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MEDICAL AND GENERAL] This cannot, however, apply to the case of France, which is stated to have only 66 idiots to every 100 lunatics. In many districts of France cretinism is common; it is practically unknown in England, where the proportion of idiots is stated as higher than in France; and it is rare in Prussia, which stands at 158 idiots to 100 lunatics. Manifestly imperfect as this table is, it shows how important an element idiocy is in social statistics; few are aware that the number of idiots and that of lunatics approach so nearly.

II. Acquired Insanity.—So far as the mental symptoms of acquired insanity are concerned, Pinel’s ancient classification, into Mania, Melancholia and Dementia, is still applicable to every case, and although numberless classifications have been advanced they are for the most

part merely terminological variations. Classifications of the insanities based on pathology and etiology have been held out as a solution of the difficulty, but, so far, pathological observations have failed to fulfil this ideal, and no thoroughly satisfactory pathological classification has emerged from them.

Classifications are after all matters of convenience; the following system admittedly is so:—

The general symptoms of acquired insanity group themselves naturally under two heads, the physical and the mental.

The physical symptoms of mental disease generally, if not invariably, precede the onset of the mental symptoms, and the patient may complain of indefinite symptoms of malaise for weeks and months before it is suspected that the disorder is about to terminate in mental

symptoms. The most general physical disorder common to the onset of all the insanities is the failure of nutrition, i.e. the patient rapidly and apparently without any apparent cause loses weight. Associated with this nutritional failure it is usual to have disturbances of the alimentary tract, such as loss of appetite, dyspepsia and obstinate constipation. During the prodromal stage of such conditions as mania and melancholia the digestive functions of the stomach and intestine are almost or completely in abeyance. To this implication of other systems consequent on impairment of the trophesial (nourishment-regulating) function of the brain can be traced a large number of the errors which exist as to the causation of idiopathic melancholia and mania. Very frequently this secondary condition is set down as the primary cause; the insanity is referred to derangements of the stomach or bowels, when in fact these are, concomitantly with the mental disturbance, results of the cerebral mischief. Doubtless these functional derangements exercise considerable influence on the progress of the case by assisting to deprave the general economy, and by producing depressing sensations in the region of the stomach. To them may probably be attributed, together with the apprehension of impending insanity, that phase of the disease spoken of by the older writers as the stadium melancholicum, which so frequently presents itself in incipient cases.

The skin and its appendages—the hair and the nails—suffer in the general disorder of nutrition which accompanies all insanities. The skin may be abnormally dry and scurfy or moist and offensive. In acute insanities rashes are not uncommon, and in chronic conditions, especially conditions of depression, crops of papules occur on the face, chest and shoulders. The hair is generally dry, loses its lustre and becomes brittle. The nails become deformed and may exhibit either excessive and irregular or diminished growth.

Where there are grave nutritional disorders it is to be expected that the chief excretions of the body should show departures from the state of health. In this article it is impossible to treat this subject fully, but it may suffice to say that in many states of depression there is a great deficiency in the excretion of the solids of the urine, particularly the nitrogenous waste products of the body; while in conditions of excitement there is an excessive output of the nitrogenous waste products. It has lately been pointed out that in many forms of insanity indoxyl is present in the urine, a substance only present when putrefactive processes are taking place in the intestinal tract.

The nervous system, both on the sensory and motor side, suffers very generally in all conditions of insanity. On the sensory side the special senses are most liable to disorder of their function, whereby false sense impressions arise which the patient from impairment of judgment is unable to correct, and hence arise the psychical symptoms known as hallucinations and delusions. Common sensibility is generally impaired.

On the motor side, impairment of the muscular power is present in many cases of depression and in all cases of dementia. The incontinence of urine so frequently seen in dementia and in acute insanity complicated with the mental symptom of confusion depends partly on impairment of muscular power and partly on disorder of the sensory apparatus of the brain and spinal cord.

The outstanding mental symptom in nearly all insanities, acute and recent or chronic, is the failure of the capacity of judgment and loss of self-control. In early acute insanities, however, the two chief symptoms which are most evident and easily noted are depression on the one hand and excitement or elevation on the other. Some distinction ought to be made between these two terms, excitement and elevation, which at present are used synonymously. Excitement is a mental state which may be and generally is associated with confusion and mental impairment, while elevation is an exaltation of the mental faculties, a condition in which there is no mental confusion, but rather an unrestrained and rapid succession of fleeting mental processes.

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. The most common hallucinations are those of sight and hearing.

Delusions are not infrequently the result of hallucinations. If the hallucinations of a melancholic patient consist in hearing voices which make accusatory statements, delusions of sin and unworthiness frequently follow. Hallucinations of the senses of taste and smell are almost invariably associated with the delusion that the patient’s food is being poisoned or that it consists of objectionable matter. On the other hand, many delusions are apparently the outcome of the patient’s mental state. They may be pleasant or disagreeable according as the condition is one of elevation or depression. 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. 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. Perversion of the moral sense is common to all the insanities, but is often the only symptom to be noticed in cases of imbecility and idiocy, and it as a rule may be the earliest symptom noticed in the early stages of the excitement of manic-depressive insanity and general paralysis.

The tendency to commit suicide, which is so common among the insane and those predisposed to insanity, is especially prevalent in patients who suffer from depression, sleeplessness and delusions of persecution. Suicidal acts may be divided into accidental, impulsive and premeditated. The accidental suicides occur in patients who are partially or totally unconscious of their surroundings, and are generally the result of terrifying hallucinations, to escape