Moral (Affective) Insanity
64 Art. III.? A Plea for its Retention in Medical Nomenclature. :Author: C. H. HUGHES, M.D., St. Louis, Mo.
Notable instances of the subversion of mind, without accompaniment of mental perversion, are found in those cases of gangliopathy which proceed to the extent of fainting, epilepsia, chorea, &c., in which either volition or both the will and consciousness are subverted. The ganglionic (visceral) origin of certain forms of hypochondria, melancholia, and hystero-mania has been admitted since the time of Hippocrates. Morbid states of the reproductive system have long been deemed sufficient sources of certain forms of mental derangement, in which the feelings rather than the reasoning processes are disordered.
It is conceded that kleptomania, pyromania, dipsomania, homicidal and suicidal impulses, and the morbid displays of pregnant women and the mind disorders connected with the critical periods of woman’s life, may have their starting point in uterine disorder, even with more unanimity and certainty than puerperal mania, for the latter is often as much an insanity of general hoemic and neuric exhaustion?anajmia and shock?as of reflex irritation. And, if reflex insanity be conceded, the possibility of moral insanity must be admitted, for the concession acknowledges the varying shades of mental involvement depending upon the degree and source of the reflected irritation, from the insane longings and freaks of pregnancy to the infanticidal and other morbid impulses of post-parlum cerebrasthenia. To concede the possibility of a homicidal or other morbid impulse not founded in delusion (and psychiatry furnishes abundant proofs of such impulses), is to admit the basis fact of moral insanity as it is clinically observable, namely, insanity not the result of reason perverted by disease.!
Abstract of paper embodying the views presented in the author’s precis on
the subject. Presented to the International Congress at London, August 1881 ? Cases omitted. This paper was designed rather to elicit argument than to exhaust the subject. t Tilt saw a case where a pressure upon an inflamed ovary excited epileptic fits. I have seen a vaginal injection cause a maniacal paroxysm, some of the injected fluid having passed up into the uterine cavity. Sir Benjamin Brodie brought on a fit. of chorea by gentle pressure over the stomach, and the effect of a smart blow in producing faintness is so well known to the prize ring that it is considered foul to hit below the belt. Even death has residted from violence done to the semilunar ganglia. But these effects are not more singular than the MORAL (AFFECTIVE) INSANITY. 65
When ganglionic disease is great, and the morbid consequences profound enough to involve the intellectual faculties in marked disorder, those who deny the possibility of insanity existing without appreciable lesion of the intellect, now willingly admit the existence of mental disease, and unwittingly, in those minor degrees of eccentric irritation connected with the period of utero-gestation and manifested in peevishness and insatiable longings and changes of temper, they charitably concede that the patient is to be excused for not putting as complete a rein upon the display of eccentric feeling and action as would be considered the proper thing in one not enceinte. The intellect may appear intact or coexistent with a minor degree of moral or emotional perversion, and the perverted moral feeling excused or extenuated, if indulged ; yet, if we pass a few steps further and venture to say that a seemingly resistless impulse to which the will yields while the intellect disapproves is insanity, then their theoretical conception of the unity of mind?it being impossible for them to understand how emotion, volition and thought can be separate?leads to the rejection of one of the most demonstrable facts in practical psychiatry as well as one of the most demonstrable facts in our every-day intercourse with minds that are not insane. Persons in the best of health are constantly acting from impulse, prejudice or passion, conforming to society’s usages and the dictates of fashion or feeling without sufficient thought.
The emotions and the intellect are not twin born, though they mutually influence each other. They do not always go hand in hand or dwell harmoniously, though tenanted together in the brain. In good cerebral organisations, they are often at war with each other. The things which even sane men ought not to do, they often do; arid those they ought to do, they sometimes do not. (The Apostle Paul confesses this of himself. If a saint can concede this much of a healthy mind, a sinner can do no less for the victim of disease. Paul was a good psychologist, and discerned, though unconscious of their physiological foundation, the ganglionic source of certain encephalic states. He was ” constantly at war with his members.” When he ” would do good, evil was present with him.”
irritation of dentition or worms, or undigested substances in the alimentary canal, causing infantile convulsions, the effect of a fistula in causing melancholia with mpulse to suicide, passing away after a successful operation, the many eccentric isources of epilepsia, tetanus, cerebral irritation, hyperemia, &c. Tait excises an ovary and cures an epilepsy, Charcot compresses one, and Kussmaul a testicle, causing reflex histero-epilepsy, and the temporary subversion of mind from wound of testicle was well known before Charcot, Kussmaul, Tait, Brodie or Tilt were known to fame.
I commend St. Paul as a psychologist to certain of our confreres. May the convincing light of truth shine upon them as it did upon the persecutor of the proto-martyr on his way to Damascus, and by way of contrition for the wrong they have done and may yet do that least commiserated of all the mentally afflicted?the emotional, the impulsive and the morally insane?may they speedily make amends by renouncing their heresies and, embracing the true faith, become followers of the faithful Rush, Pinel, Prichard, Maudsley, Bucknill, Tuke, and Ray.
Stephen had been stoned, it is true, but there still remained others to be saved. Many an honest Saul in our ranks consenting to this wrong remains to be converted. If there be any who, in perfect health, has not yielded to the dominion of impulse, emotion or passion, let him cast the first stone at the victim of mental disease, whose intellect, while it does not restrain, yet seems not touched by the morbid process which has deranged the affections, the emotions and the will.) Insanity of the emotions, propensities and passions in which the intellect, if at all disordered, is not appreciably so, or only momentarily so by being in abeyance or unable through some want of connection of the will or controlling power of the latter over the impulses and passions, is a fact however it may clash with theories of the so-called unity of mind. It is a fact as much so as ecstasy or hypnotism, somnambulism or dreaming, which are not completely harmonious and united actions of all the mental powers. As much a fact as prejudiced or biased or unconscious cerebration in the healthy working state of mind. As much a fact as the many varieties of aphasia without intellectual impairment, which the great Trosseau rejected because he was biased in judgment by the dominant theory of Condillac and Warburton that the mind could only think in speech. As much a fact as certain illusions or hallucinations in which the intellect does not concur, though during the formation stage of these mental spectra the reason may be in momentary abeyance. We should recognise the fact, though in so doing we may have to mend our theories, or even abandon them. We should never whittle down facts to preconceived metaphysical notions. All observation of the varying degrees of emotional, impulsive and intellectual life in different persons and in the same person at different ages of life, attest the possibility of disorder of the emotions, propensities, or passions, without more appreciable intellectual lesion than we see in persons who are regarded as right-minded.
Though insanity is marked generally by change of character, that change is seldom manifested in augmenting the power of the intellect and the will over the emotions or passions. On the contrary, the latter often subvert the former. Usually the disease, beginning with moral or emotional perversion, gradually involves or undermines the reason and judgment. It is thus that in the early stages moral, emotional, and impulsive disorder is mainly divorced from the intellect (if the two are ever then truly wedded), and what begins with an insanity of the feelings, propensities, or passions usually goes on (if not arrested by timely medical interference) to the graver forms of more general mental involvement. These cases may even pass, if not cured, into the stages of delusion and dementia; a fact which has led some writers to doubt their existence, unless associated with intellectual involvement, but which really proves the kinship of these contested varieties of mental derangement, even where neither delusion or other intellectual lesion appears, with universally recognised forms of insanity, just as the insane heredity of moral mania often establishes in our mind the fact of insanity as contra-distinguished from uncomplicated vice when we are in doubt. Men in their sanest states are often more influenced by their feelings, prejudices and passions than by their judgments. Insanity generally expresses itself more in action than in speech. The restlessness and constant muscular activity of many lunatics is not always the expression of disordered intellection, so much as it is an accompaniment simply of morbid feeling, or irritation of psycho-motor centres, and sometimes the acts of the insane, if their after confessions in seemingly lucid intervals may be taken as even approximately true, are not infrequently independent of both conscious thought and feeling. They appear often as blind freaks of disease or mental caprice, in which the highest intellectual centres seem only unconsciously involved.
That vigorous thinker, John Locke, who was not a mere surface observer, though he looked at insanity rather too superficially for a practical alienist, was led to the conclusion not strictly true, but not altogether erroneous, that the insane did not so much ” appear to have lost the faculty of reasoning, but having joined together some ideas very wrongly, they mistake them for truths and they err as men do who argue right from wrong principles ; for by the violence of their imaginations?having taken their fancies for realties?they make right deductions from them. Thus you will find a distracted man fancying himself a king, with a right inference requiring suitable attendance, respect and obedience; others who have thought themselves made of glass have used the caution necessary to preserve such brittle bodies. Hence it comes to pass that a man who is very sober, and of a right understanding in all other things, may in one particular be as frantic as any in Bedlam ; if either by any sudden, very strong impression, or long fixing his fancy upon one sort of thoughts, incoherent ideas have been cemented so powerfully as to remain united.”
Locke here has reference to the deluded or delusional insane, and is only in part correct, for the insane do often both reason illogically and incoherently, and establish wrong premises from which their reasoning proceeds. Doubtless the correct reasoning manifested sometimes in the affective insanities contributed to the formation of his only partly correct opinion, for in the next sentence he says, ” there are degrees of madness as there are of folly, the disorderly jumbling of ideas together is in some more, some less,” and in some (he might have concluded, had he been as familiar with the insane as they sliuuld be who aspire to correct notions respecting them) there seems to be no appreciable lesion of the reasoning faculties. Locke’s idea of insanity was that it must always be intellectual aberration, and yet his observation taught him, despite his philosophical bias, a bias in which many mental philosophers of the purely psychical school still share, that many lunaticn reasoned well. It never occurred to him to deny the existence of insanity in such, but to assume that they joined some ideas wrongly together.
With reference to another observation of Locke’s, viz.: ” that reverence gives beauty and prejudice deformity to our opinions,” it may assuredly be said with equal truth that intellectual processes in both the sane and the insane are incited to action and influenced by moral or other emotions, excited either by example of others or by disease.
Those who deny the existence of moral insanity insist that there always exists a certain degree of intellectual acquiescence that entitles it to be termed intellectual insanity, though that intellectual perversion may be, and often is no greater than that which is found in the naturally immoral and depraved ; but, if one concede this, there yet remain cases of moral and emotional disease where the intellect not only does not acquiesce in, but actually discountenances and seeks to be restrained from, the morbid impulse or to subvert the morbid feeling. Momentary impulses and suggestions of a morbid kind* * The great Mark relates of himself how he withdrew from a bridge he was about to cross, lest he should yield to the impulse which came upon him to precipitate himself into the Seine. How many persons have confessed to feeling a disposition to precipitate themselves into the water when looking over a steep precipice, or the sides or stern of a steamer. obtrude themselves upon many healthy minds like the vague feelings of unreasonable unrest and depression which obtrude unbidden into the neural chambers of the cerebral cortex. Facts like these, and a hundred others needless to enumerate, show the capability of the mental faculties to become partially involved in aberrant action without notable derangement of the reason.
Men are not considered, insane because they do not act wisely, why should it be insisted upon that the intellect should show disorder before insanity is recognised in those whose impulsions are undoubtedly of morbid source, and why should the intellectual implication, when it is found, though it be no greater than that of some men moved by passion, be insisted upon as the essential feature of the disease ?
How, then, can we doubt the possibility of forms of emotional and impulsive insanity, in which the moral faculties are so invoked by disease as to cause the individual to appear depraved ? The converse, too, is true. There may be moral exaltation from disease as well as from intellectual conviction, even from sexual excitation (excessive or suppressed gratification) religious exaltation may result as Dr Workman and others have shown, and that, too, without extatic visions or special delusions. Dr Benj. Rush* noted long ago that a morbid state of the sexual appetite ” becomes a disease both of the body and mind.” This pioneer in American psychiatry and close observer of the insane, readily discerned that the will might be deranged even “in many instances of persons of sound understandings and some of uncommon talents, the will becoming the involuntary vehicle of vicious actions through the instrumentality of the passions,” f under which head he included what he termed the lying disease, which iC differs from exculpative, fraudulent and malicious lying, in being influenced by none of the motives of any of them.” ” Persons thus diseased,” he says,” cannot speak the truth upon any subject, nor tell the same story twice in the same way, nor describe anything as it has appeared to other people. Their falsehoods are seldom calculated to injure anybody but themselves, being, for the most part, of an hyperbolical or boasting nature.” j He inferred it to be ” a corporeal disease, from its sometimes appearing in mad people, who are remarkable for veracity in healthy states of their minds,” several instances of which he saw in the Pennsylvania Hospital. He recognised certain stages of intemperance as a disease of the will, and was the first to propose a hospital for inebriates, or ” sober house,” as he termed it, comparing the weakened will of a drunkard to a paralysed limb. Rush also believed in a derangement of the principle of faith, or the believing faculty caused by disease, also in derangement of memory, under which head he includes some instances of aphasia, without the accompaniment of intellectual aberration. He was an unequivocal believer in derangement of the moral faculty, conscience and the ” sense of Deity,” and notes especially the case of a boy of thirteen years, in Bethlehem Hospital, described by Haslam, ” who was perfectly sensible of his depravity, and often asked why God had not made him like other men.’’ In the course of his life, Dr Rush was consulted in many of ” those cases of total perversion of the moral faculties.” ” One of them was addicted to every kind of mischief. Her wickedness had no intervals while awake, except when she was kept busy in some study or difficult employment.”
This great observer concluded that in these cases ” there is probably an original defective organisation in those parts of the body which are occupied by the moral faculties of the mind,”* though he could not determine where to draw the line which divides free agency from necessity, and vice from disease. He discourses further as follows : ?
“In whatever manner this question may be settled, it will readily be admitted that such persons are, in a preeminent degree, objects of compassion, and that it is the business of medicine to aid both religion and law in preventing and curing their moral alienation of mind.”
Thus did one of the fathers of American medicine contribute in the beginning of the present century to the overthrow of that opprobrious doctrine of diabolical possession, or moral depravity, which has led many a hapless lunatic to the stake and gallows, and to give us in its stead the conception of moral mania, a form of insanity just as real as the demonomania which overtook unfortunate old women past the menstrual climacteric in Cotton Mather’s day, and resulted in their being drowned for witchcraft, and which,, notwithstanding the reality of disease for its cause, finds even now in some quarters neither commiseration or extenuation, being regarded as the manifestation of a wicked and devilish spirit, entitling its possessor to the punishment of the gallows or the penitentiary, rather than the restraint and treatment of the asylum for the insane. The existence of the knowledge of right and wrong with the judge, the absence of appreciable intellectual disorder with the physician, are regarded as incompatible with their ideal conception, not of what insanity is, but of what it to them ought to be, and the penalty for this theoretical misconception of the real nature of mind is visited on the unfortunate victim of disease, whose bad luck it is to be afflicted in a manner theoretically proscribed. Theoretical views and metaphysical conceptions of mind have too long stood in the way of true progress in psychological knowledge.
To this has been due the fact that physical disease, as the basis of all forms of mania, now a generally accepted truth, was so long controverted. To this stumbling block are we indebted tor the inhuman treatment the insane received in the time of Gralen, and up to that comparatively recent period when Pinel immortalised himself and lifted humanity to a higher pedestal by striking the shackles from the madmen in the dungeons of Bicetre.
There is a somatic as well as a psychic element in mind as we are permitted to see it, to be taken account of in all study of psychical display, whether in health or disease, though what mind is we do not know, and perhaps we may never completely comprehend, save in its manifestations. All that we can see of mind is displayed in the operations of the intellect, the emotions, feelings, and the will. There is a time in life when we see but little of the former, and a time when we see more of it than of the two latter attributes of the accompaniments of mind. The emotions and the will are part of the mind, as it manifests itself to us; and whatever may be our preconception of the impossibility of their being separated, if we see them practically severed by disease, it is only just to acknowledge the fact.
To assert that the doctrine of moral insanity is a dangerous one from which society may suffer, as Mayo and his followers have done, is to render science subservient to social polity, illogical, cowardly, and. of course, unscientific, whereas social polity should be ever subservient to scientific truth, whatever that may be revealed to be. Let us always speak according to our convictions. If we trim and prune truth so that we may adapt it to social expediency, we become false lights?we degrade science, the sceptre of influence falls from us, and judicial wrongs, even murder perpetrated by strong-handed Law upon the weak and miserable, will continue to be committed in our name, and be the lasting monument of our disgraceful surrender of truth. There is moral perversion and degeneration resulting from disease, with but little, if any, appreciable intellectual lesion, less intellectual lesion oftentimes than we find in those whose lives have been given up to vice, through self-will or parental coercion or evil communication. Then let us, when occasion demands, tell the courts so, and not say we cannot conceive it possible for moral derangement to exist without concomitant intellectual aberration, while observable facts confute such theories ; and let us turn our attention to searching out, for the aid of jurists, instead of ignoring the line of demarcation between responsible and irresponsible vice, the characteristics of disease on the one hand, and on the other, voluntary moral depravity coupled with a body sound and a mind free to choose.
Moral insanity constitutes an observed and observable fact of psychology; let us not seek to theorise it out of existence. The metaphysical conception of mind, the abstraction made into an entity, as Maudsley justly observes, “has overidden discerning observation” in some quarters, and eminent and observing men have thus suffered their judgments to become biased by the idea that the faculties of the mifid cannot act separately?that to derange one must necessarily and appreciably disorder others. On this reasoning many eminent men believe the existence of moral insanity impossible, while others, among them the lamented Kay, not so biased, following in the footsteps of Prichard, who first promulgated the doctrine, see no more difficulty in recognising insanity of the moral feelings and of other impulses, pi-opensities, and passions without nccessary involvement of the higher faculties of reasoning in appreciable disorder, than the great Pin el did long before them in discerning what, up to his time, was regarded as equally inexplicable, namely, mania without the delirium of madness.
Dr Mayo,* who made the first and strongest assault on the doctrine of Prichard has unwittingly admitted, as indeed all close observers of insanity know, ” that the earliest indications of approaching insanity are moral,” and he makes the further fatal admission ” that at every period of the actual presence ” of insanity ” the powers of self-control are interfered with, the affections suppressed or altered, the passions excited or perverted.”
All practical observers concede a frequent gradual change of feeling and conduct in prodromal insanity preceding the culmination of intellectual aberration, and some who deny the possibility of moral insanity make a classification of moral imbecility, concessions which logically debar all opposition to moral insanity.
Whatever the stage at which we view mental disease, whether initial or terminal, insanity exists, as much so, as fever at any stage of typhoid or typhus fever. If a change of moral conduct have disease for its cause, it is as much entitled to be called insanity as the morbid aversions, antipathies, fears, or acts not brought about by delusion, are to be classed among the recognised evidences of mental derangement.
Bland ford’s searching analysis of Pricliard’s cases, while it divests many of them of the vestments of uncomplicated moral insanity, leaves a number that cannot be elsewhere placed, ” good examples of what may be called moral insanity if the term is to be used at all,” as Blandford himself confesses, one of which he concedes deserves to be called morally insane.*
Those who engage in the study of morbid mental phenomena with the preconception that the intellect must be always synchronously deranged in all morbid mental expression must consistently regard every act or feeling of the insane person ” as plainly the outcome of some idea present for the moment, but present, possibly, but for the moment, and then so obliterated that the individual has lost all trace of it,”f in certain morbid impulsions or feelings. Those who think ” the intellectual and emotional functions of the mind cannot be divorced, that the ideational portion of the mind is so intimately joined in operation to the emotional?the stored ideas of the brain are so influenced by the feelings of the moment, whether these arise from within or without?that the two mu?t be sound or unsound together,” will be reluctant to concede the demonstrable fact that the affective life may be greatly changed by disease, while the intellectual processes remain intact, so far as may be discernible by any known methods of testing the integrity of the reasoning powers; slow to recognise those cases in which the will and not the reason is weakened or perverted, Yet the morbid impulsions arising in neuropathic organisms often reasoned against and sometimes resisted, but finally surrendered to stand out in practical refutation of the impossible conception of the invariable unity of mind disturbed by disease.
The dipsomaniacs, the kleptomaniacs, and sometimes even pyromaniacs, yielding to impulses against their reason, are examples no less destructive to this hypothesis than the auto-: amnestic acts and impulses of hypnotism, somnambulism, and certain epileptoid states. To gauge insanity by the integrity or non-integrity of the reasoning processes alone would make the automatism of certain manifestations of alcoholism, epilepsia, and mesmerism normal mental states. The reasoning faculties in moral insanity often appear to act as correctly as in the most perfect cerebral automatism. If there is a lesion short of intellectual disease and beyond that of pure derangement of the moral faculties, and there usually is in this, as there is in all insanity, a degree of auto-amnesia by which the affected individual does not discern the change that has taken place in himself?it is simply an impaired or lost appreciation of the transformation in his character?which has been brought about by disease, but many sane persons also fail to discern their descent into vicious ways. However, if this degree of involvement of the comparing faculties be deemed sufficient to ally it to insanity in general (and it does on the basis of a part of Conolly’s definition), and thus to rescue a real mental disease from the theoretical assaults made upon it, we cheerfully concede it, for it is a fact that the morally insane, like most other insane persons, usually do not see themselves as others see them. But there are cases where the search must be exceedingly close to reveal any greater lesion. Normal mind is the sum of the aggregate display of the cerebro-psychic functions constituting the natural ” ego;”
abnormal mind consists of such disorder of one or more of the cerebro-psychic functions as causes so marked a change in the psychical characteristics of the individual, whether principally involving the emotions, the reasoning powers, or the will, as to make an inconsistency and inharmony in the person’s character inexplicable only by disease.
Moral insanity is as clearly comprehended in this definition as other forms of mental derangement, and as much entitled to be recognised as a distinctive appellation and form of disease as the many other mental affections that are named on account of their prominent symptomatic feature or features.
Not to recognise it in the present state of cerebro-mental pathology would in certain instances prove disastrous to the rights of the insane before the courts, and to their welfare elsewhere.
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