Section of Psychiatry 3

The Concept of Insanity.

By CHARLES A. MERCIER, M.D.
WHAT is insanity? What do we mean when we use the word?
What is the concept in our minds? It is not easy to say. No doubt
we all of us have a certain vague notion in our minds, but the fact that
we cannot put the notion into words shows that the notion is but vague
and cloudy, sadly lacking in precision and definiteness. For we cannot
put it into words, or, at any rate, no one has yet formulated any definition
of insanity that is generally accepted. My own definition, formulated
many years ago, that insanity is disorder of the process of adjustment of
the self to its circumstances, is, I still believe, correct and sound; but
the fact that no one else has adopted it shows that it is either not
generally understood or that it lacks some other necessar.y quality.
I shall try in this essay to correct this defect, and to produce a definition,
or at any rate a description, of insanity that, if it is not accepted, will,
at any rate, not be rejected because it is unintelligible.
The current and accepted notion of insanity is that it is unsoundness
of mind. Insanity and unsoundness of mind are convertible terms.
Insanity is unsoundness of mind, and unsoundness of mind is insanity.
That is undoubtedly the prevailing notion, and it is indisputably false.
I have shown, over and over again-what ought not to want showing,
for it is as plain and manifest as the sun in the heavens-that insanity
includes much that is not unsoundness of mind, and that unsoundness
of mind includes much that is not insanity. The two things coincide
for a part of their extent, but for a part only, and are no more conter-
minous than Europe and the British Empire are conterminous. Each
includes much that is not in the other.
I hope I may take it that my doctrine, that insanity is disorder, not
of mind alone, but of conduct also, is familiar to you. I have shown,
again and again, that there are many disorders of mind-from giddiness
and epileptic auras, through claustrophobia and agoraphobia, up to
imperative idea and obsession-that are not insane, and have scarcely
more to do with insanity than they have with astronomy; I have shown,
again and again, that in many cases of insanity we need never consider
-and never do consider-whether the mind is disordered or not; I
have shown, again and again, that we may not, and dare not, brand a
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4 Mercier: The Concept of Insanity
person as insane until we have examined his conduct and found disorder
therein; and I have shown, again and again, that even if disorder of
mind were the criterion of insanity, we must first estimate conduct; for
only through the evidence of conduct can order or disorder of mind be
known. No fact and no argument has ever been brought against this
doctrine, of which it may be said, as has been said of the doctrine of
natural selection, that the moment it is stated it is seen to be indis-
putably true; and yet it is rejected with something like indignation by
some alienists, while the rest seem as afraid to touch it as if it were
an adder or a scorpion.
I have tried, with a good deal of interest and a great deal of
solicitude, to discover what it is that lies behind this reluctance to
accept what is indisputably and manifestly true. The task has been
difficult, because, as I have said, not one fact and not one argument has
been, or, I venture to say, could be, advanced against my doctrine.
I have been confronted with an impenetrable fog of prejudice, and you
cannot fight prejudice with argument, any more than you can disperse
a fog with musketry. I set myself, however, to try to understand it,
and I think I have succeeded in discovering the marsh out of which
the fog rises; and a very surprising discovery it is.
One set of critics, or ohe critic-I really do not know whether there
is more than one-objects to the doctrine that disorder of conduct is a
constituent of insanity on the ground that conduct is a part of mind.
If conduct were a part of mind, which it is, as much as looking through
a telescope is a part of mathematics, and if insanity were the same
thing as disorder of mind, then I should suppose that disorder of
conduct nmust be a part of insanity; and I do not see that this grotesque
argument, founded upon two manifest absurdities, would tell in the
least, even if it were sound, against my doctrine. I do not propose to
contest it, because I do not think that anyone who is so constituted as
to advance it is so constituted as to see its absurdity.
Another set of critics has made against me the extraordinary charge
that in advocating the view that insanity is disorder of conduct I
ought "to address the Medico-Legal Society rather than the Medico-
Psychological "; that " if iasanity is merely disorder of conduct (I have
never said it is, and have always carefully guarded myself against saying
anything that could mean that it is), then it is more of a legal than
a medical question" (I have never said or implied that insanity is a
question); that " if conduct is disordered, the policeman comes to the
rescue of the community"; and so forth. I have pondered these

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 Section of Psychiatry 5
criticisms much and deeply, and for a long time they seemed to me
so utterly irrelevant that I could catch no glimmer of a surmise as to the
state of mind that prompted them. At last, however, the truth dawned
upon me. Again and again I rejected it as incredible and impossible,
but the conviction at length forced itself upon me that when I speak of
disorder of conduct these critics suppose I mean " disorderly conduct "
in the police court sense. They take it that I regard every insane
person as drunk and disorderly, and a proper person to be detained in
a police cell. I must say that in speaking of disorder of conduct
I no more thought it necessary to say I did not mean criminal con-
duct than in speaking of disorder of mind I thought it necessary
to explain that I did not mean criminal intention. Mind may be dis-
ordered in many ways and in many departme'nts without entertaining
the animus furandi, and conduct may be disordered in many ways
and in many departments without exhibiting itself in assaults on the
police.
However, since the terms conduct and disorder of conduct are so
widely and so grossly misunderstood, I will drop them for the moment,
and for conduct substitute acting (I must explain that I do not mean
play-acting) and speaking, and for disorder of conduct disorder in acting
and speaking; and I ask' whether it is possible to estimate insanity
without taking account of what the patient says and does. Supposing
insanity is, as everyone but myself says it is, disorder of the mind, how
are you to know whether your patient's mind is disordered unless you
observe what he does and listen to what he says ? Can you, without
these rneans, look into his miind and see what is passing therein ? Can
you hear his unspoken thoughts or feel his unexpressed emotions,
impulses, desires ? You know, or you ought to know, that you
cannot; and if you do observe what he does, and listen to what
he says, you are already, whether you know it or not, making a
study of his conduct. If you estimate his insanity by what he
says and does, as you certainly do, you are estimating insanity by
conduct; you are admitting in the most practical manner possible
that disorder of conduct is the first thing to observe in insanity, and
the thing by which you judge insanity. Whether or not his mind is
disordered is a secondary consideration-an important 'consideration, no
doubt, in many cases, but still a secondary consideration-and if you
do find his mind disordered, that does not settle the question of his
insanity; for, as I have shown over and over again, until I am tired
of showing a thing so obvious and indisputable, there are many

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6 Mercier: The Concept of Insanity
disorders of mind that are not insane, and have nothing at all to
do with insanity.
Our concept of insanity must include, therefore, as the irreducible
minimum, disorder of conduct and disorder of mind, but it needs con-
siderable modification before the concept is accurate. As yet it is too
wide in some directions and too narrow in others. It is too wide
because, although insanity is disorder of both conduct and mind, yet
not every disorder of conduct or of mind is insane. It is too narrow
because, though insanity is always disorder of conduct and of mind,
it is often more than this.
What disorders of mind are sane and what insane I have distinguished
in another place, and the conduct that answers to a state of mind is sane
or insane according as the mental state is sane or insane. Here it is
enough to say that disorder of mind is insane only when it is not recog-
nized and known by the subject of it to be disordered, and that conduct
only is insane which is not recognized and known by the actor to be
insane. Otherwise put, any recognition or knowledge that a disorder is
disorder, and especially any attempt to correct or counteract a disorder,
proves ipso facto that the disorder is sane and is excluded from the
concept of insanity. When, for instance, the victim of imperative idea
knows and proclaims that the idea is silly, irrational and absurd, he proves
thereby his sanity. When the subject of obsession seeks the shelter
of a police station and begs to be restrained from seeking by conduct to
satisfy his morbid desire, which he knows is morbid, he proves by doing
so that his disorder is sane disorder and not insane.
In as far, therefore, as disorder of conduct and mind constitute our
concept of insanity, that concept includes those disorders only that are
not recognized by the patient to be disorders, and we may define insanity
in bne sense as unrecognized or unself-recognized disorder of conduct and
mind.
The concept thus defined is not, however, our only concept of insanity.
It is not the only combination we have in our minds when we think and
speak of insanity. Often, though not always, when we think and speak
of insanity we have in our minds disorder of brain function as well as
disorder of conduct and mind, and then the concept of insanity is not
twofold, but threefold. Moreover, those, if there are any, who follow my
teaching know that to these two concepts I add a third, and hold that the
concept of insanity is not full and complete until to the disorders of
conduct, mind, and brain function we add disorder of general metabolism.
The concept is now, I believe, complete. It is at any rate complete if

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 Section of Psychiatry 7
we include under disorder of brain function the disorder of brain struc-
ture that sometimes exists. Nothing more, I think, is ever in our minds
when we think of insanity.
It is natural to ask which of these concepts is the correct one.
Ought we, when we think and speak of insanity, to mean disorder of
conduct and mind alone, or ought we to think of insanity as disorder
of conduct and mind plus disorder of brain, or ought we to add disorder
of metabolism to the concept ? We may, when we think and speak of
insanity, have either of these concepts in our minds, but which ought
we to have? Which is the true one? The answer is that each and
every one of them is right when used in the appropriate context and on
the appropriate occasion, and each of them ceases to be right and
becomes wrong if it is unwittingly substituted for one of the others, or
if it is used in the wrong context or on the wrong occasion. And since
the same name, insanity, is given to all three concepts it is not surprising,
nay, it is inevitable, that they should sometimes be used interchangeably,
and that confusion should result.
I am afraid this will seem to you a very academic discussion, a dis-
cussion in the clouds, and unworthy the attention of practical men.
What you would expect to discuss in a scientific society like this is what
physic is good for a delusion and what form of water-closet is best for
asylum use; but I submit that sensible action depends on clear thinking,
and it is you, you who hold that insanity is disorder of mind, who ought
to be the first to value orderly thinking. In every science and in every
art real progress depends in the last resort upon the clearness and the
correctness of fundamental concepts. Early or late, in every calling
a stage is at length reached at which there is stagnation or confusion
until some fundamental concept is clearly defined. There can be no
science of International Law until there is a clear concept of what
is meant by International Law. Progress in electrics was impossible
until volume and intensity were distinguished. Dynamics made a jump
forward when mass acceleration was clearly conceived; and alienism will
be none the worse for a clear concept of insanity.
Why is it that every attempt to classify insanity has grievously and
conspicuously failed ? There are more classifications of insanity than
there are writers on insanity, and no classification has -ever yet satisfied
anyone but the classifier himself, and if I may speak from my own ex-
perience, it does not always do even that. The reasons are various, but
one stands out at once as sufficient to vitiate any classification. The
first step in any classification, so logic tells us, is to delimit the things

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8 Mercier: The Concept of Insanity
to be classified, to draw a line round them, including all the things to be
classified and excluding everything else. With insanity this has never
been done. There have been few attempts, and there has certainly been
no successful attempt, to delimit insanity or to form such a definite con-
cept of it as shall separate it from the things it most resembles. When
a clear concept of insanity is obtained the first step towards a successful
classification will have been taken,' and as long as under the name in-
sanity there are included and confused two or more different concepts,
it is clear that any valid classification is quite impossible.
Again, is insanity a disease or is it merely a symptom ? Opinions
would probably be fairly equally divided, and neither side could give
a reason for the one opinion or the other, for in the first place there
is no clear concept of insanity, and in the second there is no accepted
definition of either a symptom or a disease; and to determine in these
circumstances whether insanity is a symptom or a disease is much like
determining whether brillig is a slithy tove or a gimbling wabe. In
order to decide whether insanity is a symptomn or a disease we must
first know not only what we mean by insanity, but what we mean by
a symptom and what we mean by a disease. I do not propose to
argue out here and now this matter, which I have examined elsewhere,
I merely take the results of that examination and utilize them in the
present discussion.
By a symptom I mean a sign or manifestation of disordered function.
The sign may be manifest to the sufferer alone, as in the case of pain;
or to the bystander alone, as in the case of coma; or to the skilled
examination of the physician alone, as in the case of a cardiac murmur
or of optic neuritis; or it may be manifest to both the patient and the
bystander, as in the cases of tumour, spasm, redness, and so forth; but
a symptom is a sign, perceptible to someone, that some function is
disordered. Every symptom implies and depends upon some disorder
of function, but the symptom or sign of the disorder is kept separate in
our minds from the disorder of function on which it depends, and when
thus regarded separately and apart from the disorder of function, it is a
symptom and a symptom only.
It often happens that disorder of a function manifests itself by
several symptoms. Incompetence of the mitral valve, for instance,
may manifest itself by a cardiac murmur, by ain alteration of the pulse,
by dyspncea, lividity, dropsy, and so forth. Each of these is a symptom
of mitral regurgitation, and all taken together and correlated with one
another and with the disorder of function on which they all depend,

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 Section of Psychiatry 9
constitute the disease from which the patient suffers. A disorder of
function may, however, mnanifest itself by a single symptom and no
more, as with a vesicle of herpes or of molluscum contagiosum, and the
disorder of function may, as in these cases, be so intimately bound up
with the symptom that the two are not easily distinguishable. In such
a case the single symptom of itself constitutes the disease, for a disease
consists of all the correlated disorders from which the patient suffers-
that is to say, all the disorders that can be traced to a single agent, or
to the impairment of a single function, together with the impairment of
that function and the structural change, if any, that is produced by the
agent.
Now, in the light of these definitions, is insanity a symptom, or is it
a disease ? That depends upon what we mean by insanity. It depends
upon what concept we have in our minds when we use the name. If by
insanity we mean merely disorder of conduct and of mind, and no more,
then it is clear that the observed disorder of conduct is certainly a
symptom of disorder of brain function; and it is legitimate to speak
of the inferred disorder of mind as also a symptom of disorder of the
function of the brain. In this sense of insanity, therefore, when we
mean by it, as we often do, no more than disorder of conduct and mind,
insanity is a symptom of disorder of the function of the brain-a complex
symptom, a twofold symptom, but still a symptom only. If, however,
we take up into the concept the disorder of brain function, and correlate
the three disorders together, then this concept of insanity is a mere
symptom no longer: it is now become a disease, for it includes, Pr may
include, the whole group of correlated disorders from which the patient
suffers.
The next question that presents itself is whether insanity is one
disease or more. Is it a single disease or a group of diseases? This
raises some comprehensive questions. We must find what constitutes
the difference between one disease and another, and for this purpose it
may -be necessary to discuss the more comprehensive question of the
difference between one individual thing and another, and the further
question, What is an individual thing ? I think we may take it that an
individual thing is a thing that is completely distinguishable from other
things, and does not merge and blend into any other thing. No doubt
there are individual things, such as varieties of animals and plants-
I speak of the individual variety, not the individual animal or plant-
that do in fact merge and blend into other varieties, but in such cases,
though there is no actual complete distinction, yet we always postulate

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10 Mercier: The Concept of Insanity
an arbitrary and artificial distinction, and thus fulfil the condition.
A disease is an individual thing. It is a group of correlated disorders
taken together and contemplated as one thing, just as a class is an
indefinite number of individuals taken together and contemplated as
one thing-one class. But to be an individual thing, the group must
have distinctive characters. It must as a group be distinguishable from
other groups, and must not merge and blend into them or be correlated
with them. Small-pox, for instance, is a correlated group of disorders,
some contemporaneous with others, some successive-pain, rigor, fever,
rash, perhaps delirium, smell, prostration, and so forth. This group is,
as a group, distinguishable from all other groups. It is distinguishable
mainly by the character of the rash, but also by other features, so that
although it resembles other groups in some respects-in respect of the
fever, for instance, of the thirst, the prostration, the malaise, and so
forth-yet when we take all the disorders together, the group that they
constitute is so different from all other groups as to be, on the one
hand, distinguishable from them, and, on the other, to be recognizable
as the same group when it appears in another patient. For these
reasons small-pox is a distinct disease.
Is there any form of insanity of which the same can be said? I
think there is. Paranoia, for instance, is a group of correlated disorders
of conduct and mind, and a group that is easily distinguishable from
every other group. The suspicion, the moroseness, the peculiar
character of the delusions, always of the same type, the precautions
and stratagems to outwit or counteract the imnaginary persecutors, the
exaggerated egotism, form a group of correlated disorders that is not
only distinguishable from every other group, but that never occurs in
correlation with diverse disorders of other kinds. If it did so occur, it
would not be a disease. It would be a complex symptom, or correlated
group of symptoms; but since the correlated group of symptoms con-
stitutes the whole of the correlated disorders from which the patient
suffers, since it is distinguishable from all other groups, and since it can
be recognized as the same in material respects when it occurs in patient
after patient, it is truly entitled to be called a disease.
Melancholia is another group of correlated disorders of conduct and
mind. On the mental side there is depression and self-depreciation
or abasement, and on the side of conduct there is the expression of
misery, there is lamentation and mortification. These symptoms are
correlated together: they form a group distinguishable from all other
groups, and recognizable as the same in material respects when it occurs,

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 Section of Psychiatry 11
as it does, again and again in different patients. Is melancholia there-
fore a disease ? That depends. If the group of disorders that I have
described, and that is called melancholia, constitutes the whole of the
correlated disorders from which the patient suffers, then and in such
cases melancholia is a disease; but if and when the melancholia is
correlated with a larger group of disorders, if, for instance, it is correlated
with the disorders that are grouped together under the title of general
paralysis, then melancholia is not a disease, for it does not constitute
the whole group of correlated disorders from which the patient suffers.
It is then not a disease, but a symptom of the disease, general paralysis.
Let us take another disorder, say excited conduct, correlated, as no
doubt it is, with excitement of mind. Excited conduct is often called
mania. Is mania a symptom or is it a disease ? That depends entirely
upon whether it constitutes the whole of the disorder from which the
patient suffers, or whether it is correlated with some wider disorder.
In some cases the excitement of conduct and mind is uncorrelated with
anything else except with the disorder of brain function which we
suppose it expresses, and in such cases mania is regarded correctly as
a disease; but in other cases excitement is correlated with other and
wider disorders. It is sometimes correlated with a raised temperature,
and then the excitement is one symptom, and the raised temperature
is another symptom, of the disease known as acute delirium. In other
cases excitement is correlated with the other symptoms of general
paralysis, and then it is not a disease, but is one of the symptoms
of general paralysis. In other cases again it is correlated with alcoholic
poisoning, and is then one of the symptoms of alcoholic poisoning, and
so on. What I wish to emphasize is that the very same group of
correlated disorders may be a disease or may be a symptom only,
according as it constitutes the whole of the correlated disorders from
which the patient suffers, or only a part of the whole group. No doubt
there are in every case many correlated disorders that we do not recog-
nize and do not know of, but de non apparenttibus et de non existentibus
eadem est ratio.
Disorder of conduct correlated with disorder of mind sometimes occurs
at the height of specific fevers, sometimes at their outset, and sometimes
as a sequel. When it occurs at the height of the fever, it is a symptom
only, for it constitutes not the whole of the correlated disorders from
which the patient suffers, but a subordinate part only of them. When
so occurring, the disorder of mind and conduct is called, not insanity,
but delirium, and those persons who hold that punishment is not

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12 Mercier: The Concept of Insanity
punishment when it is called withdrawal of privileges, and that a
potato is not a potato when it is called Solanum tuberosum, will doubtless
deny that the delirium of specific fevers is insanity. What they perhaps
mean if they could express themselves articulately is that in such cases
the patient does not suffer from the disease insanity, and in this I should
agree with them. In such cases the disorder of conduct and mind is
a symptom only, but it is none the less insanity for being a symptom.
It would be a most useful innovation, and would do more than anything
else could do to clear our concepts of insanity, if the symptom insanity
could always be called delirium, and the name insanity restricted to the
disease; but I fear it would be chimerical to hope for such a change,
however beneficial it might be. The insanity that is correlated with
myxcedema, with gout, with cretinism, with heart disease, with
exophthalmic goitre, as well as that which is correlated with fevers,
and which forms a symptom of these diseases, would then be called, not
insanity, but delirium; and not only these, but the insanity that
accompanies general paralysis would be called, not insanity, but delirium.
We call the disease "general paralysis of the insane" as if it were
a kind of paralysis that might attack any insane person. It would be
more accurate to call it general insanity of the paralysed, for the bodily
disorder is the antecedent; but it would be better still to call it
quaternary syphilis of the brain, which it is, and to regard the insanity
as a symptom of this disease-a delirium-which it is.

DISCUSSION.
The PRESIDENT (Sir George Savage) thanked Dr. Mercier for his very
interesting and suitable paper. This, a new Section of the Royal Society of
Medicine, had perhaps more need of a definition and circumscription of its
territory. Many years ago when lecturing at Guy's, he began his course of
mental disorders by saying " There is no such thing as insanity," " There are
plenty of insane people but no concrete disease insanity." He pointed out,
too, in " Allbutt's System of Medicine," that there was an immense difference
between insanity and unsoundness of mind-that, as Dr. Mercier had pointed
out, there were many people unsound in mind who could not be treated as
lunatics. The difficulty of the subject was well expressed by Dr. Moxon, who
said, After all, how can you define a negation? " He could not agree with all
Dr. Mercier said; for example, he had seen some persons who were very
insane but who recognized that they were insane. The importance, however, of
looking upon mental disorder in the double way indicated by Dr. Mercier was
great. Insanity, or rather mental disorder, might be a symptom, or it might

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 Section of Psychiatry 13
be a group of symptoms deserving the name disease. Great hardships might
arise from misunderstanding the difference. Thus, a young officer while on
duty has a severe attack of influenza with high fever and is delirious. There
being no camp hospitals suitable for the case he is sent to the nearest
infirmary; thence, immediately, being violent, he is certified and sent to the
asylum. He has been certified as insane and is consequently removed from
the Army. If he had been considered only as delirious he would not have lost
his profession. There were many other suggestive points in Dr. Mercier's
paper to which he trusted others present would refer.
Dr. PERCY SMITH agreed with Dr. Mercier that conduct in its widest sense
was the chief criterion of insanity. He disagreed with Dr. Mercier's state-
ment that " any recognition" by the patient of his disorder removed it from
the sphere of insanity, and pointed out that it was a familiar fact that
many patients under care had what is spoken of as an "insight" into their
condition and recognized their irresponsibility, but nevertheless could not be
regarded as otherwise than suffering from insanity. He pointed out that the
term "paranoia " had a very different signification in the writings of different
observers, and that it was not by any means always of the same type. He
invited Dr. Mercier to explain more fully at what period he would leave off
the use of the word "delirium" for an insanity beginning, for example, in
the course of typhoid fever, and which passed on into a chronic and incurable
mental state.
Dr. ERNEST JONES suggested that the difficulty in agreeing upon a medical
definition of insanity might be due to the fact that the idea of insanity was
essentially not a medical conception, but a legal or social one; the definition
of insanity must therefore necessarily fluctuate according to the changing legal
or social conditions-e.g., income of the patient, &c.-and did not depend on
any psychological or physiological conceptions. It would be better to give up
the inherently impossible task of discovering a medical definition, and to confine
ourselves to the more profitable task of defining and differentiating the various
forms of mental disorder, whether "insane" or not; in, time the use of the
word insanity, just as that of lunacy, would be confined to the laity, being
replaced in medical circles by terms based on medical knowledge.
Dr. MERCIER, in reply, said that Dr. Percy Smith had misapprehended the
nature of his (Dr. Mercier's) assertion. Of course, there were plenty of lunatics
in asylums who knew that they were in asylums, and knew in a general and
vague way that they were there because they were insane; but what they
did not know, and the ignorance stamped them as insane, was the insanity of
the specific insane acts that they did, and the insanity of -the specific things
that they said. If there was any insane person wvho recognized the insanity
of any act that he did, then that person, at the time he recognized the insanity
of- the act, was not insane as far as that particular act was concerned; and if
he recognized that what he said was the expression of a delusion, then at the
time he made that recognition he was not deluded, and as far as that delusion
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14 Mercier: The Concept of Insanity
was concerned he was not then insane; but he might have been insane at the
time he did the act or expressed the delusion, and he might still be insane in
other respects. The other conundrum that Dr. Percy Smith put was very easy
to answer. A man suffered from typhoid fever, one symptom of which was
delirium. The typhoid fever subsided and disappeared, but the delirium
persisted. Did the delirium then become the disease of insanity ? Of course
it did. There was another very common case that was on all fours. A man
suffered from acute rheumatism, one symptom of which was valvular disease
of the heart. The rheumatism subsided and disappeared, but the heart
disease remained, and remained, not as a symptom, but as a substantial disease,
existing alone. Dr. Ernest Jones advised us not to speak of our patients as
suffering from insanity, but to speak of each one as suffering from one of the
particular diseases that insanity included. Dr. Mercier would be delighted to
follow this advice if Dr. Ernest Jones would kindly enumerate these diseases.
Of course, if Dr. Ernest Jones followed the prevailing Continental fashion, and
called every case of insanity that occurred under 30 years of age dementia
pracox, and every case that occurred over 30 years of age manic-depressive
insanity, the task was simple, but to anyone who refused to follow a fashion
merely because it was a fashion there were difficulties in the way.

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