John B. Tuke, John Macpherson, Lewis C. Bruce, Alexander W. Renton and Frederick Peterson

“ Loss of memory for recent but not remote events is characteristic of chronic alcoholism and senility and even the early stage of general paralysis.
Of all the functions of the brain that of sleep is the most liable to disorder in the insane. Sleeplessness is the earliest symptom in the onset of insanity; it is universally present in all the acute forms, and the return of natural sleep is generally the first symptom of recovery. The causes of sleeplessness are very numerous, but in the majority of acute cases the sleeplessness is due to a state of toxaemia. ”

“ If the depression is the sequel to an attack of excitement, the onset may be very sudden or it may be gradual. If, on the other hand, the depression is not the sequel of excitement, the onset is very gradual and the patient complains of lassitude, incapacity for mental or physical work, loss of appetite, constipation and sleeplessness often for months before the case is recognized as one of insanity. In the fully developed disease the temperature is very rarely febrile, on the contrary it is rather subnormal in character. ”

“ 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 mood is sometimes expansive and benevolent, interruption in the flow of talk may suddenly change the subject of the conversation or the patient may with equal suddenness fly into a violent rage, use foul and obscene language, ending with loud laughter and protestations of eternal friendship. ”

“ 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. ”

“ Normal self-control is so much a matter of race, age, the state of health, moral and physical upbringing, that it is impossible to lay down any law whereby this mental quality can be gauged, or to determine when deficiency has passed from a normal to an abnormal state. In many cases of insanity there is no difficulty in appreciating the pathological nature of the deficiency, but there are others in which the conduct is otherwise so rational that one is apt to attribute the deficiency to physiological rather than to pathological causes. ”

“ The faculty of attention is variously affected in the subjects of insanity. In some the attention is entirely subjective, being occupied by sensations of misery, depression or sensory disturbances. In others the attention is objective, and attracted by every accidental sound or movement. In most of the early acute insanities the capacity of attention is wholly abolished, while in hebephrenia the stage of exhaustion which follows acute excitement, and the condition known as secondary dementia, loss of the power of attention is one of the most prominent symptoms. ”

“ Manic-depressive insanity implies that the patient may either suffer from excitement or depression which do not necessarily succeed one another in any fixed order. As a matter of fact, the majority of patients who suffer from the disease either have marked excited attacks with little or no subsequent depression, or marked attacks of depression with a subsequent period of such slight exaltation as hardly to be distinguished from a state of health. ”

“ 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. ”

“ 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. ”

“ 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 intensity and quality of the delusions are largely influenced by the intelligence and education of the patient. An educated man, for instance, who suffers from sensory disturbances is much more ingenious in his explanations as to how these sensory disturbances result from electricity, marconigrams, X-rays, &c., which he believes are used by his enemies to annoy him, than an ignorant man suffering from the same abnormal sensations. Loss of self-control is characteristic of all forms of insanity. ”

“ 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. ”

“ In the fully developed disease the appearance of the patient is typical. The expression is drawn, depressed, anxious or apprehensive. The skin is yellow and parchment like. The hair is often dry and stands out stiffly from the head. The hands are in constant movement, twisting and untwisting, picking the skin, pulling at the hair or tearing at the clothes. The patient moans continuously, or emits cries of grief and wanders aimlessly. Mentally the patient, although depressed, miserable and self-absorbed, is not confused. ”

“ 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. ”

“ 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. ”

“ Excited Melancholia.—Excited melancholia is almost invariably a disease of old age or the decline of life, and it attacks men and women with equal frequency. Chronic gastric disorders, deficient food and sleep, unhealthy occupations and environments, together with worry and mental stress, are all more or less predisposing causes of the disease. The direct exciting cause or causes have not as yet been demonstrated, but there is no doubt that the disease is associated with, or caused by, a condition of bacterial toxaemia, analogous to the bacterial toxaemias of acute and chronic rheumatism. ”

“ 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. ”

“ 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. ”

“ This, the second or persecutory stage of delusional insanity, may persist through life. The patient becomes gradually accustomed to the sensory disturbances, or possibly a certain amount of mental enfeeblement sets in which reduces the mental vigour. In other cases, the disease goes on to what Magnan calls the third stage or stage of grandiose delusions. The onset of this stage is in some cases gradual. The patient, while inveighing against the persecutions, hints at a possible cause. One man is an inventor and his enemies desire to deprive him of the results of his inventions. ”

“ The train of thought is, as it were, constantly being changed by accidental associations. Although consciousness is not impaired, the power of work is abolished as the attention cannot be directed continuously to any subject, and yet the patient may be capable of writing letters in which facts and fiction are most ingeniously blended. A typical case will pass through the emotions of joy, sorrow and rage in the course of a few minutes. The memory is not impaired and is often hyper-acute. ”

“ 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 ”

“ 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. ”

“ Mentally there is always exaltation rather than excitement, and when excitement is present it is never of a delirious nature, that is to say, the patient is cognizant of the surroundings, and the special senses are abnormally acute, particularly those of sight and hearing. Hallucinations and delusion are sometimes present, but many cases pass through several attacks without exhibiting either of these classes of symptoms. The patient is always garrulous and delighted to make any chance acquaintance the confidant of his most private affairs. ”

“ Hallucinations accompanied by delusions persist often for weeks and months, but as the patient improves physically the mental symptoms become less and less prominent.
If the patient does not recover, the physical symptoms are those of mal-nutrition, together with chronic gastric and intestinal disorder. The skin is dull and earthy in appearance, the hair dry, the nails brittle and the heart’s action weak and feeble. Mentally there is profound depression with delusions, and persistent or recurring attacks of hallucinations of hearing. ”

“ If the enfeeblement is due to failure of development or brain damage Senile Insanity. occurring in early life, it is spoken of as idiocy or imbecility. Every form of insanity which occurs after a certain period of life is apt to be regarded by some observers as senile, but although the failing mental power may colour the character of the symptoms it cannot be regarded as correct to designate, for instance, a recurrent form of mania as senile merely because it necessarily manifests itself in a subject who has lived into the senile period. ”

“ Acute mania, however, is a disease which presents itself in various forms. Adolescent cases, for instance, very commonly suffer from recurrent attacks, and the recurrent form of the disease is also to be met with in adults. The recurrent form at the onset does not differ in symptoms from that already described, but the course of the attack is shorter and more acute, so that the patient after one or two weeks of acute excitement rapidly improves, the mental symptoms pass off and the patient is apparently perfectly recovered. ”

“ The symptoms which most strongly appeal to the lay mind as conclusive evidence of mental disorder are hallucinations and delusions. Hallucinations are false sense impressions which occur without normal stimuli. The presence of hallucinations certainly indicates some functional disorder of the higher brain centres, but is not an evidence of insanity so long as the sufferer recognizes that the hallucinations are false sense impressions. So soon, however, as conduct is influenced by hallucinations, then the boundary line between sanity on the one hand and insanity on the other has been crossed. ”

“ Supervening insanity is no bar to proceedings by or against a lunatic husband or wife for divorce or separation for previous matrimonial offences. It does not avoid a marriage nor constitute per se a ground either for divorce or for judicial separation. But cruelty does not cease to be a cause of suit if it proceeds from disorderly affections or want of moral control falling short of positive insanity ”

“ 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. ”