Part 44

The occurrence of dementia is sometimes preceded by an acute hallucinatory phase, accompanied by mania or melancholia; but as a general rule, in the presenile cases, by neurasthenia, indifference, and mental apathy which extends to a disregard for the ordinary conventions and the means of subsistence.

It has pithily been remarked that the age of a man is the age of his blood-vessels. The two conditions of senile and presenile dementia cannot therefore be separated scientifically. From a clinical point of view, however, the two are distinguishable in so far as their symptoms are concerned, for the presenile cases are more complete and the process of dementia achieves its consummation earlier and quicker, while in the senile the gradual disease of the arteries and the slow decay of the mental faculties offer a different background for the manifestation of mental symptoms. Moreover, the senile patients more frequently present symptoms of recurrent attacks of acute insanity, a more pronounced emotionalism, and a greater tendency to restlessness at night. The presenile cases, on the other hand, except at the commencement of their malady, are usually free from acute and troublesome symptoms and present chiefly an apathetic indifference and irresponsiveness on the mental side, and on the physical side a neurasthenic and enfeebled bodily state. In both conditions memory is greatly impaired.

Added to senile dementia there is often found a condition of mania or melancholia or even of systematized delusional insanity. The chief symptoms of the maniacal attacks are the great motor restlessness and excitement, which are worst during the night time. Sleep is almost always seriously disturbed, and the patients rapidly become exhausted unless carefully nursed and tended. The actions of senile maniacs are often puerile and foolish, and they may exhibit impulses of a homicidal, suicidal or sexual character. The melancholic cases are also extremely restless, and their emotion is loudly expressed in an uncontrollable manner. They often have delusions of persecution. Their cries and groans have an automatic character, as if the patient, though compelled to utter them, did not experience the mental pain which he expressed. They also, many of them, eat their food ravenously, although a few obstinately refuse it. The senile delusional cases may manifest any of the classical forms of paranoia described above, but their delusions are of a rudimentary and unfinished type. The most common of all senile delusions is that they are being robbed. They therefore often hide their small valuables in corners and out-of-the-way places, and as their memories are very defective they are afterwards unable to find them. Others, who live alone, barricade their doors and try to prevent any one entering for fear of thieves. Delusions of ambition in senile subjects are usually of a very improbable and childish character. Hallucinations are generally present in the senile delusional cases.

The _treatment_ of senile insanity is from the medical point of view not hopeful; it resolves itself largely into instructions for careful nursing, suitable feeding, and the protection of the patient from all the physical dangers to which he may be exposed.

_Statistics._--The statistics of lunacy are merely of interest from a sociological point of view; for under that term are comprised all forms of insanity. It is needless to produce tables illustrative of the relative numbers of lunatics in the various countries of Europe, the systems of registration being so unequal in their working as to afford no trustworthy basis of comparison.

Even in Great Britain, where the systems are more perfect than in any other country, the tables published in the Blue Books of the three countries can only be regarded as approximately correct, the difficulty of registering all cases of lunacy being insuperable. On the 1st of January 1907, according to the returns made to the offices of the Commissioners in Lunacy, the numbers of lunatics stood thus on the registers:--

+------------------+--------+----------+---------+ | | Males. | Females. | Totals. | +------------------+--------+----------+---------+ | England and Wales| 57,176 | 66,812 | 123,988 | | Scotland | 8,594 | 8,999 | 17,593 | | Ireland | 12,254 | 11,300 | 23,554 | +------------------+--------+----------+---------+ | Gross total | 78,024 | 87,111 | 165,135 | +------------------+--------+----------+---------+

These figures show the ratio of lunatics to 100,000 of the population to be 354 in England and Wales, 312 in Scotland, and 538 in Ireland.

_Numbers of Lunatics on the 1st of January of the years 1857-1907 inclusive, according to Returns made to the Offices of the Commissioners in Lunacy for England and Wales, Scotland and Ireland._

+------+---------+----------+----------+ | | England | | | |Years.| and | Scotland.| Ireland. | | | Wales. | | | +------+---------+----------+----------+ | 1858 | .. | 5,823 | .. | | 1859 | 36,762 | 6,072 | .. | | 1860 | 38,058 | 6,273 | .. | | 1861 | 39,647 | 6,327 | .. | | 1862 | 41,129 | 6,398 | 8,055 | | 1863 | 43,118 | 6,386 | 7,862 | | 1864 | 44,795 | 6,422 | 8,272 | | 1865 | 45,950 | 6,533 | 8,845 | | 1866 | 47,648 | 6,730 | 8,964 | | 1867 | 49,086 | 6,888 | 8,962 | | 1868 | 51,000 | 7,055 | 9,086 | | 1869 | 53,177 | 7,310 | 9,454 | | 1870 | 54,713 | 7,571 | 10,082 | | 1871 | 56,755 | 7,729 | 10,257 | | 1872 | 58,640 | 7,849 | 10,767 | | 1873 | 60,296 | 7,982 | 10,958 | | 1874 | 60,027 | 8,069 | 11,326 | | 1875 | 63,793 | 8,225 | 11,583 | | 1876 | 64,916 | 8,509 | 11,777 | | 1877 | 66,636 | 8,862 | 12,123 | | 1878 | 68,538 | 9,097 | 12,380 | | 1879 | 69,885 | 9,386 | 12,585 | | 1880 | 71,191 | 9,624 | 12,819 | | 1881 | 73,113 | 10,012 | 13,062 | | 1882 | 74,842 | 10,355 | 13,444 | | 1883 | 76,765 | 10,510 | 13,882 | | 1884 | 78,528 | 10,739 | 14,088 | | 1885 | 79,704 | 10,918 | 14,279 | | 1886 | 80,156 | 11,187 | 14,590 | | 1887 | 80,891 | 11,309 | 14,702 | | 1888 | 82,643 | 11,609 | 15,263 | | 1889 | 84,340 | 11,954 | 15,685 | | 1890 | 86,067 | 12,302 | 16,159 | | 1891 | 86,795 | 12,595 | 16,251 | | 1892 | 87,848 | 12,799 | 16,688 | | 1893 | 89,822 | 13,058 | 17,124 | | 1894 | 92,067 | 13,300 | 17,276 | | 1895 | 94,081 | 13,852 | 17,665 | | 1896 | 96,446 | 14,093 | 18,357 | | 1897 | 99,365 | 14,500 | 18,966 | | 1898 | 101,972 | 14,906 | 19,590 | | 1899 | 105,086 | 15,399 | 20,304 | | 1900 | 106,611 | 15,663 | 20,863 | | 1901 | 107,944 | 15,899 | 21,169 | | 1902 | 110,713 | 16,288 | 21,630 | | 1903 | 113,964 | 16,658 | 22,138 | | 1904 | 117,199 | 16,894 | 22,794 | | 1905 | 119,829 | 17,241 | 22,996 | | 1906 | 121,979 | 17,450 | 23,365 | | 1907 | 123,988 | 17,593 | 23,554 | +------+---------+----------+----------+

There is thus an increased ratio in England and Wales of lunatics to the population (which in 1859 was 19,686,701, and in 1907 was estimated at 34,945,600) of 186.8 per 100,000 as against 354.8, and in Scotland of 157 as against 312 per 100,000. The Irish figures on the same basis have increased from 130.9 in 1862 to 538.1 in 1907. The publication of these figures has given rise to the question whether lunacy has actually become more prevalent during the last twenty years, whether there is real increase of the disease. There is a pretty general consent of all authorities that if there has been an increase it is very slight, and that the apparent increase is due, first to the improved systems of registration, and secondly (a far more powerful reason) to the increasing tendency among all classes, and especially among the poorer class, to recognize the less pronounced forms of mental disorder as being of the nature of insanity. Thirdly, the grant of four shillings per week which in 1876 was made by parliament from imperial sources for the maintenance of pauper lunatics has induced parochial authorities to regard as lunatics a large number of weak-minded paupers, and to force them into asylums in order to obtain the benefit of the grant and to relieve the rates. These views receive support from the fact that the increase of private patients, i.e. patients who are provided for out of their own funds or those of the family, has advanced in a vastly smaller ratio. In their case the increase, small as it is, can be accounted for by the growing disinclination on the part of the community to tolerate irregularities of conduct due to mental disease. And again, careful inquiry has failed to show a proportional increase of admissions into asylums of such well-marked forms as general paralysis, puerperal mania, &c. The main cause of the registered increase of lunatics is thus to be sought for in the improved registration, and parochial and family convenience. If there is an actual increase, and there is reason for believing that there is a slight actual increase, it is due to the tendency of the population to gravitate towards towns and cities, where the conditions of health are inferior to those of rural life, and where there is therefore a greater disposition to disease of all kinds.

The futility of seeking for accurate figures bearing on the relative number of lunatics in other countries is illustrated by the tables set forth in a report by the United States Census Bureau. They show that the number of registered lunatics in 1903 was 150,151; in 1890, 74,028; and in 1880, 40,942. An attempt was made in 1890 to estimate the number of insane persons outside of hospitals, which was stated to be 32,457. In 1903 no such attempt was made, as it was admitted that so many sources of fallacy existed as to render it useless. Thus the mere statement that of every 100,000 of the population (calculated at 80,000,000) 186.2 were registered as insane is of no value.

BIBLIOGRAPHY.--The following are systematic works: Bucknill and Tuke, _Psychological Medicine_ (4th edition, 1879); Griesinger, _On Mental Diseases_ (New Sydenham Society, 1867); Maudsley, _The Pathology of Mind_ (1895); Bevan Lewis, _A Text-Book of Mental Diseases_ (1899); Clouston, _Clinical Lectures on Mental Diseases_ (1892); Kraepelin, _Psychiatrie_ (1893); Krafft-Ebing, _Lehrbuch der Psychiatrie_ (1893); Regis, _A Practical Manual of Mental Medicine_ (London, 1895); Magnan, _Leçons cliniques sur les maladies mentales_ (1897); Mendil, _Leitfaden der Psychiatrie_ (1902); Mercier, _A Text-Book of Insanity_ (1902); Lewis C. Bruce, _Studies in Clinical Psychiatry_ (1906); Macpherson, _Mental Affections_ (1899); Brower-Bannister, _Practical Manual of Insanity_ (1902); Ford Robertson, _Text-Book of Pathology in Relation to Mental Diseases_ (1900). (J. B. T.; J. Mn.; L. C. B.)

II. LEGAL ASPECTS

The effect of insanity upon responsibility and civil capacity has been recognized at an early period in every system of law.

_Roman Law._--In the Roman jurisprudence its consequences were very fully developed, and the provisions and terminology of that system have largely affected the subsequent legal treatment of the subject. Its leading principles were simple and well marked. The insane person having no intelligent will, and being thus incapable of consent or voluntary

## action, could acquire no right and incur no responsibility by his own

acts (see Sohm's _Inst. Roman Law_, 3rd ed. pp. 216, 217, 219); his person and property were placed after inquiry by the magistrate under the control of a curator, who was empowered and bound to manage the property of the lunatic on his behalf (Sohm, p. 513; Hunter, _Roman Law_, pp. 732-735). The different terms by which the insane were known, such as _demens_, _furiosus_, _fatuus_, although no doubt signifying different types of insanity, did not in Roman law infer any difference of legal treatment. They were popular names, which all denoted the complete deprivation of reason.

_Medieval Law._--During the middle ages the insane were little protected. Their legal acts were annulled, and their property placed under control, but little or no attempt was made to supervise their personal treatment. In England the wardship of idiots and lunatics, which was annexed before the reign of Edward II. to the king's prerogative, had regard chiefly to the control of their lands and estates, and was only gradually elaborated into the systematic control of their persons and property now exercised under the jurisdiction in lunacy. Those whose means were insignificant were left to the care of their relations or to charity. In criminal law the plea of insanity was unavailing except in extreme cases. About the beginning of the 19th century a very considerable change commenced. The public attention was strongly attracted to the miserable condition of the insane incarcerated in asylums without any efficient check or inspection; and at the same time the medical knowledge of insanity entered on a new phase. The possibility and advantages of a better treatment of insanity were illustrated by eminent physicians, Philippe Pinel in France, H. Tuke in England, Bond, B. Rush and I. Ray in the United States; its physical origin became generally accepted; its mental phenomena were more carefully observed, and its relation was established to other mental conditions.

_Modern Law._--From this period we date the commencement of legislation such as that known in England as the Lunacy Acts, which aimed at the regulation and control of all constraint applied to the insane. Hitherto, the criteria of insanity had been very rude, and the evidence was generally of a loose and popular character; but, whenever it was fully recognized that insanity was a disease with which physicians who had studied the subject were peculiarly conversant, expert evidence obtained increased importance, and from this time became prominent in every case. The newer medical views of insanity were thus brought into contact with the old narrow conception of the law courts, and a controversy arose in the field of criminal law which in England, at least, still continues.

_Relations between Insanity and Law._--The fact of insanity may operate in law--(1) by excluding responsibility for crime; (2) by invalidating legal acts; (3) by affording ground for depriving the insane person by a legal process of the control of his person and property; or (4) by affording ground for putting him under restraint.

_Legal Terminology._--Before proceeding, however, to deal with these matters in succession, it may be desirable to say something with regard to the chief legal terms respecting persons suffering under mental disabilities. The subject is now of less importance than formerly, because the modern tendency of the law is to determine the capacity or responsibility of a person alleged to be insane by considering it with reference to the particular matter or class of matters which brings his mental condition _sub judice_. But the literature of the law of lunacy cannot be clearly understood unless the distinctions between the different terms employed to describe the insane are kept in view. The term _non compos mentis_ is as old as the statute _De praerogativa regis_ (1325), and is used sometimes, as in that statute, to indicate a species contrasted with idiot, sometimes (e.g. in Co. Litt. 246 (b)) as a genus, and afterwards, chiefly in statutes relating to the insane, in connexion with the terms "idiot" and "lunatic" as a word _ejusdem generis_. The word "idiot" (Gr. [Greek: idios], a private person, one who does not hold any public office, and [Greek: idiôtês], an ignorant and illiterate person) appears in the statute _De praerogativa regis as fatuus naturalis_, and it is placed in contradistinction to _non compos mentis_. The "idiot" is defined by Sir E. Coke (4 Rep. 124 (b)) as one who from his nativity, by a perpetual infirmity, is non compos mentis, and Sir M. Hale (_Pleas of the Crown_, i. 29) describes idiocy as "fatuity a _nativitate vel dementia naturalis_." In early times various artificial criteria of idiocy were suggested. Fitzherbert's test was the capacity of the alleged idiot to count twenty pence, or tell his age, or who were his father and mother (_De natura brevium_, 233). Swinburne proposed as a criterion of capacity, inter alia, to measure a yard of cloth or name the days in the week (_Testaments_, 42). Hale propounded the sounder view that "idiocy or not is a question of fact triable by jury and sometimes by inspection" (_Pleas of the Crown_, i. 29). The legal incidents of idiocy were at one time distinct in an important

## particular from those of lunacy. Under the statute _De praerogativa

regis_ the king was to have the rents and profits of an idiot's lands to his own use during the life of the idiot, subject merely to an obligation to provide him with necessaries. In the case of the lunatic the king was a trustee, holding his lands and tenements for his benefit and that of his family. It was on account of this difference in the legal consequences of the two states that on inquisitions distinct writs, one _de idiota inquirendo_, the other _de lunatico inquirendo_, were framed for each of them. But juries avoided finding a verdict of idiocy wherever they could, and the writ _de idiota inquirendo_ fell into desuetude. A further blow was struck at the distinction when it came to be recognized even by the legislature (see the Idiots Act 1886) that idiots are capable of being educated and trained, and it was practically abolished when the Lunacy Regulation Act 1862, in a provision reproduced in substance in the Lunacy Act 1890, limited the evidence admissible in proof of unsoundness of mind on an inquisition (without special leave of the Master trying the case) to a period of two years before the date of the inquiry, and raised a uniform issue, viz. the state of mind of the alleged lunatic at the time when the inquisition is held.

The term "lunatic," derived from the Latin _luna_ in consequence of the notion that the moon had an influence on mental disorders,[1] does not appear in the statute-book till the time of Henry VIII. (1541). Coke defines a lunatic as a "person who has sometimes his understanding and sometimes not, _qui gaudet lucidis intervallis_, and therefore he is called _non compos mentis_ so long as he has not understanding" (Co. Litt. 247 (a), 4 Rep. 124 (b)). Hale defines "lunacy" as "interpolated" (i.e. intermittent) _dementia accidentalis vel adventitia_, whether total or (a description, it will be observed, of "partial insanity") _quoad hoc vel illud_ (_Pleas of the Crown_, i. 29). In modern times, the word "lunacy" has lost its former precise signification. It is employed sometimes in the strict sense, sometimes in contradistinction to "idiocy" or "imbecility"; once at least--viz. in the Lunacy Act 1890--as including "idiot"; and frequently in conjunction with the vague terms "unsound mind" (non-sane memory) and "insane." Section 116 of the Lunacy Act 1890 has by implication extended the meaning of the term lunacy so as to include for certain purposes the incapacity of a person to manage his affairs through mental infirmity arising from disease or age. "Imbecility" is a state of mental weakness "between the limits of absolute idiocy on the one hand and of perfect capacity on the other" (see 1 Haggard, _Eccles. Rep._ p. 401).

Macnaughton's Case.

1. _The Criminal Responsibility of the Insane._--The law as to the criminal responsibility of the insane has pursued in England a curious course of development. The views of Coke and Hale give the best exposition of it in the 17th century. Both were agreed that in criminal causes the act and wrong of a madman shall not be imputed to him; both distinguished, although in different language, between _dementia naturalis_ (or a _nativitate_) and _dementia accidentalis_ or _adventitia_; and the main points in which the writings of Hale mark an advance on those of Coke are in the elaboration by the former of the doctrine of "partial insanity," and his adoption of the level of understanding of a child of fourteen years of age as the test of responsibility in criminal cases (_Pleas of the Crown_, i. 29, 30; and see Co. 4 _Rep._ 124 (b)). In the 18th century a test, still more unsatisfactory than this "child of fourteen" theory, with its identification of "healthy immaturity" with "diseased maturity" (Steph. _Hist. Crim. Law_, ii. 150), was prescribed. On the trial of Edward Arnold in 1723 for firing at and wounding Lord Onslow, Mr Justice Tracy told the jury that "a prisoner, in order to be acquitted on the ground of insanity, must be a man that is totally deprived of his understanding and memory, and doth not know what he is doing, no more than an infant, than a brute or wild beast." In the beginning of the 19th century a fresh statement of the test of criminal responsibility in mental disease was attempted. On the trial of Hadfield for shooting at George III. in Drury Lane Theatre on 15th May 1800, Lord Chief Justice Kenyon charged the jury in the following terms: "If a man is in a deranged state of mind at the time, he is not criminally answerable for his acts; but the material part of the case is whether at the very time when the act was committed the man's mind was sane." The practical effect of this ruling, had it been followed, would have been to make the question of the amenability of persons alleged to be insane to the criminal law very much one of fact, to be answered by juries according to the particular circumstances of each case, and without being aided or embarrassed by any rigid external standard. But in 1812, on the trial of Bellingham for the murder of Mr Perceval, the First Lord of the Treasury, Sir James Mansfield propounded yet another criterion of criminal responsibility in mental disease, viz. whether a prisoner has, at the time of committing an offence, a sufficient degree of capacity to distinguish between good and evil. The objection to this doctrine consisted in the fact, to which the writings of Continental and American jurists soon afterwards began to give prominence, that there are very many lunatics whose general ideas on the subject of right and wrong are quite unexceptionable, but who are yet unable, in consequence of delusions, to perceive the wrongness of particular acts. Sir James Mansfield's statement of the law was discredited in the case (4 _State Tri._ (n.s.) 847; 10 Cl. and Fin. 200) of Daniel Macnaughton, who was tried in March 1843, before Chief Justice Tindal, Mr Justice Williams and Mr Justice Coleridge, for the murder of Mr Drummond, the private secretary of Sir Robert Peel. Mr (afterwards Lord Chief Justice) Cockburn, who defended the prisoner, used Hale's doctrine of partial insanity as the foundation of the defence, and secured an acquittal, Chief Justice Tindal telling the jury that the question was whether Macnaughton was capable of distinguishing right from wrong _with respect to the act with which he stood charged_. This judicial approval of the doctrine of partial insanity formed the subject of an animated debate in the House of Lords, and in the end certain questions were put by that House to the judges, and answered by Chief Justice Tindal on behalf of all his colleagues except Mr Justice Maule, who gave independent replies. The answers to those questions are commonly called "The Rules in Macnaughton's case," and they still nominally contain the law of England as to the criminal responsibility of the insane. The points affirmed by the Rules that must be noted here are the propositions that knowledge of the nature and quality of the