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.
Psychoneuroses.
AFFECTIVE MENTAL DISEASE is a folie raisonnante, one of the reasoning
insanities, sometimes called moral insanity, and very like the moral
{154} insanity already described, except in the absence of signs of
mental degeneration and in the fact that it is a curable disorder. It
is an insanity of action, marked by scarcely noticeable mental
impairment. It often is the early stage of more serious mental
disease, and not seldom its symptoms remain, as simply change of
character, after the striking symptoms of extensive mental disorder
have disappeared. It also exists and is cured without the appearance
of more pronounced insanity. At the time of the climacteric it is a
form of mental disorder not uncommon among women, who, however,
usually fail to recognize it as such until they have recovered.
Maudsley includes under this head simple melancholia, simple mania,
and moral alienation, but it will be more convenient for the present
purpose to use the term affective mental disease as indicating a
curable moral alienation or change of character affecting the
intellect chiefly so far as the judgment and sense of propriety only
are concerned, and not dependent upon constitutional defect or
developed degenerative mental state. There is usually slight
exhilaration or depression, which alternates or varies from time to
time.
The PROGNOSIS is favorable.
The TREATMENT is brain-nutrition, with those general measures already
described.
HYPOCHONDRIASIS, as Flint[17] well says, belongs in the list of
disorders of the mind, although the mental alienation is not regarded
as amounting to insanity. The mental state is one of morbid
imagination and apprehension rather than of definite delusion, and it
consists in a belief in the existence, present or to come, of maladies
and diseased conditions for which there is no foundation in fact, in
spite of sufficient proof of their unreality. There is usually, not
always, mental depression. Its causes lie in conditions, usually
obscure, which lower the tone of the general health, including
hereditary weaknesses, or depress the vitality of the brain either by
physical wear or mental worry, and the exhausting influence of
functional disorders or of organic diseases which may not be
discovered before the autopsy. Disappointment, bad habits, want of
proper mental occupation are often at fault.
[Footnote 17: _Practice of Medicine_, p. 854.]
The physical symptoms of hypochondriasis are commonly those associated
with impaired digestion and nutrition—namely, anæmia, dyspepsia,
neurasthenia, constipation, flatulence, headache or a feeling of
discomfort after using the brain, less appetite, slight loss of flesh,
disordered sleep.
The mental indications are more or less melancholy, indisposition to
exertion, irritability, diminished power of self-control, and an
inability to cease except temporarily from interpreting signs, proved
to be trivial, as indicating grave maladies or as forewarnings of
severe disease to come. Sometimes the fixed idea is limited to a
single false conception, but oftener slight changes in physical
symptoms or differing phases of morbid introspection produce a
complete kaleidoscope of pictures of fancied misery. The whole
catalogue of diseases, or a large part of it, may be exhausted, with
the help of some of the many foolish treatises always ready for
hypochondriacs or from reading medical books and talking with
charlatans, who are consulted at rapid intervals, one after another,
both by those who wander from office to office and those who take to
their beds. The most common type of hypochondriasis arises, directly
or indirectly, {155} in some form of unhealthy or false ideas
regarding the sexual function, and in the idea that some imagined or
exaggerated abuse of it has produced or will produce most serious
evils; but there is not an organ of the body which may not be the
basis for the unwholesome thoughts. Not seldom there is simply the
delusion of especial weakness or sensitiveness or delicacy.
Hypochondriasis may be only the early stage of more serious mental
disease. It may be one manifestation of an hereditary neurosis or
psychoneurosis, or it may arise from deterioration of the body's
vitality by organic disease, especially of the abdominal or pelvic
organs or through some incurable weakness or functional disorder. In
either of these cases its cause and duration will be determined by the
clinical history. As an uncomplicated psychoneurosis hypochondria
lasts from a few months to a number of years, with very little change
in its prominent symptoms, resulting in recovery for the most part,
becoming chronic in a moderate proportion of cases, and rarely proving
fatal except by some accidental complication, including suicide.
The PATHOLOGY AND MORBID ANATOMY of the disease are unknown.
The differential DIAGNOSIS consists in the exclusion of other
diseases.
The PROGNOSIS is favorable in uncomplicated cases.
TREATMENT consists in measures to improve the general health,
especially a full diet carefully selected, hydro-therapeutics,
massage, gymnastics, horseback riding, walking, rowing, abundant and
agreeable exercise in the open air, and the management of the
patient's surroundings so as to lighten the mind and relieve from
worry, perhaps by travel, sea-voyages, etc. Argument is commonly worse
than useless, but there should be a decided impression given that the
generally morbid state is due to ill-health. The risk of suicide is so
small that restrictions of liberty directed to its prevention do more
harm than good. It goes without saying that bad habits should be
reformed, narcotics should be avoided, and a healthy occupation should
be encouraged, or, if possible, insisted upon. The difficulties in
treatment are fully as great with the highly-educated superstitious
and credulous people whom we find in the literary and professional
circles as in the ignorant and weak-minded.
MELANCHOLIA (Die Melancholie, Schwermuth, Tiefsinn, Trübsinn,
Lypemanie, Mélaneolie, Aliénation partielle depressive, Monomanie
triste, Phrenalgie, Psychalgia) is one of the functional mental
diseases, in the sense that the pathological condition of the brain
upon which it depends is not yet known, although it is thought to
begin with disturbances in circulation and nutrition, which end, if
not resulting in cure, in atrophic, degenerative, and inflammatory
states, indicating, in the great majority of cases, extensive brain
disease. As a rule, melancholia first appears in a slight change of
character; the patient is said by his friends to be not quite like
himself. After some days or months, as the case may be, the symptoms
develop into settled gloom associated with mental pain—the state known
as
Simple Melancholia (Mélancolie raisonnante), in which the events of
life are correctly observed, but, incorrectly interpreted, are the
source of constant apprehension, self-depreciation, depression, and
despondency. There are no delusions, properly speaking, and yet there
is a disposition to take the dark-side view even of circumstances
which promise {156} favorably, which amounts to a generally deluded
state of mind. Commonly there is increased irritability, now and then
a genuine moral insanity, and occasionally in neuropathic
constitutions the state of mind already described under the head of
Impulsive Insanity, of which the suicidal impulse is the least
infrequent. Sometimes there are no physical indications of disease,
but as a rule there are headache, increased sensibility to light and
noise, sleeplessness, restlessness, impaired appetite and digestion,
gastro-intestinal catarrh, marked loss of flesh, diminished or
abolished sexual desire, and in women usually delayed menstruation or
amenorrhœa. A few persons are able to keep up, in an irregular sort of
way, their customary employment. In the majority of cases it is
impossible to concentrate the mind upon work, mental occupation
fatigues the brain, and the physical strength is too impaired for
steady labor. Suicide is thought of probably in nearly every case, as
it is by many sane people at some time in their lives, but it is very
seldom committed unless there are such disgraceful or distressing acts
performed or suffered by them as would tempt to suicide in sane
people. There is no danger of deliberate homicidal acts in persons of
good character. A criminally disposed person would more readily commit
murder in simple melancholia than if free from that disease.
Simple melancholia may be the initial stage of almost all of the
mental diseases, especially acute mania, paralytic dementia, and the
severer forms of melancholia. It may be differentiated from the first
stage of mania only by waiting until other symptoms appear or not, and
the same is true with regard to distinguishing it from the forms of
melancholia involving danger to life. In the latter case, however,
there is much greater difficulty in diagnosis, inasmuch as insane
delusions may be concealed, and there may be so slight a change in the
patient's behavior when delusions appear in his mind that the closest
observation is needed to guard against them. The simple melancholia
marking the first stage of paralytic dementia is characterized by
noticeable although often slight mental impairment—a distinctly
diminished capacity for work, of which the individual himself is not
seldom conscious, whereas in the disease simple melancholia the mind's
usual power is exerted, provided its attention can be withdrawn from
morbid introspection and concentrated upon any subject, as it commonly
can be for a while.
Melancholia with delusions (acute melancholia) is commonly a further
development of simple melancholia, but sometimes its course is so
rapid that if there is a period of mental depression without delusion
it is overlooked. The earliest and most common delusion is some form
of causeless self-reproach with regard to some matter, whether trivial
or important, or of groundless self-accusation, of impossible sins of
omission or commission, but generally of some vague, undefinable
fault, as having irretrievably offended God or committed the
unpardonable sin, etc. Often this and an unfounded belief in
self-unworthiness are the only delusions present, and in that case
within narrowed limitations the mind acts soundly in other matters.
The feeling of personal fault or sin often expands to a sense of the
justice of punishment, and the consequent delusion that all sorts of
terrible things are to happen—poverty, the poorhouse, or some great
unknown dread, even involving family and friends; and from personal
sin or fault it is only a step to the belief {157} that the world is
all wrong, and to the certainty that everything is going to worse than
ruin. Illusions of sight and hearing may magnify common fires and
locomotive whistles into general conflagrations of the world and
shrieks of tormented persons. Hallucinations of the special senses may
create visions of all sorts of imaginary horrors, sounds of voices
saying every possible dreadful thing, odors most disagreeable, tastes
most vile. Anæsthesia prompts the delusion of death, and hyperæsthesia
of burning, freezing, scalding, etc. Some mysterious force within
them, which they can neither explain nor understand, drives them to
automatic acts of all kinds—to obscenity, profanity, verbigeration,
intonation of sentences, wailing, screaming, destructiveness, etc. In
cases of exceptional severity the mind seems deluded on almost every
subject: the food is poisoned, the atmosphere is deadly, the world
loses all its reality, friends their identity, things their substance.
They are to be burned alive, starved, quartered, suffocated,
smothered, drowned. Every conceivable and inconceivable thing is to
happen. The delusions are nearly always of the illogical or
unsystematized kind, although systematized delusions of persecution
are met, for the most part, in incurable cases. Deliberate plans of
suicide are formed in most cases, and are to be suspected in all.
Homicidal attempts are apt to be made upon persons whom it is desired
to save from impending calamities. Suicidal, and less often homicidal,
impulses occur. Suicide and homicide from deliberation need, to be
successful, (1) the opportunity, (2) lack of power of self-control,
and (3) a strong determination. Sometimes there is the will without
the opportunity, or the opportunity with self-control; and for this
reason persons in danger of killing themselves or others often for
months escape any acts of violence. Not seldom, too, they determine to
kill themselves or family in a particular way, and neglect other
chances so long that they are thought to be not meditating destruction
of self or others. When the determination or impulse to suicide or
homicide is persistent and desperate, no means are too horrible and no
opportunities too hopeless to be attempted. There is no reason for a
special name for these symptoms, but they have been called suicidal
melancholia and homicidal melancholia. No more is there any
justification of the term hypochondriacal melancholia for melancholia
with hypochondriacal symptoms.
In melancholia with delusions there is sooner or later, in the
majority of cases, refusal to eat, from lack of appetite, nausea, or
disgust of food, from disagreeable hallucinations of taste or smell,
from delusions that it is a sin to eat, that the stomach is full, that
the mouth is sealed or the throat obstructed, that the food is not and
cannot be paid for, that eating will do no good, etc., from a wish to
commit suicide by starving, or in the states of stupor
(attonitäts-zustände) from mental torpor or stupidity. Sometimes there
is resistance to the calls to eat, urinate, or defecate by virtue of
resistive melancholia—a condition to resist and oppose everything—or
from delusions that it will destroy the soul, etc. to follow the
natural inclinations. Refusal of food may be under certain conditions
instinctive and conservative. It is the exception for the bodily
functions to be well performed. Usually, there is obstinate
constipation, with headache, coated tongue, greater variation in daily
temperature than is usual in health, accelerated pulse, and rapid
wasting in flesh. The various anomalous sensations observed in
functional diseases of the nervous {158} system are common.
Masturbation is a not infrequent symptom of loss of self-control in
both sexes.
Acute melancholia is sometimes confounded with delusional insanity
with mental depression. In the former the delusions are evolved from
the mental state; in the latter, the mental state from the delusions.
In the former the delusions are for the most part unsystematized: the
patient cannot state why he believes them to be true; in the latter
there is correct reasoning from false premises: the delusions are
logical or systematized and of a depressing character, so that a
belief in them naturally gives rise to sadness.
Before the courts the fact should be kept in mind that persons with
acute melancholia have diminished power of self-control by virtue of
their disease, and so yield more readily to temptation than in health.
They also may have imperative conceptions—ideas so strong that they
cannot, or can with difficulty, resist carrying them out even when
they know them to be wrong; and there may be sudden outbursts of
almost maniacal excitement. They are often able to make wills and
perform contracts, in form and in detail, as well as ever, when they
are so filled with insane delusions as to be on the point of killing
themselves and their families. There is impaired capacity, however, of
recognizing the relations of persons and things to one another, a
distinct moral perversion, and a diminished recognition of obligations
and sense of responsibility. In other words, they are not always fully
themselves on those points in which they seem to be so, and yet
patients in asylums with acute melancholia have been known to give the
best of advice to their business-partners.
Melancholia with stupor (melancholia attonita) appears like complete
dementia or a mindless state, but there are now and then evidences of
intelligence. The mind is filled with overwhelming and terrible
delusions, which paralyze the will and place mental and physical
activity for a while in abeyance. It arises commonly in the course of
the less profound form of melancholia, after some great mental shock,
and there is a condition of marked anæmia of the brain, probably
symptomatic rather than pathognomonic, which if not soon relieved goes
on rapidly to atrophy and degeneration. Except when there are attacks
of frenzy, which may occur at any time, there is little danger of
active violent acts except suicide, desperate refusal of food, and
determined resistance to any care or treatment. There are the usual
indications of physical exhaustion.
In melancholia agitata the mind is clear and active, the opposite of
the condition last described, and the distressing delusions produce
such a degree of motor excitement arising from the mental suffering
that the disease closely simulates acute mania. The mind not only
reacts as readily as in health to distressing ideas, but abandons
itself more fully to their domination through diminished will-power
and lack of self-control. Almost blind acts of desperation and fury
are committed from which the utmost vigilance can hardly save them.
The three severe forms of melancholia just described are
interchangeable in the same person during the course of his illness,
so that the states of frenzy and stupor are more properly called
symptoms than classes of disease.
Melancholia among children is more common than the books state it to
be, although rarely met in the asylums. Magnan has reported a {159}
suicidal case in a child four years old, and it occurs up to the
latest years of life.
The DURATION of simple melancholia is from a few weeks to a dozen
years; of acute melancholia, from a month to two or three years, after
which it is apt to end in chronicity; melancholia stupida (with
stupor) is usually curable, if at all, in the first year, although
relapses are frequent, and in melancholia agitata from a year to three
years is the common limit of the possibility of a cure.
The PROGNOSIS in simple melancholia is favorable. Including cases
treated out of asylums, probably 90 per cent. recover; in acute
melancholia, uncomplicated with other diseases, not far from
two-thirds recover; in melancholia attonita less than half get well;
and in melancholia agitata nominal recovery occurs perhaps in a third
of the cases, although I doubt whether complete restoration to health
is seen often.
In chronic melancholia the process of mental deterioration is slow. As
the mind becomes impaired the delusions lose their activity and the
mind reacts less readily, so that a state of less suffering and
greater calm is reached, and the patients are often useful workers in
asylums for many years, or remain in their own homes a constant source
of anxiety to those who understand their condition. Many of them
commit suicide.
In treatment of melancholia the first indication is to protect society
and the individual against acts of violence. Homicidal acts are not to
be feared in simple melancholia, unless in persons of bad character
and ugly temper, or in those few cases with the symptoms, in addition,
of moral insanity or impulsive insanity. Suicide is so rare that
precautions will not often be needed against it, provided the patient
is so frank or so transparent that the appearance of distinct
delusions may be detected and then guarded against. In cases of long
standing, especially in persons beyond middle age, this is extremely
difficult, and their treatment outside of asylums must always be
attended with risk. In the other forms of melancholia the fact should
be taken for granted that the patient is suicidal, and he may be also
homicidal, so that he should be watched constantly and efficiently,
and never left alone or with weak or helpless persons, no matter how
free from suicidal determination or impulse he may have appeared. The
puerperal mother, especially, is a source of the greatest danger to
her child, even when she seems natural and fond. The degree and kind
of watching varies, according to the severity of the case, from the
constant presence or close proximity of some responsible person, who
may sleep in the same room with the usual home-surroundings, to the
most vigilant and wakeful personal care every moment day and night,
and removal of every source of possible self-injury. In some few cases
this can be well done only in an asylum or in a padded room. Some form
of restraint, either personal or by confining or limiting the
movements of the hands in rare cases of exceptional desperation, will
be found necessary.