarded as insanity, need not be dealt with here. Although, however, in their active stages, gross lesions do not produce clinical insanity, yet, if they damage or destroy convolutions, this damage may be evidenced in insanity when the coma is sufficiently cleared up for the defect of sanity to become recognisable. In every large asylum there is a proportion of weak-minded inmates whose defect of mind is owing to gross structural defect of brain, the result of previous active process.

By far the most important of the direct stresses, perhaps the most important of all the stresses which contribute to the production of insanity, is alteration in the composition of the blood by which the highest nerve regions are nourished.

Simple deficiency of nutriment reduces the efficiency of the function of the nerve tissue, which exhibits itself in deficiency of sanity. In starvation the mind is weakened according to the degree of the starvation, the attenuation of mind reaching to actual unconsciousness when the starvation is extreme, and when the deprivation of nourishment is complete and prolonged. Even when it is neither, but the heredity is bad, the weakness of mind may be accompanied by active insanity. In a large proportion of the cases of acute insanity that we have to treat, a greater or less degree of starvation Las been one of the factors in its production ; and copious feeding is one of the most important modes of treatment of acute insanity.

The deficiency in the nutritive supply of the brain may be due, not to starvation, but to haemorrhage, or to any other condition in which the blood is impoverished ; and whatever the cause of the impoverishment, the deterioration of sanity is the same, provided the impoverishment is the same in degree, and the resistive power of the nerve elements is the same. Hence we sometimes meet with insanity, usually of a very intractable type, after severe haemorrhage ; and in all exhausting disease there is some deterioration of mind — deterioration which, in persons whose nervous system was originally badly organised, may attain to actual insanity.

More potent even than attenuation of the nutritive supply to the brain is its vitiation. By introducing a poison into the blood, we can produce insanity at will. We can regulate the degree of the insanity by the amount of poison that we administer, and we can maintain the insanity as long as we please by continuing the administration of the poison. Proof of these statements is exhibited by every case of drunkenness, b}^ every case in which chloroform or ether is administered. The insanity of acute alcoholic poisoning is extremely instructive. From it we learn that the rapid administration of a very large dose of the poison will produce rapid death by coma ; that the rapid administration of a smaller dose will produce a madness of short duration, passing, in a few hours, through coma into recovery ; that a more gradual administration of several smaller doses, extending over some hours, will produce an exalted delirium of

ALCOHOL AND INSANITY 11

a milder type, passing presently into sleep, and so to recovery ; that in those who have been accustomed to take alcohol in great excess, the sudden deprivation of alcohol will produce an attack of acute insanity of very different form, characterised neither by maniacal fury nor by jovial exaltation, but by suspicion, misery, and prominent hallucinations of vision, a form of insanity which is of longer duration than the others, and lasts for several days ; and, lastly, that the administration of alcohol prolonged for years, will give rise to yet another kind of insanity, a kind in which the exaltation of the third phase is often combined with the suspicion of the fourth, and to them are added pronounced defects of intelligence, and especially of memory, and. in this form the duration is still further prolonged. It lasts for months and years, and is often irrecoverable.

The different efiects of different dosage, and of greater or less prolongation of the administration of the poison, are not all that we learn from the administration of alcohol. We learn also that the manner in which the insanity is manifested depends not only on the dosage and the mode of administration, but upon the nature of the person to whom the poison is administered. One person becomes hilarious, jovial, and braggart in his cups ; another becomes sentimental, maudlin, and confidential ; a third becomes suspicious and morose ; a fourth is cantanl^erous and quarrelsome, a fifth merely stupid, and a sixth, under the same administration of the same amount, becomes furiously maniacal, violent, and destructive.

Alcohol is very important, because it is not only one of the most frequent, but the most manageable, p^ all the poisons which produce insanity. The number of these poisons is very large, and their constitution most diverse. They include such simple substances as carbonic acid, whose intoxicating effect is seen in the delirium of heart disease, and perhaps in that of pneumonia, and substances so complex as the toxins produced by the specific organisms of zymotic disease. They include foreign substances introduced into the body from without, as well as toxins produced within the body by variation of its own metabolism, and, perhaps most deadly of all, toxins produced by invading microbes. Seeing how readily and how frequently insanity is produced by the administration of alcohol, and how very familiar we are with the delirium of fevers, a form of insanity that has for many years been recognised as due to the action of poisons, it is a little surprising that the influence of poisons in producing insanity has only recently had its due importance assigned to it ; but it is not at all surprising that as soon as the toxic origin of insanity is fully recognised it should be exaggerated, and that the claim should be made that every case of insanity is of toxic origin. This is certainly not the case ; but still, the part of bloodpoisoning in producing insanity is a very important one. It is probable that it accounts for all, or nearly all, cases of acute insanity ; and it is now certain that it has a very large share in the production of general paralysis of the insane. The nature and mode of origin of the poison are often very obscure. It is no doubt often produced within the body by some fatal variation of its own chemistry, while often it is introduced from without. Disease that is due to poisoning, whether the poison is introduced into the body or produced within it, is usually febrile in character; it is usually accompanied by raised temperature and

INSOMNIA AND INSANITY 13

other signs of fever ; but the poisons that produce insanity do not usually produce fever. In the delirium of zymotic disease there is, of course, fever. There is fever in acute delirious mania, which is probably a disease of the same class. In some cases of puerperal insanity there is fever from absorption of the decomposing contents of the uterus ; but in the great majority of cases of acute insanity, which are in my opinion due to intoxication, the temperature is not raised. This is a very important clinical observation, for occasionally the invasion of zymotic disease — of smallpox, scarlet fever, typhoid or other fever — is marked by an outbreak of acute delirium which is indistinguishable from the acute insanity due to other toxins, except by the temperature. A raised temperature in acute insanity should, therefore, always arouse suspicion of zymotic disease. ^

This is the most appropriate place in which to enumerate sleeplessness among the provocations of insanity. As with several other factors in the malady, it is difiB.- cult to determine how far it acts as a cause and how far it is a symptom merely. That there are very many persons who habitually sleep very badly — lightly, intermittently, and for an insufi&cient number of hours — and who yet never come within measurable distance of insanity, is certain. Equally certain is it that acute insanity is often preceded for days or weeks by a great and unusual degree of insomnia, and that the induction of sleep often marks the first step toward recovery ; but whether the sleeplessness is a cause or a sign of the oncoming insanity is uncertain ; nor is it very important, since in either case it is a warning, and in either case it is to be dealt with in the same way.

The indirect stresses that tend to produce insanity are of two kinds — those which arise within the limits of the organism, and those which arise in the commerce between the individual and his circumstances.

In the first class are included all those bodily processes which make large draughts upon the stored energy of the nervous system, whether the demand is made by the process of growth and development, by that of reproduction, by bodily or mental exertion, by the processes of disease, or for recuperation after illness. Any process, in short, that is generally exhausting, may contribute to the production of insanity, and a fortiori the concurrence of two or more of these processes is eminently provocative of insanity.

Close observers of the development of children know that their mental development proceeds, on the whole, alternately with their bodily development ; that they have periods in which their bodily growth is stationary, while their minds develop apace, alternating with periods in which their bodily growth is rapid and their mental development ceases, or seems even to retrograde. If, during the latter period, an injudicious attempt is made to force the mental development by close application to mental work, the consequence will be a serious " nervous breakdown " of the nature of insanity. The demand upon the energy of the brain is greater than it can supply ; it becomes so depleted that it cannot carry on its current function, and the depletion exhibits itself in some form of insanity. The same condition may result, though more rarely, from excessive addiction to athleticism when the mental development is very active. If the combined effect of concurrent physical and mental development is exhaustive, still more exhaustive is the additional demand upon the energies of the organism which is made by the

REPRODUCTION AND INSANITY 15

evolution of the reproductive function at puberty, and when to this is added the further drain of frequent masturbation, we can understand how it is that insanity, or a minor disorder of the same nature, is so frequent in adolescence, and how it is that that is the period of life when stupor and hysteria are most frequent.

The dominant role of the reproductive function in the life of every organism will be pointed out in subsequent chapters. It has now to be noted that not only is reproduction the aim and end to which all life is subservient, but that reproduction and life are mutually antagonistic — that is to say, the full and complete life- worthiness of the individual is incompatible with reproduction ; and reproduction diminishes the life-worthiness of the parent so as in some cases to destroy him or her altogether ; and in all cases to render the parent, for a time at any rate, less capable of living, less apt and less competent to maintain the struggle for existence. Seeing that the motive of existence is the reproduction of the race, it is to be expected that, when this aim is attained, existence should cease, or at any rate should approximate to its close.