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 within {140} the 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.
THE INSANE TEMPERAMENT (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, {141} 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.
TREATMENT should 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 only {142} approximately, 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.
CONSTITUTIONAL AFFECTIVE MENTAL DISEASE is 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.
The PROGNOSIS is 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.
{143} The TREATMENT is 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.
MORAL INSANITY (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
punished {144} by 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 under {145} his
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 says[15] of 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 affective {146} sphere, 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.”
[Footnote 15: _Berl. 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.