Insanity and allied neuroses : practical and clinical

Front matter

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Contents

CHAPTER PAGE

I. -What is meant by Insanity— Insanity from

Legal and Medical Standpoints ... 1

Chapter I. What Is Meant By Insanity Insanity From Legal

AND MEDICAL STANDPOINTS.

Introductory — Insanity may depend on disease of any part of the body — Eccentricity — Genius — Crime — Borderland between sanity and insanity.

I SHALL not discuss normal psychology in this manual, because, to my mind, the time has not come for the re-arrangement of our ideas on mind and its physical basis.

I feel strongly that as long as mind is supposed to be located in the skull we shall make little progress. Though I have examined sections of brains of patients dying from almost all forms of insanity, I am left with the feeling that we must be more general in our pathology if we are to understand our subject.

The first question naturally is, what is meant by insanity 1 I shall try to show clearly throughout this work that no standard of sanity as fixed by nature can under any circumstances be considered definitely to exist. " Sanity " and " insanity," as recognised by the doctor, and, in fact, by the general public, must be but terms of convenience. No person is perfectly sane in all his mental faculties, any more than he is perfectly healthy in body.

B— 14

2 Insanity and Allied Neuroses. [Chap. i.

There are flaws on the physiological side, and defects on the mental. Insanity has to be looked upon from two different aspects. From the physician's side it has to be considered as a disease of the brain, or a disorder of the mind, quite apart from any consideration of responsibility whatever. From the other side, that is, as seen by ordinary members of society, insanity is scarcely recognised until it interferes, in one way or another, with the laws that bind society together. Later on I shall trace the origin of some of the most marked forms of insanity, and I shall be able to point out that the earliest symptoms of unsoundness of mind can often be traced far back into a period in the lives of the patients when they were apparently fulfilling every social and moral duty. Even at this time, from the medical point of view, these people were sufi'ering from unsoundness of mind, which would in the end destroy both body and mind. It will be my duty chiefly to consider insanity from the physician's point of view, and in doing so we shall see that a man's sanity is to be gauged purely by what is his own normal standard.

A man, in fact, must be considered as sane or insane in relation to himself. The old and oftrepeated statement that insanity is a perversion of the ego is absolutely true. Sanity and insanity, then, are to be measured by differences or changes of habit, taste, and disposition in the individual, as well as by other symptoms of change in the nervous centres. The difference will necessarily be seen to be one not only of degree, but one of time, so that a man being sane now may be insane within a longer or shorter period. I shall take it for granted that insanity depends upon change in the nervous structures of the body ; but by no means shall I restrict the causation of insanity to changes in the brain alone. Many cases will have to be considered in which the insanity

Chap. I.] Eccentricity. 3

depends, in my opinion, upon irritation propagated along nervous tracks at a distance from the nerve centres. Some may think that, in extending my ideas of insanity as far as 'I seem to do in the above paragraph, I am going too far. But the more I see of insanity, the more convinced I am that the consideration of mental disorder can only be fairly approached by the complete consideration of general physiology, i.e. the development, growth, and decay of the body in all its parts. No development or growth can go on without the action of the nervous system. Insanity may depend upon vices of development, vices of growth, or premature degeneration, local or general ; but it may depend also upon the bad ministration of the servants of the brain. As an old writer has said, "The brain, like a gentleman, has many servants, but withal may be badly served." Insanity may seem to depend upon physical changes which, at first sight, seem to have little or nothing to do with the brain. Thus it does not need a physician's experience to know how dependent one is for energy and power of work on good digestion. The relation which exists between feelings of dyspepsia and states of melancholy must be fully recognised. For though some geniuses have been dyspeptic, the world's work is best done by people who eat well and breathe freely.

Insanity, as I have said, is a relative term, and it is necessary that I should point out the other nervous conditions to which it is allied. Many people are considered only eccentric; and from the abnormally emotional life often led by men of genius, genius is looked for as the necessary accompaniment of eccentricity ; at least, to be eccentric suggests an idea of genius. (1) Eccentric people may belong to two classes at least : those who have some insane inheritance (those, in fact, who are on the borderland of insanity), and

4 Insanity and Allied Neuroses. [Chap. i.

those wlio are passing from sanity into some form of mental disorder, and wlio may again pass through this disturbed mental borderland on recovery. (2) Eccentricity may be developed de novo just as, I believe, certain forms of mental perversion may be developed. I think injustice has been done to man's power of development and of self-government by those who would look to the parent for every quality, good or bad, possessed by the offspring. The human being comes into the world with powers of development of a most extraordinary kind, and there is hardly any limit to the power of accommodation to the environment but that of simple pliysical possibility. It is a necessity that certain persons of unstable disposition, being surrounded by unnatural circumstances and conditions, should develop abnormal properties. Thus, the person who, being somewhat niggardly, has begun by collecting trifles, such as pins, sardine boxes, horse shoes, and the like, may end in shutting himself up in an attic, in refusing to wear clothes, and being unwilling even to wash, for fear of the cost of soap and water. Such cases are looked upon as eccentric, and I might fill a book in simply narrating instances of eccentricity as seen outside asylums. Most persons have both tricks of body and tricks of mind ; have their own idiosyncracies of temperament, as we should say. If the one or the other is not duly restrained and checked, a habit is in process of development which may influence for evil the whole life of the individual. Eccentricity may appear in any one of the various departments of mental life ; so that one person may be suspicious, another may be jealous, another subtle and. untruthful, while a fourth may be violent, passionate, and revengeful. All these are properties of the sound mind, if in due subordination ; but if left unrestrained, or stimulated in growth by foolish encouragement, their tendency is to make men^

Chap. I.] Genius. 5

in the first place, eccentric, and afterwards possibly to form the groundwork of an attack of insanity. Eccentricity is rarely developed before the period of advanced middle life : or, at least, is not recognised as such. The peculiarities in younger persons, which are allied to eccentricity, are considered to belong to hysteria or moral insanity, and I am inclined to think they are justly so classed. These latter may be, and for the most part are, cases of an undeveloped disorder, which, later in life, is almost certain to assume an acute form, and, as such, many of them undoubtedly bear a blood relationship to the more marked forms of mental unsoundness. In former days a greater number of eccentric people were at large than at present, and many of these were, without doubt, like the weak-minded persons who are now condemned to the county asylums. To conclude this short notice of eccentricity, I would remark that, once fairly developed, it is probably incurable.

I have incidentally referred to genius in its connection with eccentricity and insanity. I am hardly prepared to give a definition of genius, though I would call attention to the fact that it is usually associated either with some special incomprehensible faculty for the dramatic portraiture of self-existent abnormal emotion ; or altogether dependent upon a simple over-development of an individual faculty of mind. The first, in a sense, we may call the genius of art ; the latter, that of science. With regard to genius, I must say that it is an exception to find patients with unusual capacity of any kind amoug the inmates of an asylum. There may be found " specialists " of every character and degree, that is, men with persistence in limited pursuits ; thus, I have known a patient in Bethlem who devoted years to the delicate polishing of pebbles ; and another whose one object in life was to clean windows, while

6 Insanity and Allied Neuroses. [Chap. i.

tlie speciality of a third was still more limited, for his sole aim was to keep bright the brass knobs of the water taps. Therefore, from the point of view of the superintendent of an asylum for acute cases of mental disorder, I can definitely say that it is rare to meet with extraordinary ability among the insane. On the other hand, I must, however, admit that in my experience of people out of asylums, who have been credited with genius, I have met with many who possessed marked mental peculiarities and eccentricities. It appears as if there were for each ordinary person an average quantity of nervous power and energy to be expended, and if a larger amount than usual is got rid of in one direction, there naturally results a deficiency in some other quarter ; in fact, there is loss of balance. " Want of balance " fairly describes the mental condition of many a genius. How often, for example, has one met with a man of letters, the man of taste and of energy, who objected strongly to be controlled in his lower or more animal tastes ! Thus it happens that so many men of genius have given themselves liberty, if not license.

Another way in which to look upon the relationship between genius and insanity, is to consider 'precocity. The old proverb, "A man at five, a fool at fifteen," very well illustrates what is frequently seen. Precocious children are commonly the offspring of insane or nervous parents. I have, myself, had in Bethlem one. female patient, whose two children, both under six years of age, were playing classical music in public. I have seen other children who developed almost in infancy strong animal passions. When considering idiocy, I shall have to discuss more in detail the disorders incidental to infancy and childhood, and therefore I now leave this part of the question of precocity, merely stating that, in my experience, the children of the insane may develop

Chap I.] Borderland of Insanity, 7

certain aptitudes or passions at the expense of the rest of their nervous development.

The special aptitudes are for music, sometimes for art and mathematics, and a wondeiiully retentive memory may be present. Tt is rare to see such a child with all these talents developed at one time, but it is common to see a child with one or more of these who is totally wanting in moral sense. I shall, nnder the head of " moral insanity," and when considering " hereditary neurosis," give details of such cases. One naturally passes from these considerations to the relationships of crime to mental unsoundness. I shall have to devote a chapter more especially and fully to this matter. But here I speak only of the borderland of insanity, which has been so carefully explored by Dr. Maudsley. There can be no doubt in the minds of those who see much of the criminal classes and of those who see much of the insane classes, that there is something in common between them. I must not be misunderstood in saying this, for there is an immense difference between some insane persons and some criminals ; but as the savage and the statesman have connecting links between them, so among criminals and lunatics there are many grades which approach one another very closely. To begin with, the j^hysical aspect of a chronic lunatic resembles very closely that of a confirmed criminal, and the mental degeneration of man leaves his features so changed and debased that he resembles the man who, from vice of birth or faulty surroundings, has never developed the higher social qualities. As Dr. Maudsley has well pointed out, " Though there is a borderland, there is no boundary stone ; and there are cases in which exist some insanity and much crime, and others with much insanity and little crime." And at present this borderland is the one

8 Insanity and Allied Neuroses. [Chap. i.

on which most forensic battles have to be fought. Though from theoretical points of view it may appear that any one with criminal tendencies must be looked upon as insane (as one, in fact, who cannot be calculated upon, and whose actions are not governed and controlled as are those of the ordinary social unit), yet society, as represented by lawyer, judge, and jury, will continue to hold the balance in its own hands, and punish those who may, after all, be of unsound mind, the expert's opinion notwithstanding.

The relationships of insanity to crime are further evidenced by the fact that so many criminals develop other nervous disorders while under punishment for their offences. Epilepsy is much more common among criminals than among the sane. Sense perversions are mujh more common among them also. They appear wanting in the highest of all mental power, the power of controlling, or organising and applying, what faculties they possess. Their nervous systems are unstable and easily break down. These facts, important as they are to the student of mental physiology, can at present hardly be applied in the treatment of the criminal. Though the relationship must be fully recognised, it would be no more fair to say that crime and insanity are directly connected (that is, generally connected), than it would have been fair to say that genius and insanity were similarly allied.

The test of family relationship must, after all, be connection by paternity. If a large proportion of criminals can be found having insane parents or insane children, it must be admitted that there is some closer connection between insanity and crime than mere accident. And if we can trace the development of criminal instincts to insane parentage, if we can prove the direct transmission of criminal instincts from father to son, we shall have done much

Chap. I.] PosT-MoRTEM Examinations. 9

to show that there are true links between intellectual and moral perversion.

In speaking of the inheritance of neurosis, I shall have to give instances in which some members of a family have been insane, while others have been "ne'er-clo-weels," and perhaps one member has become criminal. In the borderland now under consideration there are other tracks to be explored, and I shall have to point out that hysteria, hypochondriasis, epilepsy, somnambulism, and other allied states, are all at least more nearly related to mental unsoundness than to sanity. I am anxious not to be supposed to be of the opinion that every perversion of nervous action, every unusual display of intellectual or moral force, is to be regarded as a case requiring the interposition of the physician whose chief care has been for the insane. But till insanity is looked upon as a phase of bodily disorder, till it is seen to be related to all the other disorders of the nervous centres, it will not be justly appreciated and properly treated. Insanity, although associated with nervous disorders and change in the nervous tissues, cannot yet be localised ; we cannot say that a patient suffering from acute mauia has certain nutritional changes in his brain.

One of the greatest difficulties which has ever presented itself to the student of insanity has been the fact that post mortem so little has been found visible to the naked eye. I may say that, with my experience of years, and after seeing many hundreds of jjost-mortem examinations of the bodies of the insane, I have met with few coarse changes within the skull, and even with the higher powers of the microscope all that can often be detected may be evidences of change in the nutrition of the connective tissue of the brain. This may seem unsatisfactory ; but the time will come when the inter-relations between the millions of nerve lo Insanity and Allied Neuroses. [Chap. ii.

cells witli their manifold processes, and their dependence for healthy action upon healthy blood and pure air, will be better understood. The brain, like a kaleidoscope, consists of innumerable parts, which adapt themselves to varying patterns. A shake occurs, the pattern changes, but each one of the pieces still exists- as it did before ; no change in shape, no change in colour, only change in relationship. So, I believe, it will be found to be with many forms of insanity, change in one faculty changing the mental pattern.

Chapter II. Classification

Ideal classification — Classification of the London College of Physicians — Author's classification.

We may classify by the causes, as in epileptic, puerperal, or alcoholic insanity; or by the /brms which the symptoms assume; thus, mania, melancholia, or dementia.

We may divide cases according as to whether the senses are at fault, or the reasoning faculty is perverted. We may arrange as to whether the disorder arises in connection with development, growth, maturity, or decay, or whether the disease arises primarily in brain disease, or is secondary to other bodily illness. Further, special faculties may suffer chiefly or primarily, the senses being disordered may lead to insanity ; the organic or the reproductive sides of a man may be disordered ; his judgment and will may suffer ; memory or the moral sense may be wanting. Insanities may be acute or chronic, recurrent or circular ; they may be curable or incurable. I subjoin an ideal classification, the classification which is accepted by the London College of Physicians, and

Chap. II.] Scheme OF Classification

II finally, the classification which for convenience I follow.

shall

SCHEME OF CLASSIFICATION.

Insanity of early development ^

Causes of insanity of ^ I cMldliood

I Forms of insanity in I cMldhood "^

Insanity of adolescence \

Insanity of maturity . <

Insanity of climacteric

' Idiocy, from brain deficiency.

Idiocy, from sense deficiency.

Idiocy, from inability to develop. . Imbecility, from inability to develop fully. ' From congenital causes.

From epilepsy.

From injury or brain disease.

Mania.

Melancholia.

Moral perversion.

Due to : Onset of sexuality, masturbation.

Stress of work.

Phthisis, etc.

(Nervous system only fit for low pressure).

Symptoms : Mania with conceit.

Emotional melancholia and hypochondriasis, with liability to recnr, and tendency to mental weakness.

Mania.

Melancholia.

Dementia, General paralysis due to strain or excess.

( Delusions.

In women < "Persecutions."

( Hallucinations.

In men : Often hypochondriacal, due to visceral Oreak-down.

Insanity of age r Mania.

A Melancholia. ( Dementia.

All tend to dementia.

NOMENCLATURE OF ROYAL COLLEGE OF PHYSICIANS.

IMania.

Melancholia.

Dementia, including acqu.ired

imbecility.

Idiocy, congenital imbecility.

General jiaralysis of the insane.

Puerperal insanity.

Epileptic insanity.

Insanity of puberty.

Climacteric insanity.

Senile insanity.

Toxic insanity, alcohol, gout, lead, etc.

Delirium tremens.

Traumatic insanity.

Insanity associated with obvious morbid change or changes in the brain.

Consecutive insanity, from fevers, visceral inflammations.

12 Insanity and Allied Neuroses. [Chap. ii.

So-called cases of monomania should be named according as the prevailing symptoms are those of mania, melancholia, or dementia ; and distinct hereditary tendency should be mentioned.

I purpose making use of the following groups in

my manual :

Hysteria — Mania.

Hy pochon driasis — Melancholia.

Dementia, general and partial, primary and secondary.

States of mental weakness — Chronic mania and melancholia.

Recurrent insanity.

Delusional insanity.

General paralysis of the insane.

Paralytic insanity — Epilei^tic insanity.

Puerperal insanity — Post-connubial, puerperal, lactation.

Toxic insanity — Alcohol, lead, opium, chloral, etc. — Gout.

Visceral insanity — Renal, cardiac, pulmonary.

Insanity with syphUis — Myxoedema — Grave's disease — Asthma

— Diabetes.

Idiocy in its various degrees.

Any classification of insanity must necessarily be provisional. At all events, till our knowledge of mind in health and disease is greatly extended, I shall divide the cases we are to consider into what I have found to be convenient groups ; if not classes or orders in the kingdom of disease, they represent sufficiently definite collections of symptoms to bear general descriptions. They are, in fact, definite enough to enable the student of medicine to classify any cases which come under his care according to them. The classification will in many particulars be a cross classification, so that certain cases will ajipear under different headings. The time may come when a classification of mental disorders may be according to the physiological changes which take place in the nerve centres. In my present classification, I shall feel bound to recognise the fact that certain cases of insanity are due to disease of the brain of a very definite and observable character, and that certain other cases of insanity de- ])end for their origin on the existence of some bodily defect or degeneration, which, causing irritation at

Ch.p. II.] Recovery FROM Insanity. 13

the periphery, in the end sets up brain disease by a continuity of the nervous tissues, or by some other reflecting process. Unlike most ordinary diseases, an attack of insanity does not either pass away entirely, or kill a patient, but in the majority of cases leaves him more or less mentally crippled. The physician has often recognised the fact that a man is not the same after having a serious attack of illness. A man differs in one or more particular after he has passed through small-pox, fever, rheumatism, or even gout. It has been said that a bee-master, before he had an attack of small-pox was able to handle these stinging insects with impunity^ but after his recovery he was no longer able to follow his occupation, the bees discontinuing to like him, and even not tolerating his presence. I myself have seen several patients whose temper and dispositions have been markedly affected by an acute illness such as rheumatic fever, so that a patient who had been previously of quiet, industrious and domesticated habits, and a good wife, became, after recovery, a selfish, indolent, home-neglecting person. These are accidents when considered in relationship to general bodily diseases, but they are peculiarly common when associated with insanity. The large residuum of insanity which fills our county asylums consists to a great extent of the patients who, having had one or more attacks of insanity, have neither died nor recovered. There is, in fact, a very strong feeling prevalent that a patient once having had an attack of insanity is never cured under any circumstances. This I shall oppose entirely ; but I acknowledge that a very considerable proportion are maimed in one way or another by an attack of insanity. It is only what might be expected, for the more delicate an instrument, the greater its liability to injury by rough handling or rapidly changing conditions. The eye, itself but a window of the mind, is recognised to be

14 Insanity and Allied Neuroses. [Chap. ii.

an organ which suffers permanently from slight inflammatory or other disorders, which did not appear at first to be of much importance. Is it therefore surprising that the still more highly developed and organised human brain should show signs of storms that sweep over it %

I have been in the habit, in clinical teaching, of dividing all my patients into the curable and incurable, but I have always added that I intended in this division to separate those patients suffering from general paralysis of the insane, from those suffering from every other form of nervous disorder. In my clinical division of insanity I make the symptoms, or outward signs, the points of division. Thus we have mania, melancholia, dementia, delusional insanity, and states of weak-mindedness. Each of these classes will have to be more fully subdivided ; and a more natural form of division, in my judgment, is that which I have already referred to, and have placed at the head of this chapter.

First in this table one has the insanity of development, as seen in the arrests and perversion of children, ending almost invariably in idiocy, or in imbecility. Attacks of nervous disorder affecting the unstable developing nervous tissues of childhood, cause, as may be expected, rapid and yjermanent degeneration. It is, as it were, a destruction of a house of cards.

Next is the insanity of adolescence, and here we meet with the same forms of mental disturbance, but with a much more marked character than as seen among children. The forces are greater, perhaps rather more stable, but yet eminently mobile. The prognosis in such cases will be better than among children, and less satisfactory than among the mature.

The third division is formed by the period of maturity, and here we meet with the greatest number of insane patients. Insanity seems peculiar from

Chap. IT.] Explanation OF Classification. 15

this characteristic, that at the period of fullest vitality mental disorder is most common.

It has to be recognised that in this we often see the full blowing of the morbid flower of insane inheritance. We also see that the fine brain organism breaks down when the greatest stress is thrown upon it, and that the period of maturity is that of work, ambition, disappointment, and of the uncurbed exercise of the largest number of faculties of body and mind. At the close of the period of full maturity comes the period of change, the so-called climacteric or, in woman, menopause. Some think no such period occurs to men. But I am inclined, from my experience of the insane, to consider that (though, perhaps, later) a similar period exists, and that, in fact, a man does not pass from maturity into old age without a period of mobility or instability, during which he is assuming habits which, if duly developed, are conservators of energy. The last division, according to age, is the period of decay ; and I shall point out that there are many varieties of nervous death, some being rapidly destructive, and others leading slowly to euthanasia.

I think it necessary to make some divisions, according to the parts of the mind that seem to be affected ; and I shall point out that whereas in one case loss of energy is seen by the will-less condition of one patient, in another perversion of moral nature may be so great as to justify the use of the term moral insanity.

My division of insanity being provisional, and in no way pretending to be final, will be found more useful than elaborate new plans which would entail labour to the student to master, and which will in the end have to be thrown aside. Moreover, my classification, being on the old lines, will be understood by all i6

CHAPTER TIL

CAUSES OF INSANITY, PREDISPOSING AND EXCITING.

General predisposing causes : Effect of race — Education — Sex — Age — Neurotic predisposition — Occupation — Heredity — Constitution and temperament. Moral causes : Domestic trouble — Mental anxiety and overwork — ^Keligious excitement — Love affairs (including seduction) — Fright and nervous shock. Physical causes : Intemperance in drink — Intemperance (sexual) — Venereal disease — Self-abuse (sexual) — Over-exertion— Sunstroke — Accident or injury — Pregnancy — Parturition and the puerperal state — Lactation — Uterine and ovarian disorders— Puberty — Climacteric— Fevers — Privation and starvation— Old age — Other bodily diseases or disorders — Previous attacks — Hereditary influences ascertained (direct and collateral)— Congenital defect ascertained — Other ascertained causes — Unknown causes.

In this chapter I shall show the many contributing conditions which may aid in the development of insanity. Insanity rarely springs into existence; it begins to grow long before it is seen.

When speaking of " cause," I use the term in the widest sense for convenience, and not pretending to exact expression. The sun, the rain, the dissolving soil, the very earth-cast of the worm, contribute to the growth of the grass, and in a sense may be said to cause the grass to grow; so it is with insanity and the many and complex relations of life. I shall consider all the assisting conditions in the environment as causes, when they can be shown probably to have influenced the result.

Any division which one makes must be artificial, and suited for the present time and our limited knowledge, both moral and physical. Predisposing and exciting are but convenient expressions of the immediate conditions connected with the disorder;

Chap. III.] Predisposing Causes. 17

the effect of a moral shock may be similar in kind and in degree to that of a physical one, and the body may suffer in the same way from each. A fright or a blow may produce pallor, faintness, and sickness ; and a graver shock or blow may produce insensibility, or mental disorder of more active kinds. Thus, any division depending on terms like moral and physical must be understood to be used for convenience, and not as representing any definite idea of physiology or psychology.