INSANITY. This term ordinarily connotes more or less severe unsoundness of mind. Though its loose usage is almost synonymous with mental disease, scientifically the term should only be applied to the mental condition of an individual who, through socially inefficient conduct, has to be placed under supervision and control. The mind is the mechanism by means of which we adapt adequately to our environment and when, through its derangement, conduct is exhibited which the com munity looks upon as evidence of disease and as implying ir responsibility, the individual concerned is said to be insane and the law steps in to certify him as such. Strictly speaking, then, insanity is really a social and legal term and not medical. Mental illness is a broad concept which may include very efficient mem bers of society. No satisfactory definition can therefore be ar rived at, since it would be necessary to define what we mean by sanity, which would involve us in equal difficulties.
It is unnecessary to dwell upon the mystical conceptions of insanity which were held in the middle ages, and it will be suf ficient to note that it was only towards the close of the 18th century that this sphere of mental disorder was scientifically studied. This was a period in which materialism flourished and research devoted to the anatomy and physiology of the brain gave the workers reason to believe that the nature and causes of insanity would before long be discovered, since the advance of knowledge in the structure and functioning of the central nervous system was progressing at a rapid rate. A school of thought there fore held sway which founded insanity upon a physiological basis and endeavoured to base all pathology in terms of organic change in the brain. Although the great value of this method cannot be gainsaid, there is ample evidence that other aspects of approach ing the problem of insanity are essentially necessary. Of late years another school has advanced the belief that the majority of cases of insanity are psychogenic in origin and that even where gross physical disease has been the exciting factor, that the symptoms can only be adequately understood at the psychological level. Others, again, prefer to take a wider view-point still and regard in sanity in the light of biological or psycho-biological reactions. Modern psychological knowledge would lead us to believe that the understanding of much of the subject is made clearer when we re gard it in the light of instinctive forces conflicting with environ ment and resulting in a failure of adjustment. The mental symp toms cannot be rightly spoken of as a disease but as types of reac tion through the effort on the part of the individual to meet con ditions. For the detailed theories of such a conception, the writ ings of Freud, Jung, Adler and Adolf Meyer should be consulted. The researches of Freud in this direction are of paramount im portance and have largely revolutionized many of our ideas on psycho-pathology. The materialistic school would hold that though in many states of insanity no observable structural changes are found, they exist all the same, only they are such that our im perfect methods cannot detect them, and in time they will be discovered. At present we have insane conditions divided into those that are regarded as functional and those that are organic. In the former we have mania, melancholia and paranoia, and some would include dementia praecox. The psychogenic school would argue that though mental disease may arise secondarily to physical disorder, the symptoms are psychological reverberations of that disorder and the body of an individual must be regarded as environmental to the ego. In an integrated organism, though the basis of the wrong functioning lies in the physical sphere, some of the effects are manifested at the psychological level. The symptoms, then, are expressions of the personality, and however much we may stress the bodily aspect, that can in no way ex plain the content of a delusion or an hallucination. The fact that some individuals may take alcohol to the extent of producing severe physical disease without affecting the mind, and others will fall victims to insanity through its use, proves that psychic factors cannot be left out of calculation. The many structural changes which are found in certain forms of insanity should be reviewed as probably secondary to a perverted mentality. The bodily effects of emotion are well known and it can easily be surmised that long continued emotional stress should in time be followed by organic change. During the World 'War we had ample evidence of this. Mental reactions must be looked upon as re actions of the whole integrated organism which cannot be the expression of any one part of it. As McDougall says, mind has a nature and a structure and functions of its own which cannot be fully and adequately described in terms of structure of the brain and its processes. If this be true, as he thinks, it does not seem logically impossible that the nature of the mind itself may be disordered or impaired or defective. It seems, then, that we must steer clear of belonging to one or other of the extreme camps when we view the nature of insanity, but take a very wide vista which will embrace the study of the individual, his personal and racial history, his environment, and his physical and mental structure.
The causes of insanity will be predisposing and exciting. The former will be those conditions resident within the individual which will render him liable to suffer thus when certain factors are super-added, and the latter are those circumstances which precipitate the mental disturbance.
(2) . Civilization. It is amongst the most highly civilized that insanity is most prevalent. In the process of evolution, life in general becomes more complex, adaptation more difficult, mental conflict more in evidence. The insane, too, are found with greater frequency in the congested centres of population where the strug gle for existence is at its greatest height. The percentage of insanity is greater among the unmarried than the married.
(3) . Sex and Age. The total incidence of insanity differs but slightly in the two sexes. In the male the effects of alcohol, and syphilis, and general stress tend to balance the special strains of pregnancy, and the change of life in women. The greatest liability to such mental disorder exists between the ages of 3o and 4o, but it must be realized that there are more people living in the general community of this age. Considering the number of in sane in each decade compared to the total population of the same age, it will be found that the liability practically progressively increases from 20 to 8o years of age.
(4)• Climate. The only effect of climate is mainly that of supplying conditions which make exhaustion and infection more liable. Malaria, enteric fever and dysentery are responsible for most of the insanity attributed to climatic conditions.
(5) . Physiological Epochs. At the periods of puberty, ado lescence, child-bearing, the climacteric in women and the senium in man, there are special chemical, bodily and mental changes which render the individual more prone.
Other exogenous chemical poisons which may be productive of insanity are opium (morphine), cocaine, and metallic salts of mercury, lead and arsenic. Much more important are those toxins due to bacterial infection. Syphilis stands out in this respect prominently. When inherited, its effects may severely retard men tal development, and when acquired, it may bring about general paralysis, which constitutes 5% to r 5% of the total admissions to our mental hospitals. Indirectly, too, it may contribute to the inception of other forms of insanity. Almost any infection may produce insanity in a predisposed individual. The mental reactions occurring in the acute stage of infection are most commonly of a delirious nature, but the subsequent form of insanity will vary according to the personality. Tuberculosis, enteric fever, malaria, and influenza are frequently responsible. Of late years some in vestigators have laid great stress on infected foci somewhere in the body being causative of different insane states. With this idea in their mind, careful search for such are made in the teeth, ton sils, nasal sinuses, stomach, bowel, genitourinary passages ; and in women, the womb with its appendages. The teeth and tonsils are said to be the commonest sites, and in the hands of the more enthusiastic advocates of this conception, wonderful recovery results are claimed when these infective foci are eliminated. Re search of others has not confirmed these findings, and there is grave reason for doubting that any such one factor, and that a physical one, can be alone responsible for such a complex mental state as that of insanity. The great importance, however, of re moving possible sources of general infection is always to be borne in mind. Endogenous chemical poisons or auto-intoxication have also been presumed to be causative factors, and those of most consequence were thought to originate from the gastro-intestinal tract and as a result of chronic kidney disease. Though in some cases such agents may contribute a causative share, there is no reason for thinking they have any specific value.
(2). Injuries. Direct injuries to the head may cause structural lesions of the brain and be the immediate cause of some form of insanity, while more indirect injuries, such as concussion from falls, may also be the starting point of a mental disorder.
(3) . Bodily diseases may play a part in the production of in sanity through the interference they bring about in nutrition, circulation and fatigue.
(4)• Exhaustion or overwork has been commonly supposed to be a cause, and during the World War a certain type of insanity developed by soldiers on active service was officially designated as "exhaustion psychosis." Though prolonged mental or physical strain often seems to be the precursor of a severe mental break down, it is probable that exhaustion per se without other and more important adjuvant factors will seldom originate an insane state. The excessive fatigue is frequently a symptom, and if in any way contributory, it must be regarded as one link in a series.
(5) . Mental. Any severe mental stress may excite insanity when the predisposition exists. Commonly, the mental factor in volves some situation which the individual cannot face, and it may be said that in this difficulty he takes refuge in a world of unreal ity. Domestic trouble, financial worries, deaths of those who are near and dear, sexual problems, are the usual sources of stress met with. Sudden and horrible shocks may act similarly. This psychogenic aspect of insanity has been much studied of late years, and holds a wide field to-day which strenuously opposes the views of the materialistic school.
(9) Epileptic insanity (Since we are dealing only with insane states and not mental dis order the neuroses and psycho-neuroses such as neurasthenia [q.v.], anxiety and compulsion neuroses and hysteria are not included.) General Symptoms of Insanity.—It must be borne in mind that any of the symptoms enumerated, taken by themselves, are not necessarily evidence of an insane condition, but that they only have such an indication when taken in conjunction with each other, when studied in their individual setting and in comparison with the previous expressions of the personality. Again, it must be stressed that though they may indicate mental disorder, it is the factor of conduct that renders the case insane or not. Certain symptoms are more or less particularly associated with special forms of insanity.
General Behaviour.—Some change in this direction is usually the earliest indication noted by friends and relations. This may relate predominantly to the habits, moods, activities or content of speech. The capacity to work, the ability to adapt to circum stances, and the usual respect for the conventions of society, may likely be affected. Alcohol may be unduly indulged in, personal cleanliness and general care of the self neglected, while the char acter as a whole may undergo transformation. We may have a general over-activity, which commonly is not directed consistently towards a definite goal, and when severe may lead to violence and destructiveness. This is a prominent symptom of mania. On the other hand there may be great difficulty and slowness of voluntary movement, which is specially evinced in melancholia. Movements may be stereotyped and oft-repeated, automatic, just opposite to what we should expect, or impulsive. Curious postures may be taken up, and bizarre mannerisms shown. The stream of speech may be affected similarly. This may be greatly voluble, slow and difficult, or there may be mutism, irrelevance, incoherence.
Disorder of the emotions will be mainly evidenced by an exag gerated sense of well-being, elation or exaltation on the one hand or the reverse picture of gloom and severe depression. The mor bidity of these states will accrue from the fact that they are not warranted by the condition of the individual or his surroundings. These extreme emotions are mostly noted in one or other of the phases of manic-depressive insanity. Emotional deterioration, or apathy, is particularly seen in dementia praecox. Anxiety, morbid anger, suspicion, and general instability of the emotions are other frequent abnormalities in this sphere.
Disorders of the content of thought are usually prominent, and a delusion is regarded as specially important by the law and laity as evidence of insanity. Such false beliefs may be sane or insane. We may regard them as insane when three characteristics concern ing them are found. First, they are evidently untrue, highly im probable, or manifestly impossible. Second, they cannot be cor rected by any appeal to reason. Thirdly, they are out of harmony with the individual's education and environment. Nevertheless, sometimes a false belief may be an insane delusion without show ing any of these characteristics. Delusions may be very varied, but those of persecution and grandeur are perhaps the most frequent. They may be fixed or changeable; they may or may not affect conduct.
The process of thinking itself may be greatly modified. There is difficulty in thinking; much pre-occupation with one idea; thoughts seem stolen; they are obsessive; or everything in the environment is taken personally (ideas of reference).
Disorders of perception may affect any sense. They may be in the form of illusions which are inaccurate perceptions of some thing really and actually perceived, or hallucinations which have no sensory foundation in the environment, and are created by perverted functioning of the mind. On rare occasions hallucina tions occur in normal people. Many can be explained on a purely mental basis, while others have an organic interpretation and are based on physiological disturbances such as toxic states. Auditory hallucinations are the most common, and usually are of the nature of voices. Their content is of great importance in the study of the patient, and generally are in consonance with the delusions enter tained. Most frequently the voices are derogatory and accusa tory. Visual hallucinations are mostly noted in toxic forms of insanity. Those affecting smell, taste and touch are of much less frequent occurrence. Psychic or pseudo-hallucinations seem to occupy a position midway between imagination and the fully developed form of hallucination. There is not the same conviction of their external reality, and yet it is believed by the patient that they are brought about by some external agency. Hypnagogic hallucinations are those which occur in the state between sleeping and waking, and these have not the same morbid value. The sensations from the muscles, joints and internal organs may be affected and give rise to curious delusional ideas.
Disorders of orientation imply a lack of appreciation of three aspects of the environment, either simply or together—that of time, space and personal relations. These are not infrequent in severe forms of insanity, and are commonly noted in the con fusional conditions of delirium and toxic states.
Disorders of memory will either be complete or partial absence of memory (amnesia) which may only concern past events or be progressive and continuous; false recollections (paramnesia), when the insane patient relates with conviction and detail events which never took place ; and excessive retention of memories (hyperamnesia), which occurs in certain insane states.
Disorders of attention may involve the inability to fix the at tention for any length of time in one direction (distractability), as seen typically in mania. Where this is in excess there is liable to arise an insufficiency of perception so that orientation is ren dered defective. Enfeeblement of the power of voluntary atten tion is one of the most characteristic signs of dementia (a gradual weakening of the intellectual faculties). In other insane states there may be complete absorption of attention on one or more groups of ideas, which render the individual so self-absorbed that the surroundings are not attended to, and often not seen at all.
Various disturbances of consciousness may be manifested. Sleep may be abolished, lessened or increased. The last named is uncommon and is usually associated with brain disease or some general toxaemia. In certain insane patients such as maniacs there exists a marvellous capacity to withstand more or less prolonged sleep deprivation. Trance-like sleep may be noted in other types. In stupor the patient makes little or no response to any stimulus, and such a condition may, when severe, last for lengthy periods. Lastly, we may have symptoms pointing to definite disorders of the personality. There may be depersonalization when the individ ual feels that he is no longer himself, or that he no longer exists, or there is the last uncommon condition in which a patient believes himself to be some other person and may act on that belief. In certain severe insane states there may be a gradual dis integration of the personality, which leaves the victim without any of the acquired cultural traits, and only possessing his primi tive functions. We can now give some description of the various types of insane conditions met with according to the classification already set forth.
The manic-phase manifests itself by three main symptoms— elation, flight of ideas and general hyperactivity of mind and body. In the mildest type (hypomania) we note these symptoms in slight degree, but the efficiency of the individual is greatly reduced and alcoholic indulgence and delinquent conduct is often seen. In acute mania the symptoms are severe, speech may be so flighty as to be incoherent, and some disorientation is likely to be present. Delusions often occur, but are changeable and ridiculous in character. In the main they will be grandiose in type, but false ideas of persecution may be evinced. Activity of mind and body is constant, little if any sleep is indulged in, food not attended to, so that signs of exhaustion and loss of flesh be come marked. Such a patient may be boisterous, destructive and violent. The feeling of exaltation is extreme, and irritation and anger are easily aroused when thwarted. Simple and evanescent hallucinations are often noted. In its most extreme degree this manic phase may be delirious in its severity, and complicated by a septic blood state, brought about by physical injuries.
In the depressive phase we note exactly the opposite symptoms of great depression, difficulty in thinking and under-activity of mind and body. Here again we may speak of three grades of severity. In the mildest the individual often realizes his in validism. He moves and speaks slowly, seems incapable of effort, and sees everything as through a glass darkly. In acute melan cholia the symptoms are much more pronounced. The depression is profound and delusions of self-accusation referring to sin, poverty and being "lost" are in evidence. Hypochondriacal ideas, such as their bowels being stopped up or their brains decayed, are frequent. The personality may seem to the patient to be transformed, and hallucinations consonant with their delusions also occur. In the severest type there is stupor, and the patient lies in bed inert, with much clouding of consciousness, the victim of horrible delusions and hallucinations.
Manic-depressive insanity may last a variable period, but, though recovery is usually the rule, a recurrence of attacks is highly likely. The interval between such attacks may progres sively lessen. Certain cases may remain chronic. Any patient with any state of melancholia must be regarded as a potential suicide, and cared for accordingly.
There is a form of insanity termed involutional melancholia which is closely related to manic-depressive insanity, but which occurs at the period of involution, i.e., about 5o years of age. The symptoms are mainly similar to those in the depressive phase of manic-depressive insanity, but there is a greater tendency for the delusions to be hypochondriacal, and there is usually more or less restlessness and anxiety. Hence the old term "agitated mel ancholia." Fifty per cent make a satisfactory recovery.
In the simple type the development is insidious for years. Early on we note dreaminess, or falling off of interest, and an impover ishment of the personality. The individual becomes moody, un social, irritable and less and less able to undertake any respon sibility or apply himself to anything but a simple task. Many tramps and ne'er-do-wells come into this category.
In hebephrenia after a period of ill-health there is often an abrupt onset of confusion and depression, with disagreeable de lusions of persecution and hallucinations. With the subsidence of the acute symptoms the fundamental defect becomes apparent with the symptoms mentioned above—the most prominent being bizarre conduct, incoherent thought and vivid auditory hallucina tions.
Catatonia tends, after a depressive phase, to manifest itself by a state of stupor or excitement, which irregularly alternate. In the former we see constrained, fixed attitudes with much muscular tension, and any attempt to move the patient is met with marked resistance (negativism). A state like that of catalepsy is often maintained with curious grimaces and mutism. There may be shown the opposite condition of negativism, i.e., a great suggesti bility in which all commands are mechanically obeyed. In the ex cited phase there is a manic-like condition, with much talking, shouting and general physical activity. The actions are, how ever, absurd, stereotyped and tend to be oft repeated. Violent impulses are given way to, and much violence is frequently man ifested, which may involve homicide and suicide. Delusions and hallucinations are in evidence, and the excited period may quickly abate.
The paranoid form often appears somewhat later in life than the others, and is specially differentiated by the presence of some what systematized delusions of persecution and grandeur, which are usually absurd and fantastic, with hallucinations of hearing.
In the large majority of cases dementia praecox is a serious, chronic condition, which leads to a progressive dementia. Yet it must not be considered hopeless, for some sufferers seem to re cover entirely and others may reach a stage of betterment which permits of some adjustment to life outside a mental hospital. To prognosticate the future in any individual is a very difficult problem. The paranoid form has the worst outlook.
Paranoid symptoms and paranoid states, akin in some respects to paranoia, may be met with as part of the clinical picture in many types of insanity, such as dementia praecox, general paresis, toxic insanities and manic-depressive insanity.
Idiocy is a state of profound mental defectiveness. The lower grades are unteacbable, while the higher may be educated slightly in such ways as attending to the calls of nature. The mental de velopment does not exceed that of a normal child of two years. Physical deformities of various kinds are common, the minor de fects being usually referred to as "the stigmata of degeneration." The causes of their failure in development are varied. Heredity has an influence, while accidents and injuries connected with preg nancy and child-birth are common causes. Acute infection and especially syphilis involving the brain, often contribute. General diseases of the mother and her pelvic organs may, under certain conditions, bring about brain malformation. There are several well recognized types: I. Amaurotic family idiocy occurs mainly, if not entirely, in the Jewish race. There is blindness, from atrophy of the optic nerve, and the idiocy is accompanied by paralysis of all four limbs. The child invariably dies before the age of two years.
2. Cretinism, due to an inborn deficiency in secretion from the thyroid gland. The effect of treatment with thyroid gland pro duces marvellous results.
3. Mongolism, so called because of the resemblance of the phys ical characteristics to those belonging to the Mongolian race. Certain features connected with the skull, tongue and eyes are diagnostic.
4. Hydrocephalus, commonly known as "water on the brain." The brain is unduly pressed upon and impaired by the excessive quantity of cerebrospinal fluid which accumulates within the ventricles.
5. Microcephaly. The skull is abnormally small, being less than I Tin. in circumference.
6. Sensory-deprivation Types. Here there is no structural de fect of the brain, but owing to the child being deprived of two or more of the principal senses, such as sight and hearing, upon which mental development depends, a state of severe mental defect is established. Special training, however, and the utiliza tion of other sensory organs, may have excellent results.
7. Other types are known as inflammatory (due to brain in flammation) ; paralytic (associated with paralysis) ; epileptic (as sociated with epilepsy). (See FEEBLE-MINDEDNESS.) Senile Forms of Insanity.—These may appear of ter 6o years of age. Accompanying physical decay there may only be a gen eral mental deterioriation or dementia, which is characterised by general reduction in intellectual capacities, memory defect, involving recent events, a narrowing of interests, more or less irritability, suspiciousness and restlessness, especially at night. Upon this background of senile dementia various insane symp toms may be ingrafted. There may be a certain amount of con fusion, which may be very marked, and memory defects may be associated with all sorts of fabrications (presbyophrenia). Spe cially depressed or agitated types may be in evidence, and a para noid condition with delusions of persecution and hallucinations of hearing are at times met with. The abnormal state may be com plicated by physical symptoms due to senile morbid brain changes. The course of senile dementia is progressive until death. Such patients finally become completely demented in every respect. Af ter death the brain shows signs of atrophy and there are definite organic changes in its substance, membranes and blood vessels.
The commonest exogenous toxin productive of insanity is alco hol. As was indicated when the general causes of insanity were being considered, the relation of alcohol to insanity has hitherto been viewed in a much too superficial light. Alcohol, patently, can bring about acute and chronic insanity through its toxic effect, but there are several forms which the more modern psychi atrists look upon as other forms of mental disease, merely col oured by the added factor of alcoholism, or which may be viewed as psychopathic reactions which alcohol has allowed to come to the surface. Though these types of so-called alcoholic insanity will be mentioned here, under their several headings, it will be pointed out that, strictly speaking, they should come under a different classification. Alcohol is, undoubtedly, in its effects an indication of the nervous and mental stability of an individual. In vino veritas is a very true maxim, for it is when the influ ence of wine is at work that the true personality is manifested. The veneer of conscious control is removed, and those who, through head injury or disease, have already a diminution of cerebral control, will the more easily react to its effects. The de fect in inhibitions which are so liable to accompany the incidence of certain forms of insanity may easily lead to alcoholic habits, these then being mistaken as causative of the disorder.
Ordinary drunkenness may be pathological, and render unstable people temporarily insane. Under the influence of variable quan tities of alcohol an individual may evince maniacal frenzy, delu sions and hallucinations, and may indulge in such anti-social con duct that the law has to step in to restrain him. Subsequent to such attacks there is usually a complete blank in the memory of such episodes. The only true toxic types of alcoholic insanity are delirium tremens, alcoholic dementia and a peculiar form known as Korsakow's psychosis.
Delirium Tremens. This condition of temporary insanity is too short-lived to be seen within the walls of mental hospitals, though abnormal states may follow which necessitate supervision and control. It usually originates in a chronic alcoholic, after a severe drunken bout, but may also occur in an alcoholic who is the victim of acute disease or some gross injury. That sudden abstinence is provocative, as has been thought, is exceedingly doubtful. Most commonly, before the special symptoms manifest themselves, there is a period of a few days in which the sufferer is nervous, sleepless, restless, shaky and has no appetite. The de lirium more or less suddenly appears. The patient is quite con fused as to time and place and has the most vivid hallucinations, which are predominantly visual. These characteristically take on the form of small animals, such as rats, snakes and insects, but they may be of larger type in all kinds of fantastic shapes. Audi tory hallucinations causing apprehension are sometimes present, and all sorts of delusional experiences may be passed through. The emotion is that of great fear of meeting some awful fate and con duct is not only extremely restless, but is apt to show impulsive offence and defence. The delirium may be occupational in char acter, and the patient is constantly busy carrying out his usual duties in a make-believe world. Speech is incoherent, and mostly in touch with his hallucinatory experiences. Tremor is well marked, and is mostly noted in the small muscles of the hand, tongue and face. The condition lasts only a few days and termi nates in a long sleep. Some, however, die from exhaustion.
Alcoholic dementia is liable to result from th'e chronic toxic effect of long years of excessive alcoholic indulgence. Insidiously there is a progressive enfeeblement of the intellect, a blunting of judgment, memory, control and morality. Untruthfulness is prominent, and attitudes of jealousy and a feeling of persecution, which are common, are apt to develop into definite delusions. Finally the mental deterioration is extreme, and attended by or ganic disorders resulting from alcohol. In some cases both the mental and physical signs resemble those seen in general paralysis of the insane.
The third form of a true alcoholic insanity is called after the psychiatrist who first described the condition, and known as Korsakow's psychosis. Though the commonest causative toxin is alcohol, other poisons are sometimes responsible. It is compara tively rarely seen before the age of so, and is noted more in the female sex. It may result immediately from an attack of delirium tremens and has been looked upon as a chronic alcoholic delirium. The characteristic symptom is a peculiar falsification of memory. There is a marked defect in the recording of the events of the present and past for a variable period, but long distant experiences are well recollected. The memory gaps are unconsciously com pensated for by being filled by all sorts of fabrications, which are recounted in great detail and have every appearance of truth. The converse seems clear and intelligent, though it is highly con fused as to time and place. Hallucinations both of sight and hear ing are usually present. The mood is mostly happy and the patient has no insight into his condition. In the physical sphere there is neuritis of many of the peripheral nerves, with perhaps some local paralysis. Besides, various other structures of the nervous system may be involved. As a rule the outlook is not good, and even where much betterment ensues, the memory is left defective. There are two other forms of insanity which are usually classed as alcoholic in origin, but since the symptoms are not really due to its toxic effect, but to the fact that the alcohol has released morbid potentialities, they should not scientifically be brought under such a heading. There are so-called alcoholic hallucinosis and alcoholic In alcoholic hallucinosis the symptoms mainly in evidence are auditory hallucinations of an unpleasant nature, with delusions of persecution, in which the sexual element tends to be predom inant. The patient hears voices accusing him of all sorts of im moral practices, and concerning these he is gibed at and threat ened. He is naturally anxious, depressed and apprehensive of harm. The fact that he may identify those around him as his persecutors is liable to render him dangerous and homicidal. On the other hand, suicide as a refuge may be attempted. As a rule, recovery to sanity comes about, but the condition may become chronic.
In alcoholic paranoia there is a paranoid state in which hallu cinations, if present, are of secondary importance, the character istic symptom being delusions of jealousy and marital infidelity. These alcoholic delusions of jealousy tend to fluctuate with the amount of alcohol drunk, and commonly disappear quickly when abstinence is enforced in an institution. Very rarely the insanity becomes chronic. Other toxic agents such as opium, cocaine and miscellaneous intoxicants may cause insanity, but are too uncom mon and unimportant to need mention.
According to the report of the United States Department of Commerce, the number of insane persons in 161 of the 165 State and Federal hospitals for mental disease on Jan. i, 1927 (ex clusive of the State psychopathic hospitals, and the Federal hos pitals operated by the Veterans' Bureau, the Public Health Service, the Army and the Navy), was 250,89o, as compared with a total of 229,664 in 1923. In the country as a whole the number of mental patients under institutional care shows a steady increase.
(C. S. R.)