Galvanism is sometimes useful, applied to the head, in cases of mental torpor and stupor. That and the faradic current, used with great care, act as powerful tonics to the general nervous and muscular system.
Insomnia is often the chief manifestation of the insane taint, in which case drugs are, for the most part, worse than useless. In all forms of sleeplessness it is better to try malt, cod-liver oil, beer, food, massage, baths, exercise, rest, etc. before resorting to narcotics and sedatives. Camphor, hyoscyamus, cannabis indica, the valerianates, bromides, codeia are much less objectionable than chloral, morphine, and opium.
Where masturbation is simply an evidence of loss of self-control, it is met best by constant watching, and gradually, as the mental state improves, arranging the daily life so as to develop the feeling of self-respect. Where it depends upon local paræsthesia, opium and camphor and cold bathing are indicated.
Constipation is a troublesome symptom, especially in the states of mental depression. When a full, laxative diet, cod-liver oil, and malt do not correct it, small doses of laxatives given frequently act better than the occasional use of purgatives.
There is a class of cases which are best treated by educating the patients as one would educate a child.
In the general care of the insane it is the duty of the state to see that they have all the rights of the citizen which are consistent with their proper and safe treatment, including the benefits of property and estate. There certainly should be in all countries, as in England, officers whose duty it is to see that this is done. For a large number of people with defective or diseased brains, who are now allowed to wander about committing crimes and serving repeated sentences in reformatories, houses of correction, and prisons, an enlightened public policy would find the best, and in the end the cheapest, treatment to consist in keeping them under supervision and control as unsound members of society.
The more particular treatment of the insane differs in the various mental diseases, varying as it necessarily must according to different conditions. Its prevention is not an easy problem. Many of the external causes of insanity seem inevitable in our complex civilization: it would be impossible to widely regulate marriages, even if we knew how; those people predisposed to insanity are usually too self-confident and self-willed to receive advice; and moderation in all things, healthful occupation, temperate habits, good digestion, and, above all, out-of-door life, seem as much like a sarcasm if suggested to many of the toilers as a waste of words if recommended to the idle and luxurious, while the parents who have transmitted to their children unstable or diseased brains generally impair what chances they have in life by vicious training.
Where syphilis, drunkenness, and other marked sources of mental degeneration do not obtain, simple food, plenty of sleep, avoidance of extremes of heat and cold, plain dressing, baths, good digestion, out-of-door life, fresh air, careful attention to slight disorders or injuries of the brain and nervous system, guidance against too much study and too much excitement or dissipation, development of character and moral force, intellectual and physical training, avoidance of too much emotional, sentimental, or even artistic culture, careful watchfulness during the period of adolescence, occupation without overwork, healthful recreation, acontented or philosophical mind, and suitable marriages, would produce the strong wills and healthy organisms needed to combat the tendencies of modern life. Such a course would undoubtedly make many a child with an hereditary predisposition to insanity become a healthy parent of children in whom the same treatment would soon eliminate the family taint. The character should be strengthened to learn to overcome difficulties rather than evade them. There are cases in which such a course can be adopted, and where the physician's advice may be of untold benefit to generations.
There are many crises in life when the mind totters and seems ready to fall, which the physician is more likely to recognize than any other person. Sometimes the odds are too heavy to fight against, but often there is a transient mental disturbance in such critical cases, or an incipient insanity, according as the indications are met with wisdom and patience or with neglect, indifference, and lack of judgment. The treatment called for is of the person rather than of the mental state, and in all forms of mental disease success in treatment depends very materially upon the personality of the physician, who must adapt himself also to the personality of the patient.
In about one-fourth of the cases of insanity there is no hereditary predisposition to the disease, and its prevention can be most hopefully looked for in attention to the general laws of health, the observance of which tends to secure immunity from all diseases. In the remaining cases—three times as many, in round numbers—the most hopeful course is in abstaining from marriage altogether or in the avoidance of unwise marriages; and it is an encouraging fact that many people in the community now take that conscientious view of the matter, although if they decide what to do without competent advice they are liable to err in the opposite direction of exaggerating their morbid tendencies, and so increasing their unhealthy predisposition. There are certain groups of physical and mental manifestations which the experienced physician recognizes as signs of tendencies which only await favorable conditions—a sufficient exciting cause—in the indulgence in drink or other excesses, in the exclusive search for wealth or fame, in the absence of healthy occupation, in mental wear and worry, in over-excitement, in the various conditions of ill-health, to develop into actual insanity. This physiognomy of temperament suggests to the observant physician a warning against excess of all kinds, and a recommendation for that course in life which promises the greatest likelihood of preserving a quiet mind and a healthy body and of securing a rational employment. Too much work is less dangerous to most people than too little.
12Compare Moreau'sLa Psychologie morbideand Morel'sTraité des Dégénérences physiques, intellectuelles, et morales de l'Éspèce humaine.
MICROCEPHALISM, CRETINISM, INTELLECTUALIDIOCY, MORALIDIOCY, INTELLECTUALIMBECILITY, MORALIMBECILITY(under which Westphal, Spitzka, and others place moral insanity) are really names for different degrees of similar defects, for the most part hereditary andcongenital or resulting from disease or injury in infancy and early childhood, as distinguished from dementia, which is the result of later destructive mental or brain diseases. Idiots and the demented insane are sometimes so alike in their mental condition that, if young persons, they can be definitely distinguished one from the other only by a knowledge of the previous history of the case. Idiocy has its origin at or before birth or soon after, and terminal dementia seldom before puberty, commonly after maturity. In the United States census, where there is a doubt in the matter, the individual is classed as an idiot if the mental disorder occurred before the age of twelve in girls and fourteen in boys, and as insane (demented) if above that age.
The microcephalic brain may be as small as one-fifth the normal size, due chiefly to intra-uterine conditions for the most part unknown. Of course that means complete idiocy. The brains of other idiots differ in size and development. The mental condition in all is similar. Idiocy with the small or large or asymmetrical brain is classified, practically rather than scientifically, by Shuttleworth, as follows:
A. Congenital or Developmental13Cases.—1, Microcephalic, with small heads: forehead and occiput defective; 2, hydrocephalic; 3, plagiocephalic, with distorted heads: features in an oblique plane; 4, scaphocephalic, with keel-like distortion of forehead; 5, scrofulous cases; 6, Mongol type; 7, cretinoid cases, with stunted bodies: irregularly expanded heads and enlarged thyroid glands; 8, syphilitic cases; 9, primary neurotic, with body well developed: signs of irregular nervous action; 10, sensorial idiocy, with two or more senses deficient (e.g.sight and hearing); 11, mixed cases.
13Developmental conveniently includes those cases which, though of intra-uterine origin, become more pronounced as physical development proceeds.
B. Non-Congenital, Acquired, or Accidental.—1, Traumatic; 2, post-febrile; 3, hydrocephalic; 4, hypertrophic, with large square-built heads; 5, eclampsic; 6, epileptic; 7, paralytic; 8, idiocy by deprivation: loss of two or more senses in infancy (e.g.sight and hearing); 9, emotional idiocy, with no bodily deformity: shrinking, scared expression; 10, toxic idiocy, with no bodily deformity: malnutrition.14
14“The Physical Features of Idiocy,”Liverpool Medico-Chirurgical Journal, July, 1883.
From the creature of deformed limbs and ape-like movements, incapable of articulate speech, even in monosyllables, or systematized ideas, leading a purely vegetative life, unclean, and with the instincts of a wild beast, up to moderate mental or moral imbecility, there are endless varieties of defects and monstrosities in mind, character, morals, and instincts, differing according to the profoundness of the disorder of the brain (hydrocephalus, atrophy, sclerosis, inflammation of the brain substance or membranes, injury from compression, blows, falls, convulsions, etc.), the extent of the defect in the brain development, the amount of the degenerative hereditary taint, or, in the case of cretinism, the importance of the endemic as well as the congenital influences.
In some of the higher planes of imbecility a considerable degree of intellectual brightness, or even talent, is often observed, and every variety of mental and moral perversion or simple reckless brutality. Training often does a great deal to bring many of these unfortunate creatures within the bounds of good behavior, but their care oftener falls withinthe province of the medical superintendent in an asylum or the teacher than to the physician in general practice. They are easily led astray by others, and commit all sorts of motiveless crimes or with a trivial or disproportionate motive, and with blind disregard of consequences or inability to comprehend them. In the gallery, at Washington, of photographs of counterfeiters and of passers of counterfeit money, the faces of the latter show conclusively that they belong to the intellectually weak-minded or imbecile class. Their own amusement, gratification, or impulse is so far the basis of their conduct that only a minority are harmless if not more or less constantly watched. Fortunately, a great portion—unfortunately, not all—of the idiots are sterile, but many of the mentally and morally weak-minded, with striking congenital defects which no training can fully remedy, propagate their species indefinitely for the benefit of our prisons and asylums.
Intellectual idiocy and marked intellectual imbecility are so common as to constitute 1 in 650 of our population. Less noticeable intellectual imbecility is quite frequent in the large class of troublesome and perverse children and youth of both sexes, commonly called weak-minded.
Moral imbecility, which cannot be corrected by education, is less common.
Moral idiocy is rare. It consists in such an absence of the moral sense that it cannot be aroused. It is sometimes associated with sufficient intellectual powers to make deliberate action and premeditation quite possible. Such persons are monstrosities, who, for the safety of the community, must be kept shut up for life like wild beasts.
The fact should be remembered, from a medico-legal point of view, that the defective in mind are quite liable to short attacks of simple mania and mental depression and to epilepsy, both of the obvious type and of the obscure or masked form, so that their degrees of responsibility, or rather of irresponsibility, vary from time to time. As a rule, a good physical organization and a general condition denoting healthy circulation and nutrition mark the better brains, and constitute important elements in forming a prognosis in regard to the possibility of educating imbecile and feeble-minded children up to the point of reasonably good behavior and ability to at least partly take care of themselves. The simpler their lives and the more purely routine or imitative their work, the less their defect is noticed. Many can wheel a barrow as well as any one.
THEINSANETEMPERAMENT(Insane Diathesis, Neuro-psychopathische Constitution) is an exaggeration of the nervous temperament. It is closely allied to insanity and the neuroses, and at the critical periods of life is very apt to develop into one of them. It is congenital or due to early interference with the normal development of the brain by injury or disease. It shows itself in childhood and infancy by irregular or disturbed sleep, irritability, apprehension, strange ideas, great sensitiveness to external impressions, high temperature, delirium, or convulsions from slight causes, disagreeable dreams and visions, romancing, intense feeling, periodic headache, muscular twitchings, capricious appetite, and great intolerance of stimulants and narcotics. At puberty developmental anomalies are often observed in girls, and not seldom perverted sexual instincts in both sexes. During adolescence there are often excessive shyness or bravado, always introspection and self-consciousness, and sometimes abeyance or absence of the sexual instinct, which, however,is frequently of extraordinary intensity. The imitative and imaginative faculties may be quick. The affections and emotions are strong. Vehement dislikes are formed, and intense personal attachments result in extraordinary friendships, which not seldom swing suddenly around to bitter enmity or indifference. The natural home associations and feelings easily become disturbed or perverted. The passions are unduly a force in the character, which is commonly said to lack will-power. The individual's higher brain-centres are inhibited, and he dashes about like a ship without a rudder, fairly well if the winds are fair and the seas calm, but dependent upon the elements for the character and time of the final wreck. Invention, poetry, music, artistic taste, philanthropy, intensity, and originality are sometimes of a high order among these persons, but desultory, half-finished work and shiftlessness are much more common. With many of them concentrated, sustained effort is impossible, and attempts to keep them to it result disastrously. Their common sense, perception of the relations of life, executive or business faculty, and judgment are seldom well developed. The memory is now and then phenomenal. In later life there is a ready reaction to external circumstances, even to the weather, by which the individual is usually a little exhilarated or somewhat depressed. All sorts of vaso-motor disturbances are common and create distressing symptoms. Such people are said to be on the border-line between sanity and insanity. They are apt to be self-conscious, egoistic, suspicious, and morbidly conscientious; they easily become victims of insomnia, neurasthenic, hypochondriacal, neurotic, hysterical, or insane, and they offend against the proprieties of life or commit crimes with less cause or provocation than other persons. At the same time that many of them are among the most gifted and attractive people in their community, the majority are otherwise, and possess an uncommon capacity of making fools of themselves, being a nuisance to their friends and of little use to the world. Many of them get fairly well through life if their lives are tolerably easy or especially well regulated; if not, even they seldom escape further disturbance during the period of growing old. Their mortality-rate, especially from pulmonary consumption, is high. The prognosis is usually stated as unfavorable, largely, perhaps, because proper treatment is seldom pursued. If such children could be placed in the hands of judicious and experienced physicians from earliest years, much better results would undoubtedly be got and the downward tendency might be stopped. In the critical physiological periods of life, and under the influence of mental worry with physical strain, there is danger of breaking down. At the senile dissolution some of them lose much of their lifelong peculiarities, and as the mind fails in force and activity become more like other people. After the climacteric there may be also great improvement.
TREATMENTshould consist in the general principles of mental hygiene, especially in training the mind to self-control and to avoid introspection—in a word, in maintaining health and in having healthy occupation. The earlier in life it begins, the better. It is well for such persons, unless of uncommon gifts in some direction, as many are, to obtain quiet, routine positions in life, and to avoid its wearing responsibilities as much as possible. The question of marriage is a difficult one for the physician if he is called upon for advice. Of course the risk often can be estimated onlyapproximately, even after knowing both parties, who will heed medical counsel implicitly if it happens to coincide with their own notions. The further propagation of the neuro-psychopathic constitution in the world involves much entirely uncompensated misery, as well as genius, enthusiasm, and originality, the compensation for which is estimated by society in one way as regards Burns, Byron, De Quincey, Carlyle, Goldsmith, John Howard, and Frederick the Great's father, and in another when considering the inmates of jails and almshouses and the destroyers of home peace. Maudsley thinks that one such poet as Shelley justifies the risks of marriage in the insane diathesis, and Savage considers the neuro-psychopathic constitution a useful element in society; while Clouston holds that the world would be better off to lose the few ill-balanced geniuses, the hundreds of impracticable, unwise talented men and women, and the thousands of people who cannot get on, shiftless, given to drink, idle, improvident, and unpractical, to get rid of the insane diathesis, especially if we shall find a middle course and learn to apply the laws of heredity so as to save the best and eliminate the unsound. It is to this class probably that Pinel refers in saying that what he calls moral insanity is largely a matter of bad education. It is undoubtedly true that judicious training in very many cases would limit, if not prevent, the further development of the morbid element and strengthen the healthy side, so as to prevent actual insanity.
CONSTITUTIONALAFFECTIVEMENTALDISEASEis a further development of the congenital or hereditary predisposition to nervous or mental disease, with more or less of the marks of the neuro-psychopathic constitution. It is of two forms, the depressed and the mildly exhilarated, in neither case amounting to simple melancholia or mild mania. Sometimes the two forms are seen in a single member or in different members of one family where mental degeneration has begun. The frequent association of pulmonary consumption with these cases is possibly, in part, due to malnutrition in those persons living under the influence of more or less perpetual gloom, and to exposure and over-exertion in those who are constantly unnaturally excited, sleeping too little and driving their alert brains to the extent of exhaustion. Misanthropists, communists, iconoclasts of all kinds, enthusiasts and reformers, useful people and worse than useless, common nuisances, criminals, saints, and heroes, are found among them. Undoubtedly, in the case of criminals the tyranny of their organization deprives the intellect of much of the proper inhibitory power over the passions and evil tendencies, and yet with sufficient motive they can hold themselves considerably in check.
ThePROGNOSISis not favorable. At the critical periods of life, after severe diseases or injuries and with undue mental or physical strain, there is danger of further progress of the disease into more pronounced types; and this result is often the only way of satisfying the community that what they called meanness or wickedness was only disease. The progress of the disease is commonly very slow. It often seems like simple progressive development of character, except for the fact, generally overlooked, that it advances often in a different direction to what would be natural, and is independent of normal development. The subsidence of habitual severe headache not seldom marks a sharp advance in the severity of the mental symptoms.
TheTREATMENTis hygienic. It must begin early in life, and be devoted especially to avoidance of mental overwork, to healthy occupation, to simple habits, and to a wise mental training.
MORALINSANITY(Insanity of Action, Affective Insanity, l'Insanite morale, Moralisches Irresein, Folie raisonnante, Folie lucide, Manie sans délire of Pinel), the general moral mania of Ray, is distinguished by that writer from partial moral mania (instinctive mania, manie raisonnante of Pinel, la folie impulsive, impulsive insanity, emotional insanity, impulsives Irresein), which includes suicidal insanity, homicidal insanity, dipsomania, pyromania, kleptomania, erotomania, nymphomania, satyriasis (aidoiomania), animal impulse, perverted sexual instinct (conträre Sexualempfindung, la sensation sexuelle contraire), and topophobia, if that disease be classed among the insanities.
Moral insanity is seldom seen in the insane asylum until the disease has passed over into pronounced mental enfeeblement or delusional insanity. Purely moral insanity—“an uncontrollable violence of the emotions and instincts”—is probably as rare as purely intellectual insanity. Moral insanity is attended with some mental impairment, just as moral perversion is part of intellectual insanity. Indeed, I have heard patients complain as much of the degradation of character in their insanity as of any symptoms referable directly to the intellect. The term is not a fortunate one, but, like the expression moral treatment of the insane, it is in quite general use. It is recognized by all the authorities on mental disease, whatever may be their opinions as to the limitations of responsibility in it. It is especially to it that we can apply the words of the Autocrat of the Breakfast-Table, that the worst forms of insanity are those to which the asylum shuts its doors. It is marked by moral perversion, change of character and action, and so little intellectual impairment as to be easily overlooked by one not familiar with morbid mental phenomena.
Mild simple mania ending in recovery has been described as moral insanity even by Pinel and Pritchard, and is so miscalled rather generally at the present day. Moral deterioration is observed after fevers or physiological periods of life, following slight and moderate cerebral hemorrhages or injuries to the back and head, affecting the brain, mental strain, etc., which, in persons of the neuro-psychopathic constitution, now and then end in permanent change of character. A similar but curable mental state is the frequent beginning of more pronounced insanity, and often remains the sole evidence of unsoundness of mind even after the patient is thought well enough to be discharged from the asylum.
Although moral insanity is probably a common cause of young persons of both sexes being led into lives of licentiousness, wickedness, and crime, it is to be carefully differentiated from deliberate yielding to temptation and following lives of vice until a strong enough motive is offered for doing better or a punishment is made sufficient to be deterrent.
Moral insanity is essentially a very slowly progressive and incurable disease, starting in congenital or acquired mental deterioration, and with its symptoms. It usually ends, after long years of wretchedness to the individual and misery to his friends, in more general insanity, slowly advancing dementia, death by intercurrent disease or accident, or in suicide. It is a most distressing disease in the young, who are punishedby parents and teachers in succession, sent about from one school to another, boarded with friends or with disciplinarians until all are wearied out in turn, and all too late conclude that the case is one for a doctor or perhaps an asylum. At the evolution of the sexual power and at its decadence, during menstruation, pregnancy, childbirth, lactation, especially after fevers, blows injuring the brain, and cerebral disease or disorders of any kind, are the periods of especial danger, as more general mental disease is then developed with seemingly trivial exciting causes. The friends observe that the sufferers do not seem entirely natural. They imagine and suspect a great deal, rather than possess real delusions. They often say that their heads are not quite right, and manifest an evidently diminished capacity for mental work, which tires them or makes them irritable. Modest girls become indelicate, the truthful lie, the delicate use profane and obscene language, the mild-mannered destroy furniture and clothing, the peaceful quarrel, the gentle storm and rave; and yet there is a standard of virtue and right, often a high one, on which they theorize, and up to which they often think that they live. They take strong dislikes to those with whom they are brought in contact, especially their nearest relatives. They often lose the capacity to do work, and now and then become spendthrifts or drunkards. As a rule, there are frequent periods of quiet, amounting to depression, but rarely reaching the condition of melancholia. Alternation or periodicity in the symptoms is the rule. After threatening and even endangering the lives of those nearest to them, insulting and indelicate conduct in public, perhaps frequent arrests, a dozen times outwitting those who wish to confine them in asylums, where they belong, their minds being alert enough to attribute their conduct to drink or some cause for which they receive slight punishment, and to argue their own cases so as to convince almost any jury of their sanity, the rule is that their doubts, imaginations, and suspicions deepen into active insane delusions, their mental impairment advances to noticeable dementia, their moral deterioration goes on to such a degree of depravity that every body wonders why they had not been seen to be insane long ago, and they are secluded in an asylum or elsewhere. A not uncommon but unfortunate end is when they kill themselves before anybody but a few specialists recognize their irresponsibility. Their recklessness and want of judgment are often the cause of fatal illnesses and accidents. Clouston reports the case of a lady who by a series of extraordinary misrepresentations and clever impostures raised large sums of money on no security whatever, and spent them as recklessly; imposed on jewellers, so that they trusted her with goods worth hundreds of pounds; furnished grand houses at the expense of trusting upholsterers; introduced herself by open impudence to one great nobleman after another, and then introduced her dupes, who, on the faith of these distinguished social connections, at once disgorged money. To one person she was a great literary character; to another of royal descent; to another she had immense expectations; to another she was a stern religionist. At last all this lying, cheating, scheming, and imposture developed into marked insanity and brain disease, of which she soon died; and it was seen that all these people had been the dupes of a lunatic whose very boldness, cunning, and mendacity had been the direct result of her insanity.
S. K. Towle has reported the case of a man whom he had underhis care at the Soldiers' Home near Milwaukee, Wis., as follows: “He had been a lieutenant in a volunteer regiment, and I gave him rather more privileges on that account, but after a time I found that he was more nearly an example of total depravity than I had ever seen. There was no truth in him, and he was intelligent enough to make his lies often seem plausible to me as well as to others. By his writing and talking and conduct generally he kept the patients and their friends in a ferment, and gave me more trouble than the whole hospital besides. He had a small scar about the middle of his forehead, which he said was due to a slight flesh wound from a glancing ball in battle. While he was under my care an older brother came to see him, and he told me that up to the time his brother, my patient, who so tried my patience, entered the army he was almost a model young man, amiable and affectionate, the pet of the whole family and intimate friends; ‘But,’ said he, ‘ever since he came back he has been possessed of a devil if ever any one was.’ After a time, much to my delight, he asked for a transfer to the Soldiers' Home at Dayton, Ohio, which I got for him with commendable alacrity; and he went there. His conduct at Dayton was the same as with me, but after a few months he quite suddenly died, when an autopsy was made. In sawing open the skull, at the point of the small scar on his forehead the saw came directly upon the butt end of a conical bullet, two-thirds of which projected through the skull, piercing the membranes and into the brain. The internal table of the skull had been considerably splintered by the ball, the pieces not being entirely separated, and there was evidence of severe chronic inflammation all around, and quite a collection of pus in the brain where the ball projected into it. Here was the devil that had possessed the poor fellow—that not only took his life, but destroyed his character, lost him the love and esteem of his friends, and doomed him for half a dozen years to do things he would most have hated and despised when he was himself. Dunlap, the assistant surgeon at Dayton, told me that he found in this man's trunk letters from several—half a dozen, I think, at least—women in various places, from which it appeared that he was engaged to be married to each one of them. The letters were neatly tied up in packages, each one's separately, in several instances with photographs supposed to be of the writers, and the date of reception and reply was noted on many of the letters in a business-like way.”
As Westphal well says15of such persons, “They often think correctly and logically, and show reflection and deliberation to a certain degree; but there is a certain something lacking, and there are some general conceptions, general processes of thought and judgment, of which they are incapable. Their mentality stops short on a certain plane, especially in matters of judgment where every even uneducated person easily succeeds. They sometimes act as if they had good judgment and common sense, of which they are really destitute, particularly in regard to the proprieties of life and their proper social relations and duties. Certain of the finer feelings are absolutely impossible of development in them. Through their various nets, perverted by their mental defect, the patients often seem perverse (bösartig), passionate (leidenschaftlich), although of true sustained passion they are incapable. What seems passion is a sudden idea or fitful impulse to which they yield at once. Moral insanity is a defect in the affectivesphere, but also an intellectual defect of a peculiar kind, which is often concealed under the mask of a perverted moral sense, and which requires time and practice on the part of the physician for its detection.”
15Berl. klin. Wochenchrift, 1878, No. 15.
Moral insanity is quite certain to pursue a downward course, although something can be done by training, general hygiene, simple diet, mental discipline, avoiding overwork, a judicious choice of the few occupations of which the moral insane are capable, and a constant steadying hand to help them try to keep their balance.
IMPULSIVEINSANITYis perhaps more properly called instinctive monomania, as the morbid impulse is usually shown in only one insane propensity at a time. Like moral insanity, its manifestations are commonly periodic, or at least alternating. Under the name of emotional insanity it furnishes sympathetic juries with an excuse for finding not guilty of murder women who kill their betrayers and husbands who shoot a wife's seducer. It is a not uncommon symptom in a considerable proportion of the persons suffering from the various forms of insanity. As a separate disease it is quite rare, and includes those persons whose insanity is manifested, as Marc says, by what they do rather than by what they say. The insane impulse does not come from any logical process. It is rarely provoked by or associated with a criminal motive, except in an analogous way to the production by excitement of an epileptic attack, to which, indeed, it offers some points of similarity. There would be reason to doubt the existence of the disease unless other indications of mental degeneration were present, especially where there is proof of a criminal motive or where the criminal act and the prisoner's statements are the sole evidence of unsoundness of mind. Unconsciousness, even temporary, and loss of memory, are not symptoms of instinctive monomania. On the contrary, the mind is quite clear, and resists successfully the insane impulse so long that the person affected with it has often gained confidence that he will never yield to it; and he soon learns the fact that, there being in circumstances external to himself no reason for the crime suggested to the mind with such force, temptations do not occur to the act. While the impulse lasts a great variety of distressing mental symptoms accompany it, so intense that the impulse often cannot be resisted, and then the terrible brain-tension is relieved. I doubt whether hallucinations of hearing are found in impulsive insanity, and incline to think that all the reported cases where crimes of impulse have been committed in obedience to a voice commanding the individual to do this or that act of violence are more properly classified under other forms of mental disease. One kind of instinctive monomania sometimes disappears to be replaced by another. In developing boys and girls there is not seldom a pathological mental state during which lying, stealing, running away from home, etc. are common for several months or a few years; but this is a curable condition, and does not by any means necessarily end in instinctive monomania.
Suicidal insanity is probably the most common form of instinctive monomania. The force, or even presence, of the suicidal impulse is largely dependent upon the general tone of the system. The suicidal idea is common; it occurs to the minds of a vast number of sane people at one time or another under adverse circumstances. Hysterical women talk a lot of nonsense on the subject. Self-destruction due toself-depreciation, weariness of life, and general gloom is not uncommon in the insane temperament. It is also a refuge to proud and sensitive people who have sacrificed their honor. But this is quite different from suicidal insanity, in which the impulse is often strongest at a time when there are the most reasons for living and the greatest happiness in life if the tormenting demon urging to self-murder could be excluded. Such people finally kill themselves, in spite of their best resolutions and efforts to the contrary, if the various faculties of the mind become more and more involved as the disease goes on and the power of self-control is progressively weakened. More general insanity of the degenerative type is sometimes developed from suicidal insanity.
Homicidal insanity is fortunately still rarer than the last-mentioned form, although motiveless homicidal ideas occur to husbands and wives and parents with reference to those dearest to them, under conditions of prolonged mental strain or exhaustion, during pregnancy and the puerperal state, and at the climacterium. In suspected crimes the evidence of homicidal insanity should be clear and should rest upon the general signs of the degenerative mental state. Homicidal impulses are common enough among the insane. Just as there are persons who do not dare to have sharp instruments in their rooms for fear of killing themselves, so there are others to whose minds axes, knives, and razors suggest imperative conceptions of plans for killing another. It is difficult in either case for the physician to satisfy himself at what point real insanity begins. Seclusion under the morbid influences of an asylum is very bad treatment for the individual, and symptoms which seem very serious often disappear by restoring the general health. In a recent case,16where a youth of nineteen was acquitted of the murder of his mother on the ground of homicidal insanity, he knew that the act was wrong, realized that he had committed a crime, and was full of grief for it, as occurs in all such cases. It is the rule, too, that there is some condition of mental defect or degeneration out of which the homicidal insanity is developed.
16Quarterly Journal of Mental Science, October, 1883, p. 387.
Dipsomania, a rare manifestation of impulsive insanity, differs entirely from the acquired alcohol habit, drunkenness, acute or chronic alcoholism, delirium tremens, or habitual intoxication, all of which conditions are also more readily developed in the neuro-psychopathic constitution than in persons with healthy brains, and may reach a point constituting insanity. Dipsomania is periodic, uncontrollable, and associated with other evidences of the insane diathesis. The prognosis is unfavorable. The treatment is to improve the general nervous tone and to seclude the patient during his attacks.
Pyromania and kleptomania are not rare as symptoms of insanity of the marked forms which are observed in asylums. As manifestations of impulsive insanity—that is, as constituting a form of insanity—they are associated with other evidences of mental defect or degeneration. Burning and stealing alone are not indications of insanity. As such, they are without sane motive, and directed to objects in burning or stealing which there is no gain to the person and usually no gratification except the sense of relief which comes from yielding to the impulse, and of distressing mental symptoms if the impulse is resisted.
Nymphomania in the female, satyriasis in the male, and the variousperverse and degrading methods of gratification of the sexual instinct, may, when joined with other evidences of mental or nervous disorder, constitute one form of impulsive insanity. Erotomania, an ideal attachment without erotic feeling, is a more common mental disease, but the other evidences of insane conduct are quite striking. The same statement holds true of the many perverted instincts which, according to circumstances, are or are not manifestations of the defective brain-inhibition of disease. Animal impulse as a form of impulsive insanity I had been inclined to doubt until I recently saw two cases of as extreme mental suffering as I ever witnessed, in two refined ladies who had suffered also from some cerebral symptoms, occasional dizziness, and suicidal insanity, but who had no other symptoms of cerebral disorder than those which are grouped under the head of insane diathesis, and they not marked. It is not associated with any erotic feeling or with particular persons. There is more rapid wasting in flesh and strength and loss of sleep than in the other forms of impulsive insanity, and, in my experience, greater dread of yielding to the demon of unrest.
The perverted sexual instinct, with a feeling of repugnance to the opposite sex, has thus far been observed chiefly in persons who have been addicted to masturbation. It is marked by a passion for some individual of the same sex, by other evidences of the neuropathic condition, and commonly by a grotesque imitation of the habits or dress of the opposite sex.
The indications for treatment in impulsive insanity are cod-liver oil, the bromides, simple non-stimulating diet, open-air life, judiciously regulated exercise, mental occupation so far as is possible, and removal from suggestive surroundings and associations. The prognosis is not favorable as to the final result. If the symptoms disappear on restoration of the general health, other marked indications of cerebro-mental disorder are pretty certain to appear sooner or later.
HYSTERICALINSANITYis one of the states of mental degeneration, much less common among men than among women, arising from the further development of a neurosis, hysteria, and probably to a great extent due to bad training. Hysterical symptoms, quite marked, are very common among young persons and in single women of all ages in simple mania. They are not uncommon in simple melancholia and in other forms of mental disease. They add somewhat to the gravity of the prognosis in these cases. They constitute a group of symptoms which I suppose to be understood by those authors who speak of hysterical insanity as a disease in which the cure-rate is high. But hysterical insanity, as quite distinct from other psychoses, is quite a different matter. It is characterized by extreme and rapid mobility of the mental symptoms—amnesia, exhilaration, melancholic depression, theatrical display, suspicion, distrust, prejudice, a curious combination of truth and more or less unconscious deception, with periods of mental clearness and sound judgment which are often of greater degree than is common in their families; sleeplessness, distressing and grotesque hallucinations of sight, distortion and perversion of facts rather than definite delusions, visions, hyperæsthesias, anæsthesias, paræsthesias, exceeding sensitiveness to light, touch, and sound, morbid attachments, fanciful beliefs, an unhealthy imagination, abortive or sensational suicidal manœuvres, occasional outbursts of violence, a curious combination of unspeakablewretchedness alternating with joy, generosity, and selfishness—of gifts and graces on the one hand and exactions on the other. The mental instability is like a vane veered by every zephyr. The most trifling causes start a mental whirlwind. There is no disease giving rise to more genuine suffering or appealing more strongly for the sympathy which, freely given, only does harm. One such person in the house wears out and outlives one after another every healthy member of the family who is unwisely allowed to devote herself with conscientious zeal to the invalid.
ThePROGNOSISis unfavorable. While the symptoms may be alleviated and a nominal cure may be effected, a relapse or the development of some other troublesome form of insanity or neurosis is the rule, to which the exceptions occur for the most part in women in whom there is also some serious curable uterine disease or a state of excessive physical prostration which can be relieved.
TheTREATMENTof hysterical insanity demands tact and educating power which will tax to the utmost the ingenuity of the wisest physician. Sympathetic friends, and sympathy in general, are useful in moderation, but they oftener do great harm, because they are excessive; and the care which does good is that which, while being kind and firm, tends to develop strength and character. The will and the imagination are so extraordinarily powerful that their wise direction and government constitute the most important part of successful treatment. Diversion, occupation, and the development of self-control, with careful attention to the general laws of health, are quite important. The temptation to use drugs is, like the fascination of being pitied and petted, very great, as alcohol, chloral, or opium often acts like magic for the time being, and there is generally a craving for one or all of them. But they are utterly demoralizing in the end. The habitual use of stimulants and narcotics in such cases only increases the evil. The fact must be recognized that the hysterical insane are often least responsible where they seem most so, and that they must be treated with unending patience, kindness, gentle firmness, and a wise ignoring of most of the symptoms. Simple palliative sedatives which cannot do harm must sometimes be used, but the general rule, the less active treatment the better, is safest. In the few cases where benefit has been got from removal of the ovaries, healthy or diseased, the improvement, if it shall prove to be lasting, will probably be attributable to the great physiological shock from the operation rather than to any relation of the ovaries to the disease. Removal from home is usually advisable for a time at least—often it is necessary; and if residence in an asylum is not thought to be wise, properly-selected hydropathic establishments or private asylums are useful. Living in a judicious physician's home is desirable when a suitable one can be found. In an asylum a rational letting-alone treatment is found to be the most successful. If the patient remains at home, hired nurses should be in charge of the patient, or at least not members of the family. Safe seclusion will be found necessary for the few who will not otherwise be prevented from committing crimes and offences of startling ingenuity or conspicuous publicity.
EPILEPTICINSANITYarises from a neurosis, epilepsy, which almost inevitably ends in mental deterioration of greater or less degree, from scarcely noticeable impairment to complete dementia. The insanity maybe a continuous state; it may be subsequent to the epileptic attack, or precede it, or take the place of it. Epileptic dementia is more nearly allied to idiocy than dementia following other mental diseases, and it is associated with a degree of moral perversion and brutality which is quite uncommon in other dementia. The insanity following or preceding the epileptic attack is attended with stupor, delusions of persecution, confusion, transitory fury, or a condition quite analogous to somnambulism or cerebral automatism; and the same may be said of insanity replacing the epileptic attack, except that the most common condition in it is a violent maniacal fury, with unconsciousness, and subsequent nearly if not quite complete amnesia. The forms of mental impairment are progressive in the vast majority of cases. The other forms are more amenable to the usual treatment of epilepsy, and sometimes diminish in severity as the disease advances and the mind becomes weakened. In the fury which takes the place of the epileptic convulsion there is in nearly every case—I am inclined to think in all cases—an intellectual aura, a slight change of action, observable early enough to give warning of the approaching storm, which can always be mitigated, and often entirely prevented, by absolute rest in bed and the use of chloral and the bromides.
Although some few epileptics become well without treatment, and a small number permanently recover under treatment, thePROGNOSISis even less favorable for the epileptic insane. The care of insane epileptics should embrace, in the first place, safety to the community by secluding those dangerous to it, and, second, the usual hygienic and medical treatment of epilepsy.
Epileptic vertigo, analogous to petit mal, is a transitory mania, often associated with passing delusions.
With regard to the responsibility of the epileptic insane—and, indeed, all epileptics—the facts should be borne in mind that their mental state is usually one of such instability that a slight irritation of any kind is apt to induce a full or modified convulsion, and that under provocation they commit partly volitional crimes, for which they are not fully responsible.
HYPOCHONDRIACALINSANITYdiffers only in degree from hypochondriasis, described on a subsequent page. It is an incurable manifestation of one type of the mental degenerations. It is slowly progressive, and often ends in dementia. It differs from hypochondriacal melancholia in being an evolution of mental defect or degeneration, and in the fact that the mental depression, which is usually of a mild, periodic, or impulsive form, is secondary to the other symptoms, and not, as in hypochondriacal melancholia, the mental condition out of which the hypochondriacal symptoms are evolved.
TheTREATMENTconsists in attention to the general laws of health, occupation, and a fattening diet. It is seldom successfully managed without occasional recourse to an asylum at least, and oftenest a permanent residence in hospitals, occasionally changing, is quite necessary.
PERIODICINSANITY, usually mania or melancholia, is marked by attacks recurring at more or less regular intervals, with a partial but not complete return to the previous mental health between them. It is one of the incurable degenerative mental diseases. The seeming recovery is only apparent, and the mental deterioration is progressive, although quite slow. The form of insanity is also not seldom a folie raisonnante (affectiveor moral insanity) with periods of all sorts of excesses, destructive tendencies, tramp-life, destructive acts, drunkenness, stealing, indecent exposure, etc. In the intervals, which may be short or long, and which sometimes correspond to certain seasons of the year, the mental condition is still a pathological one, with the usual signs of mental degeneration, thereby being differentiated from recurrent insanity, one of the curable psychoneuroses, in which there is a state of mental health between the successive attacks, but no sort of regularity or periodicity in the recurrences. The prognosis is unfavorable, except in so far as a quiet life in an asylum tends to prolong the intervals between the periodic outbreaks, as well as to prevent annoyance to the community during them.
CIRCULARINSANITY(Alternating insanity, Folie circulaire, Folie à double forme, Folie à formes alternes, Die cyclische Psychose, Das circuläre Irresein) consists in a psycho-rhythm or succession, in uniform order in each particular case, of (1) mental exaltation in all degrees, from mild exhilaration or even gayness to acute mania, and (2) mental depression of all conditions, torpor, or anergic stupor. These two opposite mental conditions are separated in the vast majority of cases by a shorter or longer interval of the normal mental state, in which, however, there is soon observed some mental impairment, however slight, rarely amounting to pronounced dementia except in old age. Sometimes the three states shade off into each other, so that it is difficult to say just where one begins and the other ends; less often the transition is abrupt, sometimes during sleep. The interval between the two opposite conditions of mind may succeed either of the other mental stages, but the order once established is maintained. The duration of the vicious circle varies in succeeding attacks, sometimes becoming longer, sometimes shorter, in the progress of the disease. The relative duration of the three succeeding mental condition also varies, but the type of each remains identical, or at least changes very gradually. The state of mental exaltation often resembles moral insanity, with all sorts of immoral impulses and tendencies, and may then properly be called an insanity of action. The depression sometimes goes no farther than sluggishness of will. The tendency of the disease is to shorten life only slightly, if at all, except from the chance of suicide in the depressed state and from exhaustion when the excited stage is one of active mania. The shortest duration of the cycle in my experience has been twenty-four hours, and the longest reported extends over several years. It sometimes remains an affective insanity in its whole course, without delusions and with little more dementia than might happen from simply a corresponding advance in age without mental disease.
During the period of excitement some supervision or control will usually be desirable, and removal to some retreat or asylum will often be necessary. In the depressed stage the indications are to maintain the general health, to meet the chances of suicide, and if there are delusions to obviate the risks of danger to other persons. If the interval of comparative mental health is of considerable duration, the ordinary occupation of the patient can commonly be followed at that time for a number of years, rarely for life; but a better result may be looked for if the patient's circumstances are such that he can give up active and anxious work for some quiet occupation not involving great care.
PRIMARYINSANITY(primäre Verrücktheit, primordiale Verrücktheit,originäre Verrücktheit) is usually a further development of an hereditary predisposition to mental disease. The term primary monomania, although used as an equivalent for primäre Verrücktheit, seems to me too narrow for a disease in which the leading delusion may change so many times. Primary insanity is sometimes congenital, and may be developed also by injury or by disease involving the brain early in life or during the physiological changes at puberty, possibly by self-abuse, in persons of an unstable mental organization. It often develops so slowly with the character as to almost seem part of it, until it reaches such a degree of insane delusion of self-importance and expansive ideas as to be unmistakable insanity. There are also delusions of persecution, distrust, and suspicion, erotomania, and moral perversion, in spite of high claims to superior character, and indeed in spite of a high standard of life in some particulars. Perhaps the most striking symptom of primary insanity is the great variety of imperative conceptions (Zwangsvorstellungen) by virtue of which the individual is impelled, by a force often irresistible, to commit various offences against propriety and the laws, even to murder, as well as to perform countless acts of unwisdom or folly. There are usually physical indications of chronic or old cerebral disease, or of defect or degeneration in the incomplete or asymmetrical development of the brain, which, however, may be no more than are found in persons who might not be classed as of unsound mind. Attacks of simple mania (mental excitement) of short duration are quite common, and there is a progressive impairment of the higher faculties of the brain—those which come last in a high order of civilization—although there may be acuteness of memory, perspicacity, and shrewdness which seem altogether phenomenal as compared with the other mental qualities. There is no form of mental disease which is better expressed by the word craziness than primary insanity, no other in which the victim is more thoroughly in the grasp of his malady, and yet no other in which he is more likely to be held responsible for the crazy acts which he may perform, because his inherent mental state, out of which his generally deluded frame of mind is evolved, gives rise to delusive ideas of such a character that they are not universally recognized, even by physicians of experience in mental disease, as insane delusions, but are considered by some of them as the prevarications of a criminally-minded person. When these persons commit crimes, too, they often do so with methods and motives quite like those of the ordinary criminal.
ThePROGNOSISin primary insanity, after the disease is fully developed, is in the highest degree unfavorable. It remains to be seen how much can be done by moral training in childhood and youth to correct the evil tendency. The education of those who get into the courts and insane asylums, so far as my knowledge of such cases goes, has been bad to the last degree, so that, in my opinion, there has been a fair difference of opinion as to which of them the law should treat as criminals and which as insane persons.
TREATMENTfor the most part requires absolute control of the individual, which there is usually no one in the family sound enough to maintain. If begun early, training away from home may accomplish much. Restraint in some institution is commonly called for, but the vast majority of the primary insane are allowed to take their chances inthe world, and as many end in jails and prisons or on the scaffold as in asylums.
The states of mental defect and degeneration, except in the case of idiocy or marked imbecility, are not associated with such obvious physical evidences of deviation from a normal mental standard as to make them pathognomonic. While asymmetry and other cerebral defects are frequently observed in them, it must be acknowledged with Schüle that similar and as extensive gross intracranial anomalies are found in persons who could not be called of unsound mind, and that this statement holds true even of primary insanity, in which some writers have laid so much stress upon the value of any indication of imperfect or asymmetrical cerebral development. Any defect in the brain, however, is far more common among persons of unsound mind than among those of sound mind, and therefore in doubtful cases it is of a certain value as corroborative evidence of mental infirmity or impairment.
Spitzka places as signs of the insane constitution (1) atypical asymmetry of the cerebral hemispheres as regards bulk; (2) atypical asymmetry in the gyral development; (3) persistence of embryonic features in the gyral arrangement; (4) defective development of the great interhemispheric commissure; (5) irregular and defective development of the great ganglia and of the conducting tracts; (6) anomalies in the development of the minute elements of the brain; (7) abnormal arrangement of the cerebral vascular channels,—at the same time acknowledging that there are cases of insanity of inherited origin in which cerebral defects are not discernible. It is too early to estimate the value and importance of the finer or qualitative cerebral defects as giving rise to insanity. Benedikt finds them also in criminals.
With regard to responsibility before the law, the statutes of no country provide for any criterion by which accountability is defined in these cases; medical witnesses differ in opinion as to their criminality, and the courts are obliged to interpret the law to suit individual cases.
The states of mental defect and degeneration are not sharply defined. They run more or less into one another. The fact should also be kept in mind that isolated symptoms and groups of symptoms belonging to them are repeatedly found in curable conditions of physical and mental exhaustion in neurotic persons.
The degenerative mental states are thought to be increasing, to furnish material for the increase in the otherwise curable insanities, and to thus include much of that portion of the community which is most filling up our institutions with incurable cases. It is probably in the prevention of them, or at least in the proper training and disposition of children affected with them or predisposed to them, that the most can be done to stay the increase of insanity. Perhaps at some time unwise marriages of passion and sentiment will be less common than now, and the rights of children to a fair start in life more considered.