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 to {147}
self-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,[16] where 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.
[Footnote 16: _Quarterly 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 various
{148} perverse 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.
HYSTERICAL INSANITY is 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 unspeakable {149} wretchedness
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.
The PROGNOSIS is 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.
The TREATMENT of 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.
EPILEPTIC INSANITY arises 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
may {150} be 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, the PROGNOSIS is
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.
HYPOCHONDRIACAL INSANITY differs 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.
The TREATMENT consists 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.
PERIODIC INSANITY, 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 (affective {151} or 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.
CIRCULAR INSANITY (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.
PRIMARY INSANITY (primäre Verrücktheit, primordiale Verrücktheit,
{152} 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.
The PROGNOSIS in 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.
TREATMENT for 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
in {153} the world, and as many end in jails and prisons or on the
scaffold as in asylums.