Insanity, its classification, diagnosis, and treatment; a manual for students and practitioners of medicine

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Preface

The present work was originally intended to cover no other ground than the Definition, Classification, and Diagnosis of Insanity. The requests and suggestions of his pupils and professional friends have induced the writer to enlarge the original essay to the dimensions of a general treatise. In so doing, special stress has been laid on those points which will probably prove comparatively new to many American readers, and which it might be naturally expected would find a place in the first systematic treatise on insanity published on this side of the Atlantic since the days of the immortal Rush.

The individual views of the writer concerning classification, the desirability of re-establishing the group of the monomanias, the pathogenesis of paretic dementia, the mechanism of delusions, and the relation of somatic anomalies to transmitted insanity have been previously published in journal articles in the Medical Gazette, St. Louis Clinical Record, the Chicago Journal of Nervous and Mental Diseases, the American Journal of Neurology and Psychiatry, and particularly in the supplement of the latter — the W. & S. Tuke memorial essay on the " Somatic Etiology of Insanity." For fuller literary references than it was deemed well to introduce in a manual intended for the general practitioner's use, the reader is referred to the articles published in the periodicals mentioned. A full bibliography will accompany the larger work on insanity, which the writer has in preparation and which will appear in a few years.

It is scarcely necessary for the writer to state that he has

10 PREFACE.

not aimed at presenting more than a surface view of the domain of insanity, in a volume of the modest dimensions of this manual. He has felt that there exists a need for a treatise which, without being so exhaustive as to tire and bewilder the beginner and the general medical reader, shall direct attention to such of the salient points of psychiatry as the general practitioner may be reasonably expected to familiarize himself with — particularly if he desires to fill the position, so often forced on him, of acting as the first counsellor of a family in cases of insanity. The writer will consider the object of this treatise fully accomplished if the task of acquiring the rudiments of a difficult and intricate branch of medicine is thereby rendered easier. And if these lines should awaken an interest in the subject which will induce the reader to consult those more voluminous and classical works to which the present one may be considered a mere introduction, his most sanguine expectations will be realized.

New York, 137 East 50th Street, April 10, 1883.

THE GENERAL CHARACTERS AND THE CLASSIFICATION OF INSANITY.

CHAPTER I. The Definition of Insanity

Insanity is a term applied to certain results of brain disease and brain defect which invalidate mental integrity. It is inaccurate to state that insanity is itself a disease. It is, strictly speaking, merely a symptom which may be due to many different morbid conditions, having this one feature in common: that they involve the organ of the mind.

From this point of view the term insanity is used in a sense analogous to that in which " aphasia" is employed. The aphasic symptom-group comprises derangements of the function of articulate speech, which may be manifestations of a cerebral defect, of gross cerebral disease, and of disturbance in the cerebral circulation. These conditions differing so widely amongst themselves in their pathological character must, in order to produce aphasia, agree in one essential respect: their regional distribution — that is, they must affect the central speech organ, the speech centres, and the speech tracts in a similar way. While the point at, and the extent to which the cerebral mechanism is disturbed by a lesion, determines the existence of this prominent symptom, it is not the location but the intrinsic nature of the lesion, be it a hemorrhage, a tumor, or a nutritive interference, that determines the name of the patient's disease.

Theoretically it should be the same with insanity. The disease manifesting mental derangement maybe an inflammation of the brain and its membranes, or a brain injury — a brain wasting, or an original brain-defect — a mal-nutrition, or a reflex disturbance of that organ; and in such conditions must we seek for the groundwork of a scientific nomenclature and classification of the morbid states underlying mental derangement. Unfortunately, sufficient positive observations on which to base a fliorough pathology of these diseased states are, as yet, desiderata. The scalpel, the testtube, the microscope, the sphygmograph, the ophthalmoscope, and delicate electrical apparatus have been diligently employed by able and earnest investigators; but these appliances and the most elaborate methods of the laboratory have more frequently failed than succeeded in revealing the organic conditions responsible for mental disturbance.

It is for this reason that while the ideal aim of the progressive alienist will continue to be the solution of the great problem of the physical foundation of insanity, he is commonly limited when he makes a diagnosis to a recognition of disease manifestations, and not of disease; when he classifies, to a classification of symptom groups; and when he treats insanity, to the treatment of symptomatic states. The conceptions and processes of mental science are hence traditional and empirical to a great extent. In some degree this is also due to the fact that the conventional discrimination between insanity and other symptoms of disease of the brain, however practically necessary, is from a scientific point of view both arbitrary and artificial. This becomes most evident when we attempt to define insanity.

It may be safely asserted that, in the present state of our knowledge, it is impossible to frame a definition of insanity which, while it meets the practical every-day requirements, js constructed on scientific principles. The failure of the best authorities to furnish such a one proves that until the material elements of mental derangement become more accessible to observation than they now are, scientific definitions must in large part rest on hypotheses. The practical need, however, is for a definition which shall include neither ambiguous nor theoretical terms. That the brain is the organ of the mind is an axiom of physiology, that insanity is a manifestation of a brain disorder is a resulting dogma of medical

THE DEFINITION OF INSANITY. 19

psychology; but even if we could establish the existence of a brain-lesion in every case of brain disturbance, we would not be able to formulate the topographical and patho-histological conditions which determine the falling of its manifestations within the boundaries of insanity in one case, and without them in another. And neither the axioms of physiology nor the dogmas of medical psychology are regarded with sufficient respect in our courts of law — where the problem of an accurate definition of insanity is apt to be most emphatically presented to the medical mind — to render their use in filling this gap in our knowledge either satisfactory or profitable.*

The following appears to the writer to comply with the chief requirements of a practical definition, although it labors under the disadvantage of length:

Insanity is either the inability of the individual to correctly register and reproduce impressions (and conceptions based on these) in sufficient number and intensity to seri'e as guides to actions in harmony with the individual' s age, circumstances, and surroundings, and to limit himself to the registration as subjective realities of impressions transmitted by the peripheral organs of sensation; or the failure to properly co-ordinate such impressions, and to thereon frame logical conclusions and actions : these inabilities and failures being in every instance considered as excluding the ordinary influence of sleep, trance, somnambulism, the common manifestations of the general neuroses, such as epilepsy, hysteria and chorea, of febrile delirium, coma, acute intoxications, intense mental preoccupation, and the ordinary immediate effects of nervous shock and injury.

The first condition of a definition is that it shall be descriptive of the subject to be defined. The above depicts the fundamental error at the root of every form of those

* It is significant in this connection, that none of the most recent German writers on insanity attempt to give a definition of "insanity." The chief discussion as to the possibility of concocting such a definition has taken place in the Anglo-Saxon countries, and this for reasons it is not necessary to dilate on, indicates that the chief need for the definition is a medico-legal one. If this want, were not the main motor, it is doubtful whether an English author on Lunacy (Shepard) would have offered such a definition as " insanity is a disease of the neurine batteries of the brain," with such an object as his avowed one of puzzling the lawyers! That a clearly formulated definition of insanity is not indispensable to the scientific psychiatrist is illustrated by the incontestable fact that mental pathology has made more rapid progress in Germany, Italy and France, where little stress is laid on such definitions, than in England or America.

acquired and congenital mental deficiencies and perversions which pass under the designation insanity. The "inability to correctly register experiences and impressions in sufficient number" to serve as guides to rational conduct is the essential feature of idiocy and imbecility, whether moral or intellectual. The inability to limit the registration of impressions to such as are "received by the peripheral organs of sensation," is the foundation of the insane hallucination and illusion. The failure to co-ordinate impressions as the basis of " logical conclusions," is the characteristic feature of those insanities manifesting themselves by the formation of delusive opinion, insane projects, and imperative conceptions. Finally, the impaired reproduction of those impressions and experiences which are to serve as guides to rational conduct, constitutes the main feature of those acute insanities and their secondary sequelae which are not covered by the other terms of the definition. The latter, therefore, complies also with the second condition of a definition, in that it covers the whole ground included under the term which it is intended to define.

The qualifying clauses are added for the purpose of filling the third requirement: that nothing outside the limits of the field to be defined shall be included in the definition. The words "in harmony with the individual's age, circumstances, and surroundings," exclude the elements of immaturity, mal-developmenl of the sense-organs and members, defective education, and the influence of great popular movements on the human mind. They predicate as the standard of mental health that of the age which the individual has reached, of the period of time in which he lives, and of the class of society to which he belongs. In other words, the definition accommodates itself to the fact that the standard of mental health is a variable one. A lack of understanding, of reasoning power and of responsiveness, which would be a grave indication of unsoundness of mind in a person of previously high intellectual power and culture, might not have so grave a meaning in the case of a member of the lower orders of society or of an inferior race. The normal intellectual status of a Tasmanian is quantitatively inferior to that of some Caucasian imbeciles; and indeed authors have compared certain manifestations of insanity to anthropological degenerations in an atavistic sense. Again, the conduct of a Hindoo fakir, of a religious fanatic, or a revivalist, while it oversteps the boun-

THE DEFINITION OF INSANITY. 21

daries of reason in more than one direction, is not insanity; because, however strange and suggestive of insanity such conduct may be, it is in consonance with the individual's surroundings, and the result of educational influences and mental contagion occurring within physiological limits.

Similar qualifications apply to the more positive signs of insanity. Beliefs which in the earlier periods of history were creeds with the majority of mankind would to-day in members of a civilized race rank with the insane delusion. The behavior of the adolescent, if marking the conduct of a person of mature years, has a sinister signification which it does not have at the period of life to which such conduct naturally appertains. The phantastic tendencies of the child, the prodigality and romancing of youth, the conservatism, lethargy, and miserly inclinations of old age, are phases in the normal evolution and involution of mind; but phantastic tendencies in a person of middle life, prodigality and romancing in aged persons, or habitual suspiciousness, miserliness, and lethargy in a child or youth, constitute wide departures from the standard of mental health of those respective periods of life, and suggest, if they do not prove, the existence of insanity.

In characterizing the insane hallucination and illusion, that is, the registration of impressions which either are not received at all or imperfectly transmitted from the peripheral organs of sensation, it is necessary to add the words "subjectively real, " because hallucinations not accepted as realities sometimes occur in the sane (as when Goethe met his own figure on the road from Strasburg to Sesenheim), and herein differ from the insane hallucination, whose reality the patient is convinced of for the time being. It is also necessary to specify that a registration does not enter the field of mental unsoundness unless it is unjustified by a peripheral impression. We thus exclude from the domain of insanity the deceptive impressions produced by diplopia, scotomata, photopsia, diseases of the peripheral nerves, and the entotic sounds as well as those arising from imperfections of the sense organs.

Here the definition might terminate from a strictly scientific point of view; it is thus far merely a paraphrase of the dictum that insanity is a deficiency or perversion of the mental faculties, not provoked by any external cause, but arising and developing within the ego. There are, however, many conditions of temporary deficiency or perversion of the mind, not provoked by any external cause, which do not fall within the strict conception of insanity, and must be excluded in its definition. The phenomena of hallucinatory insanity and stupor are closely simulated by febrile delirium and coma; Indian hemp produces a condition very much like a mild form of expansive mania; finally, alcoholic intoxication imitates in its various degrees almost every phase of paretic dementia.

In excluding the phenomena of intoxication it is necessary to employ the qualifying adjective " acute," because the chronic intoxications producing those results detailed in the definition, are actual insanities; alcoholic and opium insanity being examples.

The bearing of the remaining qualifying clauses is almost self-evident. Several of them would be unnecessary but for the desirability of meeting even the most finical and hypercritical objections in a definition whose chief uses are of a medico-legal nature. The ordinary phenomena of epilepsy, hysteria, and the immediate results of nervous injury and shock are not insanity; but the extraordinary complications of the ordinary nervous diseases and the remote consequences of nervous shock and injury, if these lead to the development of the signs included in the first clauses of the definition, respectively become insanity of the epileptic, hysterical, choreic, and traumatic variety.

Mental concentration and preoccupation lead to some of the results which might be included under the clause, " inability to correctly register and reproduce impressions in sufficient number and intensity to serve as guides to action in consonance with the individual's age and surroundings." The abstracted man stuffing his pipe with his neighbor's finger, the Scotch professor, who, reminded that he had omitted to apologize to a lady against whom he had stumbled, politely excused himself to the cow who next collided with him, Archimedes oblivious that the soldier rushing into his apartment, where he was engaged over a geometrical problem, was about to kill him, the soldier who, in the exaltation of battle, rushes on after receiving a fatal wound, — are all instances of the action of physiological laws, whose results have a superficial, but only a very superficial, resemblance to the abstraction of certain demented patients, and which require to be excluded by the physician when defining insanity to those who are, or affect to be, misled by surface resemblances.

On some occasion the question of defining what is called " legal insanity" may be presented to the reader of these lines. When that question is asked, he may safely challenge the questioner to show him a broken leg or a case of small-pox in a hospital ward which is not a broken leg or a case of small-pox in law; to show him a tumor or a softening of the brain, which is meningitis or sclerosis in law, or to define the conditions under which any disease-symptom becomes an indication of health. When these conditions are complied with, and not till then, may the physician attempt to define " insanity in law" as distinguished from insanity in science. In the mean time he may rest contented with the dictum of one of the best legal authorities that that cannot be sanity in law which is insanity in science, just as nothing can be a fact in science and a fiction in law at one and the same time.

CHAPTER II. The Delusions of the Insane

The characteristic evidences of insanity, although they are all manifestations of disordered action of the central nervous axis, may for practical purposes be divided into two groups: the mental symptoms proper, and the somatic, or the physical indications. While the former are mainly objects of study for general diagnostic and medico-legal purposes, and furnish important hints for moral treatment, the latter constitute our guides for physical treatment, and enlighten us, as far as signs observed during life can, as to the fundamental nature of the disorder. The significance of these physical evidences, however profound it appears to the experienced mental pathologist, is appreciable and interesting to the student only when taken in connection with what even the untutored eye regards as the essential and characteristic feature of insanity: its mental results. It is therefore best to begin the consideration of the subject with the latter.

To probably no other class of symptoms of mental derangement does so much interest and interest of so manifold a character attach as to the delusions of the insane. These perversions of the conceptional sphere have indeed

• had the high medico-legal position assigned to them — it is scarcely necessary to add, erroneously — of constituting the criteria of insanity, and from the days of Willis* Haslam, and Esquirol down, practical alienists have based many important indications for prognosis and treatment of mental disorders, on the special character of the delusions accompanying them.

There is no evidence of insanity which constitutes so proper a starting-point for study as the insane delusion. Though even on first sight the most complex and mysterious of the symptoms of mental disorder, it is yet that manifestation which strikes the mind of the novice with the greatest force. It is the symptom to which the readiest expression is given by the patient himself; the one which can be most readily laid bare before a class in the course of clinical demonstration; and the one which offers to the beginner in psychiatry that obvious contrast with sanity which is the most satisfactory because the most tangible to his mind. For the very reason that the insane delusion is considered to be the criterion of insanity by the laity and the legal profession, the common presence and patency of this symptom in the insane, it should constitute the introduction to the study of the subject.

The lay conception of a lung disorder associates it with cough and expectoration. Now, while cough and expectoration do not constitute the most essential signs of lung affections, yet the clinical teacher who will analyze these phenomena before the new-comer, and point out their true meaning before proceeding to the physical signs — whose recognition and interpretation require experience and acumen — does that new-comer a far greater service than he who endeavors to override the untutored mind by ignoring all which the latter has hitherto been cognizant of, and by presenting abstractions which the beginner is altogether unfitted to comprehend.

Insane delusions, that is, faulty ideas growing out of a perversion or weakening of the logical apparatus, are primarily divided by authorities according to their expansive or depressive character; and further subdivisions are based on the contents of the delusion, as to whether it relates for example to sexual, political, religious, or bodily matters. Thus expansive delusions include: ambitious, erotic, and religious ones; the depressive group: hypochondriacal delusions and those of persecution.

All these terms are admissable designations of what are frequently accidental characters of the delusion; but any system of classification which bases fundamental distinctions on them, is necessarily faulty (see Monomania). A paretic dement may entertain the delusion that he is a king, so may a monomaniac and so may an imbecile or a dement; but nowhere does an old German saying, which translated reads: when two d.o the same thing it is not therefore the same — apply so well as here. In the cases hinted at, although the external dress of the delusion is formally the same, yet its logical foundation and structure is different in each. To study that difference is to analyze the essential nature of the insanity of which the delusion is but an evidence. As a result of such a study it is found that the external dress of the delusion is of very subsidiary importance. Its essential features are the method in which it has been developed and the manner in which it is defended by the patient.

Delusions may be divided into the genuine and the spurious. The former group consists of those delusions which have been mainly created by the patient himself; the latter, of those which have been altogether adopted from others. The former alone are of intrinsic importance to the alienist; the latter have only a relative bearing to such extent as it may be necessary to consider the possibility of their existence as a factor in differential diagnosis. They are found in weak-minded patients as evidences of an imitative tendency.

The genuine delusions of the insane, when classified according to their synthesis, naturally fall into two great groups. We find that certain delusions have a complex logical organization — the systematized delusions; while others are devoid of such an organization, are not as plausibly based, as elaborately expressed, and as skilfully defended

THE UNSYSTEMATIZED DELUSIONS.

The various forms of delusion ordinarily admitted fall under both of these heads. That is, we may have either delusions of grandeur or depressive delusions of the systematized as well as of the unsystematized type, and the same applies to their sub-varieties. In order to fully characterize a given delusion, it hence becomes necessary to incorporate all these elements. If, for example, a medical student, as in a reported case, believes that he is suffering from spinal disease, and bases this delusion on alleged symptoms which might justify the belief, if they were not due to illusional misinterpretations and hallucinatory visions of his spinal cord, he is suffering from a systematized hypochondriacal delusion. But a person who is unable to give connected reasons for such beliefs as that his body is decaying, that his heart is turned to ice, and that his intestines are stopped up, is afflicted with an unsystematized hypochondriacal delusion. In like manner the patient who claims that he is pursued by enemies, because he imagines that people are looking at him in a peculiar way, dogging his footsteps, putting poison in his food, calling out his name at night; and that they do all this to prevent him from making good his claims to a throne, an authorship, or an invention, is a sufferer from systematized delusions of persecution. While he who alleges that he is pursued by voices and by persons, although he does this on the strength of similar hallucinations, and can assign no other ground than a subjective feeling of worthlessness or criminality, exhibits the unsystematized delusion of persecution.

To answer the question as to whether a given delusion is systematized or unsystematized, is of vastly greater importance than to determine its more superficial features. Take a persecutory delusion, for example! If it is systematized, it may be assumed that we have to deal with that chronic primary insanity, the Verruecktheit of the Germans, the Monomanie of the French, the Monomania of some English authors. If, on the other hand, it is unsystematized, we know with equal certainty that the patient's disorder is a melancholia, unless other evidences point to the existence of senile and secondary insanity, or of paretic dementia in its first stage. (See Diagnosis.)

When we proceed, a little later on, to analyze the mechanism of the principal varieties of systematized expansive delusions, namely, the simple, or those relating to social and political ambitions; the erotic, or those involving sexual relations, and the religious, we will find, that while they all indicate a certain degree of logical enfeeblement, that this enfeeblement is more pronounced in the case of the two latter varieties than of the former. The highest general mental activity is found with those lunatics who cherish systematized delusions of social ambition; the patients who are the political reformers, claimants to thrones, inventors of flying machines, or the pe/petuum mobile. And panaceas for all earthly ills, the poets, the military and the

THE DELUSIONS OF THE INSANE. 2J

diplomatic geniuses of asylums. The patient here acts consistently with his assumed character, and the continued existence of a certain amount of mental ability and energy is shown by the formation of projects which, whatever their ultimate feasibility — and they sometimes are feasible — are undertaken with some attention to the patient's actual circumstances and to detail. Sometimes, especially with patients of high previous culture, the systematized expansive delusion is not of such a character as to lead to an error in the patient's sense of identity, but limited to his self-esteem in the abstract. He writes doggerel or mediocre verse, for example, and imagines himself as great a poet as Byron; or he invents some unimportant mechanical contrivance, and lays claim to the gratitude of a nation or a king. Not infrequently he commits plagiarism in a quasiunconscious manner.

Systematized delusions of an erotic character are found as the leading symptoms of the so-called "Erotomania." This perversion is not necessarily accompanied by animal sexual desire, and the adjective erotic is here used in its classical sense.* The patient, noted in his adolescence for his romantic tendencies, construes an ideal of the other sex in his day-dreams, and subsequently discovers the incorporation of this ideal in some actual or imaginary personage, usually in a more exalted social circle than his own. He then spins out a perfect romance with the adored personage as its subject, and according as the external circumstances appear to him momentarily favorable or unfavorable, expansive or depressive delusions are added to and incorporated with the erotic ones. As a rule the affection for the adored object remains as chaste and pure as it begins; a sort of distant, romantic worship, insane for the reason that unimportant occurrences, accidental resemblances, facts which have no natural connection with the individual or his or her real or imaginary contemplated partner, and hallucinations are woven into the delusive conception, which consequently assumes such a predominating position in the patient's mental horizon as to entirely overshadow it.

Systematized delusions of a religious character are usually rooted in an early developing devotional tendency, and

* In the treatise of Bucknill and Tuke erotomania, and the so-called " nymphomania," which is an entirely different condition and not necessarily accompanied by delusions, nor ordinarily by amatory conceptions of the higher kind, are thrown together.

brought to full bloom by incidental circumstances, either actual or in the shape of hallucinations. It is not uncommon to find such patients designated as cases of religious melancholia, because, supposing themselves assailed by inimical or diabolical forces, or commanded to fast for a long period, or forever, they become sad and anxious or refuse food. But to call a patient who, aside from these actions, which are consistently regulated by the false ideas, believes himself or herself to be God, the Christ, a saint, the Messiah, a religious reformer, or the Virgin Mary, and who, perhaps, the very next day passes into visionary or ecstatic states, all the time systematizing his or her acts and notions — a melancholiac, is to involve one's self in a profound contradiction with the established use of that term.

Among the systematized delusions of a depressive character, the antitheses of all the preceding forms are found. This is well exemplified in cases where the subjects develop delusions of persecution overwhelming the ambitious notions previously dominating the mental sphere. How very unessential the line of demarkation between the depressive and expansive delusion really is, is made apparent by the fact that an expansive religious, erotic, or socially ambitious delusion may within a few days become depressive through the development of persecutory ideas; just as the reverse is occasionally observed. In fact, such expansive and depressive delusions often are entertained by the patient at one and the same time.

When an individual, without any manifest disturbance of his emotional or affective state, in full possession of the memories accumulated in the receptive sphere, and able to carry out most or all of the duties of his particular position in life, as some of the sufferers are, is found to cherish such a gross error as an insane delusion, firmly believing in the reality of that which from his education and surroundings he would be expected to recognize as absurd, the observer is naturally puzzled to account for the phenomenon. The component elements of the systematized delusion are individually the same as those which are combined to form healthy conceptions; they differ in that they are faultily united. In this respect the insane delusion does not differ from the faulty conclusions which constitute the error of the sane. But while the error of the sane person is based on faulty and not on perverted perceptions, on imperfect or vicious training, and on lack of experience, and disappears before the corrected evidence of the senses, improved educational methods, and broader experience; the sufferer from the insane delusion is unable, for the time being, to correct that delusion by a similar process. His logical apparatus stands powerless before the controlling conception. There is a fundamental weakening of those logical inhibitions or checks which the collateral elements of the ego constitute for the day-dreams and speculations of a sane person. What is a wish or fear of the sane mind becomes an article of faith with the delusional lunatic; what is a mere possibility in reality becomes a fixed fact in support of that article of faith with the insane; and finally the perceptions themselves are perverted and enslaved to add new building material to the faulty mental structure. It is because the physiological ego is weakened that the morbid ego is permitted to arise out of the small beginnings which a healthy ego could have held in check, and for this reason the following legal definition of the insane delusion — that it is a faulty belief, out of which the subject cannot be reasoned by adequate methods for the time being — is a sound one.*