The TREATMENT consists in attention to the general laws of health, occupation, and a fattening diet. It is seldom successfully managed without occasional recourse to an asylum at least, and oftenest a permanent residence in hospitals, occasionally changing, is quite necessary.
PERIODIC INSANITY, usually mania or melancholia, is marked by attacks recurring at more or less regular intervals, with a partial but not complete return to the previous mental health between them. It is one of the incurable degenerative mental diseases. The seeming recovery is only apparent, and the mental deterioration is progressive, although quite slow. The form of insanity is also not seldom a folie raisonnante (affective or moral insanity) with periods of all sorts of excesses, destructive tendencies, tramp-life, destructive acts, drunkenness, stealing, indecent exposure, etc. In the intervals, which may be short or long, and which sometimes correspond to certain seasons of the year, the mental condition is still a pathological one, with the usual signs of mental degeneration, thereby being differentiated from recurrent insanity, one of the curable psychoneuroses, in which there is a state of mental health between the successive attacks, but no sort of regularity or periodicity in the recurrences. The prognosis is unfavorable, except in so far as a quiet life in an asylum tends to prolong the intervals between the periodic outbreaks, as well as to prevent annoyance to the community during them.
CIRCULAR INSANITY (Alternating insanity, Folie circulaire, Folie à double forme, Folie à formes alternes, Die cyclische Psychose, Das circuläre Irresein) consists in a psycho-rhythm or succession, in uniform order in each particular case, of (1) mental exaltation in all degrees, from mild exhilaration or even gayness to acute mania, and (2) mental depression of all conditions, torpor, or anergic stupor. These two opposite mental conditions are separated in the vast majority of cases by a shorter or longer interval of the normal mental state, in which, however, there is soon observed some mental impairment, however slight, rarely amounting to pronounced dementia except in old age. Sometimes the three states shade off into each other, so that it is difficult to say just where one begins and the other ends; less often the transition is abrupt, sometimes during sleep. The interval between the two opposite conditions of mind may succeed either of the other mental stages, but the order once established is maintained. The duration of the vicious circle varies in succeeding attacks, sometimes becoming longer, sometimes shorter, in the progress of the disease. The relative duration of the three succeeding mental condition also varies, but the type of each remains identical, or at least changes very gradually. The state of mental exaltation often resembles moral insanity, with all sorts of immoral impulses and tendencies, and may then properly be called an insanity of action. The depression sometimes goes no farther than sluggishness of will. The tendency of the disease is to shorten life only slightly, if at all, except from the chance of suicide in the depressed state and from exhaustion when the excited stage is one of active mania. The shortest duration of the cycle in my experience has been twenty-four hours, and the longest reported extends over several years. It sometimes remains an affective insanity in its whole course, without delusions and with little more dementia than might happen from simply a corresponding advance in age without mental disease.
During the period of excitement some supervision or control will usually be desirable, and removal to some retreat or asylum will often be necessary. In the depressed stage the indications are to maintain the general health, to meet the chances of suicide, and if there are delusions to obviate the risks of danger to other persons. If the interval of comparative mental health is of considerable duration, the ordinary occupation of the patient can commonly be followed at that time for a number of years, rarely for life; but a better result may be looked for if the patient's circumstances are such that he can give up active and anxious work for some quiet occupation not involving great care.
PRIMARY INSANITY (primäre Verrücktheit, primordiale Verrücktheit, originäre Verrücktheit) is usually a further development of an hereditary predisposition to mental disease. The term primary monomania, although used as an equivalent for primäre Verrücktheit, seems to me too narrow for a disease in which the leading delusion may change so many times. Primary insanity is sometimes congenital, and may be developed also by injury or by disease involving the brain early in life or during the physiological changes at puberty, possibly by self-abuse, in persons of an unstable mental organization. It often develops so slowly with the character as to almost seem part of it, until it reaches such a degree of insane delusion of self-importance and expansive ideas as to be unmistakable insanity. There are also delusions of persecution, distrust, and suspicion, erotomania, and moral perversion, in spite of high claims to superior character, and indeed in spite of a high standard of life in some particulars. Perhaps the most striking symptom of primary insanity is the great variety of imperative conceptions (Zwangsvorstellungen) by virtue of which the individual is impelled, by a force often irresistible, to commit various offences against propriety and the laws, even to murder, as well as to perform countless acts of unwisdom or folly. There are usually physical indications of chronic or old cerebral disease, or of defect or degeneration in the incomplete or asymmetrical development of the brain, which, however, may be no more than are found in persons who might not be classed as of unsound mind. Attacks of simple mania (mental excitement) of short duration are quite common, and there is a progressive impairment of the higher faculties of the brain—those which come last in a high order of civilization—although there may be acuteness of memory, perspicacity, and shrewdness which seem altogether phenomenal as compared with the other mental qualities. There is no form of mental disease which is better expressed by the word craziness than primary insanity, no other in which the victim is more thoroughly in the grasp of his malady, and yet no other in which he is more likely to be held responsible for the crazy acts which he may perform, because his inherent mental state, out of which his generally deluded frame of mind is evolved, gives rise to delusive ideas of such a character that they are not universally recognized, even by physicians of experience in mental disease, as insane delusions, but are considered by some of them as the prevarications of a criminally-minded person. When these persons commit crimes, too, they often do so with methods and motives quite like those of the ordinary criminal.
The PROGNOSIS in primary insanity, after the disease is fully developed, is in the highest degree unfavorable. It remains to be seen how much can be done by moral training in childhood and youth to correct the evil tendency. The education of those who get into the courts and insane asylums, so far as my knowledge of such cases goes, has been bad to the last degree, so that, in my opinion, there has been a fair difference of opinion as to which of them the law should treat as criminals and which as insane persons.
TREATMENT for the most part requires absolute control of the individual, which there is usually no one in the family sound enough to maintain. If begun early, training away from home may accomplish much. Restraint in some institution is commonly called for, but the vast majority of the primary insane are allowed to take their chances in the world, and as many end in jails and prisons or on the scaffold as in asylums.
The states of mental defect and degeneration, except in the case of idiocy or marked imbecility, are not associated with such obvious physical evidences of deviation from a normal mental standard as to make them pathognomonic. While asymmetry and other cerebral defects are frequently observed in them, it must be acknowledged with Schüle that similar and as extensive gross intracranial anomalies are found in persons who could not be called of unsound mind, and that this statement holds true even of primary insanity, in which some writers have laid so much stress upon the value of any indication of imperfect or asymmetrical cerebral development. Any defect in the brain, however, is far more common among persons of unsound mind than among those of sound mind, and therefore in doubtful cases it is of a certain value as corroborative evidence of mental infirmity or impairment.
Spitzka places as signs of the insane constitution (1) atypical asymmetry of the cerebral hemispheres as regards bulk; (2) atypical asymmetry in the gyral development; (3) persistence of embryonic features in the gyral arrangement; (4) defective development of the great interhemispheric commissure; (5) irregular and defective development of the great ganglia and of the conducting tracts; (6) anomalies in the development of the minute elements of the brain; (7) abnormal arrangement of the cerebral vascular channels,—at the same time acknowledging that there are cases of insanity of inherited origin in which cerebral defects are not discernible. It is too early to estimate the value and importance of the finer or qualitative cerebral defects as giving rise to insanity. Benedikt finds them also in criminals.
With regard to responsibility before the law, the statutes of no country provide for any criterion by which accountability is defined in these cases; medical witnesses differ in opinion as to their criminality, and the courts are obliged to interpret the law to suit individual cases.