Two features of the Spanish Inquisition are especially noteworthy: the prosecutions for “speeches suspected of heresy†and the censure of books. The great scholar Pedro de Lerma, who after fifty years at Paris (where he was dean of the faculty of theology) had returned to Spain as abbot of Compluto, was called upon in 1537 to abjure eleven “Erasmian†propositions, and was forced to return to Paris to die. Juan de Vergara and his brother were summoned before the Inquisition for favouring Erasmus and his writings, and detained several years before they were acquitted. Fray Alonso de Virues, chaplain to Charles V., was imprisoned on an absurd charge of depreciating the monastic state, and was only released by the pope at the instance of the emperor. Mateo Pascual, professor of theology at Alcala, who had in a public lecture expressed a doubt as to purgatory, suffered imprisonment and the confiscation of his goods. A similar fate befell Montemayor, Las Brozas and Luis de la Cadena.
The censure of books was established in 1502 by Ferdinand and Isabella as a state institution. All books had to pass through the hands of the bishops; in 1521 the Inquisition took upon itself the examination of books suspected of Lutheran heresy. In 1554 Charles V. divided the responsibility for the censorship between the Royal Council, whose duty it was to grant or refuse theimprimaturto manuscripts and the Inquisition, which retained the right of prohibiting books which it judged to be pernicious; but after 1527 it also gave the licence to print. In 1547 the Suprema produced an Index of prohibited books, drawn up in 1546 by the university of Louvain; it was completed especially as regards Spanish books, in 1551, and several later editions were published. Moreover, therevisores de librosmight present themselves in the name of the Holy Office in any private library or bookshop and confiscate prohibited books. In 1558 the penalty of death and confiscation of property was decreed against any bookseller or individual who should keep in his possession condemned books. The censure of books was eventually abolished in 1812.
Bibliography.—A critical bibliography was drawn up by P. Fredericq in the preface to the French translation (1900) of H. C. Lea’s important standard work:History of the Inquisition in the Middle Ages(3 vols., London, 1888). See also J. Havet,L’Hérésie et le bras séculier au moyen âge jusqu’au XIIIesièclein theŒuvres complètes, vol. ii. (Paris, 1896); Ch. V. Langlois,L’Inquisition d’après des travaux récents(Paris, 1901); Douais,L’Inquisition(Paris, 1907); E. Vacandard,L’Inquisition(Paris, 1907); Douais,Documents pour servir à l’histoire de l’inquisition dans le Languedoc(2 vols., Paris, 1900); Döllinger,Beiträge zur Sektengeschichte des Mittelalters(2 vols., Munich, 1890. The second volume is composed of documents); Molinier,L’Inquisition dans le midi de la France au XIIIeet au XIVesiècle. Étude sur les sources de son histoire(Paris, 1880); P. Fredericq,Corpus documentorum inquisitionis haereticae pravitatis neerlandicae(1205-1525) (4 vols., Ghent, 1889-1900); Tanon,Histoire des tribunaux de l’inquisition en France(Paris, 1893); Hansen,Inquisition, Hexenwahn und Hexenverfolgung(Munich, 1900); Llorente,Histoire critique de l’inquisition d’Espagne(4 vols., Paris, 1818); H. C. Lea,History of the Inquisition of Spain(5 vols., London, 1905-1908); S. Reinach, articles on Lea’sHistory of the Inquisition of Spainin theRevue critique(1906, 1907, 1908) andCultes, mythes et religions(Paris, 1908), tome iii.
Bibliography.—A critical bibliography was drawn up by P. Fredericq in the preface to the French translation (1900) of H. C. Lea’s important standard work:History of the Inquisition in the Middle Ages(3 vols., London, 1888). See also J. Havet,L’Hérésie et le bras séculier au moyen âge jusqu’au XIIIesièclein theŒuvres complètes, vol. ii. (Paris, 1896); Ch. V. Langlois,L’Inquisition d’après des travaux récents(Paris, 1901); Douais,L’Inquisition(Paris, 1907); E. Vacandard,L’Inquisition(Paris, 1907); Douais,Documents pour servir à l’histoire de l’inquisition dans le Languedoc(2 vols., Paris, 1900); Döllinger,Beiträge zur Sektengeschichte des Mittelalters(2 vols., Munich, 1890. The second volume is composed of documents); Molinier,L’Inquisition dans le midi de la France au XIIIeet au XIVesiècle. Étude sur les sources de son histoire(Paris, 1880); P. Fredericq,Corpus documentorum inquisitionis haereticae pravitatis neerlandicae(1205-1525) (4 vols., Ghent, 1889-1900); Tanon,Histoire des tribunaux de l’inquisition en France(Paris, 1893); Hansen,Inquisition, Hexenwahn und Hexenverfolgung(Munich, 1900); Llorente,Histoire critique de l’inquisition d’Espagne(4 vols., Paris, 1818); H. C. Lea,History of the Inquisition of Spain(5 vols., London, 1905-1908); S. Reinach, articles on Lea’sHistory of the Inquisition of Spainin theRevue critique(1906, 1907, 1908) andCultes, mythes et religions(Paris, 1908), tome iii.
(P. A.)
1Pierre de Beauvoisis (?), choir-master (grand-chantre) of the university of Paris (1184), bishop of Tournai (1191), of Paris (1196); died as a Cistercian in 1197. He was beatified.2He was bornc.1261, was a Dominican at Limoges in 1279, successively prior of Albi (1294), Carcassonne (1297), Castres (1301) and Limoges (1305), inquisitor at Toulouse (1307), bishop of Tuy (1323) and of Lodève (1325). He died in 1331.3Peter, a Dominican, born at Verona, was murdered near Milan in 1252 and canonized in 1253.4Guillaume de St Amour (d. 1272), named after his birthplace in the Jura, was canon of Beauvais and rector of the university of Paris. He was conspicuous as the mouthpiece of the secular clergy in their attacks on the mendicant orders, the Dominicans in particular.5The name ofvauderie,i.e.the Vaudois or Waldensian heresy, had come to be used of witchcraft.
1Pierre de Beauvoisis (?), choir-master (grand-chantre) of the university of Paris (1184), bishop of Tournai (1191), of Paris (1196); died as a Cistercian in 1197. He was beatified.
2He was bornc.1261, was a Dominican at Limoges in 1279, successively prior of Albi (1294), Carcassonne (1297), Castres (1301) and Limoges (1305), inquisitor at Toulouse (1307), bishop of Tuy (1323) and of Lodève (1325). He died in 1331.
3Peter, a Dominican, born at Verona, was murdered near Milan in 1252 and canonized in 1253.
4Guillaume de St Amour (d. 1272), named after his birthplace in the Jura, was canon of Beauvais and rector of the university of Paris. He was conspicuous as the mouthpiece of the secular clergy in their attacks on the mendicant orders, the Dominicans in particular.
5The name ofvauderie,i.e.the Vaudois or Waldensian heresy, had come to be used of witchcraft.
INSANITY(from Lat.in, not, andsanus, sound), a generic term applied to certain morbid mental conditions produced by defect or disease of the brain. The synonyms in more or less frequent use arelunacy(from a supposed influence of the moon),mental disease,alienation,derangement,aberration,madness,unsoundness of mind. The termPsychiatry(ψυχή, mind, andἰατÏεία, treatment) is applied to the study and treatment of the condition.
I. Medical and General
There are many diseases of the general system productive of disturbance of the mental faculties, which, either on account of their transient nature, from their being associated with the course of a particular disease, or from theirDefinition.slight intensity, are not included under the head of insanity proper. From a strictly scientific point of view it cannot be doubted that the fever patient in his delirium, or the drunkard in his excitement or stupor, is insane; the brain of either being under the influence of a morbific agent or of a poison, the mental faculties are deranged; yet such derangements are regarded as functional disturbances,i.e.disturbances produced by agencies which experience tells will, in the majority of cases, pass off within a given period without permanent results on the tissues of the organ. The comprehensive scientific view of the position is that all diseases of the nervous system, whether primary or secondary, congenital or acquired, should, in the words of Griesinger, be regarded as one inseparable whole, of which the so-called mental diseases comprise only a moderate proportion. However important it may be for the physician to keep this principle before him, it may be freely admitted that it cannot be carried out fully in practice, and that social considerations compel the medical profession and the public at large to draw an arbitrary line between such functional diseases of the nervous system ashysteria,hypochondriasisanddeliriumon the one hand, and such conditions asmania,melancholia,stuporanddementiaon the other.
All attempts at a short definition of the term “insanity†have proved unsatisfactory; perhaps the nearest approach to accuracy is attained by the rough statement that it isa symptom of disease of the brain inducing disordered mental symptoms—the term disease being used in its widest acceptance. But even this definition is at once too comprehensive, as under it might be included certain of the functional disturbances alluded to, and too exclusive, as it does not comprehend certain rare transitory forms. Still, taken over all, this may be accepted as the least defective short definition; and moreover it possesses the great practical advantage of keeping before the student the primary fact that insanity is the result of disease of the brain (seeBrain, andNeuropathology), and that it is not a mere immaterial disorder of the intellect. In the earliest epochs of medicine the corporeal character of insanity was generally admitted, and it was not until the superstitious ignorance of the middle ages had obliterated the scientific, though by no means always accurate, deductions of the early writers, that any theory of its purely psychical character arose. At the present day it is unnecessary to combat such a theory, as it is universally accepted that the brain is the organ through which mental phenomena are manifested, and therefore that it is impossible to conceive of the existence of an insane mind in a healthy brain. On this basis insanity may be defined as consisting inmorbid conditions of the brain, the results of defective formation or altered nutrition of its substance induced by local or general morbid processes, and characterized especially by non-development, obliteration, impairment or perversion of one or more of its psychical functions. Thus insanity is not a simple condition; it comprises a large number of diseased states of the brain, gathered under one popular term, on account of mental defect or aberration being the predominant symptom.
The insanities are sharply divided into two great classes—theCongenitaland theAcquired. Under the head of Congenital Insanity must be considered all cases in which, from whatever cause, brain development has been arrested, with consequentClassification.impotentiality of development of the mental faculties; under that of Acquired Insanity all those in which the brain has been born healthy but has suffered from morbid processes affecting it primarily, or from diseased states of the general system implicating it secondarily. In studying the causation of these two great classes, it will be found that certain remote influences exist which are believed to be commonly predisposing; these will be considered as such, leaving the proximate or exciting causes until each class with its subdivisions comes under review.
In most treatises on the subject will be found discussed the bearing which civilization, nationality, occupation, education, &c., have, or are supposed to have, on the production of insanity. Such discussions are as a rule eminentlyCausation.unsatisfactory, founded as they are on common observation, broad generalizations, and very imperfect statistics. As they are for the most part negative in result, at the best almost entirely irrelevant to the present purpose, it is proposed merely to summarize shortly the general outcome of what has been arrived at by those authorities who have sought to assess the value to be attached to the influence exercised by such factors, without entering in any detail on the theories involved. The causes of insanity may be divided into (a) general, and (b) proximate.
(a)General Causes.—1.Civilization.—Although insanity is by no means unknown amongst savage races, there can be no reasonable doubt that it is much more frequently developed in civilized communities; also that, as the former come under the influence of civilization, the percentage of lunacy is increased. This is in consonance with the observation of disease of whatever nature, and is dependent in the case of insanity on the wear and tear of nerve tissue involved in the struggle for existence, the physically depressing effects of pauperism, and on the abuse of alcoholic stimulants; each of which morbid factors falls to be considered separately as a proximate cause. In considering the influence of civilization upon the production of insanity, regard must be had to the more evolved ethical attitude towards disease in general which exists in civilized communities as well as to the more perfect recognition and registration of insanity.2.Nationality.—In the face of the imperfect social statistics afforded by most European and American nations, and in their total absence or inaccessibility amongst the rest of mankind, it is impossible to adduce any trustworthy statement under this head.3.Occupation.—There is nothing to prove that insanity is in any way connected with the prosecution of any trade or professionper se. Even if statistics existed (which they do not) showing the proportion of lunatics belonging to different occupations to the 1000 of the population, it is obvious that no accurate deductionquoadthe influence of occupation could be drawn.4.Education.—There is no evidence to show that education has any influence over either the production or the prevention of insanity. The general result of discussions on the above subjects has been the production of a series of arithmetical statements, which have either a misleading bearing or no bearing at all on the question. In the study of insanity statistics are of slight value from the scientific point of view, and are only valuable in its financial aspects.5.Inheritance.—The hereditary transmission of a liability to mental disease must be reckoned as the most important among all predisposing causes of insanity. It is probably well within the mark to say that at least 50% of the insane have a direct or collateral hereditary tendency towards insanity. The true significance of this factor cannot as yet be explained or described shortly and clearly, but it cannot be too definitely stated that it is not the insanity which is inherited, but only the predisposition to the manifestation of mental symptoms in the presence of a sufficient exciting cause. The most widely and generally accepted view of the exciting cause of insanity is that the predisposed brain readily breaks down under mental stress or bodily privations. There is, however, another view which has been recently advanced to the effect that the majority of mental diseases are secondary to bodily disorders, hereditary predisposition being the equally predisposing causal factor. There is probably truth in both these views, and such an admission accentuates the complexity of the factorship of heredity. If insanity can be induced by physical disorders, which must essentially be of the nature of toxic action or of mechanical agency which can alter or influence the functional powers of the brain, then it is probable that hereditary predisposition to insanity means, not only the transmission of an unstable nervous system, but also a constitution which is either peculiarly liable to the production of such toxic or poisonous substances, or incapable of effectively dealing with the toxins or poisonous substances normally formed during metabolic processes. Such a view broadens our conception of the factorship of hereditary transmission and offersexplanation as to the manner in which insanity may appear in families previously free from the taint. Very frequently we find in the history of insane patients that although there may be no insanity in the family there are undoubted indications of nervous alongside of physical instability, the parental nervous defects taking the form of extreme nervousness, vagabondage, epilepsy, want of mental balance, inequality in mental development or endowment, extreme mental brilliancy in one direction associated with marked deficiency in others, the physical defects showing themselves in the form of insanity; liability to tubercular and rheumatic infections. The failure of constitutional power which allows of the invasion of the tubercle bacillus and the micrococcus rheumaticus in certain members of a family is apparently closely allied to that which favours the development of mental symptoms in others.6.Consanguinity.—It has been strongly asserted that consanguineous marriage is a prolific source of nervous instability. There is considerable diversity of opinion on this subject; the general outcome of the investigations of many careful inquirers appears to be that the offspring of healthy cousins of a healthy stock is not more liable to nervous disease than that of unrelated parents, but that evil consequences follow where there is a strong tendency in the family to degeneration, not only in the direction of the original diathesis, but also towards instability of the nervous system. The objection to the marriage of blood relations does not arise from the bare fact of their relationship, but has its ground in the fear of their having a vicious variation of constitution, which, in their children, is prone to become intensified. There is sufficient evidence adducible to prove that close breeding is productive of degeneration; and when the multiform functions of the nervous system are taken into account, it may almost be assumed, not only that it suffers concomitantly with other organs, but that it may also be the first to suffer independently.7.Parental Weakness.—Of the other causes affecting the parents which appear to have an influence in engendering a predisposition to insanity in the offspring, the abuse of alcoholic stimulants and opiates, over-exertion of the mental faculties, advanced age and weak health may be cited. Great stress has been laid on the influence exercised by the first of these conditions, and many extreme statements have been made regarding it. Such statements must be accepted with reserve, for, although there is reason for attaching considerable weight to the history of ancestral intemperance as a probable causating influence, it has been generally assumed as the proved cause by those who have treated of the subject, without reference to other agencies which may have acted in common with it, or quite independently of it. However unsatisfactory from a scientific point of view it may appear, the general statement must stand that whatever tends to lower the nervous energy of a parent may modify the development of the progeny. Constitutional tendency to nervous instability once established in a family may make itself felt in various directions—epilepsy, hysteria, hypochondriasis, neuralgia, certain forms of paralysis, insanity, eccentricity. It is asserted that exceptional genius in an individual member is a phenomenal indication. Confined to the question of insanity, the morbid inheritance may manifest itself in two directions—in defective brain organization manifest from birth, or from the age at which its faculties are potential,i.e.congenital insanity; or in the neurotic diathesis, which may be present in a brain to all appearance congenitally perfect, and may present itself merely by a tendency to break down under circumstances which would not affect a person of originally healthy constitution.8.Periodic Influence.—The evolutional periods of puberty, adolescence, utero-gestation, the climacteric period and old age exercise an effect upon the nervous system. It may be freely admitted that the nexus between physiological processes and mental disturbances is, as regards certain of the periods, obscure, and that the causal relation is dependent more on induction than on demonstration; but it may be pleaded that it is not more obscure in respect of insanity than of many other diseases. The pathological difficulty obtains mostly in the relation of the earlier evolutional periods, puberty and adolescence, to insanity; in the others a physiologico-pathological nexus may be traced; but in regard to the former there is nothing to take hold of except the purely physiological process of development of the sexual function, the expansion of the intellectual powers, and rapid increase of the bulk of the body. Although in thoroughly stable subjects due provision is made for these evolutional processes, it is not difficult to conceive that in the nervously unstable a considerable risk is run by the brain in consequence of the strain laid on it. Between the adolescent and climacteric periods the constitution of the nervous, as of the other systems, becomes established, and disturbance is not likely to occur, except from some accidental circumstances apart from evolution. In the most healthily constituted individuals the “change of life†expresses itself by some loss of vigour. The nourishing (trophesial) function becomes less active, and either various degrees of wasting occur or there is a tendency towards restitution in bulk of tissues by a less highly organized material. The most important instance of the latter tendency is fatty degeneration of muscle, to which the arterial system is very liable. In the mass of mankind those changes assume no pathological importance: the man or woman of middle life passes into advanced age without serious constitutional disturbance; on the other hand, there may be a break down of the system due to involutional changes in special organs, as, for instance, fatty degeneration of the heart. In all probability the insanity of the climacteric period may be referred to two pathological conditions: it may depend on structural changes in the brain due to fatty degeneration of its arteries and cells, or it may be a secondary result of general systemic disturbance, as indicated by cessation of menstruation in the female and possibly by some analogous modification of the sexual function in men. The senile period brings with it further reduction of formative activity; all the tissues waste, and are liable to fatty and calcareous degeneration. Here again, the arteries of the brain are very generally implicated; atheroma in some degree is almost always present, but is by no means necessarily followed by insanity.The various and profound modifications of the system which attend the periods of utero-gestation, pregnancy and child-bearing do not leave the nervous centres unaffected. Most women are liable to slight changes of disposition and temper, morbid longings, strange likes and dislikes during pregnancy, more especially during the earlier months; but these are universally accepted as accompaniments of the condition not involving any doubts as to sanity. But there are various factors at work in the system during pregnancy which have grave influence on the nervous system, more especially in those hereditarily predisposed, and in those gravid for the first time. There is modification of direction of the blood towards a new focus, and its quality is changed, as is shown by an increase of fibrin and water and a decrease of albumen. To such physical influences are superadded the discomfort and uneasiness of the situation, mental anxiety and anticipation of danger, and in the unmarried the horror of disgrace. In the puerperal (recently delivered) woman there are to be taken into pathological account, in addition to the dangers of sepsis, the various depressing influences of child-bed, its various accidents reducing vitality, the sudden return to ordinary physiological conditions, the rapid call for a new focus of nutrition, the translation as it were of the blood supply from the uterus to the mammae—all physical influences liable to affect the brain. These influences may act independently of moral shock; but, where this is coincident, there is a condition of the nervous system unprepared to resist its action.(b)Proximate Causes.—The proximate causes of insanity may be divided into (1) toxic agents, (2) mechanical injury to the brain, including apoplexies and tumours, and (3) arterial degeneration.1.Toxic Agents.—The definite nature of the symptoms in the majority of the forms of acute insanity leave little reason to doubt that they result from an invasion of the system by toxins of various kinds. The symptoms referred to may be briefly indicated as follows: (i.) Pyrexia, or fever generally of an irregular type; (ii.) Hyperleucocytosis, or an increase of the white blood corpuscles, which is the chief method by which the animal organism protects itself against the noxious influence of micro-organisms and their toxins. In such cases as typhoid fever, which is caused by a bacillus, or Malta fever which is caused by a coccus, it is found that if the blood serum of the patient is mixedin vitrowith a broth culture of the infecting organism in a dilution of 1 in 50, that the bacilli or the cocci, as the case may be, when examined microscopically, are seen to run into groups or clusters. The organisms are said to be agglutinated, and the substance in the serum which produces this reaction is termed an agglutinine. In many of the forms of insanity which present the symptom of hyperleucocytosis there can also be demonstrated the fact that the blood serum of the patients contains agglutinines to certain members of a group of streptococci (so called on account of their tendency to grow in the form of a chain,στÏεπτός); (iii.) the rapid organic affection of the special nerve elements depending upon the virulence of the toxin, and the resistance of the individual to its influence; (iv.) the marked physical deterioration as indicated by emaciation and other changes in nutrition; (v.) the close analogy between the character of many of the mental symptoms,e.g.delirium, hallucinations or depression, and the symptoms produced artificially by the administration of certain poisonous drugs.The toxic substances which are generally believed to be associated with the causation of mental disorders may be divided into three great classes: (a) those which arise from the morbific products of metabolism within the body itself “auto-intoxicantsâ€; (b) those due to the invasion of the blood or tissues by micro-organisms; (c) organic or inorganic poisons introduced into the system voluntarily or accidentally.(a) Auto-intoxication may be due to defective metabolism or to physiological instability, or to both combined. The results of defective metabolism are most clearly manifested in the mental symptoms which not infrequently accompany such diseases as gout, diabetes or obesity, all of which depend primarily upon a deficient chemical elaboration of the products of metabolism. The association of gout and rheumatism with nervous and mental diseases is historical, and the gravest forms of spinal and cerebral degeneration have been found in association with diabetes. Until the pathology of these affections is better understood we are not in a position to determine the nature of the toxins which appear to be the cause of these diseases and of their accompanying nervoussymptoms. Physiological instability is usually manifested by neurotic persons under the strain of any unusual change in their environment. If, for instance, any material change in the food supply consisting either in a decrease of its quality or quantity, or in a failure to assimilate it properly, the nerve-cells become exhausted and irritable, sleep is diminished and a condition known as the delirium of collapse or exhaustion may supervene. An extreme instance of this condition is presented by the delirium occurring in shipwrecked persons, who having to take to the boats are suddenly deprived of food, water or both. Poisoning of the nervous system may also result from the defective action of special glands such as the thyroid, the liver or the kidneys. These conditions are specially exemplified in the mental disturbances which accompany exophthalmic goitre, uraemic poisoning, and the conditions of depression which are observed in jaundice and other forms of hepatic insufficiency.The results of modern research point to a growing belief in the frequency of infection of the nervous system from the hosts of micro-organisms which infest the alimentary tract. No definite or substantiated discoveries have as yet been formulated which would justify us in treating this source of infection as more than a highly probable causative influence.(b) When we turn, however, to the potentiality of infection by micro-organisms introduced from without into the system we are upon surer if not upon entirely definite ground. A special form of insanity called by Weber, who first described it, the delirium of collapse, was observed by him to follow certain infectious diseases such as typhus fever and pneumonia. In later years it has been frequently observed to follow attacks of influenza. Recently our views have broadened and we find that the delirium of collapse is an acute, confusional insanity which may arise without any previous febrile symptoms, and is in fact one of the common forms of acute insanity. The nature of the physical symptoms, the mental confusion and hallucinations which accompany it, as well as the fact that it frequently follows some other infective disease, leave no doubt as to its toxic origin. A similar and analogous condition is presented by incidence of general paralysis after a previous syphilitic infection. The symptoms of general paralysis coupled with the extensive and rapid degeneration of not only the nervous but of the whole of the body tissues point to a microbic disease of intense virulence which, though probably not syphilitic, is yet induced, and enhanced in its action by the previous devitalizing action of the syphilitic toxin. There is abundant evidence to show that emotions which powerfully affect the mind, if long continued, conduce towards a condition of metabolic change, which in its turn deleteriously affects the nervous system, and which may terminate in inducing a true toxic insanity.One of the best examples of insanity arising from micro-organisms is that form which occurs after childbirth, and which is known as puerperal mania. Other insanities may, it is true, arise at this period, but those which occur within the first fourteen days after parturition are generally of infective origin. The confusional nature of the mental symptoms, the delirium and the physical symptoms are sufficient indications of the analogy of this form of mental aberration with such other toxic forms of insanity as we find arising from septic wounds and which sometimes accompany the early toxic stages of virulent infectious diseases such as typhus, diphtheria or malignant scarlet fever.The infective origin of puerperal mania is undoubted, though, as yet, no special pathogenic organism has been isolated. Dr Douglas (Ed. Med. Journ., 1897, i. 413) found the staphylococcus pyogenes aureus present in the blood in one case; Jackman (quotedloc. cit.) found the micrococcus pneumonial crouposae in one case; while Haultain (Ed. Med. Journ., 1897, ii. 131) found only the bacillus coli communis in the blood and secretions of several cases. From our experience of similar mental and physical symptoms produced as a result of septic wounds or which succeed surgical operations there seems to be no doubt that several forms of micrococci or streptococci of a virulent character are capable by means of the toxins they exude of causing acute delirium or mania of a confusional clinical type when introduced into the body.(c) Accidental and voluntary poisonings of the system which result in insanity are illustrated by the forms of insanity which follow phosphorus or lead poisoning and by Pellagra. The voluntary intoxication of the system by such drugs as morphia and alcohol will be treated of below.2 and 3. Mechanical injuries to the brain arise from direct violence to the skull, from apoplectic hemorrhage or embolism, or from rapidly growing tumours, or from arterial degeneration.
(a)General Causes.—1.Civilization.—Although insanity is by no means unknown amongst savage races, there can be no reasonable doubt that it is much more frequently developed in civilized communities; also that, as the former come under the influence of civilization, the percentage of lunacy is increased. This is in consonance with the observation of disease of whatever nature, and is dependent in the case of insanity on the wear and tear of nerve tissue involved in the struggle for existence, the physically depressing effects of pauperism, and on the abuse of alcoholic stimulants; each of which morbid factors falls to be considered separately as a proximate cause. In considering the influence of civilization upon the production of insanity, regard must be had to the more evolved ethical attitude towards disease in general which exists in civilized communities as well as to the more perfect recognition and registration of insanity.
2.Nationality.—In the face of the imperfect social statistics afforded by most European and American nations, and in their total absence or inaccessibility amongst the rest of mankind, it is impossible to adduce any trustworthy statement under this head.
3.Occupation.—There is nothing to prove that insanity is in any way connected with the prosecution of any trade or professionper se. Even if statistics existed (which they do not) showing the proportion of lunatics belonging to different occupations to the 1000 of the population, it is obvious that no accurate deductionquoadthe influence of occupation could be drawn.
4.Education.—There is no evidence to show that education has any influence over either the production or the prevention of insanity. The general result of discussions on the above subjects has been the production of a series of arithmetical statements, which have either a misleading bearing or no bearing at all on the question. In the study of insanity statistics are of slight value from the scientific point of view, and are only valuable in its financial aspects.
5.Inheritance.—The hereditary transmission of a liability to mental disease must be reckoned as the most important among all predisposing causes of insanity. It is probably well within the mark to say that at least 50% of the insane have a direct or collateral hereditary tendency towards insanity. The true significance of this factor cannot as yet be explained or described shortly and clearly, but it cannot be too definitely stated that it is not the insanity which is inherited, but only the predisposition to the manifestation of mental symptoms in the presence of a sufficient exciting cause. The most widely and generally accepted view of the exciting cause of insanity is that the predisposed brain readily breaks down under mental stress or bodily privations. There is, however, another view which has been recently advanced to the effect that the majority of mental diseases are secondary to bodily disorders, hereditary predisposition being the equally predisposing causal factor. There is probably truth in both these views, and such an admission accentuates the complexity of the factorship of heredity. If insanity can be induced by physical disorders, which must essentially be of the nature of toxic action or of mechanical agency which can alter or influence the functional powers of the brain, then it is probable that hereditary predisposition to insanity means, not only the transmission of an unstable nervous system, but also a constitution which is either peculiarly liable to the production of such toxic or poisonous substances, or incapable of effectively dealing with the toxins or poisonous substances normally formed during metabolic processes. Such a view broadens our conception of the factorship of hereditary transmission and offersexplanation as to the manner in which insanity may appear in families previously free from the taint. Very frequently we find in the history of insane patients that although there may be no insanity in the family there are undoubted indications of nervous alongside of physical instability, the parental nervous defects taking the form of extreme nervousness, vagabondage, epilepsy, want of mental balance, inequality in mental development or endowment, extreme mental brilliancy in one direction associated with marked deficiency in others, the physical defects showing themselves in the form of insanity; liability to tubercular and rheumatic infections. The failure of constitutional power which allows of the invasion of the tubercle bacillus and the micrococcus rheumaticus in certain members of a family is apparently closely allied to that which favours the development of mental symptoms in others.
6.Consanguinity.—It has been strongly asserted that consanguineous marriage is a prolific source of nervous instability. There is considerable diversity of opinion on this subject; the general outcome of the investigations of many careful inquirers appears to be that the offspring of healthy cousins of a healthy stock is not more liable to nervous disease than that of unrelated parents, but that evil consequences follow where there is a strong tendency in the family to degeneration, not only in the direction of the original diathesis, but also towards instability of the nervous system. The objection to the marriage of blood relations does not arise from the bare fact of their relationship, but has its ground in the fear of their having a vicious variation of constitution, which, in their children, is prone to become intensified. There is sufficient evidence adducible to prove that close breeding is productive of degeneration; and when the multiform functions of the nervous system are taken into account, it may almost be assumed, not only that it suffers concomitantly with other organs, but that it may also be the first to suffer independently.
7.Parental Weakness.—Of the other causes affecting the parents which appear to have an influence in engendering a predisposition to insanity in the offspring, the abuse of alcoholic stimulants and opiates, over-exertion of the mental faculties, advanced age and weak health may be cited. Great stress has been laid on the influence exercised by the first of these conditions, and many extreme statements have been made regarding it. Such statements must be accepted with reserve, for, although there is reason for attaching considerable weight to the history of ancestral intemperance as a probable causating influence, it has been generally assumed as the proved cause by those who have treated of the subject, without reference to other agencies which may have acted in common with it, or quite independently of it. However unsatisfactory from a scientific point of view it may appear, the general statement must stand that whatever tends to lower the nervous energy of a parent may modify the development of the progeny. Constitutional tendency to nervous instability once established in a family may make itself felt in various directions—epilepsy, hysteria, hypochondriasis, neuralgia, certain forms of paralysis, insanity, eccentricity. It is asserted that exceptional genius in an individual member is a phenomenal indication. Confined to the question of insanity, the morbid inheritance may manifest itself in two directions—in defective brain organization manifest from birth, or from the age at which its faculties are potential,i.e.congenital insanity; or in the neurotic diathesis, which may be present in a brain to all appearance congenitally perfect, and may present itself merely by a tendency to break down under circumstances which would not affect a person of originally healthy constitution.
8.Periodic Influence.—The evolutional periods of puberty, adolescence, utero-gestation, the climacteric period and old age exercise an effect upon the nervous system. It may be freely admitted that the nexus between physiological processes and mental disturbances is, as regards certain of the periods, obscure, and that the causal relation is dependent more on induction than on demonstration; but it may be pleaded that it is not more obscure in respect of insanity than of many other diseases. The pathological difficulty obtains mostly in the relation of the earlier evolutional periods, puberty and adolescence, to insanity; in the others a physiologico-pathological nexus may be traced; but in regard to the former there is nothing to take hold of except the purely physiological process of development of the sexual function, the expansion of the intellectual powers, and rapid increase of the bulk of the body. Although in thoroughly stable subjects due provision is made for these evolutional processes, it is not difficult to conceive that in the nervously unstable a considerable risk is run by the brain in consequence of the strain laid on it. Between the adolescent and climacteric periods the constitution of the nervous, as of the other systems, becomes established, and disturbance is not likely to occur, except from some accidental circumstances apart from evolution. In the most healthily constituted individuals the “change of life†expresses itself by some loss of vigour. The nourishing (trophesial) function becomes less active, and either various degrees of wasting occur or there is a tendency towards restitution in bulk of tissues by a less highly organized material. The most important instance of the latter tendency is fatty degeneration of muscle, to which the arterial system is very liable. In the mass of mankind those changes assume no pathological importance: the man or woman of middle life passes into advanced age without serious constitutional disturbance; on the other hand, there may be a break down of the system due to involutional changes in special organs, as, for instance, fatty degeneration of the heart. In all probability the insanity of the climacteric period may be referred to two pathological conditions: it may depend on structural changes in the brain due to fatty degeneration of its arteries and cells, or it may be a secondary result of general systemic disturbance, as indicated by cessation of menstruation in the female and possibly by some analogous modification of the sexual function in men. The senile period brings with it further reduction of formative activity; all the tissues waste, and are liable to fatty and calcareous degeneration. Here again, the arteries of the brain are very generally implicated; atheroma in some degree is almost always present, but is by no means necessarily followed by insanity.
The various and profound modifications of the system which attend the periods of utero-gestation, pregnancy and child-bearing do not leave the nervous centres unaffected. Most women are liable to slight changes of disposition and temper, morbid longings, strange likes and dislikes during pregnancy, more especially during the earlier months; but these are universally accepted as accompaniments of the condition not involving any doubts as to sanity. But there are various factors at work in the system during pregnancy which have grave influence on the nervous system, more especially in those hereditarily predisposed, and in those gravid for the first time. There is modification of direction of the blood towards a new focus, and its quality is changed, as is shown by an increase of fibrin and water and a decrease of albumen. To such physical influences are superadded the discomfort and uneasiness of the situation, mental anxiety and anticipation of danger, and in the unmarried the horror of disgrace. In the puerperal (recently delivered) woman there are to be taken into pathological account, in addition to the dangers of sepsis, the various depressing influences of child-bed, its various accidents reducing vitality, the sudden return to ordinary physiological conditions, the rapid call for a new focus of nutrition, the translation as it were of the blood supply from the uterus to the mammae—all physical influences liable to affect the brain. These influences may act independently of moral shock; but, where this is coincident, there is a condition of the nervous system unprepared to resist its action.
(b)Proximate Causes.—The proximate causes of insanity may be divided into (1) toxic agents, (2) mechanical injury to the brain, including apoplexies and tumours, and (3) arterial degeneration.
1.Toxic Agents.—The definite nature of the symptoms in the majority of the forms of acute insanity leave little reason to doubt that they result from an invasion of the system by toxins of various kinds. The symptoms referred to may be briefly indicated as follows: (i.) Pyrexia, or fever generally of an irregular type; (ii.) Hyperleucocytosis, or an increase of the white blood corpuscles, which is the chief method by which the animal organism protects itself against the noxious influence of micro-organisms and their toxins. In such cases as typhoid fever, which is caused by a bacillus, or Malta fever which is caused by a coccus, it is found that if the blood serum of the patient is mixedin vitrowith a broth culture of the infecting organism in a dilution of 1 in 50, that the bacilli or the cocci, as the case may be, when examined microscopically, are seen to run into groups or clusters. The organisms are said to be agglutinated, and the substance in the serum which produces this reaction is termed an agglutinine. In many of the forms of insanity which present the symptom of hyperleucocytosis there can also be demonstrated the fact that the blood serum of the patients contains agglutinines to certain members of a group of streptococci (so called on account of their tendency to grow in the form of a chain,στÏεπτός); (iii.) the rapid organic affection of the special nerve elements depending upon the virulence of the toxin, and the resistance of the individual to its influence; (iv.) the marked physical deterioration as indicated by emaciation and other changes in nutrition; (v.) the close analogy between the character of many of the mental symptoms,e.g.delirium, hallucinations or depression, and the symptoms produced artificially by the administration of certain poisonous drugs.
The toxic substances which are generally believed to be associated with the causation of mental disorders may be divided into three great classes: (a) those which arise from the morbific products of metabolism within the body itself “auto-intoxicantsâ€; (b) those due to the invasion of the blood or tissues by micro-organisms; (c) organic or inorganic poisons introduced into the system voluntarily or accidentally.
(a) Auto-intoxication may be due to defective metabolism or to physiological instability, or to both combined. The results of defective metabolism are most clearly manifested in the mental symptoms which not infrequently accompany such diseases as gout, diabetes or obesity, all of which depend primarily upon a deficient chemical elaboration of the products of metabolism. The association of gout and rheumatism with nervous and mental diseases is historical, and the gravest forms of spinal and cerebral degeneration have been found in association with diabetes. Until the pathology of these affections is better understood we are not in a position to determine the nature of the toxins which appear to be the cause of these diseases and of their accompanying nervoussymptoms. Physiological instability is usually manifested by neurotic persons under the strain of any unusual change in their environment. If, for instance, any material change in the food supply consisting either in a decrease of its quality or quantity, or in a failure to assimilate it properly, the nerve-cells become exhausted and irritable, sleep is diminished and a condition known as the delirium of collapse or exhaustion may supervene. An extreme instance of this condition is presented by the delirium occurring in shipwrecked persons, who having to take to the boats are suddenly deprived of food, water or both. Poisoning of the nervous system may also result from the defective action of special glands such as the thyroid, the liver or the kidneys. These conditions are specially exemplified in the mental disturbances which accompany exophthalmic goitre, uraemic poisoning, and the conditions of depression which are observed in jaundice and other forms of hepatic insufficiency.
The results of modern research point to a growing belief in the frequency of infection of the nervous system from the hosts of micro-organisms which infest the alimentary tract. No definite or substantiated discoveries have as yet been formulated which would justify us in treating this source of infection as more than a highly probable causative influence.
(b) When we turn, however, to the potentiality of infection by micro-organisms introduced from without into the system we are upon surer if not upon entirely definite ground. A special form of insanity called by Weber, who first described it, the delirium of collapse, was observed by him to follow certain infectious diseases such as typhus fever and pneumonia. In later years it has been frequently observed to follow attacks of influenza. Recently our views have broadened and we find that the delirium of collapse is an acute, confusional insanity which may arise without any previous febrile symptoms, and is in fact one of the common forms of acute insanity. The nature of the physical symptoms, the mental confusion and hallucinations which accompany it, as well as the fact that it frequently follows some other infective disease, leave no doubt as to its toxic origin. A similar and analogous condition is presented by incidence of general paralysis after a previous syphilitic infection. The symptoms of general paralysis coupled with the extensive and rapid degeneration of not only the nervous but of the whole of the body tissues point to a microbic disease of intense virulence which, though probably not syphilitic, is yet induced, and enhanced in its action by the previous devitalizing action of the syphilitic toxin. There is abundant evidence to show that emotions which powerfully affect the mind, if long continued, conduce towards a condition of metabolic change, which in its turn deleteriously affects the nervous system, and which may terminate in inducing a true toxic insanity.
One of the best examples of insanity arising from micro-organisms is that form which occurs after childbirth, and which is known as puerperal mania. Other insanities may, it is true, arise at this period, but those which occur within the first fourteen days after parturition are generally of infective origin. The confusional nature of the mental symptoms, the delirium and the physical symptoms are sufficient indications of the analogy of this form of mental aberration with such other toxic forms of insanity as we find arising from septic wounds and which sometimes accompany the early toxic stages of virulent infectious diseases such as typhus, diphtheria or malignant scarlet fever.
The infective origin of puerperal mania is undoubted, though, as yet, no special pathogenic organism has been isolated. Dr Douglas (Ed. Med. Journ., 1897, i. 413) found the staphylococcus pyogenes aureus present in the blood in one case; Jackman (quotedloc. cit.) found the micrococcus pneumonial crouposae in one case; while Haultain (Ed. Med. Journ., 1897, ii. 131) found only the bacillus coli communis in the blood and secretions of several cases. From our experience of similar mental and physical symptoms produced as a result of septic wounds or which succeed surgical operations there seems to be no doubt that several forms of micrococci or streptococci of a virulent character are capable by means of the toxins they exude of causing acute delirium or mania of a confusional clinical type when introduced into the body.
(c) Accidental and voluntary poisonings of the system which result in insanity are illustrated by the forms of insanity which follow phosphorus or lead poisoning and by Pellagra. The voluntary intoxication of the system by such drugs as morphia and alcohol will be treated of below.
2 and 3. Mechanical injuries to the brain arise from direct violence to the skull, from apoplectic hemorrhage or embolism, or from rapidly growing tumours, or from arterial degeneration.
The forms of insanity may be divided into (I.) Congenital Mental Defect and (II.) Acquired Insanity.
I.Forms of Insanity.Congenital Mental Defect.—The morbid mental conditions which fall to be considered under this head areIdiocy(with its modification, Imbecility) andCretinism(q.v.).
Idiocy(from Gr.ἰδιώτης, in its secondary meaning of a deprived person). In treating of idiocy it must be carefully borne in mind that we are dealing with mental phenomena dissociated for the most part from active bodily disease, and that,Idiocy.in whatever degree it may exist, we have to deal with a brain condition fixed by the pathological circumstances under which its possessor came into the world or by such as had been present before full cerebral activity could be developed, and the symptoms of which are not dependent on the intervention of any subsequent morbid process. From the earliest ages the termAmentiahas been applied to this condition, in contradistinction toDementia, the mental weakness following on acquired insanity.
The causes of congenital idiocy may be divided into four classes: (1) hereditary predisposition, (2) constitutional conditions of one or both parents affecting the constitution of the infant, (3) injuries of the infant prior to or at birth, and (4) injuries or diseases affecting the infant head during infancy. All these classes of causes may act in two directions: they may produce either non-development or abnormal development of the cranial bones as evidenced by microcephalism, or by deformity of the head; or they may induce a more subtle morbid condition of the constituent elements of the brain. As a rule, the pathological process is more easily traceable in the case of the last three classes than in the first. For instance, in the case of constitutional conditions of the parents we may have a history of syphilis, a disease which often leaves its traces on the bones of the skull; and in the third case congenital malformation of the brain may be produced by mechanical causes acting on the child in utero, such as an attempt to procure abortion, or deformities of the maternal pelvis rendering labour difficult and instrumental interference necessary. In such cases the bones of the skull may be injured; it is only fair, however, to say that more brains are saved than injured by instrumental interference. With regard to the fourth class, it is evident that the term congenital is not strictly applicable; but, as the period of life implicated is that prior to the potentiality of the manifestation of the intellectual powers, and as the result is identical with that of the other classes of causes, it is warrantable to connect it with them, on pathological principles more than as a mere matter of convenience.
Dr Ireland, in his workOn Idiocy and Imbecility(1877), classifies idiots from the standpoint of pathology as follows: (1) Genetous idiocy: in this form, which he holds to be complete before birth, he believes the presumption of heredity to be stronger than in other forms; the vitality of the general system is stated to be lower than normal; the palate is arched and narrow, the teeth misshapen, irregular and prone to decay and the patient dwarfish in appearance; the head is generally unsymmetrical and the commissures occasionally atrophied; (2) Microcephalic idiocy, a term which explains itself; (3) Eclampsic idiocy, due to the effects of infantile convulsions; (4) Epileptic idiocy; (5) Hydrocephalic idiocy, a term which explains itself; (6) Paralytic idiocy, a rare form, due to the brain injury causing the paralysis; (7) Traumatic idiocy, a form produced by the third class of causes above mentioned; (8) Inflammatory idiocy; (9) Idiocy by deprivation of one or more of the special senses.
The general conformation of the idiot is generally imperfect; he is sometimes deformed, but more frequently the frame is merely awkwardly put together, and he is usually of short stature. Only about one-fourth of all idiots have heads smaller than the average. Many cases are on record in which the cranial measurements exceed the average. It is the irregularity of development of the bones of the skull, especially at the base, which marks the condition. Cases, however, often present themselves in which the skull is perfect in form and size. In such the mischief has begun in the brain matter. The palate is often highly arched; hare-lip is not uncommon; in fact congenital defect or malformation of other organs than the brain is more commonly met with among idiots than in the general community. Of the special senses, hearing is most frequently affected. Sight is good, although co-ordination may be defective. Many are mute. On account of the mental dullness it is difficult to determine whether the senses of touch, taste and smell sufferimpairment; but the impression is that their acuteness is below the average. It is needless to attempt a description of the mental phenomena of idiots, which range between utter want of intelligence and mere weakness of intellect.
The termImbecilityhas been conventionally employed to indicate the less profound degrees of idiocy, but in point of fact no distinct line of demarcation can be drawn between the conditions. As the scale of imbeciles ascends it is found that the condition is evidenced not so much by obtuseness as by irregularity of intellectual development. This serves to mark the difference between the extreme stupidity of the lowest of the healthy and the highest forms of the morbidly deprived type. The two conditions do not merge gradually one into the other. Absolute stupidity and sottishness mark many cases of idiocy, but only in the lowest type, where no dubiety of opinion can exist as to its nature, and in a manner which can never be mistaken for the dulness of the man who is less talented than the average of mankind. Where in theory the morbid (in the sense of deprivation) and the healthy types might be supposed to approach each other, in practice we find that, in fact, no debatable ground exists. The uniformity of dulness of the former stands in marked opposition to the irregularity of mental conformation in the latter. Comparatively speaking, there are few idiots or imbeciles who are uniformly deprived of mental power; some may be utterly sottish, living a mere vegetable existence, but every one must have heard of the quaint and crafty sayings of manifest idiots, indicating the presence of no mean power of applied observation. In institutions for the treatment of idiots and imbeciles, children are found not only able to read and write, but even capable of applying the simpler rules of arithmetic. A man may possess a very considerable meed of receptive faculty and yet be idiotic in respect of the power of application; he may be physically disabled from relation, and so be manifestly a deprived person, unfit to take a position in the world on the same platform as his fellows.
Dr Ireland subdivides idiots, for the purpose of education, into five grades, the first comprising those who can neither speak nor understand speech, the second those who can understand a few easy words, the third those who can speak and can be taught to work, the fourth those who can be taught to read and write, and the fifth those who can read books for themselves. The treatment of idiocy and imbecility consists almost entirely of attention to hygiene and the building up of the enfeebled constitution, along with endeavours to develop what small amount of faculty exists by patiently applied educational influences. The success which has attended this line of treatment in many public and private institutions has been very considerable. It may be safely stated that most idiotic or imbecile children have a better chance of amelioration in asylums devoted to them than by any amount of care at home.
In the class of idiots just spoken of, imperfect development of the intellectual faculties is the prominent feature, so prominent that it masks the arrest of potentiality of development of the moral sense, the absence of which, even if noticed, is regarded as relatively unimportant; but, in conducting the practical study of congenital idiots, a class presents itself in which the moral sense is wanting or deficient, whilst the intellectual powers are apparently up to the average. It is the custom of writers on the subject to speak of “intellectual†and “moral†idiots. The terms are convenient for clinical purposes, but the two conditions cannot be dissociated, and the terms therefore severally only imply a specially marked deprivation of intellect or of moral sense in a given case. The everyday observer has no difficulty in recognizing as a fact that deficiency in receptive capacity is evidence of imperfect cerebral development; but it is not so patent to him that the perception of right or wrong can be compromised through the same cause, or to comprehend that loss of moral sense may result from disease. The same difficulty does not present itself to the pathologist; for, in the case of a child born under circumstances adverse to brain development, and in whom no process of education can develop an appreciation of what is right or wrong, although the intellectual faculties appear to be but slightly blunted, or not blunted at all, he cannot avoid connecting the physical peculiarity with the pathological evidence. The world is apt enough to refer any fault in intellectual development, manifested by imperfect receptivity, to a definite physical cause, and is willing to base opinion on comparatively slight data; but it is not so ready to accept the theory of a pathological implication of the intellectual attributes concerned in the perception of the difference between right and wrong. Were, however, two cases pitted one against another—the first one of so-called intellectual, the second one of so-called moral idiocy—it would be found that, except as regards the psychical manifestations, the cases might be identical. In both there might be a family history of tendency to degeneration, a peculiar cranial conformation, a history of previous symptoms during infancy, and of a series of indications of mental incapacities during adolescence, differing only in this, that in the first the prominent indication of mental weakness was inability to add two and two together, in the second the prominent feature was incapacity to distinguish right from wrong. What complicates the question of moral idiocy is that many of its subjects can, when an abstract proposition is placed before them, answer according to the dictates of morality, which they may have learnt by rote. If asked whether it is right or wrong to lie or steal they will say it is wrong; still, when they themselves are detected in either offence, there is an evident non-recognition of its concrete nature. The question of moral idiocy will always be a moot one between the casuist and the pathologist; but, when the whole natural history of such cases is studied, there are points of differentiation between their morbid depravation and mere moral depravity. Family history, individual peculiarities, the general bizarre nature of the phenomena, remove such cases from the category of crime.
Statistics.—According to the census returns of 1901 the total number of persons described as idiots and imbeciles in England and Wales was 48,882, the equality of the sexes being remarkable, namely, 24,480 males and 24,402 females. Compared with the entire population the ratio is 1 idiot or imbecile to 665 persons, or 15 per 10,000 persons living. Whether the returns are defective, owing to the sensitiveness of persons who would desire to conceal the occurrence of idiocy in their families, we have no means of knowing; but such a feeling is no doubt likely to exist among those who look upon mental infirmity as humiliating, rather than, as one of the many physical evils which afflict humanity. Dr. Ireland estimates that there is 1 idiot or imbecile to every 500 persons in countries that have a census. The following table shows the number of idiots according to official returns of the various countries:—Males.Females.Total.Proportionto 100,000of Pop.England and Wales24,48024,40248,882150Scotland3,2463,3776,623148Ireland2,9462,2705,216117France (including cretins) (1872)20,45614,67735,13397Germany (1871)——33,73982Sweden (1870)——1,63238Norway (1891)1,3571,0742,431121Denmark (1888-89)2,1061,7513,857200For the United States there are no later census figures than 1890 when the feeble-minded or idiotic were recorded as 95,571 (52,940 males and 42,631 females). In 1904 (Special Report of Bureau of Census, 1906) the “feeble-minded†were estimated at 150,000.The relative frequency of congenital and acquired insanity in various countries is shown in the following table, taken from Koch’s statistics of insanity in Württemberg, which gives the number of idiots to 100 lunatics:—Prussia158France66Bavaria154Denmark58Saxony162Sweden22Austria53Norway65Hungary140England and Wales74Canton of Bern117Scotland68America79Ireland69It is difficult to understand the wide divergence of these figures, except it be that in certain states, such as Prussia and Bavaria, dements have been taken along with aments and in others cretins.This cannot, however, apply to the case of France, which is stated to have only 66 idiots to every 100 lunatics. In many districts of France cretinism is common; it is practically unknown in England, where the proportion of idiots is stated as higher than in France; and it is rare in Prussia, which stands at 158 idiots to 100 lunatics. Manifestly imperfect as this table is, it shows how important an element idiocy is in social statistics; few are aware that the number of idiots and that of lunatics approach so nearly.
Statistics.—According to the census returns of 1901 the total number of persons described as idiots and imbeciles in England and Wales was 48,882, the equality of the sexes being remarkable, namely, 24,480 males and 24,402 females. Compared with the entire population the ratio is 1 idiot or imbecile to 665 persons, or 15 per 10,000 persons living. Whether the returns are defective, owing to the sensitiveness of persons who would desire to conceal the occurrence of idiocy in their families, we have no means of knowing; but such a feeling is no doubt likely to exist among those who look upon mental infirmity as humiliating, rather than, as one of the many physical evils which afflict humanity. Dr. Ireland estimates that there is 1 idiot or imbecile to every 500 persons in countries that have a census. The following table shows the number of idiots according to official returns of the various countries:—
For the United States there are no later census figures than 1890 when the feeble-minded or idiotic were recorded as 95,571 (52,940 males and 42,631 females). In 1904 (Special Report of Bureau of Census, 1906) the “feeble-minded†were estimated at 150,000.
The relative frequency of congenital and acquired insanity in various countries is shown in the following table, taken from Koch’s statistics of insanity in Württemberg, which gives the number of idiots to 100 lunatics:—
It is difficult to understand the wide divergence of these figures, except it be that in certain states, such as Prussia and Bavaria, dements have been taken along with aments and in others cretins.This cannot, however, apply to the case of France, which is stated to have only 66 idiots to every 100 lunatics. In many districts of France cretinism is common; it is practically unknown in England, where the proportion of idiots is stated as higher than in France; and it is rare in Prussia, which stands at 158 idiots to 100 lunatics. Manifestly imperfect as this table is, it shows how important an element idiocy is in social statistics; few are aware that the number of idiots and that of lunatics approach so nearly.
II.Acquired Insanity.—So far as the mental symptoms of acquired insanity are concerned, Pinel’s ancient classification,Acquired Insanity.intoMania,MelancholiaandDementia, is still applicable to every case, and although numberless classifications have been advanced they are for the most part merely terminological variations. Classifications of the insanities based on pathology and etiology have been held out as a solution of the difficulty, but, so far, pathological observations have failed to fulfil this ideal, and no thoroughly satisfactory pathological classification has emerged from them.
Classifications are after all matters of convenience; the following system admittedly is so:—