frequently observed—partly, perhaps, due to general anæmia, in part to
circulation of diseased blood in the brain, and partly from tubercular
deposits. Other diseases act directly upon the brain and nervous
system, as leptomeningitis, pachymeningitis, sclerosis, capillary
aneurisms, embolisms, cerebral hemorrhage, tumors, disease of
arteries, syphilis, caries, exostosis, abscess, internal otitis,
sunstroke; still others by disturbances in the cerebral circulation,
as diseases of the heart and kidneys; others by vitiating the blood
circulating in the brain, as in the acute stage of febrile disorders;
others in some general unknown way, as chorea, hysteria, epilepsy,
gout, rheumatism, malaria, pneumonia; and still others during the
period of convalescence or of general exhaustion, which is often
associated with infectious diseases or chronic disease attended with
general anæmia. The more violent and curable psychoses occur at the
height of acute diseases, those of longer duration and of less
favorable result during convalescence. Among other recognized causes
are prolonged and obstinate dyspepsia, the psychological changes, if
morbidly developed or attended with accident, at puberty, during
pregnancy, at childbirth, during the puerperal state or lactation, and
at the climacterium, and rarely various affections of the abdominal
and pelvic organs.
Chronic alcoholism produces disease of the small blood-vessels of the
brain and the consequences of that condition, causing insanity in a
considerable proportion of cases, and almost always some mental
impairment. Insanity occurs under conditions of cerebral hyperæmia and
of cerebral anæmia, although their relation as cause and effect is
very obscure. The habitual use of hasheesh gives rise to a
disagreeable form of dementia, and so does opium, but more rarely. The
effects of poisoning from iodoform, lead, mercury, bromide of
potassium, hydrate of chloral, belladonna, tobacco, when reported as
producing insanity, are usually transitory.
Cases have been reported of two persons being exposed to the same
causes and having similar attacks of insanity (folie à deux), and also
of folie induite or folie communiquée, where several persons have
adopted the delusions of a person of influence among them, one of the
most remarkable instances of which was the case of the seventeen
grammar-school-taught Adventists of Pocasset, who accepted the insane
belief of their leader, Freeman, that, like Abraham, he had been
commanded by the Lord to kill his child, that she was to rise on the
third day after he {120} had killed her, and that he was to become a
great evangelist. So-called epidemic insanity, choreomania, and
demonopathy belong in this class.
From untrained, ill-balanced men and women, whose lives are ill
regulated, the ranks of the insane are largely filled. Insanity is
often the ultimate wreck of a life ill guided, directed chiefly by
caprice and passion and weakened by indulgence. In that case it is,
like much habitual drunkenness, as much a fault as a disease. The
individual will not behave with decency and propriety for so long a
time that, finally, especially after the age when the brain begins to
fail, he cannot.
SYMPTOMATOLOGY AND COURSE.—The distinguishing symptoms of insanity are
mental. In some forms of insanity they are mental only; in others
these symptoms are associated with others, such as also occur in
diseases not necessarily affecting the mind. The earliest mental
symptoms are change of character, increased irritability, less feeling
of accountability, a lower moral tone, moral perversion, diminished
stability, loss of interest, lessened power of concentration and
self-control, impulsive acts, anxiety or the opposite condition of
mind, perverted or exaggerated force of the emotions, restlessness,
apprehension, sleeplessness, impaired will, slight depression or
barely noticeable exhilaration: things and persons seem changed in
some vague, unexplained way. There is an alteration in the way in
which the person is affected by his surroundings.
The next symptoms are more purely intellectual. Delusions are often at
first based upon some fact, and are merged into insane delusions only
as the mind, in becoming weakened, loses power of comparison and
judgment. Often they arise out of the disordered condition of mind.
Hallucinations of any of the special senses, illusions, perverted
ideas, mental confusion, mental hyperæsthesia or anæsthesia, delirium,
stupor, exaltation, depression, impairment or loss of memory,
quickened or dulled conception and perception, increased or diminished
intellectual activity and acumen, distorted association of ideas,
imperative conceptions, all sorts of anomalies of consciousness and
free will, uncontrollable and uncontrolled insane impulses, are
common. The intellectual and moral symptoms appear nearly or quite
together in very acute disease, and they together increase in
intensity, and finally entirely control the individual. Many of the
insane recognize the fact of their insanity. Some of them understand
the nature of their disease quite well, discuss their cases
intelligently, and frequently ask why they, automaton-like, are
impelled by a force which they cannot resist to constantly do things
which their intelligence and better nature condemn. Not a few are
confined in places of safety by their own preference.
The physical symptoms of insanity are perverted sensations of almost
every conceivable kind, resulting in depraved instincts and acts,
psycho-motor excitability, convulsive action, choreic movements,
uncontrollable muscular agitation (springing, shouting, swearing,
dancing, running, destructive tendencies, etc.), elevation or
depression of pulse, respiration, or temperature, loss of appetite,
digestive disturbances, pain, fever, tetanic and cataleptic rigidity,
paralysis, tremor, ataxia, epileptic seizures, convulsions, muscular
contractions, increased or decreased secretions and excretions,
disturbances of general nutrition.
The course of the various mental diseases is to a great extent
chronic, some forms being incurable from the beginning, others curable
to such {121} an extent that of recent cases from one-half to
nine-tenths recover, of whom a considerable proportion remain well to
their death. The duration of the mental diseases is from a few days to
a lifetime, sometimes not even shortening life. The termination is
oftenest in incurable chronicity or dementia, less often in permanent
recovery without recurrence, and still less often in death from the
first attack. Unfortunately, the essentially incurable and the curable
forms of mental disease are classed together in statistics of
insanity. While many types are absolutely fatal or certain to end in
hopeless chronicity or dementia, others tend to recovery. In some
forms relapses and recurrent attacks are to be expected: in others
they seldom occur. In many cases there is no more probability of
transmission to children than in Bright's disease, and no more
likelihood of subsequent attacks than in typhoid fever.
MORBID ANATOMY AND PATHOLOGY.—It is thought by the best observers that
insanity depends upon a functional brain disturbance, or at least upon
a disordered condition which it is beyond our present power to
discover, and that the normal working of the mind depends upon a brain
healthy to such an extent that its millions of functional activities,
in their endless relations to each other, preserve a state of
equilibrium; or, in other words, that the higher centres maintain
their power of control over the lower. It is doubtless true that this
relation depends in general upon a healthy brain, but it is not yet
known to what extent. Disease of the brain or its membranes,
apparently slight, often seems to cause insanity, and often there is
marked disease without insanity. We certainly cannot place all the
pathological conditions found in the brain of a person dying insane in
direct causal relation to his insanity. The anæmia observed by Meynert
in melancholia and the hyperæmia of maniacal excitement, even if
proved to be universal in those conditions, may be only symptoms of
the underlying disease or caused by it. It is certain that there are
indications of as great anæmia or hyperæmia in other states without
insanity.
Insanity in its initial stage does not, as a rule, involve a
recognizable deviation from the normal structure of the brain, and the
patient may die before such pathological changes are so manifest that
we can detect them. But if the disease has been of long standing, in
the majority of cases the brain shows evident marks of disease, and
there may be found no striking indication to the naked eye of
deviation from a healthy condition, when a microscopic examination
reveals signs of advanced cerebral disease. The limited knowledge of
the cerebral structure and function which pathologists possess, and
the consequent difficulty in detecting changes from the healthy state,
indicate that the failure to find them is attributable in not a few
instances to the fault of the investigator rather than to the nature
of the disease. Certain it is that the better acquainted we have
become with the anatomy of the brain and with its functions and
sensible qualities, and the more thorough and painstaking we have been
in our examinations, the rarer it has become to find a case of
insanity where no organic changes are observed after death, although
it is true that we do not understand all the relations between these
changes and the symptoms observed during life.
A large abscess of the brain, a hemorrhage, a tumor, or a wound of the
cortex or other portion of the brain, various degrees of inflammation,
{122} meningitis, are sometimes followed by insanity and sometimes
not; and we do not yet understand the reason for the difference.
Indeed, nearly every pathological condition of the brain known in
insanity—in kind, if not in extent and degree—may be found in diseased
or injured brains where there has been no mental disease in
consequence. There is only one disease, general paralysis of the
insane, in which the morbid appearances discoverable after death with
our present knowledge bear a definite relation to the most constant
manifestations during life. And yet, with pathological changes so
similar that we are not able to detect their essential difference, the
mental symptoms of the first stage of general paralysis may be most
various. Rosenbach has found in the brains of starved dogs and
guinea-pigs as extensive changes as in well-marked primary dementia,
in which the pathological conditions are more extensive than in any
other form of acute insanity.[7] That is to say, when we have
discovered and described all the morbid appearances in the brain of an
insane person we have taken only the first step in accounting for his
insanity.
[Footnote 7: _Centralblatt für Nevr. Psych. und ger. Med._, 1884, p.
33.]
The localization of many of the cerebral functions, the discovery of a
psychomotor tract, and the constant accessions to our knowledge of the
physiology of the brain are throwing much light on the subject. But
all efforts to localize the intellectual and moral functions of the
brain, except generally to agree with the teachings of a century ago
and to place them for the most part in the anterior and antero-lateral
portions of the cortex, have thus far failed of success, the most
careful observers still thinking that local lesions when apparently
causing insanity do so by injuring the action of the brain as a whole,
and not of any particular part.
In some cases of insanity, with never anything like acute disease,
where death occurs from the weakness of old age or some intercurrent
malady, the brain does not present any recognizable difference from
those of sane people whose brains have worn out with their bodies. In
those forms of mental disease where changes are found, the most
important and constant are in the cortex of the brain, especially in
the fore, upper, and middle parts of the periphery, involving usually
also the membranes. In beginning acute mania the condition of the
blood affecting the brain or the pathological changes are probably as
nearly identical with those in the acute stage of pneumonia, certain
forms of typhoid fever, cerebro-spinal meningitis, and other diseases
as the symptoms of the mania are now and then difficult to
differentiate from those of the other diseases just mentioned. In
rheumatism, syphilis, malarial poisoning, and Bright's disease with
mania we find no distinctive pathological conditions to account for
the maniacal symptoms.
If asked whether there is a fixed lesion of the brain or any of its
parts corresponding to given psychological changes, we should be
obliged to say no, except in the case of incurable dementia. If asked
whether there are important morbid changes corresponding with all
cases of insanity, we can only say yes, sooner or later, in the
majority of cases, and that there are certain destructive lesions,
chiefly inflammatory, atrophic, and degenerative, which invariably
mean marked deterioration of the mind. As regards diseases of other
organs than the brain, the insane, like the sane, die of all of them,
and in especially large numbers of pulmonary consumption.
{123} Insanity may, both in its acute and chronic form, be the result
or symptom of simple anomalous excitation or nutrition of the brain or
of inhibition of some of its portions, without any change in its gross
appearance which can be detected by our present methods of research.
In the majority of cases there are found diseased conditions which
become more manifest the longer the duration of the disease, appearing
for the most part in the blood-vessels, pia mater, and cortex of the
brain, but also in the medullary portion, many of which are recognized
only in their late stages. In the functional mental diseases there is
no characteristic lesion of the brain as yet recognizable, even in the
latest stages, more than is to be found in the brains of persons dying
from other causes. When apparently local injuries or diseases cause
insanity, they probably do so through a general disturbance of the
brain or through diffuse disease resulting therefrom and for the most
part affecting both hemispheres. The molecular, chemical, anatomical,
physiological, pathological, or physical changes in the brain which
give rise to insanity, and their relation to the grosser pathological
conditions of the brain, are still not clearly made out.
In terminal dementia, especially in the last stage of paralytic
dementia, nearly every tissue and organ of the body may be found to
have undergone pathological changes, of which by far the greater
portion is secondary to disease of the brain; and it is impossible to
say how much of the brain lesions in these and other conditions of
mental unsoundness is secondary to the disease or an accidental
complication.
DIAGNOSIS.—In the diagnosis of insanity the physician assumes a
responsibility for which he is liable under the common law. It is
important, therefore, to avoid mistakes as far as possible. In the
majority of cases the patient's unsoundness of mind is evident before
he is brought to the doctor, but in not a few the symptoms are
obscure, and they are often rendered more difficult of correct
understanding and appreciation by the deception or reticence of the
patient and by the prejudices of his friends.
First, before seeing the patient it is well to get from his family,
friends, and physician a full knowledge of his natural state, all the
facts known to them relating to strange behavior, delusions, etc., as
they give most useful hints with regard to the method of examination.
Apparent familiarity with an insane person's delusions will often
secure their immediate acknowledgment. In a case of any obscurity or
where there is doubt that other causes than insanity may have produced
the unusual behavior, and particularly if any legal steps are to be
taken regarding guardianship, restriction of liberty, commitment to an
asylum, validity of wills and contracts, capacity to manage property,
marriage, etc., it is imperative that both sides of the question be
fully heard before any positive opinion is given. After the patient's
confidence has been gained in general conversation, during which his
appearance, manner, and mental condition as to intelligence,
coherence, memory, judgment, perception, and capacity may be noted and
compared with his normal standard, he should be examined carefully for
any external evidence of lack of development or of injuries to the
head. As in all other diseases, the condition of every organ of the
body should be noted; a complete diagnosis should be made. The
expression of the face often indicates such excessive excitement,
gloom, stupor, suspicion, or fear as must be due to insanity alone.
{124} Throughout the examination the questions and manner of the
physician should be such as to avoid suggesting unpleasant ideas or
associations to the patient. The matter of suicide should never be
first mentioned by the questioner, and not seldom he does best who
listens most and lets his patient disclose his morbid ideas and
impulses, as he will frequently be led to do, if at all, by the
manifestation of interest and sympathy, and of knowledge of the
symptoms of the disease in hand, on the part of the physician. He
often gets enough for his purpose without getting the whole story,
upon which it sometimes does harm, or at least is not best, that the
patient should dwell. In the diagnosis of mental disease, however, as
well as in estimating responsibility, the fact must be borne in mind
that a controlling delusion may be concealed for months or even years,
and that the symptoms and mental condition of insane people vary so
much at different times that it may be quite possible to get distinct
evidence of unsoundness of mind at one time and not at another. The
power of self-control is also liable to the same variation or
alternation.
If the patient has no reason for simulation, it is commonly best to
tell him the object of the examination. The family history should be
learned from others, as questioning the patient on these points is apt
to put him in a train of thought unfavorable to a hopeful view of his
own case. After full personal questions concerning himself and his
environment, one can usually tell whether there are unreasonable
suspicions, violent impulses, perverted feelings with regard to his
family, delusions, hallucinations, or illusions. A delusion's
existence must often be accepted, however, from the behavior of the
patient and from the statements of those about him. Hallucinations of
hearing must sometimes be inferred from the attitude of listening to
imagined voices; and prolonged observation under circumstances such
that the patient does not know that he is watched will often settle
the question of his insanity when other means have failed. A careful
examination should, of course, be always made for the physical and
rational signs of disease. In the differential diagnosis care must be
used not to mistake for insanity the acute diseases typhoid fever,
meningitis, smallpox before the period of eruption, pneumonia,
cerebro-spinal meningitis, narcotism or delirium from drugs, and
alcoholism—errors which have been made, and which can be avoided by
deferring one's opinion for a sufficient time.
The detection of simulation is more difficult, especially as the
insane sometimes feign insanity for a purpose, or, on the other hand,
accuse themselves of wrong acts which they never committed. In
general, it may be said that sane persons pretending to be insane very
much overdo their part, do not make their symptoms conform to any
recognized type of disease, and have a strong motive for their
deception, as well as for the act for which they wish to be considered
irresponsible. Their insanity first appears after the deed; they are
exhausted by their efforts to seem mad, and appear quite sane if
watched when they think that they are unobserved. A crime performed
without accomplices, with no plan or a silly one for escape, and with
no sane motive, is usually itself evidence of insanity. On the other
hand, people partly demented by chronic insanity often commit crimes
with all the method and motive of the criminal. In not a few cases,
especially when the fact or not of impaired intellect cannot be
decided by comparison with a previous condition, the question of {125}
insanity, or at least of responsibility, will be beyond human wisdom.
A correct diagnosis can, of course, not be made without a familiarity
with the various forms of mental disease; and insanity is now so well
understood that a sufficient examination of an insane person should
develop the clinical history of some known type of disease in nearly
every case.
Little has been said of the physical evidences of insanity, because
there is little to say. Conditions of mental torpor, depression, and
excitement are associated with the physical manifestations which we
would naturally expect in those mental states. Coarse brain disease
with insanity or without may have identical physical signs; paralytic
dementia is the only disease in which corporeal indications really
assist in forming a diagnosis.
A family predisposition to mental disease does not materially affect
the question of fact whether a given individual is insane or not,
except that in a doubtful case it adds to the probability of insanity,
and is thus far a factor of importance as corroborating other
evidences of an unsound mind.
PROGNOSIS.—The prognosis in insanity depends first upon the type of
disease, mania, melancholia, and some forms attended with confusion
and stupor being the most curable; the forms attended with
systematized delusions or with periodicity which is not dependent upon
menstruation, folie circulaire, and moral insanity rarely so, and the
organic brain diseases, congenital insanity, and confirmed primary
delusional insanity (monomania) hopeless. The acute forms are far more
curable than those of a subacute type: 60 per cent. of the cures in
insanity occur in the first half year of treatment, 25 per cent. in
the second half, and 2.5 per cent. in the second year, roughly
speaking. In chronic cases a reported cure is most commonly only a
remission, and after several years of existence insanity is generally
incurable, although rare cases of cure in mania have been reported
after even from six to fourteen years of treatment, and in melancholia
after twelve years. So long as there is no permanent dementia and
there are distinct intervals of mental clearness, no matter how short
or how far apart, there is hope of final recovery in the curable
mental diseases.
People of sound families, with insanity of an acute type arising from
physical causes, often make such speedy and complete recovery as to
justify their subsequent marrying if they wish, while those of
unstable nervous organization recover more slowly and oftener relapse.
Insanity from so-called moral causes, too, is of more unfavorable
outlook than if from the physical causes, if we exclude organic brain
disease. A person with good physical education, excellent mental
training, and self-control is more likely to get well than one with a
vicious bringing up. The ages of maturity and middle years are most
favorable to complete recovery. In women there are more first cures
and more relapses, according to Krafft-Ebing. In general, the
mortality of the insane in asylums is about four times that of the
sane of all ages, or approximately six times that of the sane at the
ages when insanity prevails.