2. Moral insanity.

3. Primary monomania (primäre Verrücktheit-persecutory, erotic, religious, ambitious).

4. With imperative conceptions.

5. Insanity from constitutional neuroses

6. Periodical.

epileptic.
hysterical.
hypochondriacal.

III. CEREBRAL DISEASES WITH MARKED MENTAL SYMPTOMS.

1. Paralytic dementia.

2. Cerebral syphilis.

3. Chronic alcoholism.
4. Senile dementia.

5. Acute delirium.

B. ARRESTED CEREBRAL DEVELOPMENT.

1. Idiocy.

2. Cretinism.

Ziehen has given the most recent, and in many respects the best, classification of this decad:

II. PSYCHOSES WITH INTELLECTUAL DEFECT.

a. Congenital weakness (idiocy, imbecility, feeble-mindedness).

b. Acquired weakness, or dementia.

1. Paralytic dementia.

2. Senile dementia.

3. Secondary dementia (after functional psychoses).

4. Secondary dementia (after cerebral lesions, syphilis, etc.).

5. Epileptic dementia.

6. Alcoholic dementia.

To any but the expert and special student some of these classifications must, indeed, be mystifying and incomprehensible. They are forbidding to the ordinary student and to the general practitioner, and might well induce him to shun the realms of psychiatry which open

before him so uninvitingly and present such obstacles to his progress. And the fact is that they are interesting to the specialist alone because they are as yet quite impracticable from the standpoint of actual utility, as is evidenced by the employment even by the physicians of asylums, who are nothing if not practical alienists, of far simpler schemes of classification in the preparation of statistics for their annual reports and in the histories entered upon their case-books. If the asylum practitioners are compelled for practical purposes to adopt a simple method of classification, how is the novitiate in psychiatric learning to surpass them in the diagnosis and grouping of his cases? Here, for instance, is the latest classification for statistical purposes made for the asylums of New York State by the State Commission in Lunacy (1897):

With this direct evidence of the practical necessity of a simple grouping of cases into forms of insanity which are readily distinguished from one another, I have felt that I could not do better in my teaching than to adopt some similar arrangement. It took me a long time, after beginning a residence of several years in a large insane asylum, to crystallize the types, which were at first very confusing, into some sort of systematic division. The student or practitioner unfamiliar with insanity would, upon a visit to a large institution, probably be first struck by the peculiar shapes of heads of some of the patients. He would find, upon inquiry, that the cases with malformed crania were congenital idiots, imbeciles, or feeble-minded, and before much time had elapsed he would unconsciously make in his own mind the two great divisions of the insane into those with diseased brains and those with defective brains. The former class includes the brains which had developed normally for years and had then fallen a prey to disease; the latter the brains affected by congenital defect or by defect acquired through organic diseases in earliest childhood. In other words, he would separate them first into the insane proper and idiots. The term idiocy comprises three degrees of mental impairment—profound idiocy, moderate defect or imbecility, and mere weakness of mind, or feeble

mindedness.

Now, as the student proceeds to study the physiognomy, conduct, and speech of the cases of insanity proper, he distinguishes, ere long, states of depression (the gloomy visages and unhappy ideas of melan

cholia) and states of exaltation (the ideomotor excitement of mania). Their histories will tell him whether they are acute, subacute, chronic, or recurrent, and whether they are puerperal, lactational, climacteric, senile, epileptic, hysterical, toxic, etc., in their origin. A very small percentage of cases presents the curious phenomena of alternating phases of mania, lucid intervals, and melancholia, giving the entity a cyclical character, and these rare examples of mental disorder are distinguished as circular insanity.

of

Epilepsy is found in a considerable proportion of the inmates of asylums, sometimes conjoined with idiocy, sometimes with dementia, sometimes with symptoms of mania or melancholia, and often presenting peculiar qualities of mental disorder which render the subject of epileptic insanity worthy of a separate chapter. A very large group patients in the asylum would probably impress him as being idiotic or imbecile by their speech and demeanor, and yet he would observe them to have normally shaped heads, and traces of old intelligence might be manifest. By inquiry into the histories of these numerous patients he would find that the mental enfeeblement so plainly apparent had been a sequel to a serious antecedent brain-storm, had followed upon an attack of mania or melancholia, and that the designation of this condition is accordingly secondary or terminal dementia. The term "dementia" means in psychiatry enfeeblement of the mind. There are rare cases where such enfeeblement develops ab initio—e. g., without either of the antecedent psychoses just described, and this condition is entitled primary dementia.

Still another considerable group of cases becomes distinct upon further study, a syndrome identified by progressive mental enfeeblement, accompanied by progressively increasing paresis or paralysis of the muscles of speech, of the face, of deglutition, of the limbs, in fact of the whole body,-dementia paralytica, general paresis, or general paralysis of the insane,-with its phases of grandiose ideas, tremor, epileptiform and apoplectiform episodes, exaggerated or lost knee-jerks, and Argyll Robertson pupils.

He would then begin to be puzzled by the fixed delusions of persecution and grandeur, especially by the former, which he would encounter in many patients,-in some rather confused, weak, and transitory; in others systematized into a most elaborate scheme, with considerable logic and intelligence. Some study of these would lead the student to place the less elaborate persecutory ideas among the melancholiacs, alcoholics, etc., the less elaborate grandiose ideas among the chronic maniacs and general paretics, while the wonderfully elaborated delusions of grandeur and persecution of paranoia would lead him to recognize under this heading the remarkable mental disorder known to the Germans as “primäre Verrücktheit," to the English as chronic delusional insanity, and once familiar to us by the rather indefinite term of monomania.

I shall leave for discussion under separate headings any further subdivisions that seem to me useful. The outline just given must serve the purpose of a foundation upon which the student will rear such superstructure as his time and inclination may permit. Accordingly,

the chapters on special forms of insanity in this book will be simply arranged as follows:

GENERAL ETIOLOGY OF INSANITY.

THE proportion of the insane to normal individuals may be stated to be about 1 to 300 of the population, though this proportion varies somewhat within narrow limits among different races and countries. It is probable that the intemperate use of alcohol and drugs, the spreading of syphilis, and the overstimulation in many directions of modern civilization have determined an increase difficult to estimate, but nevertheless palpable, of insanity in the present century as compared with past centuries.

The amount of such increase might easily seem to be large, on superficial examination, because of the imperfection of census-taking in the past, the accumulation of the chronic insane, and in new communities the constant upbuilding of new asylums.

Sex. As regards sex, women and men are about equally affected, for the particular etiological factors determining insanity in the one (such as the puerperal period, the menopause, etc.) are evenly balanced by the special causes acting upon the other (struggle for existence, drunkenness, syphilis, etc.), and both sexes are about alike in their susceptibility to the two great etiological elements in alienation of the mind -heredity and mental or bodily strain.

Age. The question of age is of great importance in a study of the etiology of insanity. While individuals are liable to mental aberration at any age, yet there are particular periods of life characterized by special vulnerability. In general, it may be said that this vulnerability is greatest in women between the ages of twenty-five and thirty-five, and in men between twenty and fifty, for it is at middle age that we find the maximum accumulation of etiological factors. But there are physiological epochs that influence markedly the line of psychic morbidity, and these are the periods of puberty and adolescence (fourteen to twenty years), that of genital involution in women (forty-five), and that of senile involution (sixty to seventy years).

But the chief factors in the causation of insanity may be summed up

in two words-heredity and strain. The former is responsible for instability of the nervous system, the latter is multiform in character, comprising all of the stresses, physical and mental, direct and indirect, autochthonous and environmental, which may undermine the nervous constitution and bring it to its point of collapse.

Heredity. In determining the factor of heredity we must not be content with ascertaining the existence of psychoses in the ascendants, but must seek, by careful interrogation of various members of the family, for some of the hereditary equivalents, such as epilepsy, chorea, hysteria, neurasthenia, somnambulism, migraine, organic diseases of the central nervous system, criminal tendencies, eccentricities of character, drunkenness, etc., for these equivalents are interchangeable from one generation to another, and are simply evidences of instability of the nervous system. It is the unstable nervous organization that is inherited, not a particular neurosis or psychosis, and it must be our aim in the investigation of the progenitors to discover the evidence of this.

That the statistics of insanity as regards heredity are often faultily gathered is too well known. In the first place, the recorder of the history of a patient frequently neglects to extend his inquiry far enough to include all of the transmissible psychoneuroses, and, in the second, the relatives are prone to conceal any supposed hereditary taint in the family. Here, for example, is a table prepared by the Lunacy Commissioners, showing the causes of insanity in 136,478 admissions to asylums in England and Wales, in which I find the item "hereditary influence ascertained" 20.5 per cent. Surely, so small a figure does not represent the true proportion of heredity as an etiological factor!

It will take many decads of much more careful compilation of histories to establish the actual ratio, but we shall attain nearer to the facts year by year.

No one has better formulated the principles of heredity in relation to insanity than Mercier,1 who points out, among other things, that, besides the importance of the direct transmission of an unstable nervous system, there is another law of heredity, which is known as the law of sanguinity. Two parents may be perfectly stable and have normal organisms, and yet produce offspring with unstable and abnormal nervous constitutions, because of the unsuitability of the sexual elements of the parents to each other. The perfect organization of the progeny is the result of three factors-the quality of the germ (which brings matter), the quality of the sperm (which brings force), and the suitability of the one to the other.

The laws of heredity as they relate to insanity may be summarized briefly as follows:

1. The child tends to inherit every attribute of both parents.

2. Contradictory attributes can not be inherited from both parents. 3. The child may inherit the attributes of either parent solely. 4. It may inherit the qualities of one parent in some respects and of the other in other respects.

1 "Sanity and Insanity."