THE LIMITS OF INSANITY.

The symptoms of psychical disorders resemble those of the body in this: that they are not phenomena absolutely unlike those of the normal state, but are mere modifications of the latter. In the vast majority of instances they consist in a relative augmentation or diminution of healthy conditions, so that for every symptom of insanity we are able to point out an analogous normal process of the mind.

Considering that even in somatic medicine, with the aid of all the appliances there at our command, we can not always draw the line between health and disease, we certainly ought not to expect to do so in every case presented to psychiatry, concerned as this branch is with a far more complicated organism than any other department of medicine. Nor should we draw the limits of health too narrowly; we have to allow sufficient room for all varieties of minds.

Let a sane man undergo a mental shock, say the death of a near relative. He will experience an intense depression of feeling, and will very likely be overwhelmed with grief. The events of the world around him will pass unnoticed, and things that had excited his interest in the highest degree will fail to make upon him the slightest impression. The intensity of this condition will vary with different men. One will be more susceptible to psychical pains than another. One will be able to fight down his feelings with his reason, while another will give himself over to unbridled grief. But whether in greater degree or less, in some measure, in the circumstances supposed, the sane man will always experience such grief. Complete psychical anæsthesia, or insensibility, is a symptom of psychical disease. We observe it in the most diverse forms of insanity.

On the other hand, it is not unusual to find persons in whom such a depression of spirits as we have described is brought on by quite trifling causes. The refusal of a new dress or seal-skin sack, rainy weather which interferes with a projected picnic, and things of that description, may suffice to bring on a shower of tears and to conjure up a state of despair, or at least of deep mental perturbation. In fact, this is the regular result with children. But in adults we call it excessive sensitiveness, or psychical hyperæsthesia. It is especially met with in hysterical and degenerate individuals.

Finally, the same state of deep depression and complete apathy is also found without the slightest outward reason, being brought on by inward conditions. In that case we diagnose a grave psychical malady—to wit, melancholia.

It is the same with the cheerful emotions. Any sound man may, upon a particularly joyful occasion, as upon the successful passage of an examination, or the winning of a lottery prize, give way to an exuberance of behaviour which a hysterical or degenerate subject will exhibit upon the most trifling occasion. But if such a state is brought on without any external reason whatever, it betokens a form of disease which may pass into foaming rage; and this we term mania.

It is just the same with anger, vexation, fear, anxiety, and other emotions. From the normal psychical action we pass through successive exaggerations of emotion to a rage quite without reason but determined by inward conditions.

Even irrational emotion is not without its analogue within the latitude of the normal state of our spirits. Almost every man has his ups and downs of spirits, his greater or less mental tone. One day, he knows not why, he is in good condition for work; another day he has to force himself to his duty. An artist says, “It is of no use; I am in no trim for work to-day; I am not in the mood for it.” If we imagined curves to be drawn of these moods in different men, we should find waves of small amplitude even in the most solid and stolid men of business; while passing to the artists, and from them to the Skimpoles, and from them, again, to persons usually called hysterical, the oscillations would be greater and greater. The slight spontaneous irregularities of temper of the perfectly sane man will be manifest only to his most intimate companions; for he will contrive to give his moods a factitious backing of reason, though this may perhaps deceive no close observer. But the hysterical, and those who abandon self-government, will in the wildest fashion give rein to every freak, quite forgetful of the company in which they may be. We can, however, assign no accurate limits to healthy variations. We can not say, At this point precisely sanity ends and madness begins. There is no such boundary in Nature. The difference between a particular disposition and insanity is but a question of more or less.

All our impressions, whether of the external world or of ourselves, are conveyed to us by the sensory-nerves. The excitation of a sensory-nerve terminal results in a sensation at the central end of the peripheral nerve, in the brain. Hence the excitation is propagated to the cortex, or outer part of the brain, where is the terminus of the sensory tract; and here the sensation, brayed, as it were, with the residua of former impressions, is converted into a perception. Every sensation that has once been worked up into a perception is capable of being spontaneously or voluntarily excited anew. The re-excitation or reminiscence of an image which has so arisen, whether by a peripheral excitation, or spontaneously, or voluntarily, brings along with it the recollection of other images. Those connecting nerve fibres, by means of which associated sensations are produced, are termed associational tracts. The aggregate of a great multitude of reminiscential images belonging to different organs of sense makes what we call a perceptual idea, or percept (Vorstellung). For example, let the word bell be mentioned. What does it mean? It brings up the optical image of a certain cubic curve, the form of the outline of the bell; it brings up the four letters b e l l; it brings up the sound the instrument produces; and, finally, it brings up the sonorous syllable which we are accustomed to fancy resembles that sound. All these images (and mind, that in psychology we speak of auditory, olfactory, and other reminiscences as images) are recalled, and with them traces of other things associated with bells—some merry sleighing-party of the hearer’s youth; his wedding-day, perhaps; the dreadful summons of the people on some occasion of a fire or of anticipated invasion; and, possibly, some well-remembered funeral. All these things come welling up to us, like the swelling of the sound produced by interferences. Language has no word more vividly significant than bell, because the more memorial images cluster about an idea, the clearer will it be, and the easier reproduced, or, in other words, the more it clings to the memory. If you have to remember a name you ask to have it written down, because the auditory image will be more readily reproduced if once associated with the visual image.

The more intense and extraordinary an original impression of sense, the more distinctly will it be reproduced. But after a while the reproduced image loses its distinctive characters. It becomes vague, and in that sense weaker. The remembered sound of the cannon of a distant battlefield, though not perhaps less loud, is less distinguished from other remembered sounds, unless, indeed, more recent experiences refresh our memory.

The period of time within which a memorial stimulus of given power can excite a recollection of given definiteness varies through a wide range with different individuals. Within the latitude of health there are good and bad memories, and memories of different kinds. In pathological cases, this action of the cortex may sink almost or quite to zero, or be exaggerated surprisingly.

As a multitude of impressions are worked together into an image, and a multitude of images into a perceptual idea, so a complexus of perceptual ideas has for its resultant a thought, wherein there is a representation of the way events happen, in general, and of the relation of our ego to the macrocosm. Such general conception of the relation between the inner and outer world makes what the psychologist means by self-consciousness—or, as it has been called, the consciousness of consciousness, or superintending-consciousness (Oberbewusstsein).

The procedure of thought is perfected in an arrangement of ideas in sequence. In the waking state there is a ceaseless flow of percepts—that is, a continual thinking-process takes place in the brain. Those percepts are occasionally excited by the peripheral organs, or they are supplied by inward excitations following the tracts of association.

The sequence of percepts may be determined either involuntarily by spontaneous associations and outward impressions, or by the active exercise of attention.

Stimuli from the peripheral organs of sense may be called centripetal actions, the operations of association intra-central, and the idea due to the will centrifugal. The function of this centrifugal action is to bring the ideas into a regular sequence by excluding unsuitable centripetal percepts, and by strengthening some associations and weakening others. In common speech we call this centrifugal action attention. It fulfils one of the most important offices of the mind, since without it thought could not be made purposive.

The power of attention of a sane man has to be considerable, so that he may hold his ideas in the right order for a long time without fatigue. In idiots, on the other hand, it is occasionally so completely wanting that they can not swerve the slow current of their ideas. Between these two extremes every possible grade of this power is met with. Every teacher of children knows that some of them concentrate their thoughts with comparatively little difficulty, while others are at the mercy of every little presentation in the room or out at the window, as well as of their own recollections.

The process of association may follow different principles. An idea may melt into another inwardly allied to it. I hear a musical air, for example. This sets all sorts of subconscious ideas relating to music into motion toward the surface of consciousness. Some circumstance or other, perhaps its recent prominence, gives a clear outline, let us suppose, to the idea of the Magic Flute before the others. Now, it is particularly ideas of operatic music whose gradual movement toward emergence is accelerated. I find myself reviewing several operas; or, if a number of such ideas emerge at once, a general conception of operatic music is formed in my mind. Among these pictures, perhaps one of a grand performance at La Scala may, by its splendour, obliterate others. By this time my reminiscences of oratorios, symphonies, chamber music, etc., are sinking back into slumber, while pictures of various opera houses are crowding up to the surface. Their multitude prevents my distinctly dwelling upon any one. The resultant is a general idea of theatrical architecture. Now memories of other magnificent pieces of architecture begin to take places in the composite photograph of my imagination, and as, by the operation of fatigue, the intense assertiveness of the ideas which have been longer before my mind wanes, perhaps the resultant of those that remain leaves me thinking of triumphal arches. This is an imaginary example of a train of association governed chiefly by the principle called resemblance—that is, by the intrinsic affinities of ideas. Another principle is that called contiguity, where an idea, A, calls up another, B, having no inward affinity for it, because the sequence of B upon A has an analogy, or inward affinity, with the sequence of b upon a, where b and a are ideas which occurred at some previous time, b following after a. For example, I see a porringer, let us say, which I remember to have used in my childhood. The whole scene straightway completes itself in my imagination—the chamber, the furniture, the nurse, appear before me. Thence my fancy is carried forward to the day when that nurse was married from the house, and the image of the man she married is called up. Then follows the picture of a visit I subsequently made to see how the couple were prospering, etc. These ideas follow one another because similar ideas did follow one another upon a former presentation of them. The principles of resemblance and contiguity may act in conjunction, as they do in the minds of those who are continually chasing puns and rhymes. Here ideas the most incongruous may be associated, because the former recalls by contiguity a word or phrase which by resemblance calls forth another word, which in its turn reproduces by contiguity the second idea. We make use of this sort of association in mnemonic verses, such as “Thirty days hath September,” etc. Countless systems of artificial memory repose on the same principle; and so does the very natural method of attending to a general rule observable among certain objects for the sake of remembering the objects themselves.

The rapidity with which the process of associative reproduction takes place can be little varied by any effort of the will. It depends upon the freshness or fatigue of the nervous system at the time. It differs, too, with different individuals. Under pathological conditions it may either sink to such a minimum that patients will themselves complain of their vacuity of mind and mental retardation, or it may become an abnormal rush of ideas. When the rapidity of the associative process is slightly increased, the patient feels extremely well. He is in the mood for brilliant performances, thoughts fly to him, his conversation sparkles, he improvises, he impresses those about him as being a witty and clever man. With a still greater rapidity of associative action there is such a rush of ideas that they tumble over one another, lose their logical relations, and end in a delirious whirl.

We have thus far considered only cases in which every idea is excited by a stimulus external or associational. We now come to a different phenomenon. Almost every man knows what it is, while endeavouring to think consecutively, suddenly to have an unwelcome image obtrude itself; perhaps a musical air which he has of late heard too often repeats itself in his brain without being led up to at all. We often hear it said, “I can not get that accursed tune out of my head.” Phenomena of this kind are to be explained by the tendency of some part of the cortex which has been excessively excited to pass into the active condition spontaneously. In quite an analogous way the most complicated percepts may spring up spontaneously, breaking into the normal current of thought. When an idea thus becomes a continual hindrance to rational thought, we call it an imperative idea. It forms a disease inflicting, as a rule, great torment and anguish upon the patient, and leads to further complications.

We have said that every sense-perception once experienced may be reproduced without any new stimulus. Now, if, independently of any associational process, a reminiscential image is excited spontaneously with extraordinary strength, the vividness, or subjective intensity of the idea, may be so heightened as to take on every characteristic of actual perception. Let an excitation run over the path which leads from the subcortical centre which is the seat of the primary sensation to the cortical centre of perception, and whether it have a centrifugal origin, or whether it be centripetally propagated, the result will ordinarily be the same—namely, that we shall project the percept into our idea of the outward world. We shall unhesitatingly accept the thing we see or the language we hear as real external experiences, although the whole may be nothing but hallucination.

The relative intensity with which a given perception can be reproduced by a given person depends on the intensity of the original excitation and the degree of attention that had been originally bestowed upon it. In different persons the intensity of reproductive power varies exceedingly. It is low in some minds; while others, especially artists, possess a very high degree of imagination. Some painters can at will call up visual images which they proceed to copy upon their canvas just as if they were painting from Nature; and a successful writer for the orchestra will seem to hear the effect of a given combination of instruments, so as to achieve with unerring certainty results that the greatest theoretician could not rival.

Muscular motions are of three kinds—the automatic, the reflex, and the voluntary. Automatic motions, such as the beating of the heart and ordinary respiration, are caused by the action of special centres; and though they may be influenced by reflex, or even in some measure by voluntary action, they act, nevertheless, independently. Reflex motions originate in centres which do not, like the automatic centres, produce any excitations, but only receive them from sensory nerves. Examples are the contraction of the pupil of the eye under increased illumination, and winking upon any touch of the eyelid.

To bring about a voluntary motion, a centripetal impulse is ordinarily requisite, to stimulate the psychomotor centre. Yet it is possible for the excitation to arise within that centre. Every man has his peculiar tricks, unless he has taken pains to conquer them. He pulls his beard, or sniffs, or bites his mustache, or rubs his hands, or gives some peculiar twitch, more or less annoying to his neighbours, unconsciously to himself and without any outward stimulus, simply in consequence of a chronically excited state of some centre. These excitations are sometimes sufficient to produce large and co-ordinated motions for which, in ordinary circumstances, the co-operation of the will would be requisite. Many people can not sit long still without an uncontrollable impulse to move about. They jump up from their work, take a turn or two up and down the room, and then sit down to their work again.

Such excitations as these may likewise be exaggerated to the point of disease. In mania they are seen in their most extreme form. Patients yell, rage, strike, and smash, without knowing what they are about.

Among the most important symptoms of psychical maladies, often most difficult to recognize, are delusions. The general public imagines that delusions consist essentially in believing something that is utterly absurd. Nothing could be more erroneous. A delusion may be in substance quite true, while the sheerest nonsense may be produced in the mind without any delusion. A person may fancy he has a living creature in his body, and, though it may in fact be true that he has a tapeworm, yet, if the opinion is not founded on any sound process of thought, it certainly is none the less to be classed along with genuine delusions because it accidentally happens to come true.

Of three so-called “spiritualists,” let one be a simpleton who, without any logical conviction, has been led—by sheer credulity, or weak assent to energetic assertion—to admit the phenomena of mediumship. Let the second be a learned man who has been imposed upon by legerdemain, and who endeavours to explain what he thinks he has seen in a scientific way; and let the third be one with whom the belief is of the nature of an insane delusion. They all believe the same thing; so that it can not be said that it is the nature of what is believed that constitutes the insanity. It is rather the mode in which the belief has come about, its relation to the other operations of the mind, its mode of expression, its relation to the interests of the believer, that must be relied upon to determine the alienist to diagnose a true delusion.

Anomalies of the propensities play a great part in the pathology of the mind. Like the other symptoms of insanity, abnormal impulses are but quantitative or qualitative modifications of healthy conditions. Psychiatry has never discovered any new passion. The appetites vary greatly in different individuals; and here again we must take care to allow sufficient latitude to healthy variations. The feeling of hunger, or the propensity to eat, may in the most diverse psychical disorders be enormously exalted. This is called hyperorexia. It sometimes goes so far that the patient tries to devour whatever he can lay hands on. This is called sitomania. On the other hand, the propensity may be distinctly lowered in intensity or even lost. This is called anorexia. Of course, none of these states includes cases in which the modification of the appetite is caused by derangements of the organs of digestion. Finally, the desire for food may be directed to strange substances, as often happens to pregnant women. In the insane this perversion of appetite will sometimes be so great as to induce them to eat straw, earth, worms, and even their own filth.

We sometimes find the other propensities equally deranged. The sexual impulse may be exalted to the highest degree—a state called satyriasis in men, nymphomania in women. The sexual appetite may be depressed or lost in total impotence. It may be perverted to one’s own sex or to other things.

I must apologize for this general description of the symptoms of insanity, which does not directly concern the subject of this book. I have entered upon it for the purpose of showing that, in order to determine the state of mental sanity or insanity, it does not suffice to produce certain extraordinary or absurd modes of behaviour or temper; that we can hardly pronounce a man to be insane from any conduct until we know what his motives are; and, finally, that we are not to judge from a part of his mental actions, but must get a clear notion of his whole mental condition. I have further endeavoured to show that, as far as single symptoms go, no sharp line of demarcation can be drawn between mental sanity and insanity. Just as there are physically strong men and physically weak men, men of large bodies and men of puny bodies, so within the limits of health there are mental athletes and mental weaklings. Moreover, just as no two men are in person counterparts the one of the other, so there are no two whose characters are precisely alike. There are perfectly healthy men with extraordinary physiognomies or peculiarities of bodily structure; and in like manner unusual traits of character are to be met with. The study of such men may be interesting to the psychologist, but it does not directly concern the pathology of the mind.