INSANITY 103 character of excited psychical action, such as grief and anxiety of business, over-prolonged study and domestic affliction, the combination does not affect the position ; but when we have a history of one or more of such psychical influences being associated with a depraved condition of the general system, with poverty, with excess in alcoholic stimulants, or with hereditary predisposition, it appears at the first glance difficult to assess the value to be attached to each in the production of brain disease. This complica tion is, however, more apparent than real ; weakness of the system, whether produced by disease or by malnutrition, only implies a condition in which cerebral degeneration is more likely to occur, but where there is no reason to believe it would have occurred if the brain, weakened along with the other organs of the body, had not been subjected to over-excitation. It may be argued that the brain excitation would not have produced the lesion if the tone of the general system had not been lowered : that is as it may be, it is a proposition which cannot be accepted or denied positively in the absence of positive data. But negative data obtain which warrant its refusal. These are twofold : --a depraved condition of the general system is a frequent result of over-excitation of the brain, the result being liable to be mistaken for the efficient cause ; and the history and symptoms of insanity resulting from special morbid con ditions of the system differ materially from those produced by over-excitation. The action of alt these varied morbid factors is in the direction of solution of continuity of cerebral elements, and consequently of perversion of psychical function. And here a wide gap opens itself in the study of brain pathology in its relation to morbid psychology. No adequate theory lias been advanced to account for the sequence of a parti cular type or train of morbid mental symptoms on a parti cular morbid condition of the brain. In the most definite forms of insanity, those of which the morbid anatomy is pretty definitely determined, there is not the slightest suggestion afforded of the causation of the peculiar type of mental symptoms which symptomatize them, or for the alternation of symptoms in an individual case, or for diversity of symptoms apparently starting from the same cause. All that is known is that when the hemispherical ganglia are diseased we may have excitement or depression of feeling, delusion, or obfuscation of the intellectual and moral qualities ; but why in one case excitement, in another delusion, and in a third both, is an utter mystery. Classification. The mental symptoms of acquired insanity have been classified from the time of Pinel it might, save from some slight difference in the application of the terms, be said from the time of Hippocrates as mania, melancholia, and dementia, according as exaltation or depression of feel ing or weakness of intellect presents itself most prominently in a given case. To these has been added delusional insanity, spoken of by certain authors as monomania. Numberless classifications founded on psychological con siderations have been advanced, involving, however, more variety in terminology than in principle ; all such, when analysed, are reducible to the primitive mania, melancholia, and dementia. Pritchard asserted that mental symptoms were divisible into two great classes, according as the intellectual and moral faculties were implicated. This principle falls to the ground from the simple but most important fact that the primary symptom in all insanities is perversion of the moral sense, and that this perversion pervades all cases of mental disease to their termination. This change of morale amounts to various degrees of per version of the ordinary character and disposition of the individual. He becomes indifferent to social considerations, apathetic and neglectful of the personal and family duties, evinces dislike and suspicion of friends and relatives, and may betake himself to excess in alcoholic stimulants and other forms of dissipation. There is a general concentration of his ideas on himself, which is often spoken of as the selfishness of the insane. According to the direction in action in which perversion of the moral sense is manifested such so-called forms of insanity have been constructed as dipsomania, kleptomania, erotomania, Arc., which, however, are to be regarded as merely accidental phenomena. Moral insanity may appear to exist alone at certain times in certain cases, but it is greatly to bo doubted whether it really ever exists apart from intellectual perversion. The mere fact that a person cannot appreciate the change in himself, can not, as it were, disapprove of his own actions, is evidence that the moral faculties are not alone implicated. The converse proposition may be stated even more strongly intellectual insanity never exists without moral perversion. Moral perversion is, however, only one of the initial symptoms. In most insanities a " period of incubation " is observed, generally spoken of as the prodromal or initial period. Sudden and violent outbursts of insanity are occa sionally reported, but, when these are carefully examined into, a train of prodromal symptoms, physical as well as psychical, can almost invariably be traced. These symptoms are for the most part insidious in character. Founding on the statements of patients suffering from premonitory symptoms, on those made by others, who, having recovered, are able to carry back their recollection to the incidence of the prodromal stage, and on the direct observation of the physician, physical indications are the first to present them selves. These consist in a feeling of fulness in the head, throbbing of the forehead and eyeballs, flashes of light before the eyes, and general malaise. The mental symptoms follow closely, and consist, in addition to the change in morale already spoken of, in restlessness, irritability, inability to apply the mind to the everyday affairs of life, and sleeplessness. In certain forms this description of the prodromal symptoms requires some slight modification. They are very generally accompanied by impairment of general health. The classification of the insanities according to the predominant mental symptom is adopted in almost all treatises on the subject ; but there is a growing convic tion that this basis is neither so scientific nor so con venient as a classification based on pathology. Mania, melancholia, and dementia are merely symptoms of brain disease. If these symptoms were constant in even a considerable majority of all cases, there would be better warrant for employing them as a basis of nosology ; but they vary so widely in kind and degree, they run so closely one into the other, they may all appear in an individual case within so very short a space of time, that their use is generally misleading, even as indicating the mental condi tion of a patient. In many cases of insanity mania may present itself to-day, melancholia to-morrow, and dementia the day after, being, in fact, indications of the course of the complaint. It is undoubtedly true that in a proportion of the insane there is a general predominance of one or other of these conditions, but it is equally true that there is an equal proportion in which the application of any one of these terms is open to question. Thus we may have a melancholic mania or a maniacal melancholia. Moreover, there are many forms of insanity of which the connexion with the causation is so intimate that even those authors who adhere to the archaic classification cannot refuse to acknowledge them as pathological classes, and are com pelled to treat of them under their pathological designa tions ; puerperal insanity, epileptic insanity, senile insanity, and general paralysis may be cited as prominent examples.
