as a toxic insanity, and it is such through the disorders of the general metabolism it induces in its later stages, when the mental disease usually appears. The evidence that it is directly due to any bacterial toxin, like the virus of syphilis, seems to us, however, to be lacking. Exhaustion.-It is difficult often to separate the insanities of nervous exhaustion from those due to toxins, either of internal or external origin. The post-febrile insanities, which are typical in their phases of nervous weakness, may be due to one cause as much as to the other, and even in those cases from overstrain and stress acting directly upon the nerve elements it is not always possible to exclude a toxic factor. We know, however, with tolerable certainty that there is a nervous exhaustion from fatigue, and from lack of balance between waste and nutrition, that may go to the length of destroying mental equilibrium, and often does so, thus producing what may be called a pure exhaustive psychosis. This may occur after wasting diseases, after overwork, physical or mental, after hardships and starvation, masturbation and sexual excesses, and whatever depresses nutrition and fatigues the nervecells without allowing proper restoration for sufficient periods. Organic Causes.-These include gross diseases of the brain, such as occur from arterial disease, sclerotic changes, hemorrhages, embolism, etc. Under this head we have apoplexies, softenings, senile wasting, neuritis, morbid growths, etc. In conclusion, it should be said that in perhaps a majority of instances the attack of insanity has more than one of these classes of causes in play in its origination. Thus, in the case of paresis which is directly excited by worries and mental stress there must be, as a rule, a system prepared by the toxins of specific disease. In many cases, also, of exhaustive insanity, some toxic agency, mental shock, or some other disturbing factor enters into the production of the attack. The causes of any attack of insanity are not always obvious, and often require close study; sometimes the alleged or supposed causes-for example, masturbation or religious excitement-are found to be mere early symptoms, and to have no etiologic connection whatever with the disease. On account of these facts hospital statistics are unreliable to a large extent, as they give, as a rule, only the alleged causes as stated in the paper of commitment, which are very often erroneous. In every case the remote as well as the apparent immediate causes should be taken into consideration, and questions of hereditary taint, neurotic personal antecedents, previous habits, etc., be thoroughly investigated. It must be remembered, also, that in most cases the causal factors are multiple; it is not the rule for any one to be the sole agency in producing the insanity. This is true of the exciting causes by themselves, and still back of these we have to reckon with the great predisposing influences which are in action in nearly every case. In conclusion, something should be said of the contagion of insanity. It is popularly believed that those who have to do with and care for the insane are themselves specially liable to be similarly afflicted. This is true only when predisposition exists; the contagion is purely mental, the influence of association, and generally implies a pre-existing mental weakness on the part of the recipient. Folie a deux, or communicated or imposed insanity, is the imposition by a stronger mind on a weaker one of its own delusions. It is generally observed in cases of very close association and relationship, as between parent and child, brothers and sisters; and the communicated insanity is very generally cured by removal from contact or association. with the imposing agent. Only when both are alike seized with similar delusions, and neither one is the passive party rather than the other, the so-called simultaneous insanity,-is the prognosis alike unfavorable for both. It is not well, as a rule, for children or young persons in the formative stage of mind or character to too intimately associate with the insane, though the danger is probably not so great as is popularly supposed. This is especially the case when insanity is in the family, as then a predisposition may be assumed to exist. This has an important practical bearing on the question of the home treatment of insanity, that hardly requires any explanation. CHAPTER III. PATHOLOGY. IN the definition of insanity adopted here the pathology of insanity is expressed; it is a disease or defect of the brain. Speaking more exactly, it may be said to be a derangement of the functions of those parts of the brain, the centers of the cerebral cortex and their connections, that are concerned in the intellectual and emotional life of the individual. Taking all forms of mental alienation into consideration, we have in the extreme types of idiocy a very obvious cerebral defect; the organ of the mind is insufficiently developed to permit the performance of its normal functions, and the defect is often a gross macroscopic one, intelligible even to the ordinary observer in the microcephalism and the misshapen cranium which correspond to the expressionless visage and the purely animal propensities and behavior. From this extreme we have every gradation in the more or less pronounced type of partial idiocy and imbecility down through the various degenerative forms of alienation to the intellectual paranoiac or cyclic case, in whom only careful measurements and the observation of an expert can detect the stigmata. In all of these there is a more or less pronounced cerebral defect; the mental alienation is the result of arrested or misdirected development, due either to fatal congenital defects, or to those that, existing, lacked the counteracting influences of training or environment. Not every case of cerebral degeneration tends inevitably to insanity, but such structural deficiencies seriously handicap their bearers in the difficult struggle for existence, and very often lead to mental disorder when not obviated by care and training, especially through the critical developmental epochs of life. If we were to examine the inmates of any large asylum and compare them with an equal number of individuals of like social position outside its walls, we would probably be struck with the excessive proportion of misshapen crania, facial, aural, and other deformities in the one class as compared to the other, taking each as a whole. If we take a special group of insanities, the degenerative types, the paranoiacs, the hysteric and neuropathic cases generally, only for the comparison, the difference will be still more marked. According to Knecht,* these degenerative stigmata are four or five times as frequent in the chronic insane as in normal individuals. They are the external signs of the insane predisposition, and, as Spiller † says, "they are related to still further abnormalities in the finer structure of the brain that cannot be detected by the microscope." It does not follow, however, that the reverse of this is true, that the finer structural defects connected with mental alienation are necessarily connected with macroscopic signs. The grosser abnormalities, either in external physical stigmata or aberration in the cerebral convolutions, may be absent or so inconspicuous as not to be characteristic. This, it is true, is only the case in a minority of the insane, and more especially in those in whom no predisposition is known to exist. In the not very common cases where there is opportunity for an autopsy of acute insanity, there is usually, beyond a congestion and the conditions referable to the disorder that directly carried off the patient, nothing in the naked-eye findings that accounts for the mental disorder. Until within a few years it was certainly true, *Verein deutscher Irrenärzte, Hannover, 1897, "Neurol. Centralbl.," 1897, No. 20. "Philadelphia Med. Jour.," Mar. 12, 1898. |