Diseases of the Abdominal Organs.— More or less inflammation of the intestinal mucous membrane is not uncommon among the insane. It is at the bottom of that colliquative diarrhoea which at last carries off many feeble patients, mostly those suffering from paralytic dementia, but now and then even some who are maniacal or melancholic. The changed position of the colon especially noted by Esquirol-the transverse portion of which lies in the hypogastric region or in the pelvis-is not of any real importance or of any special significance.

All sorts of disorders of one or more of the abdominal organs have been met with in particular cases, but not in any constant relation to any particular form of insanity. Rokitansky noticed a considerable increase and induration of the celiac axis in a case of hypochondriasis with great wasting. Cancer of the stomach, liver, or of some other part, has been discovered in cases where there existed during life a delusion with regard to some animal or man being present in the belly; in one case, described by Esquirol, where delusions of this sort were most extravagant, there was chronic peritonitis which had glued together the intestines. Diseases of the sexual organs are, as already pointed out, of some importance in the causation of insanity. In the female, prolapsus of the uterus, fibrous tumour of the uterus, ovarian cyst, &c. may in some few cases impart to the insanity a sexual character, or become the conditions of peculiar delusions; but in other cases of like disease there may be no sort of connexion traceable between the character of the in-anity and the particular disease. Remember only that, by reason of the consensus of parts-the intimate connexion and interaction between one organ and another as parts of an organic whole-disorder of any organ must conspire with other predisposing or exciting causes to produce insanity.

IT

CHAPTER V.

THE DIAGNOSIS OF INSANITY.

T might seem to be no difficult matter to determine when a man's mind is unsound, and yet the diagnosis is as difficult. in some cases as it is easy in others. So imperceptibly does physiological function pass into pathological function throughout the organism, that it is impossible to say where one ends and the other begins in the case of any organ: disease is not any mischievous entity that has taken possession of the body, and must be driven out of it as the evil spirit was driven out of the demoniac: it is simply vital action under other conditions than those which we agree to call natural or typical. Unsoundness of mind is that degree of deviation from healthy mental life which it is agreed by the common consent of mankind to regard as morbid. That there should be extreme uncertainty in deciding in particular cases, arises from the fact that various acts which may be the results of insanity may also be the acts of vicious or criminal persons, in whom there is no reason to suspect disease. It will not, however, suffice to make it the positive criterion of insanity, that a man is unable to restrain his actions; for, in the first place, there are some criminals who by reason of a bad organization cannot, in. face of certain temptations, control their actions; and, in the second place, there are persons unquestionably insane who are quite capable of controlling their actions, if they have a sufficiently strong motive for doing so there are some insane persons who are really criminal, on the one hand, and, on the other, there are criminals who are really insane. The experience of those connected with prisons proves, that weak-mindedness predominates in the criminal

population as a class. Mr. Bruce Thomson states that, in the General Prison for Scotland, as many as one in nine, or nearly 12 per cent. were positively weak-minded, and that epilepsy is found to prevail in much larger proportion among prisoners than in the population at large. Without doubt, there must at times occur doubtful cases which it is uncertain whether to treat as diseased or to punish as criminal. We are accordingly sometimes placed in a great difficulty, and driven to argue in a vicious circle. Thus, we infer unsoundness of mind because of the character of the acts; and, on the other hand, it is because we think there is disease of mind that we pronounce the acts insane. The fact is that every case should be examined on its own merits; the previous history of the patient and his present symptoms being most carefully studied, and the opinion given being founded on a calm and scrupulous consideration of all circumstances of the case, physical as well as mental. Furnished not merely with psychological theories, but with a medical knowledge of the different varieties of insanity, based on a large medical experience, we shall be in a position to appreciate the importance of some symptoms, and to interpret the meaning of others, which would escape the attention of those who have not practically studied insanity, and thus at any rate to throw some light on a doubtful case. It is certainly far from evident that the popular opinion is correct which assumes that a rough common sense is best suited to guide the decision; one cannot indeed but think that special study and experience of the phenomena of obscure disease must furnish better grounds for a just judgment concerning it than entire ignorance can. Lord Westbury, speaking as Lord Chancellor, in the House of Lords, before he fell from the height of place which gave a factitious weight to any opinions which he expressed, thought it not unbecoming his high intellectual and official position to conden.n "the evil habit which had up of assuming that insanity was a physical disease, and not a subject of moral inquiry," and to affirm that it was not necessary "that a man should have studied the subject of insanity in order to form a conclu on whether a man was or was not a lunatic." It may well be doubted whether a Lord Chancellor • Journal of Mental Science, October 1866.

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ever before gave such complacent and dogmatic utterance to so erroneous, mischievous, and unfortunate an opinion. It was one which, falling in with and strengthening the current of popular prejudice, was received with applause, and did considerable mischief, at the time, but which cannot fail to be remembered with surprise in the future as a striking example of the utter ignorance of the nature of mental disease displayed by one of the greatest legal intellects of his day. But this is not the place to criticize Lord Westbury, or to combat his opinions respecting insanity; we are concerned exclusively with insanity as a physical disease, not with subjects of moral inquiry.

Acute mania is not likely to be overlooked, or to be confounded with any other disease. The only doubtful question in regard to it will be in the event of an impostor attempting to simulate it, or of a drunkard actually simulating it. Certainly he must be a clever impostor who can simulate the wild restless eye, the ceaseless movements, the quick fragmentary associations of ideas, and the volubility of utterance of acute mania so as to deceive an experienced observer; nor can he, however skilful an actor, pass days without sleep, and even weeks with only a few hours' sleep, maintaining a continual activity, as the acute maniac does. The skin in acute mania is dry and harsh, or cool and clammy, but the skin of a pretender who tries to keep up a prolonged muscular agitation will hardly fail to be hot and sweating. Meningitis will be known from mania by its own positive symptoms-by the premonitory rigors, when they occur, the cephalalgia, the fever, the contracted pupil, and the intolerance of light; by a muscular activity which is paroxysmal, not continuous, and by frequent spasms and convulsions; by the acute severity and incoherent character of the delirium and by the vivid illusions of the senses; and by the rapid progress of the disease either to recovery or to death. Delirium tremens will be distinguished by its own characteristic symptoms-the muscular tremors, the peculiar fearful illusions and hallucinations, the cold skin, feeble pulse, and the white and tremulous tongue. But there are cases in which positive insanity is produced by drink, and they are sometimes the occasion of great injustice being done by our legal tribunals: some persons who have a strong predisposition to insanity, or who have been once

insane, or who have had a severe injury of the head at some time, do actually become truly maniacal for a while after an alcoholic debauch, or are rendered temporarily maniacal-being probably thought drunk-by a very little liquor. Certain it is that there are persons whom alcoholic intemperance does not make drunk, but makes mad. In this condition vivid hallucinations are apt to arise, and the sufferer may perpetrate crime not knowing afterwards what he has done, and certainly at the time not knowing the nature of the act. On one occasion I was asked to see in the gaol a respectable builder, who was undergoing imprisonment for a rape on a servant girl under fourteen years of age, and I was never more convinced of anything in my life than of the truth of the man's assertion, that he remembered nothing whatever of the crime which he had committed. He had for some time heard voices speaking to him, which had no existence out of his mind, and he had been continually drinking for some days before the crime. There was no attempt at concealment or deception; he spoke with perfect candour; and he still heard voices speaking to him through the ventilator of his cell. Many such instances have been recorded, and it is high time they were recognised by those who preside over the administration of justice: the common erroneous notion that if a person becomes furious after intemperance he must be either "mad drunk" or at most have delirium tremens has unquestionably worked much mischief. It admits of no doubt that the effect of continued intemperance or of a debauch may be a genuine acute mania, marked by active and violent delirium.

Chronic mania is the most likely to be feigned, and if feigned with skill the imposture may deceive many. However, the impostor generally "o'ersteps the modesty of nature," and overacts his part; he is extreme in the extravagance of what he says and does, while he falls hort of his part in the emotional expression of the maniacal countenance. Thinking that a lunatic is widely different from a sane person, he exaggerates and rants, and produces something not like a lunatic. He pretends perhaps that he cannot remember things, as what day follows another, or how many days there are in a week, that he cannot add the simplest figures together, and acts foolishly and answers stupidly where a ral lunatic who was not an idiot