Chapter 21

Treatment.—No treatment arrests or diverts the course of katatonia, and the acute symptoms of the disease as they arise must be treated on hospital principles.

Hebephrenia.—This is a disease of adolescence (Gr.ἥβη) which was first described by Hecker and Kahlbaum and more recently by Kraepelin and other foreign workers. Hebephrenia is not yet recognized by British alienists.Hebephrenia.The descriptions of the disease are indefinite and confusing, but there are some grounds for the belief that such an entity does exist, although it is probably more correct to say that as yet the symptoms are very imperfectly understood. Hebephrenia is always a disease of adolescence and never occurs during adult life. It attacks women more frequently than men, and according to Kahlbaum hereditary predisposition to insanity is present in over 50% of the cases attacked. The onset of the disease is invariably associated with two symptoms. On the physical side an arrested or delayed development and on the mental a gradual failure of the power of attention andconcentrated thought. The onset of the condition is always gradual and the symptoms which first attract attention are mental. The patient becomes restless, is unable to settle to work, becomes solitary and peculiar in habits and sometimes dissolute and mischievous. As the disease advances the patient becomes more and more enfeebled, laughs and mutters to himself and wanders aimlessly and without object. There is no natural curiosity, no interest in life and no desire for occupation. Later, delusions may appear and also hallucinations of hearing, and under their influence the patient may be impulsive and violent. Physically the subjects are always badly developed. The temperature is at times slightly elevated and at intervals the white blood corpuscles are markedly increased. The menstrual function in women is suppressed and both male and female cases are addicted to masturbation. According to Kraepelin 5% of the cases recover, 15% are so far relieved as to be able to live at home, but are mentally enfeebled, the remaining 80% become hopelessly demented. The patients who recover frequently show at the onset of their disease acute symptoms, such as mild excitement, slightly febrile temperature and quick pulse-rate. When recovery does take place there is marked improvement in development. The subjects of hebephrenia are peculiarly liable to tubercular infection and many die of phthisis.

There is no special treatment for hebephrenia beyond attention to the general health.

Insanity following upon Injuries to the Brain, or Apoplexies or Tumours or Arterial Degeneration.(a)Traumatic Insanity.—Insanity following blows on the head is divided into (1) the forms in which the insanity immediatelyTraumatic Insanity.follows the accident; (2) the form in which there is an intermediate prodromal stage characterized by strange conduct and alteration in disposition; and (3) in which the mental symptoms occur months or years after the accident, which can have at most but a remote predisposing causal relation to the insanity. The cases which immediately succeed injuries to the head are in all respects similar to confusional insanity after operations or after fevers. There is generally a noisy incoherent delirium, accompanied by hallucinations of sight or of hearing, and fleeting unsystematized delusions. The physical symptoms present all the features of severe nervous shock.

In those cases in which there is an intervening prodromal condition, with altered character and disposition, there is usually a more or less severe accidental implication of the cortex cerebri, either by depression of bone or local hemorrhage, or meningitic sub-inflammatory local lesions. Most of the cases during the prodromal stage are sullen, morose or suspicious, and indifferent to their friends and surroundings. At the end of the prodromal stage there most usually occurs an attack of acute mania of a furious impulsive kind. The cases which for many years after injury are said to have remained sane will generally be found upon examination and inquiry to exhibit symptoms of hereditary degeneration or of acquired degeneracy, which may or may not be a consequence of the accident.

The most common site of vascular lesion is one of the branches of the middle cerebral artery within the sylvian fissure, or of one of the smaller branches of the same artery which go directly to supply the chief basal ganglia. When an artery like the middle cerebral or one of its branches becomes either through rupture or blocking of its lumen, incapable of performing its function of supplying nutrition to important cerebral areas, there ensues devitality of the nervous tissues, frequently followed by softening and chronic inflammation. It is these secondary changes which give rise to and maintain those peculiar mental aberrations known as post-apoplectic insanity.

Various characteristic physical symptoms, depending upon the seat of the cerebral lesion, are met with in the course of this form of insanity. These consist of paraplegias, hemiplegias and muscular contractures. Speech defects are very common, being due either to the enfeebled mental condition, to paralysis of the nerve supplying the muscles of the face and tongue, or to aphasia caused by implication of those parts of the cortex which are intimately associated with the faculty of speech. Mental symptoms vary considerably in different cases and in accordance with the seat and extent of the lesion. There is almost always present, however, a certain degree of mental enfeeblement, accompanied by loss of memory and of judgment, often by mental confusion. Another very general mental symptom is the presence of emotionalism which leads the patient to be affected either to tears or to laughter upon trifling and inadequate occasions.

Cerebral tumours do not necessarily produce insanity. Indeed it has been computed that not one half of the cases become insane. When insanity appears it is met with in all degrees varying from slight mental dulness up to complete dementia, and from mere moral perversion up to the most intense form of maniacal excitement. On the physical side the various symptoms of cerebral tumour such as coma, ataxia, paralysis, headache, vomiting, optic neuritis and epileptiform convulsions are met with. All forms of so-called moral changes and of changes of disposition are met with as mental symptoms and all the ordinary forms of insanity may occur in varying intensity; but by far the most common mental change occurring in connexion with cerebral tumour is a progressive enfeeblement of the intelligence, unattended with any more harmful symptoms than mental deterioration which ends in complete dementia.

(b)Arterial Degeneration.—Arterial degeneration is a common cause of mental impairment, especially of that form of mental affection known as “Early” dementia. It also predisposes to embolism and thrombosis,Insanity due to Arterial Degeneration.which often results in the paralytic and aphasic groups of nerve disturbance, and which are always accompanied by more or less marked interference with normal cerebral action.

The commonest seat for atheroma of the cerebral vessels is the arteries at the base of the brain and their main branches, especially the middle cerebral. As a general rule the other arteries of the cerebrum are not implicated to the same extent, although in a not inconsiderable number of cases of the disease all the arteries of the brain may participate in the change. When this is so, we obtain those definite symptoms of slowly advancing dementia commencing in late middle life and ending in complete dementia before the usual period for the appearance of senile dementia. The same appearances are met with in certain patients who have attained the age in which senile changes in the arteries are not unexpected. As a rule atheroma in the cerebral vessels is but a part of a general atheroma of all the arteries of the body. Atheroma is common after middle life and increases in frequency with age. The chief causes are syphilis, alcoholism, the gouty and rheumatic diatheses and above all Bright’s disease of the kidneys. Perhaps certain forms of Bright’s disease, owing to the tendency to raise the blood pressure, are of all causes the most common.

It is not easy to say to what extent, alone, the arteriosclerosis is effectual in inducing the gradual failure of the mental powers, and to what extent it is assisted in its operation by the action on the brain-cells of the general toxic substances which give rise to the arterial atheroma. In any case there can be no question that the gradual mechanical diminution of the blood-supply to the cortex caused by the occlusion of the lumen of the arteries is a factor of great importance in the production of mental incapacity.

General Paralysis of the Insane(syn. General Paralysis,dementia paralytica, progressive dementia) is a disease characterized by symptoms of progressive degeneration of the central nervous system, more particularly of the motorGeneral Paralysis.centres. The disease is almost invariably fatal. Apparent recoveries do very occasionally occur, though this is denied by the majority of alienists. The disease is in every case associated with gradually advancing mental enfeeblement, and very frequently is complicated by attacks of mental disease.

General paralysis, which is a very common disease, was first recognized in France; it was identified by J. E. D. Esquirol, and further described and elaborated by A. L. J. Bayle, Delaye and J. L. Calmeil, the latter giving it the name ofparalysie générale des aliénés.

As first described by the earlier writers the disease was regarded as being invariably associated with delusions of grandeur. At the present day this description does not apply to the majority of cases admitted into asylums. The change may be explained as being either due to an alteration in the type of the disease, or more probably the disease is better understood and more frequently diagnosed than formerly, the diagnosis being now entirely dependent on the physical and not on the mental symptoms. This latter may also be the explanation why general paralysis is much more common at the present day in British asylums than it was. The total death-rate from this disease in English and Scottish asylums rose from 1321 in 1894 to 1795 in 1904.

General paralysis attacks men much more frequently than women, and occurs between the ages of 35 and 50 years. It is essentially a disease of town life. In asylums which draw their patients from country districts in Scotland and Ireland, the disease is rare, whereas in those which draw their population from large cities the disease is extremely common.

Considerable diversity of opinion exists at present regarding the causation of general paralysis. Hereditary predisposition admittedly plays a very small part in its causation. There is, however, an almost universal agreement that the disease is essentially the result of toxaemia or poisoning, and that acquired or inherited syphilitic infection is an important predisposing factor. A history of syphilitic infection occurs in from 70 to 90% of the patients affected. At first it was held that general paralysis was a late syphilitic manifestation, but as it was found that no benefit followed the use of anti-syphilitic remedies the theory was advanced that general paralysis was a secondary auto-intoxication following upon syphilitic infection. The latest view is that the disease is a bacterial invasion, to which syphilis, alcoholism, excessive mental and physical strain, and a too exclusively nitrogenous diet, only act as predisposing causes. This latter theory has been recently advanced and elaborated by Ford Robertson and McRae of Edinburgh.

Whatever the cause of general paralysis may be, the disease is essentially progressive in character, marked by frequent remissions and so typical in its physical symptoms and pathology that we regard the bacterial theory with favour, although we are far from satisfied that the actual causative factor has as yet been discovered.

For descriptive purposes the disease is most conveniently divided into three stages,—called respectively the first, second and third,—but it must be understood that no clear line of demarcation divides these stages from one another.

The onset of general paralysis is slow and gradual, and the earliest symptoms may be either physical or mental. The disease may commence either in the brain itself or the spinal cord may be primarily the seat of lesion, the brain becoming affected secondarily. When the disease originates in the spinal cord the symptoms are similar to those of locomotor ataxia, and it is now believed that general paralysis and locomotor ataxia are one and the same disease; in the one case the cord, in the other the brain, being the primary seat of lesion. The early physical symptoms are generally motor. The patient loses energy, readily becomes tired, and the capacity for finely co-ordinated motor acts, such as are required in playing games of skill, is impaired. Transient attacks of partial paralysis of a hand, arm, leg or one side of the body, or of the speech centre are not uncommon. In a few cases the special senses are affected early and the patient may complain of attacks of dimness of vision or impairment of hearing. Or the symptoms may be purely mental and affect the highest and most recently acquired attributes of man, the moral sense and the faculty of self-control. The patient then becomes irritable, bursts into violent passions over trifles, changes in character and habits, frequently takes alcohol to excess and behaves in an extravagant, foolish manner. Theft is often committed in this stage and the thefts are characterized by an open, purposeless manner of commission. The memory is impaired and the patient is easily influenced by others, that is to say he becomes facile. In other cases a wild attack of sudden excitement, following upon a period of restlessness and sleeplessness may be the first symptom which attracts attention. Whatever the mode of onset the physical symptoms which characterize the disease come on sooner or later. The speech is slurred and the facial muscles lose their tone, giving the face a flattened expression. The muscular power is impaired, the gait is straddling and the patient sways on turning. All the muscles of the body, but particularly those of the tongue, upper lip and hands, which are most highly innervated, present the symptom of fine fibrillary tremors. The pupils become irregular in outline, often unequal in size and either one or both fail to react normally to the stimuli of light, or of accommodation for near or distant vision.

As the disease advances there is greater excitability and a tendency to emotionalism. In classical cases the general exaltation of ideas becomes so great as to lead the patient to the commission of insanely extravagant acts, such as purchases of large numbers of useless articles, or of lands and houses far beyond his means, numerous indiscriminate proposals of marriage, the suggestion of utterly absurdcommercialschemes, or attempts at feats beyond his physical powers. The mental symptoms, in short, are very similar to those of the elevated stage of manic-depressive insanity.

Delusions of the wildest character may also be present. The patient may believe himself to be in possession of millions of money, to be unsurpassed in strength and agility, to be a great and overruling genius, and the recipient of the highest honours. This grandiose condition is by no means present in every case and is not in itself diagnostic of the disease. But mental facility, placid contentment, complete loss of judgment and affection for family and friends, with impaired memory, are symptoms universally present. As the disease advances the motor symptoms become more prominent. The patient has great difficulty in writing, misses letters out of words, words out of sentences, and writes in a large laboured hand. The expression becomes fatuous. The speech is difficult and the facial muscles are thrown into marked tremors whenever any attempt at speech is made. The voice changes in timbre and becomes high-pitched and monotonous. The gait is weak and uncertain and the reflexes are exaggerated. In the first stage the patient, through restlessness and sleeplessness, becomes thin and haggard. As the second stage approaches sleep returns, the patient lays on flesh and becomes puffy and unhealthy in appearance. The mental symptoms are marked by greater facility and enfeeblement, while the paralysis of all the muscles steadily advances. The patient is now peculiarly liable to what are called congestive seizures or epileptiform attacks. The temperature rises, the face becomes flushed and the skin moist. Twitchings are noticed in a hand or arm. These twitchings gradually spread until they may involve the whole body. The patient is now unconscious, bathed in perspiration, which is offensive. The bowels and bladder empty themselves reflexly or become distended, and bedsores are very liable to form over the heels, elbows and back. Congestive seizures frequently last for days and may prove fatal or, on the other hand, the patient may have recurrent attacks and finally die of exhaustion or some accidental disease, such as pneumonia. In the second stage of the disease the patient eats greedily, and as the food is frequently swallowed unmasticated, choking is not an uncommon accident. The special senses of taste and smell are also much disordered. We have seen a case of general paralysis, in the second stage drink a glass of quinine and water under the impression that he was drinking whisky.

The third stage of the disease is characterized by sleeplessness and rapid loss of body weight. Mentally the patient becomes quite demented. On the physical side the paralysis advances rapidly, so that the patient becomes bedridden and speechless. Death may occur as the result of exhaustion, or a congestive seizure, or of some intercurrent illness.

The duration of the disease is between eighteen months and three years, although it has been known to persist for seven.

No curative measures have so far proved of any avail in the treatment of general paralysis.

Insanity Associated with Epilepsy.—The term “epileptic insanity,” which has for many years been in common use, is now regarded as a misnomer. There is in short no such disease as epileptic insanity. A brain, however,Epileptic Insanity.which is so unstable as to exhibit the sudden discharges of nervous energy which are known as epileptic seizures, is prone to be attacked by insanity also, but there is no form of mental disease exclusively associated with epilepsy. Many epileptics suffer from the disease for a lifetime and never exhibit symptoms of insanity. The majority of patients, however, who suffer from epilepsy are liable to exhibit certain mental symptoms which are regarded as characteristic of the disease. Some suffer from recurrent attacks of depression, ill-humour and irritability, which may readily pass into violence under provocation. Others are emotionally fervid in religious observances, though sadly deficient in the practice of the religious life. A third class are liable to attacks of semi-consciousness which may either follow upon or take the place of a seizure, and during these attacks actions are performed automatically and without consciousness on the part of the patient.

When epileptics do become insane the insanity is generally one of the forms of mania. Either the patient suffers from sudden furious attacks of excitement in which consciousness is entirely abolished, or the mania is of the type of the elevated stage of folie circulaire (manic-depressive insanity) and alternates with periods of deep depression. In the elevated period the patient shows exaggerated self-esteem, with passionate outbursts of anger, and periods of religious emotionalism. While in the stage of depression the patient is often actively suicidal.

Epileptic patients who suffer from recurrent attacks of delirious mania are liable to certain nervous symptoms which indicate that not only are the motor centres in the brain damaged, but that the motor tracts in the spinal cord are also affected. The gait becomes awkward and laboured, the feet being lifted high off the ground and the legs thrown forward with a jerk. The tendon reflexes are at the same time exaggerated. These symptoms indicate descending degeneration of the motor tracts of the cord.

If the mental attacks partake of the character of elevation or depression the mental functions suffer more than the motor. These patients, in course of time, become delusional, enfeebled and childish, and in some cases the enfeeblement ends in complete dementia of a very degraded type.

Where insanity is superadded to epilepsy the prognosis is unfavourable.

Insanity Associated with or caused by Alcoholic and Drug Intoxication.—The true rôle of alcoholic indulgence in the production of insanity is at present very imperfectly understood. In many cases the alcoholism is merely aToxic Insanity.symptom of the mental disease—a result, not a cause. In others, alcohol seems to act purely as a predisposing factor, breaking down the resistance of the patient and disordering the metabolism to such an extent that bodily disorders are engendered which produce well-marked and easily recognized mental symptoms. In others, again, alcohol itself may possibly act as a direct toxin, disordering the functions of the brain. In the latter class may be included the nervous phenomena of drunkenness, which commence with excitement and confusion of ideas, and terminate in stupor with partial paralysis of all the muscles. Certain brains which, either through innate weakness or as the result of direct injury, have become peculiarly liable to toxic influences, under the influence of even moderate quantities of alcohol pass into a state closely resembling delirious mania, a state commonly spoken of asmania a potu.

Delirium Tremens.—Delirium tremens is the form of mental disorder most commonly associated with alcoholic indulgence in the lay mind. Considerable doubt exists, however, as to whether the disease is directly or secondarily the result of alcoholic poisoning. Much evidence exists in favour of the latter supposition. Delirium tremens may occur in persons who have never presented the symptom of drunkenness, or it may occur weeks after the patient has ceased to drink alcohol, and in such cases the actual exciting cause of the disease may be some accidental complication, such as a severe accident, a surgical operation, or an attack of pneumonia or erysipelas.

The early symptoms are always physical. The stomach is disordered. The desire for food is absent, and there may be abdominal pain and vomiting. The hands are tremulous, and the patient is unable to sleep. At this stage the disease may be checked by the administration of an aperient and some sedative such as bromide and chloral. The mental symptoms vary greatly in their severity. In a mild case one may talk to the patient for some time before discovering any mental abnormality, and then it will be found that confusion exists regarding his position and the identity of those around him, while the memory is also impaired for recent events. Hallucinations of sight and hearing may be present. The hallucinations of sight may be readily induced by pressure upon the eyeballs. If the symptoms are more acute they usually come on suddenly, generally during the evening or night. The patient becomes excited, suffers from vivid hallucinations of sight and hearing which produce great fear, and these hallucinations may be so engrossing as to render him quite oblivious to the environment. The hallucinations of sight are characterized by the false sense impressions taking the forms of animals or insects which surround or menace the patient. Visions may also appear in the form of flames, goblins or fairies. The hallucinations of hearing rarely consist of voices, but are more of the nature of whistlings, and ringings in the ears, shouts, groans or screams which seem to fill the air, or emanate from the walls or floors of the room. All the special senses may be affected, but sight and hearing are always implicated. Delirium tremens is a short-lived disease, generally running its course in from four to five days. Recovery is always preceded by the return of the power of sleep.

The patient must be carefully nursed and constantly watched, as homicidal and suicidal impulses are liable to occur under the terrifying influence of the hallucinations. The food should be concentrated and fluid, given frequently and in small quantities.

Chronic Alcoholic Insanity.—Almost any mental disorder may be associated with chronic alcoholism, but the most characteristic mental symptoms are delusions of suspicion and persecution which resemble very closely those of the persecution stage of systematized delusional insanity. The appearance of the patient is bloated and heavy; the tongue is furred and tremulous, and symptoms of gastric and intestinal disorder are usually present. The gait is awkward and dragging, owing to the partial paralysis of the extensor muscles of the lower limbs. All the skeletal muscles are tremulous, particularly those of the tongue, lips and hands. The common sensibility of the skin is disordered so that the patient complains of sensory disturbances, such as tinglings and prickings of the skin, which may be interpreted as electric shocks. In some cases the mental symptoms may be concealed, but delusions and hallucinations, particularly hallucinations of sight and hearing, are very commonly present. The delusions are often directly the outcome of the physical state; the disordered stomach suggesting poisoning, and the disturbances of the special senses being interpreted as various forms of persecution. The patient hears voices shouting foul abuse at him; all his thoughts are read and repeated aloud; electric shocks are sent through him at night; gases are pumped into his room. Sexual delusions are very common and frequently affect marital relations by arousing suspicions regarding the fidelity of wife or husband; or the delusions may be more gross and take the form of belief in actual attempts at sexual mutilations. The memory is always impaired.

Patients who in addition to chronic alcoholism are also insane are always dangerous and liable to sudden and apparently causeless outbursts of violence.

Dipsomania.—Dipsomania is a condition characterized by recurrent or periodic attacks of an irresistible craving forstimulants. The general bodily condition has a great deal to do with the onset of the attack, that is to say, the patient is more liable to an attack when the bodily condition is low than when the health is good. The attacks may be frequent or recur at very long intervals. They generally last for a few weeks, and may be complicated by symptoms of excitement, delusions or hallucinations.

Treatmentconsists in attention to the general health between attacks, with the use of such tonics as arsenic and strychnine. During the attack the patient should be confined to bed and treated with sedatives.

Morphinism.—The morphia habit is most commonly contracted by persons of a neurotic constitution. The mental symptoms associated with the disease may arise either as the result of an overdose, when the patient suffers from hallucinations, confusion and mild delirium, frequently associated with vomiting. On the other hand, mental symptoms very similar to those of delirium tremens may occur as the result of suddenly cutting off the supply of morphia in a patient addicted to the habit. Finally, chronic morphia intoxication produces mentalsymptomsvery similar to those of chronic alcoholism. This latter condition, characterized by delusions of persecution, mental enfeeblement and loss of memory, is hopelessly incurable. The patient is always thin and anaemic on account of digestive disturbances. There is weakness or slight paralysis of the lower limbs, and the skeletal muscles are tremulous.

Treatment.—The quantity of the drug used must be gradually reduced until it is finally discontinued, and during treatment the patient must be confined to bed.

Senile Insanity.—States of mental enfeeblement are always the result of failure of development or of structural changes in the cortical grey matter of the brain. If the enfeeblement is due to failure of development or brain damageSenile Insanity.occurring in early life, it is spoken of asidiocyor imbecility. Every form of insanity which occurs after a certain period of life is apt to be regarded by some observers as senile, but although the failing mental power may colour the character of the symptoms it cannot be regarded as correct to designate, for instance, a recurrent form of mania as senile merely because it necessarily manifests itself in a subject who has lived into the senile period. On the other hand, many persons first suffer from mental derangement at an advanced period of life without at the same time manifesting any marked failure of mental power, while others only manifest their insanity as a result of the decay of their mental faculties.

From this statement it will be seen that senile insanity is a complex of different conditions, some of them accompanied by dementia, others without dementia.

Senile Dementiais distinguished occasionally into “senile” properly so called, and “presenile” dementia, which supervenes at middle age or even earlier.

The occurrence of dementia is sometimes preceded by an acute hallucinatory phase, accompanied by mania or melancholia; but as a general rule, in the presenile cases, by neurasthenia, indifference, and mental apathy which extends to a disregard for the ordinary conventions and the means of subsistence.

It has pithily been remarked that the age of a man is the age of his blood-vessels. The two conditions of senile and presenile dementia cannot therefore be separated scientifically. From a clinical point of view, however, the two are distinguishable in so far as their symptoms are concerned, for the presenile cases are more complete and the process of dementia achieves its consummation earlier and quicker, while in the senile the gradual disease of the arteries and the slow decay of the mental faculties offer a different background for the manifestation of mental symptoms. Moreover, the senile patients more frequently present symptoms of recurrent attacks of acute insanity, a more pronounced emotionalism, and a greater tendency to restlessness at night. The presenile cases, on the other hand, except at the commencement of their malady, are usually free from acute and troublesome symptoms and present chiefly an apathetic indifference and irresponsiveness on the mental side, and on the physical side a neurasthenic and enfeebled bodily state. In both conditions memory is greatly impaired.

Added to senile dementia there is often found a condition of mania or melancholia or even of systematized delusional insanity. The chief symptoms of the maniacal attacks are the great motor restlessness and excitement, which are worst during the night time. Sleep is almost always seriously disturbed, and the patients rapidly become exhausted unless carefully nursed and tended. The actions of senile maniacs are often puerile and foolish, and they may exhibit impulses of a homicidal, suicidal or sexual character. The melancholic cases are also extremely restless, and their emotion is loudly expressed in an uncontrollable manner. They often have delusions of persecution. Their cries and groans have an automatic character, as if the patient, though compelled to utter them, did not experience the mental pain which he expressed. They also, many of them, eat their food ravenously, although a few obstinately refuse it. The senile delusional cases may manifest any of the classical forms of paranoia described above, but their delusions are of a rudimentary and unfinished type. The most common of all senile delusions is that they are being robbed. They therefore often hide their small valuables in corners and out-of-the-way places, and as their memories are very defective they are afterwards unable to find them. Others, who live alone, barricade their doors and try to prevent any one entering for fear of thieves. Delusions of ambition in senile subjects are usually of a very improbable and childish character. Hallucinations are generally present in the senile delusional cases.

Thetreatmentof senile insanity is from the medical point of view not hopeful; it resolves itself largely into instructions for careful nursing, suitable feeding, and the protection of the patient from all the physical dangers to which he may be exposed.Statistics.—The statistics of lunacy are merely of interest from a sociological point of view; for under that term are comprised all forms of insanity. It is needless to produce tables illustrative of the relative numbers of lunatics in the various countries of Europe, the systems of registration being so unequal in their working as to afford no trustworthy basis of comparison.Even in Great Britain, where the systems are more perfect than in any other country, the tables published in the Blue Books of the three countries can only be regarded as approximately correct, the difficulty of registering all cases of lunacy being insuperable. On the 1st of January 1907, according to the returns made to the offices of the Commissioners in Lunacy, the numbers of lunatics stood thus on the registers:—Males.Females.Totals.England and Wales57,17666,812123,988Scotland8,5948,99917,593Ireland12,25411,30023,554Gross total78,02487,111165,135These figures show the ratio of lunatics to 100,000 of the population to be 354 in England and Wales, 312 in Scotland, and 538 in Ireland.Numbers of Lunatics on the 1st of January of the years 1857-1907 inclusive, according to Returns made to the Offices of the Commissioners in Lunacy for England and Wales, Scotland and Ireland.Years.EnglandandWales.Scotland.Ireland.1858..5,823..185936,7626,072..186038,0586,273..186139,6476,327..186241,1296,3988,055186343,1186,3867,862186444,7956,4228,272186545,9506,5338,845186647,6486,7308,964186749,0866,8888,962186851,0007,0559,086186953,1777,3109,454187054,7137,57110,082187156,7557,72910,257187258,6407,84910,767187360,2967,98210,958187460,0278,06911,326187563,7938,22511,583187664,9168,50911,777187766,6368,86212,123187868,5389,09712,380187969,8859,38612,585188071,1919,62412,819188173,11310,01213,062188274,84210,35513,444188376,76510,51013,882188478,52810,73914,088188579,70410,91814,279188680,15611,18714,590188780,89111,30914,702188882,64311,60915,263188984,34011,95415,685189086,06712,30216,159189186,79512,59516,251189287,84812,79916,688189389,82213,05817,124189492,06713,30017,276189594,08113,85217,665189696,44614,09318,357189799,36514,50018,9661898101,97214,90619,5901899105,08615,39920,3041900106,61115,66320,8631901107,94415,89921,1691902110,71316,28821,6301903113,96416,65822,1381904117,19916,89422,7941905119,82917,24122,9961906121,97917,45023,3651907123,98817,59323,554There is thus an increased ratio in England and Wales of lunatics to the population (which in 1859 was 19,686,701, and in 1907 was estimated at 34,945,600) of 186.8 per 100,000 as against 354.8, and in Scotland of 157 as against 312 per 100,000. The Irish figures on the same basis have increased from 130.9 in 1862 to 538.1 in 1907. The publication of these figures has given rise to the question whether lunacy has actually become more prevalent during the last twenty years, whether there is real increase of the disease. There is a pretty general consent of all authorities that if there has been an increase it is very slight, and that the apparent increase is due, first to the improved systems of registration, and secondly (a far more powerful reason) to the increasing tendency among all classes, and especially among the poorer class, to recognize the less pronounced forms of mental disorder as being of the nature of insanity. Thirdly, the grant of four shillings per week which in 1876 was made by parliament from imperial sources for the maintenance of pauper lunatics has induced parochial authorities to regard as lunatics a large number of weak-minded paupers, and to force them into asylums in order to obtain the benefit of the grant and to relieve the rates. These views receive support from the fact that the increase of private patients,i.e.patients who are provided for out of their own funds or those of the family, has advanced in a vastly smaller ratio. In their case the increase, small as it is, can be accounted for by the growing disinclination on the part of the community to tolerate irregularities of conduct due to mental disease. And again, careful inquiry has failed to show a proportional increase of admissions into asylums of such well-marked forms as general paralysis, puerperal mania, &c. The main cause of the registered increase of lunatics is thus to be sought for in the improved registration, and parochial and family convenience. If there is an actual increase, and there is reason for believing that there is a slight actual increase, it is due to the tendency of the population to gravitate towards towns and cities, where the conditions of health are inferior to those of rural life, and where there is therefore a greater disposition to disease of all kinds.The futility of seeking for accurate figures bearing on the relative number of lunatics in other countries is illustrated by the tables set forth in a report by the United States Census Bureau. They show that the number of registered lunatics in 1903 was 150,151; in 1890, 74,028; and in 1880, 40,942. An attempt was made in 1890 to estimate the number of insane persons outside of hospitals, which was stated to be 32,457. In 1903 no such attempt was made, as it was admitted that so many sources of fallacy existed as to render it useless. Thus the mere statement that of every 100,000 of the population (calculated at 80,000,000) 186.2 were registered as insane is of no value.Bibliography.—The following are systematic works: Bucknill and Tuke,Psychological Medicine(4th edition, 1879); Griesinger,On Mental Diseases(New Sydenham Society, 1867); Maudsley,The Pathology of Mind(1895); Bevan Lewis,A Text-Book of Mental Diseases(1899); Clouston,Clinical Lectures on Mental Diseases(1892); Kraepelin,Psychiatrie(1893); Krafft-Ebing,Lehrbuch der Psychiatrie(1893); Regis,A Practical Manual of Mental Medicine(London, 1895); Magnan,Leçons cliniques sur les maladies mentales(1897); Mendil,Leitfaden der Psychiatrie(1902); Mercier,A Text-Book of Insanity(1902); Lewis C. Bruce,Studies in Clinical Psychiatry(1906); Macpherson,Mental Affections(1899); Brower-Bannister,Practical Manual of Insanity(1902); Ford Robertson,Text-Book of Pathology in Relation to Mental Diseases(1900).

Statistics.—The statistics of lunacy are merely of interest from a sociological point of view; for under that term are comprised all forms of insanity. It is needless to produce tables illustrative of the relative numbers of lunatics in the various countries of Europe, the systems of registration being so unequal in their working as to afford no trustworthy basis of comparison.

Even in Great Britain, where the systems are more perfect than in any other country, the tables published in the Blue Books of the three countries can only be regarded as approximately correct, the difficulty of registering all cases of lunacy being insuperable. On the 1st of January 1907, according to the returns made to the offices of the Commissioners in Lunacy, the numbers of lunatics stood thus on the registers:—

These figures show the ratio of lunatics to 100,000 of the population to be 354 in England and Wales, 312 in Scotland, and 538 in Ireland.

Numbers of Lunatics on the 1st of January of the years 1857-1907 inclusive, according to Returns made to the Offices of the Commissioners in Lunacy for England and Wales, Scotland and Ireland.

There is thus an increased ratio in England and Wales of lunatics to the population (which in 1859 was 19,686,701, and in 1907 was estimated at 34,945,600) of 186.8 per 100,000 as against 354.8, and in Scotland of 157 as against 312 per 100,000. The Irish figures on the same basis have increased from 130.9 in 1862 to 538.1 in 1907. The publication of these figures has given rise to the question whether lunacy has actually become more prevalent during the last twenty years, whether there is real increase of the disease. There is a pretty general consent of all authorities that if there has been an increase it is very slight, and that the apparent increase is due, first to the improved systems of registration, and secondly (a far more powerful reason) to the increasing tendency among all classes, and especially among the poorer class, to recognize the less pronounced forms of mental disorder as being of the nature of insanity. Thirdly, the grant of four shillings per week which in 1876 was made by parliament from imperial sources for the maintenance of pauper lunatics has induced parochial authorities to regard as lunatics a large number of weak-minded paupers, and to force them into asylums in order to obtain the benefit of the grant and to relieve the rates. These views receive support from the fact that the increase of private patients,i.e.patients who are provided for out of their own funds or those of the family, has advanced in a vastly smaller ratio. In their case the increase, small as it is, can be accounted for by the growing disinclination on the part of the community to tolerate irregularities of conduct due to mental disease. And again, careful inquiry has failed to show a proportional increase of admissions into asylums of such well-marked forms as general paralysis, puerperal mania, &c. The main cause of the registered increase of lunatics is thus to be sought for in the improved registration, and parochial and family convenience. If there is an actual increase, and there is reason for believing that there is a slight actual increase, it is due to the tendency of the population to gravitate towards towns and cities, where the conditions of health are inferior to those of rural life, and where there is therefore a greater disposition to disease of all kinds.

The futility of seeking for accurate figures bearing on the relative number of lunatics in other countries is illustrated by the tables set forth in a report by the United States Census Bureau. They show that the number of registered lunatics in 1903 was 150,151; in 1890, 74,028; and in 1880, 40,942. An attempt was made in 1890 to estimate the number of insane persons outside of hospitals, which was stated to be 32,457. In 1903 no such attempt was made, as it was admitted that so many sources of fallacy existed as to render it useless. Thus the mere statement that of every 100,000 of the population (calculated at 80,000,000) 186.2 were registered as insane is of no value.

Bibliography.—The following are systematic works: Bucknill and Tuke,Psychological Medicine(4th edition, 1879); Griesinger,On Mental Diseases(New Sydenham Society, 1867); Maudsley,The Pathology of Mind(1895); Bevan Lewis,A Text-Book of Mental Diseases(1899); Clouston,Clinical Lectures on Mental Diseases(1892); Kraepelin,Psychiatrie(1893); Krafft-Ebing,Lehrbuch der Psychiatrie(1893); Regis,A Practical Manual of Mental Medicine(London, 1895); Magnan,Leçons cliniques sur les maladies mentales(1897); Mendil,Leitfaden der Psychiatrie(1902); Mercier,A Text-Book of Insanity(1902); Lewis C. Bruce,Studies in Clinical Psychiatry(1906); Macpherson,Mental Affections(1899); Brower-Bannister,Practical Manual of Insanity(1902); Ford Robertson,Text-Book of Pathology in Relation to Mental Diseases(1900).

(J. B. T.; J. Mn.; L. C. B.)

II. Legal Aspects

The effect of insanity upon responsibility and civil capacity has been recognized at an early period in every system of law.

Roman Law.—In the Roman jurisprudence its consequences were very fully developed, and the provisions and terminology of that system have largely affected the subsequent legal treatment of the subject. Its leading principles were simple and well marked. The insane person having no intelligent will, and being thus incapable of consent or voluntary action, could acquire no right and incur no responsibility by his own acts (see Sohm’sInst. Roman Law, 3rd ed. pp. 216, 217, 219); his person and property were placed after inquiry by the magistrate under the control of a curator, who was empowered and bound to manage the property of the lunatic on his behalf (Sohm, p. 513; Hunter,Roman Law, pp. 732-735). The different terms by which the insane were known, such asdemens,furiosus,fatuus, although no doubt signifying different types of insanity, did not in Roman law infer any difference of legal treatment. They were popular names, which all denoted the complete deprivation of reason.

Medieval Law.—During the middle ages the insane were little protected. Their legal acts were annulled, and their property placed under control, but little or no attempt was made to supervise their personal treatment. In England the wardship of idiots and lunatics, which was annexed before the reign of Edward II. to the king’s prerogative, had regard chiefly to the control of their lands and estates, and was only gradually elaborated into the systematic control of their persons and property now exercised under the jurisdiction in lunacy. Those whose means were insignificant were left to the care of their relations or to charity. In criminal law the plea of insanity was unavailing except in extreme cases. About the beginning of the 19th century a very considerable change commenced. The public attention was strongly attracted to the miserable condition of the insane incarcerated in asylums without any efficient check or inspection; and at the same time the medical knowledge of insanity entered on a new phase. The possibility and advantages of a better treatment of insanity were illustrated by eminent physicians, Philippe Pinel in France, H. Tuke in England, Bond, B. Rush and I. Ray in the United States; its physical origin became generally accepted; its mental phenomena were more carefully observed, and its relation was established to other mental conditions.

Modern Law.—From this period we date the commencement of legislation such as that known in England as the Lunacy Acts, which aimed at the regulation and control of all constraint applied to the insane. Hitherto, the criteria of insanity had been very rude, and the evidence was generally of a loose and popular character; but, whenever it was fully recognized that insanity was a disease with which physicians who had studied the subject were peculiarly conversant, expert evidence obtained increased importance, and from this time became prominent in every case. The newer medical views of insanity were thus brought into contact with the old narrow conception of the law courts, and a controversy arose in the field of criminal law which in England, at least, still continues.

Relations between Insanity and Law.—The fact of insanity may operate in law—(1) by excluding responsibility for crime; (2) by invalidating legal acts; (3) by affording ground for depriving the insane person by a legal process of the control of his person and property; or (4) by affording ground for putting him under restraint.

Legal Terminology.—Before proceeding, however, to deal withthese matters in succession, it may be desirable to say something with regard to the chief legal terms respecting persons suffering under mental disabilities. The subject is now of less importance than formerly, because the modern tendency of the law is to determine the capacity or responsibility of a person alleged to be insane by considering it with reference to the particular matter or class of matters which brings his mental conditionsub judice. But the literature of the law of lunacy cannot be clearly understood unless the distinctions between the different terms employed to describe the insane are kept in view. The termnon compos mentisis as old as the statuteDe praerogativa regis(1325), and is used sometimes, as in that statute, to indicate a species contrasted with idiot, sometimes (e.g.in Co. Litt. 246 (b)) as a genus, and afterwards, chiefly in statutes relating to the insane, in connexion with the terms “idiot” and “lunatic” as a wordejusdem generis. The word “idiot” (Gr.ἴδιος, a private person, one who does not hold any public office, andἰδιώτης, an ignorant and illiterate person) appears in the statuteDe praerogativa regis as fatuus naturalis, and it is placed in contradistinction tonon compos mentis. The “idiot” is defined by Sir E. Coke (4 Rep. 124 (b)) as one who from his nativity, by a perpetual infirmity, is non compos mentis, and Sir M. Hale (Pleas of the Crown, i. 29) describes idiocy as “fatuity anativitate vel dementia naturalis.” In early times various artificial criteria of idiocy were suggested. Fitzherbert’s test was the capacity of the alleged idiot to count twenty pence, or tell his age, or who were his father and mother (De natura brevium, 233). Swinburne proposed as a criterion of capacity, inter alia, to measure a yard of cloth or name the days in the week (Testaments, 42). Hale propounded the sounder view that “idiocy or not is a question of fact triable by jury and sometimes by inspection” (Pleas of the Crown, i. 29). The legal incidents of idiocy were at one time distinct in an important particular from those of lunacy. Under the statuteDe praerogativa registhe king was to have the rents and profits of an idiot’s lands to his own use during the life of the idiot, subject merely to an obligation to provide him with necessaries. In the case of the lunatic the king was a trustee, holding his lands and tenements for his benefit and that of his family. It was on account of this difference in the legal consequences of the two states that on inquisitions distinct writs, onede idiota inquirendo, the otherde lunatico inquirendo, were framed for each of them. But juries avoided finding a verdict of idiocy wherever they could, and the writde idiota inquirendofell into desuetude. A further blow was struck at the distinction when it came to be recognized even by the legislature (see the Idiots Act 1886) that idiots are capable of being educated and trained, and it was practically abolished when the Lunacy Regulation Act 1862, in a provision reproduced in substance in the Lunacy Act 1890, limited the evidence admissible in proof of unsoundness of mind on an inquisition (without special leave of the Master trying the case) to a period of two years before the date of the inquiry, and raised a uniform issue, viz. the state of mind of the alleged lunatic at the time when the inquisition is held.

The term “lunatic,” derived from the Latinlunain consequence of the notion that the moon had an influence on mental disorders,1does not appear in the statute-book till the time of Henry VIII. (1541). Coke defines a lunatic as a “person who has sometimes his understanding and sometimes not,qui gaudet lucidis intervallis, and therefore he is callednon compos mentisso long as he has not understanding” (Co. Litt. 247 (a), 4 Rep. 124 (b)). Hale defines “lunacy” as “interpolated” (i.e.intermittent)dementia accidentalis vel adventitia, whether total or (a description, it will be observed, of “partial insanity”)quoad hoc vel illud(Pleas of the Crown, i. 29). In modern times, the word “lunacy” has lost its former precise signification. It is employed sometimes in the strict sense, sometimes in contradistinction to “idiocy” or “imbecility”; once at least—viz. in the Lunacy Act 1890—as including “idiot”; and frequently in conjunction with the vague terms “unsound mind” (non-sane memory) and “insane.” Section 116 of the Lunacy Act 1890 has by implication extended the meaning of the term lunacy so as to include for certain purposes the incapacity of a person to manage his affairs through mental infirmity arising from disease or age. “Imbecility” is a state of mental weakness “between the limits of absolute idiocy on the one hand and of perfect capacity on the other” (see 1 Haggard,Eccles. Rep.p. 401).

1.The Criminal Responsibility of the Insane.—The law as to the criminal responsibility of the insane has pursued in England a curious course of development. The views of Coke and Hale give the best exposition of it in the 17th century. Both were agreed that in criminal causes the act and wrong of a madman shall not be imputed to him; both distinguished, although in different language, betweendementia naturalis(or anativitate) anddementia accidentalisoradventitia; and the main points in which the writings of Hale mark an advance on those of Coke are in the elaboration by the former of the doctrine of “partial insanity,” and his adoption of the level of understanding of a child of fourteen years of age as the test of responsibility in criminal cases (Pleas of the Crown, i. 29, 30; and see Co. 4Rep.124 (b)). In the 18th century a test, still more unsatisfactory than this “child of fourteen” theory, with its identification of “healthy immaturity” with “diseased maturity” (Steph.Hist. Crim. Law, ii. 150), was prescribed. On the trial of Edward Arnold in 1723 for firing at and wounding Lord Onslow, Mr Justice Tracy told the jury that “a prisoner, in order to be acquitted on the ground of insanity, must be a man that is totally deprived of his understanding and memory, and doth not know what he is doing, no more than an infant, than a brute or wild beast.” In the beginning of the 19th century a fresh statement of the test of criminal responsibility in mental disease was attempted. On the trial of Hadfield for shooting at George III. in Drury Lane Theatre on 15th May 1800, Lord Chief Justice Kenyon charged the jury in the following terms: “If a man is in a deranged state of mind at the time, he is not criminally answerable for his acts; but the material part of the case is whether at the very time when the act was committed the man’s mind was sane.” The practical effect of this ruling, had it been followed, would have been to make the question of the amenability of persons alleged to be insane to the criminal law very much one of fact, to be answered by juries according to the particular circumstances of each case, and without being aided or embarrassed by any rigid external standard. But in 1812, on the trial of Bellingham for the murder of Mr Perceval, the First Lord of the Treasury, Sir James Mansfield propounded yet another criterion of criminal responsibility in mental disease, viz. whether a prisoner has, at the time of committing an offence, a sufficient degree of capacity to distinguish between good and evil. The objection to this doctrine consisted in the fact, to which the writings of Continental and American jurists soon afterwards began to give prominence, that there are very many lunatics whose general ideas on the subject of right and wrong are quite unexceptionable, but who are yet unable, in consequence of delusions, to perceive the wrongness of particularMacnaughton’s Case.acts. Sir James Mansfield’s statement of the law was discredited in the case (4State Tri.(n.s.) 847; 10 Cl. and Fin. 200) of Daniel Macnaughton, who was tried in March 1843, before Chief Justice Tindal, Mr Justice Williams and Mr Justice Coleridge, for the murder of Mr Drummond, the private secretary of Sir Robert Peel. Mr (afterwards Lord Chief Justice) Cockburn, who defended the prisoner, used Hale’s doctrine of partial insanity as the foundation of the defence, and secured an acquittal, Chief Justice Tindal telling the jury that the question was whether Macnaughton was capable of distinguishing right from wrongwith respect to the act with which he stood charged. This judicial approval of the doctrine of partial insanity formed the subject of an animated debate in the House of Lords, and in the end certain questions were put by that House to the judges, and answered by Chief Justice Tindal on behalf of all his colleagues except Mr Justice Maule, who gaveindependent replies. The answers to those questions are commonly called “The Rules in Macnaughton’s case,” and they still nominally contain the law of England as to the criminal responsibility of the insane. The points affirmed by the Rules that must be noted here are the propositions that knowledge of the nature and quality of the particular criminal act, at the time of its commission, is the test of criminal responsibility, and that delusion is a valid exculpatory plea, when, and only when, the fancies of the insane person, if they had been facts, would have been so. The Rules in Macnaughton’s case are open to serious criticism. They ignore, at least on a literal interpretation, those forms of mental disease which may, for the present purpose, be roughly grouped under the heading “moral insanity,” and in which the moral faculties are more obviously deranged than the mental—the affections and the will, rather than the reason, being apparently disordered. The test propounded with reference to delusions has also been strenuously attacked by medical writers, and especially by Dr Maudsley in his work onResponsibility in Mental Disease, on the ground that it first assumes a man to have a delusion in regard to a particular subject, and then expects and requires him to reason sanely upon it. It may be pointed out, however, that in thus localizing the range of the immunity which insane delusion confers, the criminal law is merely following the course which,mutatis mutandis, the civil law has, with general acceptance, adopted in questions as to the contractual and testamentary capacity of the insane.

The Rules in Macnaughton’s case have, as regards moral insanity, undergone considerable modification. Soon after they were laid down, Sir (then Mr) James Fitz-James Stephen, in an article in theJuridical Papers, i. 67, on the policy of maintaining the existing law as to the criminal responsibility of the insane, foreshadowed the view which he subsequently propounded in hisHistory of the Criminal Law, ii. 163, that no man who was deprived by mental disease of the power of passing a fairly rational judgment on the moral character of an act could be said to “know” its nature and quality within the meaning of the Rules; and it has in recent years been found possible in practice so to manipulate the test of the criminal responsibility which they prescribed as to afford protection to the accused in the by no means infrequent cases of insanity which in its literal interpretation it would leave without excuse.

In Scotland the Rules in Macnaughton’s case are recognized, but, as in England, there is a tendency among judges to adopt a generous construction of them. Mental unsoundness insufficient to bar trial, or to exempt from punishment, may still, it is said, be present in a degree which is regarded as reducing the offence from a higher to a lower category,—a doctrine first practically applied in Scotland, it is believed, in 1867 by Lord Deas; and the fact that a prisoner is of weak or ill-regulated mind is often urged with success as a plea in mitigation of punishment. The Indian Penal Code (Act XLV. of 1860, § 84) expressly adopts the English test of criminal responsibility, but the qualifications noted in the case of Scotland have received some measure of judicial acceptance (see Mayne,Crim. Law Ind., 3rd ed., pp. 403-419; Nelson,Ind. Pen. Code, 3rd ed., pp. 135 et seq.). The Rules in Macnaughton’s case have also been adopted in substance in those colonies which have codified the criminal law. The following typical references may be given: 55 and 56 Vict. (Can.) c. 29, § 11; 57 Vict. (N.Z.), No. 56 of 1893, § 23; No. 101 of 1888 (St Lucia), § 50; No. 5 of 1876 (Gold Coast), § 49 (b); No. 2 of 1883, art. 77 (Ceylon); No. 4 of 1871, art. 84 (Straits Settlements). On the other hand, a departure towards a recognition of “moral insanity” is made by the Queensland Criminal Code (No. 9 of 1899), § 27 of which provides that “a person is not criminally responsible for an act” if at the time of doing it “he is in such a state of mental disease ... as to deprive him ... of capacity to control his actions”: and the law has been defined in the same sense in the Cape of Good Hope in the case ofQueenv.Hay(1899, 16 S.C.R. 290). The Rules were rapidly reproduced in the United States, but the modern trend of American judicial opinion is adverse to them (see Clevenger,Med. Jur. of Ins.p. 125;Parsonsv.State(1887) 81 Ala. 577). On the Continent of Europe moral insanity and irresistible impulse are freely recognized as exculpatory pleas (see the FrenchCode Penal, § 64; BelgianCode Penal, § 71; GermanPenal Code, § 51; ItalianPenal Code, §§ 46, 47).

Not only is insanity at the time of the commission of an offence a valid exculpatory plea, but supervening insanity stays the action of the criminal law at every stage from arrest up to punishment. High treason was formerly an exception, but the statute making it so (33 Hen. VIII. c. 20) was repealed in the time of Philip and Mary. The Home Secretary has power, under the Criminal Lunatics Act 1884 to order by warrant the removal of a prisoner, certified to be insane, to a lunatic asylum, before2trial or after trial, whether under sentence of death or not. Prisoners dealt with under these provisions are styled “Secretary of State’s lunatics.” On the other hand, a prisoner who on arraignment appears, or is found by the jury to be unfit to plead, or who is found “guilty but insane” at the time of committing the offence—a verdict substituted by the Trial of Lunatics Act 1883 for the old verdict of “acquitted on the ground of insanity,” in the hope that the formal conviction recorded in the new finding might have a deterrent effect on the mentally unstable—is committed to a criminal lunatic asylum by the order of the judge trying the case, to be detained there “during the king’s pleasure.” Lunatics of this class are called “king’s pleasure lunatics.” There was no doubt at common law as to the power of the courts to order the detention of criminal lunatics in safe custody, but, prior to 1800, the practice was varying and uncertain. On the acquittal of Hadfield, however, in that year for the attempted murder of George III., a question arose as to the provision which was to be made for his detention, and the Criminal Lunatics Act 1800, part of which is still in force, was passed to affirm the law on the subject.

The Criminal Lunatics Act contains provisions similar to those of the Lunacy Act 1890, as to the discharge (conditional or absolute) and transfer of criminal lunatics and the detention of persons becoming pauper lunatics. The expenses of the maintenance of criminal lunatics are defrayed out of moneys provided by Parliament (Crim. Luns. Act 1884, and Hansard, 3rd series, vol. ccxc. p. 75; 139 Com. Jo. pp. 336, 340, 344). The Lunatics’ Removal (India) Act 1851 provides for the removal to a criminal lunatic asylum in Great Britain of persons found guilty of crimes and offences in India, and acquitted on the ground of insanity. Similar provisions with regard to colonial criminal lunatics are contained in the Colonial Prisoners’ Removal Act 1884; and the policy of this statute has been followed by No 5. of 1894 (New South Wales), and Ordin. No. 2 of 1895 (Falkland Islands). Indian law (see Act V. of 1898, §§ 464-475) and the laws of the colonies (the Cape Act No. 1 of 1897 is a typical example) as to the trial of lunatics are similar to the English. In Scotland all the criminal lunatics, except those who may have been removed to the ordinary asylums or have been discharged, are confined in the Criminal Asylum established at Perth in connexion with H.M.’s General Prison, and regulated by special acts (23 & 24 Vict. c. 105, and 40 & 41 Vict. c. 53). Provision similar to the English has been made for prisoners found insane as a bar to trial, or acquitted on the ground of insanity or becoming insane in confinement. In New York, Michigan and other American states there are criminal lunatic asylums. Elsewhere insane criminals are apparently detained in state prisons, &c. The statutory rules as to the maintenance of criminal lunatic asylums, the treatment of the criminal insane, and the plea of insanity in criminal courts in America, closely resemble English practice.The only special point in Continental law calling for notice is the system by which official experts report for the guidance of the tribunals on questions of alleged criminal irresponsibility (see,e.g., the GermanCode of Penal Procedure, § 293, and cp. § 81).

2.Insanity and Civil Capacity.—The law as to the civil capacity of the insane was for some time influenced in Great Britain by the view propounded by Lord Brougham in 1848 in the case ofWaringv.Waring, and by Sir J. P. Wilde in a later case, raising the question of the validity of a marriage, that, as the mind is one and indivisible, the least disorder of its faculties was fatal to civil capacity. In the leading case ofBanksv.Goodfellowin 1870, the court of queen’s bench, in an elaborate judgment delivered by Chief Justice Cockburn, disapproved of this doctrine, and in effect laid down the principle that the question of capacity must be considered with strict reference to the act which has to be or has been done. Thus a certain degree of unsoundness of mind is not now, in the absence of undue influence, a bar to the formation of a valid marriage, if the party whose capacity is in question knew at the time of the marriage the nature of the engagement entered into (but see 51 Geo. III. c. 37 as to the marriage of lunatics so found by inquisition). Again, a man whose mind is affected may make a valid will, if he possesses at the time of executing it a memory sufficiently active to recall the nature and extent of his property, the persons who have claims upon his bounty, and a judgment and will sufficiently free from the influence of morbid ideas or external control to determine the relative strength of those claims. So far has this rule been carried, that in 1893 probate was granted of the will of a lady who was a Chancery lunatic at the date of its execution, and died without the inquisition having been superseded. (Roev.Nix, 1893, P. 55.) It is also now settled that the simple contract of a lunatic is voidable and not void, and is binding upon him, unless he can show that at the time of making it he was, to the knowledge of the other party, so insane as not to know what he was about. (Imperial Loan Co.v.Stone, 1892, 1 Q.B. 599.) The test established byBanksv.Goodfellowis applied also in a number of minor points in which civil capacity comes into question,e.g.competency of the insane as witnesses. The law implies, on the part of a lunatic, whether so found or not, an obligation to pay a reasonable price for “necessaries” supplied to him; and the term “necessaries” means goods suitable to his condition in life and to his actual requirements at the time of sale and delivery (Sale of Goods Act 1893).

The question of the liability of an insane person for tort appears still to be undecided (see Pollock onTorts, 7th ed. p. 53; Clerk and Lindsell onTorts, 2nd ed. pp. 39, 40;Law Quart. Rev.vol. xiii. p. 325). Supervening insanity is no bar to proceedings by or against a lunatic husband or wife for divorce or separation for previous matrimonial offences. It does not avoid a marriage nor constituteper sea ground either for divorce or for judicial separation. But cruelty does not cease to be a cause of suit if it proceeds from disorderly affections or want of moral control falling short of positive insanity; and possibly even cruelty springing from intermittent or recurrent insanity might be held a ground for judicial separation, since in such case the party offended against cannot obtain protection by securing the permanent confinement of the offending spouse. Whether insanity at the time when an alleged matrimonial offence was committed is a bar to a suit for divorce or separation is an open question; and in any event, in order that it may be so, the insanity must be of such a character as to have prevented the insane party from knowing the nature and consequences of the act at the time of its commission. The laws of Scotland, Ireland, India (see,e.g., Act IX. of 1872, § 12), the colonies and the United States are substantially identical with English law on the subject of the civil capacity of the insane. The German Civil Code (§ 1569) recognizes the lunacy of a spouse as a ground for divorce, but only where the malady continues during at least three years of the union, and has reached such a pitch that intellectual intercourse between the spouses is impossible, and that every prospect of a restoration of such association is excluded. If one of the spouses obtains a divorce on the ground of the lunacy of the other the former has to allow alimony, just as a husband declared to be the sole guilty party in a divorce suit would have to do (§§ 1585, 1578).

3.The Jurisdiction in Lunacy.—In order to effect a change in the status of persons alleged to be of unsound mind, and to bring their persons and property under control, the aid of the jurisdiction in lunacy must be invoked. Under the unrepealed statuteDe Praerogativa Regis(1325) the care and custody of lunatics belong to the Crown. But the Crown has, at least since the 16th century, exercised this branch of the prerogative by delegates, and principally through the Lord Chancellor—not as head of the Court of Chancery, but as the representative and delegate of the sovereign. Under the Lunacy Acts 1890 and 1891, the jurisdiction in lunacy is exercised first by the Lord Chancellor and such of the Lords Justices and other judges as may be invested with it by the sign-manual; and, secondly, by the two Masters in Lunacy, appointed by the Lord Chancellor, from members of the bar of at least ten years’ standing, whose duties include the holding of inquisitions and summary inquiries, and the making of most of the consequential orders dealing with the persons and estates of lunatics. County court judges may also exercise a limited jurisdiction in lunacy in the case of lunatics as to whom a reception order has been made, if their entire property is under £200 in value, and no relative or friend is willing to undertake the management of it; in partnership cases where the assets do not exceed £500; and upon application by the guardians of any union for payment of expenses incurred by them in relation to any lunatic.

Persons of unsound mind are brought under the jurisdiction in lunacy either by an inquisitionde lunatico inquirendo, or, in certain cases which will be adverted to below, by proceedings instituted under § 116 of the Lunacy Act 1890, which is now the great practice section in the Lunacy Office. Prior to 1853 a special commission was issued to the Masters in each alleged case of lunacy. But by the Lunacy Regulation Act of that year a general commission was directed to the Masters, empowering them to proceed in each case in which the Lord Chancellor by order required an inquisition to be held. This procedure is still in force. A special commission would now be issued only where both Masters were personally interested in the subject of the inquiry, or for some other similar reason. An inquisition is ordered by the judge in lunacy (a term which does not, for this purpose, at present include the Masters, although this is one of the points in regard to which a change in the law has been suggested, on the petition generally of a near relative of the alleged lunatic). The inquiry is held before one of the Masters, and a jury may be summoned if the alleged lunatic, being within the jurisdiction, demands it, unless the judge is satisfied that he is not competent to form and express such a wish; and even in that case the Master has power to direct trial by jury if he thinks fit on consideration of the evidence. Where the alleged lunatic is not within the jurisdiction the trial must be by jury; and the judge in lunacy may direct this mode of trial to be adopted in any case whatever.

A few points of general interest in connexion with inquisitions must be noted. In practice thirty-four jurors are summoned by the sheriff, and not more than twenty-four are empanelled. Twelve at least must concur in the verdict. Counsel for the petitioner ought to act in the judicial spirit expected from counsel for the prosecution in criminal cases. The issue to be determined on an inquisition is “whether or not the alleged lunatic is at the time of the inquisition of unsound mind, and incapable of managing himself and his affairs” (a special verdict may, however, be found that the lunatic is capable of managing himself, although not his affairs, and that he is not dangerous to others); and without the direction of the person holding the inquisition, no evidence as to the lunatic’s conduct at any time being more than two years before the inquisition is to be receivable. This limitation, both of the issue and of the evidence, was imposed with a view to preventing the recurrence of such cases as that of Mr Windham in 1861-1862, when the inquiry ranged over the whole life of an alleged lunatic, forty-eight witnesses beingexamined on behalf of the petitioners and ninety-one on behalf of the respondents, while the hearing lasted for thirty-four days. For the purpose of assisting the Master or jury in arriving at a decision, provision is made for the personal examination of the alleged lunatic by them on oath or otherwise, and either in open court or in private, as may be directed. The proceedings on inquisition are open to the public. When a person has been found lunatic by inquisition he becomes subject to the jurisdiction in lunacy, and remains so (unless he succeeds in setting aside the verdict by a “traverse”—a proceeding which ultimately comes before, and is determined by, the King’s Bench Division in London or at the assizes) until his recovery, when the inquisition may be put an end to by a procedure technically known as “supersedeas,” or by his death. The results of the inquisition are worked out in the Lunacy Office. The control of the estate, and, except where he was found incapable of managing his property only, of the person of the lunatic is entrusted to committees of the estate and person, who are appointed by, and accountable to, the Master in Lunacy, and whose legal position corresponds roughly with that of the tutors and curators of the civil law. The committee of the estate in particular exercises over the property of the lunatic, with the sanction or by the order of the Master, very wide powers of management and administration, including the raising of money by sale, charge or otherwise, to pay the lunatic’s debts, or provide for his past or future maintenance, charges for permanent improvements, the sale of any property belonging to the lunatic, the execution of powers vested in him and the performance of contracts relating to property.

Back to Index Next