often associated with a manner on the part of the patient suggesting
disbelief in them, and sometimes the patient smiles or laughs at the
astonishing character of his statements. There is a self-conscious
element at times, suggesting mimicry or hysteria; a certain pathos is
universal; opposition and contradiction, even to refusal to eat, leave
the bed, dress, wash, are quite common; and nurse and physician are
tired out with the monotony of the mental and physical state.
Well-marked catalepsy is not common in my experience, although it
occurs; and in all cases I have seen the mental state and physical
atony suggesting that condition. Little attention has as yet been
given to katatonia in asylums in this country. Judging from my own
experience, it is not a common disease.
{167} Its CAUSES apparently lie in prolonged mental exhaustion and
inattention to bodily health. I have been led to suspect syphilis as
at least a predisposing cause.
The COURSE AND DURATION of katatonia are tedious, and even if there is
apparent recovery from the first attack, the tendency is to relapses
and to slowly-advancing dementia and death from those causes of which
dements in hospitals die, especially phthisis. I have never seen a
complete and permanent recovery.
The MORBID ANATOMY of katatonia suggests a deep-seated neurosis, the
precise nature of which we do not understand. In terminal stages there
are atrophy and degeneration and all that goes with them.
The CLINICAL HISTORY of katatonia is so characteristic that it need be
confused with the other diseases already mentioned as simulating
features of it, and with the early stage of general paralysis, only
through insufficient observation or too hasty diagnosis.
It is difficult to treat katatonia without the conveniences of a
hospital.
PRIMARY CONFUSIONAL INSANITY is a term recently introduced for a form
of mental disease of which the most marked features are moderate fever
rapidly developed, confusion, incoherence, and mild delirium. The
onset of the disease is rapid. In some of the cases which I have seen
the diagnosis was made of typhoid fever, although the clinical marks
of that disease were absent, the general appearance of the patient in
the two diseases being quite similar.
There is no real melancholia or exaltation, no rapid flow of ideas,
and no dementia. Hallucinations of the special senses are common;
there is a consciousness of illness; the delusions are unsystematized,
and the confusion of ideas frequently goes to the point of not being
able to recognize persons and places. The usual signs of fever are
present for a few days, but the temperature rarely exceeds 102° F.,
and soon drops to nearly or quite the normal.
The COURSE of the disease is quite rapid, and if recovery does not
take place in several weeks or a few months, chronic insanity with
delusions or dementia of various degrees may be expected.
The MORBID ANATOMY is not distinctive of this condition in the early
stage, and we cannot yet differentiate it from simple fevers by the
post-mortem. If ending in incurability, the atrophic and degenerative
changes of chronic mental disease are found.
As regards removal from home, the considerations already referred to
should be the guide. It is a good rule to keep the patient at home if
a suitable one for the purpose, and to resort to the asylum in case of
chronicity or troublesome complications.
PRIMARY DELUSIONAL INSANITY (Folie systematisée, Verrücktheit[20])
differs from secondary delusional insanity in the facts that the
disease arises primarily, and not secondarily to other mental
diseases; that there is little or no mental enfeeblement in the early
stage; and that the delusions, although fixed and systematized, are
limited. It has the advantage of allowing the avoidance of the
misleading terms monomanie of the French and monomania of English and
American writers, the narrower forms of which may be included under
the term primary insanity (primäre {168} Verrücktheit), including the
further developments of the neuropathic constitution, especially those
with the physical marks of degeneration described by Sander as
originäre Verrücktheit, and those marked by imperative conceptions and
such delusions of self-importance, suspicion, etc. as seem to some
people evidence of insanity, while by others they are considered as
simply false beliefs not indicating mental disease. Unlike primary
insanity, which is one of the states of mental defect and
degeneration, and incurable, primary delusional insanity may occur in
persons of healthy mental organization, and may end in recovery,[21]
although it is one of the most distinctly hereditary forms of
insanity, generally speaking.
[Footnote 20: Called also by some writers Wahnsinn, although they use
the term for secondary delusional insanity also.]
[Footnote 21: Some writers include both diseases under the term
monomania, and make both incurable degenerative states, which is
contrary to my experience. Clouston also has seen cures in what he
calls monomania (primary delusional insanity) without the neuropathic
taint.]
There are several subdivisions of primary delusional insanity,
according to the character of the delusions: (1) with delusions of
unseen agency, suspicion, and persecution; (2) with delusions of
personal exaltation; (3) with delusions transformed from sensations.
Delusions of unseen agency, suspicion, and persecution appear either
acutely and expand very rapidly in a few weeks, or from a very
insidious beginning so gradually that they may exist for months or
years before they are detected. The general indications of illness
consist in impaired sleep, slight loss of flesh, some reserve or
shyness in relations with other people, and diminished ability to
concentrate the mind in the usual occupations. The mental impairment
at first is very slight, and shows itself (1) in the readiness with
which the absurd delusions are believed and the fixedness of their
hold on the mind, and (2) in the diminished general power of judgment
and self-control in the little matters of daily life, at first so
slight that it is not seen except in matters requiring some effort to
maintain the customary equilibrium. Hallucinations, especially of
hearing, appear. In the progress of the disease the mind loses power
of self-control more and more, the delusions become more fixed,
concealment is no longer possible, and the patient is so annoyed or
angered that he repeatedly seeks relief from the courts
(Querulantenwahnsinn) or commits some act of violence in self-defence.
The common delusions are of marital infidelity, attempts at poisoning,
mesmerism, electricity, influence through telegraphs, telephones,
poisoned air, etc., signs of which are evolved directly from the
consciousness or transformed from common sights and sounds, such as
ringing of bells, striking of clocks, simple ordinary motions, etc.
The delusions in time produce a state of mental depression.
In some cases the primary delusion is of personal exaltation, attended
with persecution and mental depression. The individual thinks himself
some great personage unjustly deprived of his rights.
Delusions of grandeur or of personal exaltation develop in the same
way, usually subacutely from what might seem a foolish fancy rather
than an insane belief. The Napoleons, kings, queens, greatest
financiers, gods, etc. of the insane asylums are those who reason
correctly if one concedes the truth of their false premises, until the
progress of the disease produces such general brain-enfeeblement that
their premises and their {169} reasoning from them are both insane.
The delusions lose their fixedness, and their force too, in the
general lowering of the mind's strength, and complaints and boasts and
acts of anger become fewer, and finally cease.
The COURSE of the disease is nearly always subacute in the beginning
and chronic to the end in the two forms of primary delusional
insanity—that is, with (1) delusions of persecution and mental
depression, and (2) delusions of grandeur. A few cases with acute
development result in recovery, most of which relapse. The course is
for the most part to chronic delusional insanity attended with
moderate dementia.
The MORBID ANATOMY is not known, except that atrophic and degenerative
changes—not distinctive, however—are found in the terminal stages.
The patient is rarely willing to be treated as an ill person, for he
is sure of the correctness of his delusions. If during the first
attack he can be entirely removed from his daily associations by
change of scene and travel, or, if that is not possible, by admission
or commitment to an asylum, before the delusions become fixed and
while it is still safe for him to be at large, there is reasonable
chance of recovery. Second or third attacks very seldom end in
recovery unless they arise from alcoholic excess, when entire
abstinence for a sufficient length of time affords fair hope of a
favorable result, except in cases of long-standing drunkenness.
TREATMENT, when the delusions have become fixed, involves, chiefly,
safety to society or its comfort. The patients rarely commit suicide,
driven to desperation by their delusions of persecution when they are
particularly horrible. The more common tendency is to acts of violence
toward others, so that seclusion in an asylum is usually the only safe
course to pursue for delusions which one week may be directed against
certain persons who can easily be gotten out of the way, the next week
may be directed against others, and so on indefinitely. Delusions of
grandeur may be only a nuisance or annoyance, but may at any time
become sources of danger. The course is, for the most part, to
slowly-advancing dementia. Asylum treatment offers no chances of
recovery in cases not depending upon alcoholic excess, but becomes
necessary for the protection of society.
Transformed delusions (sensorielle Verrücktheit) arise usually in some
anomaly of sensation, which probably directs the delusions already
forming in a mind in the early stage of disease rather than causes the
disease. The causes lie in a deep-seated exhaustion of the nervous
system, especially in the neuropathic constitution and profound
hysteria. Various anomalous sensations give rise to a belief in
delusions as to their being caused by individuals for a purpose, or to
their being an indication of all sorts of impossible and most
extraordinary changes in the part: the chest is of stone, the leg of
brass, the head on fire, the hand ice, and so on indefinitely.
Hallucinations and a cataleptiform state are common. The variety of
delusions which may arise is almost endless, and they may have their
origin in the unhealthy action of any organ in the body: one of the
most troublesome forms, called ovarian insanity by Skae, causes single
women of severely continent lives to imagine all sorts of impossible
marital relations with men whose lives are equally beyond scandal and
above suspicion.
Without proper care the COURSE of the disease is to slowly-advancing
{170} dementia; and this may be expected when there is organic disease
of any important organ of the body.
Before the delusions are fixed, diversion, change of scene, travel
under agreeable circumstances and judiciously regulated, may be of
great benefit. In the later stage of firmly-fixed delusion asylum
treatment offers more chances of success.
In all the forms of primary delusional insanity the whole history of
the case is difficult to get at, and there may be, and usually is, so
strong a tinge of possibility at least, if not of actual probability,
in the delusions, in the early stage of the disease, that a correct
diagnosis cannot be arrived at until the time and opportunity for a
cure have passed.
DOUBTING INSANITY (Folie du doute, Maladie du doute, Grübelsucht) is
classed by Régis[22] as a form of melancholia (mélancolie délirante),
on the ground that it has the three elements of melancholia—namely,
fixed ideas (délire) of a sad nature, general mental depression, and
tendency to suicide. The melancholia is secondary, however, rather
than primary, and doubting insanity belongs more properly under the
head of a psycho-convulsive mental disease closely allied to
delusional insanity, like which it is more commonly a manifestation of
psychoneurotic heredity, appearing for the most part among the
cultivated classes. It consists in an uncontrollable doubt and
indecision, unanswerable by any degree of rational explanation,
regarding the occupations, duties, or events of the day, religion, a
future life, the commonest acts, or the most abstruse problems of
life. Doubting insanity essentially depends upon an anomalous action
of the will, with imperative conceptions and impulses. It is classed
by some writers as a monomania of the degenerative type. Schüle calls
it Verrücktheit sensu strictiori, using the term Verrücktheit also for
the three forms of primary delusional insanity just described.
[Footnote 22: _Manuel pratique de Médecine mentale_.]
Délire du toucher, an insane dread of touching certain objects, and
the morbid fear of defilement, called by Hammond mysophobia (similar
names may be multiplied indefinitely), belong in the same category.
There are mild cases of all these forms of disease, which seem like
simple weakness of character, others requiring for treatment the
conveniences of the retreat for nervous and mental diseases, with a
fair prospect of recovery, and still others tending to chronicity in
which hallucinations, delusions, and dementia appear only as a further
development into another form of insanity. They may, in mild degrees,
be symptoms in the course of other mental diseases, especially
melancholia, like many other manifestations of morbid mental energy,
such as Doctor Johnson's inability to enter a room with his left foot
first or to pass a lamp-post without striking it with his cane, etc.
PRIMARY MENTAL DETERIORATION or PRIMARY BRAIN ATROPHY is a term
suggested for a curable impairment of the mind arising from
brain-exhaustion in persons, usually men, between the ages of from
fifty-five to sixty-five. I have found it in some cases associated
with interstitial nephritis and with degenerative disease of the walls
of the heart, and have suspected atheroma of the cerebral arteries or
possibly endo-arteritis of specific or other origin. It occurs at a
time when atrophy of the brain is naturally taking place. There are
the usual indications of physical wear and such marked deterioration
of the mental powers as to {171} seriously interfere with the capacity
to attend to customary business and every-day duties, and to closely
simulate the early stage of paralytic dementia. There occur also, in a
certain proportion of cases, epileptiform convulsions, slight attacks
of dizziness, petit mal, and always disappearance of sexual power and
desire. There may or may not be headache. The patient recognizes his
condition, his mental depression does not far exceed the physiological
limit, and there is no reasonable risk of suicide, except from reasons
which would impel a sane man to it.
Under the influence of rest, if begun early, tonics, and a strict
regard to the laws of health the symptoms commonly disappear if there
is no organic disease. I have never seen the brain recover its tone to
the extent of making it safe or even possible to resume the previous
kind and amount of work. In a certain proportion of cases there is
striking mental impairment, even dementia, and the primary atrophy of
the brain sometimes makes rapid progress to unconsciousness and death.
It is not possible to say, by the degree of atrophy found post-mortem,
whether there was or was not primary mental deterioration during life.
The TREATMENT consists in entire freedom from care, rest from work,
travel, tonics, etc.
As mental disease is more than a brain disease, and is a disease of
the intellect, each age from infancy up (and each individuality)
impresses its peculiar mark upon it, and there are certain terms in
common use to express insanity associated with certain physiological
processes whose meaning should be explained.
INSANITY OF CHILDHOOD is for the most part only a further development
of a congenital state of mental defect. I have seen, however,
well-marked mania, melancholia, primary dementia, and primary
delusional insanity before the age of puberty. Typical acute mania I
have seen twice in children two years old, apparently arising in
normal brains after severe injuries to the head. This is quite
uncommon, and the number of cases thus far observed is too few to make
me feel sure that my own experience of a favorable result as to
recovery in uncomplicated cases will be generally confirmed. At best,
after a cure there is a more or less decided arrest of brain
development.
HEBEPHRENIA (insanity of pubescence and adolescence) occurs within the
ages of fourteen and twenty-three or thereabouts. Like insanity in
general among persons in early life, it most commonly indicates an
hereditary predisposition to mental or nervous diseases or an
early-developed brain defect or injury, possibly an exalted emotional
state or an increased nervous sensitiveness produced by masturbation.
It is a mild form of primary dementia, modified by the mental changes
going on during adolescence. Indeed, it is simply an exaggeration and
prolongation of the curious psychological development of that period,
too well known to need description, which goes on in the most
insidious way possible through months or years of what seems
silliness, absurd fancies, foolish sentimentality, egotism, impaired
common sense, and diminished judgment and self-control, to a
slowly-advancing dementia, which even then is not always recognized as
disease. The result is an arrest of brain development on various
planes of intellect, and a preservation of the youth's tastes and
sense and intelligence, as modified by the morbid propensities
characterizing an unhealthy development of the change from boyhood or
girlhood and {172} youth to adult life, with the adult's strength—a
curious combination of intellectual brightness, it may be, with lack
of mind. For this characteristic condition Westphal uses the
expressive term Permanenz der Flegeljahre (permanence of the usually
transitory state, which then commonly results in permanent arrest of
brain development on the plane of the mind at a definite age of
adolescence); and yet there may be more than that—mental
deterioration, which in years may lead to pronounced dementia. Cases
of primary dementia occurring within the years of puberty and
adolescence are often classed as hebephrenia and conversely, so that
one term, primary dementia, is thought sufficient by many writers on
insanity.
In the early stage there is sadness, hardly amounting to melancholia,
and it usually constitutes an important symptom to the end, although,
like all the other changes in the mental state, it is superficial to
the extent of at times seeming almost insincere. Masturbation is
common. Occasional outbursts of violence are also common, often with
mental confusion, incoherence, or stupor, and in severe cases there
occur, usually, attacks of temporary fury, with distressing or
agonizing hallucinations of sight and hearing, and delirium, which may
all last for a very short time or for a number of days. In young women
and girls these outbursts may be coincident with menstruation or in
the intervals. The countenance loses somewhat in expression in all
cases, and becomes almost vacant or quite so in those in which the
dementia becomes well marked. A mild form of the disease is quite
common, and consists in an undue intensity or a prolongation of the
curious psychological phenomena commonly observed during adolescence.
It is marked by aimlessness, changeability, self-assertion,
exaggerated self-consciousness, with, perhaps, propensity to lie or
steal or run away from home, and ending without any apparent damage to
the mind, except that the individual is less of a success in life than
he would have been but for his illness.
The course is slow, and although in the majority of cases mental
impairment is arrested before reaching what may be properly called
complete dementia, in well-marked cases the duration of the disease is
long and its results last for life. In many cases progress continues
with extreme slowness to extinction of the mental faculties. Oftener
the individual simply, in a certain sense, fails to reach that stage
of intellectual maturity and strength which he otherwise would have
attained. It is not always easy to draw the line between the
psychological and the pathological changes that take place during the
years of adolescence, and there are many mild cases of hebephrenia in
which various kinds of failure in life are due to this disease rather
than to the faults or vices to which the failure may be attributed.
In TREATMENT irritability, restlessness, absence of a power and sense
of responsibility, and sleepless, excitable nights, are the most
difficult symptoms to combat. The restlessness and irritability often
lead to refusal to be reasonably controlled and to a tendency to
wander away from home with theatrical displays, so as, in the case of
girls particularly, to require restraint, especially if the
excitability should be so great as to amount to outbursts of violence
or should lead to sexual improprieties.
The fact should be borne in mind that there is a diseased brain which
needs nutrition, rest, and discipline, which must be proportioned to
suit each case. Outdoor, simple life, with sea-bathing,
carefully-selected diet, {173} without too much meat, exercise, mental
training limited to the requirements of each patient, are the chief
reliances. Iron, cod-liver oil, and arsenic are useful tonics.
Stimulants, including tea and coffee, should be avoided. Quiet nights
and necessary repose can be secured by bromides, exercise, and opiates
used sparingly, which also control the impulse to masturbation. A
sound education, a healthy experience of the rough and tumble of
youthful life, and the careful avoidance of processes and habits of
indulgence will often prevent the symptoms of disease from growing
into traits of character and habits of life. On the other hand, in
some cases there is a half-conscious struggle between the fine traits
of character and the demoralizing influences of the disease, and a
most pathetic effort to keep the better nature's supremacy over the
lower impulses set free or developed by the destructive tendencies of
a fearful malady.
MENSTRUAL INSANITY differs from other periodic insanity in not being
necessarily a further development of an hereditary or acquired state
of mental degeneration, and in being curable in a fair proportion of
cases.
INSANITY OF GESTATION, PUERPERAL INSANITY, AND INSANITY OF LACTATION
do not call for any further comment than the remark that they
represent causes and conditions rather than types of disease.
CLIMACTERIC INSANITY in women and in men is usually a curable folie
raisonnante—insanity of action or affective insanity, which may
develop into secondary dementia or chronic insanity with delusions. It
does not necessarily include all acute forms of insanity occurring at
the climacterium, but only those slowly developing with the
physiological changes going on.
The course is usually subacute, the duration a couple of years or
more, and the termination in about half the cases is in recovery.
Permanent change of character and further progress to incurable
insanity are perhaps about equally common.
TREATMENT consists in a sedative and fattening diet, simple, healthful
conditions of life. Removal to an asylum or some form of restraint is
needed where the conduct is such as to demand seclusion and control.