David Skae

"At one point I thought of directing your attention to the medico-legal relations of Insanity, with a special reference to the oproprium which has so often been thrown upon medical witnesses for the unseemly differences and contradictions displayed by them in our courts of law in questions as to the existence of Imbecility and Insanity. I have strong conviction that these differences and contradictions are entirely due to the “lawers”, and the very imperfect and erroneous legal defintions of Idiocy and Insanity, and nor to the “Doctors”. And I think we ought, both as individuals and as an Association, to use all our energies and influence to bring about a revision of the legal distinctions regarding Insanity, so as to get their distinctions and definitions in conformity with ours, or, more correctly speaking, in conformity with nature and facts;-with those descriptions and distinctions which we have derived from the careful study of mental disease. Let the legal responsibility, or legal capacities of each class so recognized, be at the same time fixed and determined by law, and then-and then only-will the greater part of the difficulties and discrepancies of medical testimony entirely disappear."

"From my own personal experience, then, and from what I have observed in the practical experience of others-of the many distinguished and talented young men who have studies Insanity under my care,-it has always struck me, that the moment they came into actual persona contact with the insane, all their preconceived notions of Insanity derived from our systematic works were found to be vague, misty, and purely conventional descriptions of what they actually saw. Acute Mania, instead of being the frightfully agonizing picture drawn by Chiauggi, was only presented to them in the transient and babbling excitement of a harmless and frightened, but dirty unifying, and destructive patient. The gradations between Acute Mania and Mania, and Chronic Mania and Dementia have osme degree of noise and destructiveness, they found to be so gradual, that it was very difficult, and, in fact, only a conventional matter to say where the one beganand the other ended. In “Idiots” and “Dements” they found every degree of mental impairment-from simple loss of memory and slight childishness, to total fatuity, and obliteration of all the mental faculties. Among the so-called “Monomaniacs”, thy found very few who were “Monomaniacs” at all : most of them were insane on severalsubjects, although presenting some more “salient” feature”, such as the fear of poison, hanging, or eternal damnation, or the belief of exalted rank or enormous wealth or power. Many of them had no delusions at all; and gradually we began to discover that the “Moral Insanity”,which was confined to our text-books to a few cases of homicidal and suicidal impulse, ran through every variety of Insanity as at present classified,-so that we found Acute Mania and Chronic Mania, and Melancholia and Monomania or Self-esteem or Pride, and of Fear, all existing without any delusions."

"The next point which has struck me in my experience, both in respect to others and myself, whether as regards cases placed under our care, or cases in regard to which were asked to give our opinion in consultation, is the mode in which we all very soon come to look at any new case. We do not ask ourselves, nor do we seek to determine by the questions we put to the patient or his friends, what the nosological name of his particular form of Insanity is. What we are solicitous to know is the “natural history” of the disease before us, and its cause. Is it a Congenital disease? It is one associated with Epilepsy caused by masturbation, by paturation, or protracted lactation, or some other debilitating cause, or by hard drinking? Is it a case of orgnaic Brain disease, or General Paralysis? Is it one connected with Phthisis-with the critical period, or with the atheromatous vessels of the brain of the Senile Dement? Such are the kind of questions we seek to solve, in order to form a diagnosis of the nature of the case, and in order to enable us to answer the anxious inquiries of friend as to its probable termination ; and such instinctively and practically are the data upon which we classify the cases, which are placed under our case, in our own minds. Why, then, should we adopt another ground of classification in our tables and text-books? And why should we perpetuate a nomenclature so indefinite and conventional, and which has no other foundation upon which to rest than an imperfect, of not an obsolete, system of psychology? Were our physiology of the Brain as perfect as that of the Lungs-were we able to predicate what particular portion of the Brain was affected in each case of Insanity-I cannot see how our present mode of classifying the varieties of the disease (according to the character of the mental symptoms) would ever be one of practical utility. We do not classify the various disease in which delirium is present by the character of the mental affection l we do not describe acute or violent delirium, or muttering delirium, or fugacious and wandering delirium, or coma, as “diseases” ; we describe the diseases upon which they depend, of some of which we know as little as we do of Insanity, but of which we know at least the natural history,- the origin, course, and probable termination ; and we describe, accordingly, inflammatory fewer, typhus and typhoid fevers, phthisis, uraemic poisoning, and the other diseases of which these different forms of delirium are only symptoms. Why should we proeed upon another principle in regard to Insanity? Why should we attempt to group and classify the varieties of Insanity by the “mental” symptoms, and not, as we do in other disease, by the “bodily disease” of which those mental perversions are but the signs?"

"My proposition, then, is this-that we ought to classify all the varieties of Insanity to use a botanical term, in their natural orders or families; or, to use a phrase more familiar to the Physician’s er, that we should group them in accordance with the “natural history” or each. Now, I observe, in starting, that wherever we have a very “distinct” natural history of any form of Insanity, we at present always refer it to its natural order, without reference to the character of the mental disorder. All our Epileptics are classified “as such”, whether they are demented or Monomaniacs, or subject to paroroxyms of Acute Mania. It is Insanity with epilepsy. “Puerperal Mania” forms a distinct group whether the patient is maniacal, suicidal, or melancholic. “General Paralysis” afford another group, and none of us ever think of referring a General Paralytic to any other group than that of the natural family to which he belongs, whether is maniacal a man of exalted wealth and rank, a melancholic, or a dement. Is it not possible to extend the same rational and practical method of classification to all the other varieties of Insanity? I do think it can be done, at least to a very great extent; and I do think that this is, in the present state of our knowledge, the only rational and really practical basis of classification."

"The first natural group is obviously “Idiocy”, including Imbecility under all its various forms and degrees, until we come down, or up rather, to the mere mild Dundrearyism of an effete and degenerate race. To this class must be referred a large number of cases of “moral idiocy and imbecility”, many of which at present get mixed up, by our present mode of classification, among the Insane, as Monomaniacs of various kinds. Such are many cases, familiar to all of you, of congenital moral perversion, instinctive cruelty, and destructiveness and theft. Many of our most noted Kleptomaniacs have had the tendency from childhood, and have been “moral imbeciles”. In fact, as far as a I know, all of them have been so ; when we meet with Kleptomania in cases of Insanity” it is only as one of many other symptoms, as when we find it associated, as often do, with General Paralysis. I would refer all those cases of Insanity, which are hut the development and aggravation of a congenital moral perversion, or want of balance, to the class of congenital moral imbeciles."

"The second natural group appears to me to be the Epileptics. Epilepsy is emphatically a disease of childhood, and when it is established at that period, it arrests the development of the Brain, and is associated with Idiocy and Imbecility. In other cases, we have it associated with maniacal paroxysms, Monomania, or Dementia, or total Fatuity. All the cases, whatever the mental symptoms may be, or however they may vary, as they often do, during the progress of the disease, still they form a distinct natural family, of which the epileptic seizures are the most prominent symptoms, and the causes of that state of the nervous system which conditions the mental derangement with which each case is complicated."

"The third natural family I would assign to the Masturbators. Although I designate this family by the cause only which originates the Insanity, yet I think it cannot be denied that that vice produces a group of symptoms which are quite characteristic and easily recognised, and give to the cases a special natural history ; — the peculiar imbecility and shy habits of the very youthful victim ; the suspicion, and fear, and dread, and suicidal impulses, and palpitations, and scared look, and feeble body, of the older offenders, passing gradually into Dementia or Fatuity, with other characteristic features familiar to all of you, and which I do not stop to enlarge on, — all combine to stamp and define this as a natural order or family."

"Next comes a well-known group, but with protean lineaments, yet familiar to all of us, cases of Hysterical Mania. I need not weary you by an attempt to describe its varied features, from cases of singular moral perversion, living without food, giving birth to mice and toads, passing all sorts of curious things with the urine, up through the long and singular forms it presents with varied sexual and erotic symptoms, until we find it presenting a truly maniacal aspect. You must know them all, and yet you recognise in all with readiness the Hysteria, which characterises every variety, and makes your prognosis and treatment so different from what, in the absence of that significant mark, it would have been. This is certainly a well-marked natural order."

"The Insanity of the critical period of life is a form very familiar to us ; and I have no doubt you have recognised a critical period in the male sex as well as in the female, — a period of life at which, in many men, great disturbance of the normal state of the feelings and emotions is experienced, in some instances amounting to an insanity of the same type as that generally met with in females at their critical period — namely, a monomania of fear, despondency, remorse, hopelessness, passing occasionally into Dementia. This variety I would designate as Climacteric Insanity. There is a form of Insanity common to females, different from Hysterical Mania, or Nymphomania, and which, I think, is commonly associated with Ovarian disease, sometimes with uterine disease, and of which one of the most common symptoms is a sexual hallucination, — the belief that certain persons visit them and co- habit with them during the night, and other similar delusions. This form might be denominated Utero-mania, or Ovario-mania. It is, I think, par excellence the Insanity of old maids."

"The next natural order is doubtless Senile Insanity, occasionally commencing in the form of Mania, more frequently in the form of Melancholia, but most frequently during its whole course presenting the well known features of Dementia, in all its degrees, from simple impairment of the memory down to total Fatuity ; and de- pendent, I believe, upon an atheromatous condition of the vessels of the Brain, and the consequent changes which take place in the nutritive and reparative processes of the cerebral tissues. This form of Insanity I hope to see fully described in an early number of the Journal by my friend Dr Yellowlees."

"I would strongly press upon you this view of the subject, — one to which I have already referred, that this is, in fact, the stand- point from which we all instinctively view a case of Insanity, when called upon as practical men to form a diagnosis, or offer a prognosis, upon any case submitted to us for the first time. We ask ourselves, is this a case of congenital moral perversion or intellectual deficiency? Is it one connected with masturbation, with pubescence, with hysteria, with phthisis, with drinking, with uterine disease, with brain disease, and so forth ? If this is true, surely this is at least the practical basis upon which to form a Classification of the Insane; and if not the most scientific, it is certainly more so than the present poor, uncertain, and conventional one, or perhaps than any one which can be founded upon a physiological or psychological basis, in our present very imperfect knowledge of the physiology of the Brain. It has this especial merit, at least — that it ever keeps before us the all-important principle, that Insanity is a disease of the body, whether it be of some remote organ sympathetically acting on the mind, or of the material organ of the mind itself."