Essays In Pastoral Medicine Part 26

_The Tramp_.--One of the striking manifestations of paranoia in our modern life is the tramp. Most people are inclined to consider that the cause for the wandering life of these unfortunates is rather what a distinguished physician euphemistically called by the scientific name, _pigritia indurata_, that is, chronic laziness, than any pathological condition of mind. Most tramps, however, will be found, on that close acquaintances.h.i.+p which alone will justify judgment of their actions, to have many other peculiarities of mind besides the s.h.i.+ftlessness which prompts them to wander more or less aimlessly from place to place. After all, it will hardly be denied that the calm {297} acceptance of the notion that it is more satisfactory to indulge in laziness and wander without home or fireside, suffering the many privations and hards.h.i.+ps, especially from the weather which these creatures do, rather than work and be respected and comfortable among their fellows, is of itself irrational.

Many of these tramps prove on close acquaintance to be interesting pathological characters. Various stages of outspoken paranoia will be found to exist among them. It is not unusual to find that certain among them have acquired the idea not so uncommon now among large cla.s.ses of humanity, that the world is so unjust in its treatment of the labouring man, that work seems to them almost a persecution that must be undergone for the sake of the pittance derived from it.

Sometimes there is the actual extrinsic idea of personal persecution for some fancied wrong done to a large corporation during a strike, or labour troubles, which they cherish as the reason for which they have had to give up a fixed habitation, and resign the idea of supporting themselves honestly and respectably. This persecution stage of paranoia easily turns to the second phase of this affection as already described, that in which the fancied victim of persecution becomes in turn the persecutor. Tramps thus readily give way to even organised attempts at revenge upon social order, and are led to believe themselves justified in attempts to burn and otherwise destroy property because of their enmity towards property holders and employers generally. Not infrequently the third stage of paranoia, in which there are delusions of grandeur, may be observed.

Personally I have known two tramps who wandered about the country with these grandiose ideas. One of them thought that he had in his possession immense wealth in the shape of large checks, signed supposedly by various important capitalists, and even foreign rulers.

These checks were actually signed in the names of these personages, at the tramp's own request, by any chance pa.s.ser-by or acquaintance. This patient died in a country insane asylum in the demented stage of paranoia, having gone through all the usual phases of the disease.

Another tramp was confident that each recurring election he was to be elected to one of the highest offices in {298} the state, or even to be made President of the United States. Not every one was taken into his confidence in this matter, however. The simplest declaration after the election from any chance acquaintance would a.s.sure him of his success at the polls, and on more than one occasion he turned up at the Capitol to claim exalted office, but was generally inoffensive in his ways, and was rather readily persuaded that his term of office did not begin for some time. It is easy to understand that a person might come into the possession of the idea that the official holding office in his stead should be removed; the result might very well be one of the sad tragedies supposedly due to anarchism, but really to paranoia.

Of course as with criminals, so with tramps; not a few of them take up this manner of life without any sufficient justification in their mental state to lessen our worst opinion of them. I do not think I should hesitate to say, however, that the majority of these unfortunates present distinct signs of physical and mental degeneration and are rather deserving of pity and care than of condemnation. They need, as a rule, very special environment to enable them to lead ordinary, respectable lives, because they were not originally endowed with sufficient initiative and independence of spirit to enable them to carry on the struggle for life in the midst of the hurry and bustle of our modern civilisation. As the pressure of the time becomes severer, more of these unfit come into evidence. They arc examples of the lowered mental states, unable to stand the rivalry with fellowmen, and ready to give up the struggle whenever the example of others who have already given it up is brought prominently to their notice.

It is not a little surprising how many of these tramps belonged originally to excellent, respectable families. Careful investigation of their personal history, however, will show that they have been, as a rule, backward children at school, always a little awkward in the way they took hold of things early in life, unsuccessful in the rivalries of school compet.i.tions, and in their first efforts at labour after school days were over. They always needed the encouragement of those whom they loved and respected, to keep them at their unsatisfactorily fulfilled tasks. They were the predestined failures {299} in life, and have found out their uselessness early in their careers. This is the view of tramp life that is coming to be realised as true by all those who have studied the question, not from the standpoint of theory, but of practical experience with it.

_So-called Monomania_. The old term for paranoia employed for a long time was monomania, a word coined by Esquirol at the beginning of the nineteenth century. This word has dropped out of the terminology of mental diseases because there is no such thing as a patient suffering from a single symptom of mental disturbance, that is, being mentally perturbed on but one line of thought. There are always others, though they may be hidden except from the careful investigator. When Esquirol introduced the term he applied it to the most prominent symptom of the patient's mental alienation, but did not intend it to be taken as excluding other symptoms by which the essential nature of the patient's insanity could be diagnosed. Careful study will always disclose the fact that other symptoms are present. The word monomania has been an unfortunate one for scientific psychiatry, because it has been abused to s.h.i.+eld criminals. The plea is often heard that a person under charge of crime is really subject to some mania that brought about the commission of the crime.

We often hear of kleptomania as a defence for persons who have failed to recognise the distinction between _meum_ and _tuum_, and are haled before the court because of the detection of infringements of this distinction. True kleptomaniacs there are, but there are always other symptoms of their mental disturbance besides the tendency to steal.

Their queerness in other ways has usually been recognised by their friends and by their family physician before the incident which calls attention to this special form of disequilibration occurs.

Kleptomaniacs, too, are usually p.r.o.ne to take things of little value, or not especially suited to their wants and for which they have practically no use.

It is true collectors, that is, those who have a hobby for gathering curiosities of one kind or another to make a collection, may become so interested in additions to their collection {300} as to be tempted to appropriate to themselves articles of which they can not otherwise obtain possession. Such actions may easily go beyond the bounds of reason. It must be remembered however, that the collection mania itself is often so p.r.o.nounced as to be a little beyond the bounds of ordinary rationality.

Other so-called monomaniacs have the same characteristic and are a.s.sociated with related symptoms of mental disturbance. Pyromania is sometimes pleaded as a defense for arson. It is a legitimate defense, however, only when the careful tracing of the patient's history beforehand shows the existence of other symptoms of mental unbalance.

The homicidal mania is of the same order. There have been cases where men seem to have delighted in inflicting injuries or death upon fellow creatures from pure malice. Such cases as that of Jack the Ripper, for instance, are undoubtedly due to a special tendency to take life. In these cases, however, a.s.sociated symptoms are never lacking. It is not improbable that in Jack the Ripper's case a s.e.xual element was present, because the victims were always of one low cla.s.s, and that the general character of the murderer would have revealed his irresponsibility. There are several stories of children--whose mothers delighted in seeing their husbands, who were butchers, slaughter animals--who seem to have had a veritable mania for seeing blood flow and to have exercised it in the murder of human beings.

Only the most careful examinations of the previous life of the patient, the investigation of childish tendencies and habits at school, and the incidents of boyhood and youth will sometimes enable the expert to recognise the constant existence of symptoms of mental disequilibration, the decided manifestation of which leads to serious events in after life. Monomania as a defense for crime has brought expert evidence into great disrepute. In this matter the greatest care is undoubtedly needed, however, for it is easy to do great wrong and punish the irresponsible victim of an impulse over which he has no proper control. On the other hand, it must not be forgotten that no such thing is known to exist as the perversion of the will on a single point. Moral insanity with regard to one special set of actions is a delusion that the {301} increase of knowledge with regard to mental diseases has erased from the text books on this subject.

_Responsibility of Paranoiacs_.--From what has been said it is easy to understand how difficult is the determination of the responsibility of paranoiacs. Many cla.s.ses of persons ordinarily considered to be quite responsible for their actions are yet so circ.u.mstanced that they are led into the performance of actions usually not considered rational, though not tempted thereto by any benefit directly accruing to themselves. On the contrary, it not infrequently happens that the mode of life adopted by the paranoiacs is of such a kind as would of itself, because of the hards.h.i.+ps involved or the mental trials, deter ordinary people from following it. Paranoia, at least in its severer forms, completely justifies the plea of irresponsibility for actions committed. When it is remembered, however, that paranoiacs are often cunning enough to take advantage of their own supposed queerness voluntarily to commit crimes they might otherwise be deterred from by fear of punishment, some idea of the difficulty of the decision in these cases may be appreciated.

It is important, of course, that the physician should, as far as possible, avoid falling into the error of judging such people too harshly, since after all on him depends the att.i.tude of society towards them. It would seem to be quite as important that the clergyman should occupy an advanced position in this matter. It might seem that charity could easily be overdone; it must never be forgotten, however, that it is better that ninety-nine guilty should escape rather than that one innocent person should be punished.

As a matter of fact, prejudice is much more likely to be against the supposed criminal than in his favour. While it is often declared that too many persons, who have done at least material wrong, are allowed to escape deserved punishment, as our knowledge of mental diseases increases there is more and more of a tendency on the part of experts to recognise that for many apparently voluntary actions men have only a modic.u.m of responsibility. Responsibility is, after all, not the same in all men, but modified very much by the character of the individual, by his environment and by the {302} motives which have come to be the well-springs of his actions. No two men are equal in their responsibility when there is question of certain temptations to do wrong. Some men find it perfectly easy to resist allurements to dishonesty which others can not resist. Some men are perfectly free as regards their att.i.tude towards indulgence in spirituous liquors.

Others find it almost impossible to resist their cravings in this direction. One might go through the list of pa.s.sionate actions and find this true with regard to every one of them. If this must be admitted with regard to men who are considered perfectly sane and responsible, how much more so does it become true of those who are already somewhat mentally unbalanced?

Unfortunately, the tendency to judge harshly, rather than mercifully, still continues to be one main reason for the infliction of punishment where often it is not deserved. Above all the clergyman must be a leader in this tendency to mercy, and his influence should be felt in popular education in this regard. It only too often happens that clergymen are found to be strenuous upholders of the opinion that right is simply right and wrong, wrong, and that a man who knows the difference between right and wrong must be considered as responsible for his actions, no matter what modifying circ.u.mstances or mental conditions may enter into the problem of the decision as to his responsibility. If the clergyman would but realise how difficult in any individual case must be such a decision, and how much must be known with regard to the previous character of the individual, then a great beginning for the modification of the present over-severe modes of thought will have been made.

From a theoretic standpoint, it would not be easy to state all that the physician considers necessary to enable him to make his decision as to individual responsibility. Perhaps, however, the consideration of a series of cases that have attracted widespread attention, and which have been most carefully investigated in all their circ.u.mstances, may present the methods of responsible determination better than any set of rules. Three presidents of the United States have been murdered within forty years. The murderers were native-born {303} Americans. In none of the three cases was there any adequate motive for the commission of the crime. The a.s.sa.s.sin in President Lincoln's case might, it is true, be presumed to have a sufficient political motive, but no entirely sane man could have thought for a moment that any good would be accomplished at that time for the South by the removal of Lincoln. A man of known erratic tendency, with the craving for theatrical effects deeply ingrained in his nature, with a personal history not entirely free from even more serious manifestations of mental disequilibration, and with a family history of more than suspicious character as regards the mental qualities of his ancestors, committed the crime. He met his death at the hands of pursuing soldiers. Such was the temper of the time, that had he been captured alive he would surely have suffered the formal legal death penalty. Even as it was, public sentiment clamoured for legal victims and unfortunately they were found.

It seems clear, beyond all doubt, that in this case complete responsibility for his action was not present in the a.s.sa.s.sin himself.

The courts decided later that there had been a conspiracy, but there has always been the feeling that justice was misled by over-zeal to find scapegoats for injured public sentiment. There is no doubt that it is an extremely difficult matter to say what shall be done to the a.s.sa.s.sin in such a case. The unfortunate result is as much an accident as the fatal consequences of any other perverted natural force. An earthquake may kill its thousands and the inevitable must simply be accepted. Society may protect itself from the further manifestations of such perverse individuals by confining the unfortunate murderer for life, but capital punishment, in the sense of a sanction for broken law, can scarcely be considered to have a place in the given conditions.

With regard to the murderer of our second a.s.sa.s.sinated President we had the farce of a long-drawn-out public trial of a man who was evidently not in his right senses. Once more a victim had to be found to satisfy injured public feeling. Guiteau was condemned to death and suffered the death penalty. Any one who reads the proceedings of the trial and who realises the significance of the motive that Guiteau {304} himself gave for his act, will appreciate that the court had to do with an irresponsible doer of a material but not a moral wrong.

There were many signs of mental disequilibration in Guiteau's previous career. It is on these eventually that the expert in mental diseases must depend in order to enable him to obtain a proper estimate of the extent of the mental disturbance in any given individual. It may seem that many real criminals can be defended on this same principle of finding an inadequate motive for their crimes. There are, however, certain signs of irrationality not difficult to detect if the previous life of the individual be carefully scrutinised and these must form the ultimate criterion as to criminal responsibility.

With regard to the third murderer of a President the case is clear. He was an ignorant, somewhat conceited individual, but he presented none of the signs of true mental disequilibration that can ordinarily be depended on to indicate such a disturbance of the physical basis of mind as impairs responsibility. He was not entirely without a motive, which in the mind of a brooding, conceited individual, might seem to be adequate for the commission of the crime. His sentence of the death penalty was then in accord with the judgment of the best mental experts. How society shall protect itself, and especially its high officials, against such notoriety seekers is hard to say.

The consideration of these cases gives a clear idea of how a physician endeavours to fill up gaps in his knowledge of the character of the man, his heredity and environment, as well as his previous actions at various times in life when under the stress of emotion. It may be considered that such a weighing of circ.u.mstances will serve to excuse many genuine criminals who eminently deserve to be punished. This is, however, the a.s.sumption of the older generation who considered that if a man did a material wrong he must be punished for it. It is a heritage of the day, when even accidental killing was considered to demand some punishment. At the present time the tendency is rather to consider only the moral wrong, that is, to calculate responsibility only for such actions as are committed with due {305} deliberation, intention, and the knowledge of right and wrong as well as the freedom to perform the action. The old English legal opinion which declared a man responsible if he knows that what he is doing is wrong has now given way in most judicial proceedings to the principle that the man must not only know that he is doing wrong, but that he must also realise that he is free not to do that which he knows to be wrong.

That is to say, if he feels himself compelled to the commission of crime, there is surely an impairment of responsibility. Such impulses to do wrong without adequate motive occur not infrequently among those whose mental condition is not perfectly normal, and this must always be taken into consideration in the ultimate decision as to their responsibility for their action.

JAMES J. WALSH.

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XXVII

SUICIDES

It is a very difficult problem at times to explain just how a suicide is due to mental alienation in a person whose intellectual powers appeared previously unimpaired, yet in most of the cases a knowledge of all the circ.u.mstances and of the individual himself would lead inevitably to this more charitable view. Most suicides are persons that have been recognised as paranoiacs and likely to do queer things for a long time beforehand. Indeed, some of the melancholic qualities on which the unfortunate impulse to self-murder depends are likely to have exhibited themselves in former generations. Not long since it was argued that the regular occurrence of a certain number of suicides every year--varying in various places, always on the increase, but evidently showing a definite relations.h.i.+p to certain local conditions --demonstrate that the human will is not free, since from a set of statistics one can foretell about how many cases of suicide would take place in a given city during the next year. As a matter of fact, suicides are not in possession of free will as a rule, but are the victims of circ.u.mstances and are unable to resist external influences.

The most important feature of suicide in recent years is the constant increase in the number, the increase affecting disproportionately young adults. This increase in the number of suicides is no illusion; it is not due to more careful statistics. It is true that in recent years, that is to say during the last quarter of a century particularly, the unsparing investigation by the authorities of all cases of suspicious death, and their report by sensational newspapers, has added somewhat to the apparent number of suicides. {307} Families were accustomed to announce accidental death and have their story unquestioned, in a certain number of cases, where now there is no hope of concealment because of the unfortunate publicity that has crept into life. This increase, however, would account for only a small additional number of suicides, while the actual figures have more than trebled in the last thirty years.

This increase has come especially in the large cities. According to the report of the New York Board of Health, there were 1,308 suicides in New York City during the decade from 1870 to 1880. During the decade from 1890 to 1900 there were 3,944 suicides. This increase is much more than the corresponding increase in population. During the first decade mentioned there were 124 suicides per million of population. During the last decade this had risen to 196 suicides per million. The increase is nearly 60 per centum. The increase is variously distributed over the different ages. While every five years from twenty upwards shows a percentage of increase in the number of suicides committed, somewhat less than the percentage of increase for all ages, the five years between fifteen and twenty shows an increase of 106 per centum. In a word the deaths of adolescents from suicide have more than doubled in the last thirty years.

Towards the end of the last decade of the nineteenth century there was for a time a cessation of the continuous increase. This occurred during the years 1898 and 1899. Apparently it was due to the fact that the occupation of the country with other interests, the war and its problems, and the fact that an era of prosperity made material conditions better, and thus gave less occasion for depression of spirits. During the years since 1900, however, the increase has not only rea.s.serted itself, but has more than made up for the period during which suicides were less frequent. The increase during the last four years is more than was noted during the six years from 1891 to 1897.

The same increase has been noted in European cities. The higher the scale of civilisation in a city, or at least the greater the material progress and the more strenuous the life, {308} the higher the death rate. In Dresden, for instance, the rate is 51 suicides per 100,000 every year. In Paris it is 42, in Berlin it is 36; while in Lisbon and Madrid it is lowest, being only respectively two and three per 100,000 per year. While suicides are more common among men than women in all countries, this is not true for certain ages. Between the ages of fifteen and twenty-five the suicides of women are more numerous than those of men. The suicides of women are increasing faster than those of men. Fifty years ago the proportion was five to one. Twenty years ago it had fallen from three to one. Now it is less than two and a half to one. The saddest feature of the suicide situation is the increasing number of the children who commit suicide.

Almost needless to say, children's suicides are without any serious motives and are usually due to an attack of pique because of a slight from a playmate, a reprimand at home, a rebuke from a teacher, envy of the success of a companion, disappointment over a pa.s.sing love affair, sometimes a peculiar attachment in the case of weak and morbid individuals, the manifestations of which are resented by its object, or are forbidden by parents and guardians. These unfortunate accidents have become so common now that special care must be taken with regard to children of neurotic heredity. When in previous generations there have been the manifestations of lack of mental equilibrium, then children's mutterings with regard to possible recourse to suicide should be the signal for the exercise of close surveillance. As far as possible such children should be kept from the strenuous compet.i.tion at school in modern life.

As has been well pointed out there is no doubt that the power of suggestion and example has much to do with the increase of suicide.

Dymond, an authority in the matter, says, "The power of the example of the suicide is much greater than has been thought. Every act of suicide tacitly conveys the sanction of one more judgment in its favour. Frequency of repet.i.tion diminishes the sensation of abhorrence and makes succeeding sufferers, even of less degree, resort to it with less reluctance."

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Our modern newspapers, by supplying all the details of every suicide that occurs, especially if it presents any criminally interesting features or morbidly sentimental accessories, familiarise the mind, particularly of the impressionable young, with the idea of suicide.

When troubles come lack of experience in life makes the youthful mind forecast a future of hopeless suffering. Love episodes are responsible for most of the suicides in the young, while sickness and physical ills are the causes in the old. In a certain number of cases, however, domestic quarrels, and especially the infliction of punishment on the young at an age when they are beginning to feel their independence and their right to be delivered from what they are p.r.o.ne to consider restriction, are apt to be followed in the morbidly unstable by thoughts of suicide.

The important practical question is the prevention of the fulfilment of the morbid impulse during these impressionable years. Many a young person has been saved from suicide at this time to realise the enormity of the act and to live without any further temptation to its commission for a long lifetime. As a rule the motive for the act is so trivial and often so insensate that it is not difficult to make patients (because patients they truly are) see the folly of their irrational impulse.

In order to forestall the putting into action of their impulse it is important that those who are close to the patient should have some realisation of the possibility of its occurrence. There are usually some signs beforehand of the possibility of the crime. Many of these early suicides have distinct tendencies to and stigmata of hebephrenic melancholia. The best known symptoms of this condition are those described by Dr. Peterson, the present president of State Commission of Lunacy of New York in his book on mental diseases. The symptoms noted are extraordinarily rapid and paradoxical changes of disposition. Depressed ideas intrude themselves in the midst of boisterous gaiety, and untimely jocularity in the deepest depression, or at solemn moments. Then there is the paradoxical facial expression, the so-called paramimia, that is, a look of joy and pleasure when really mental depression is present, or a look of depression when joyful sentiments {310} are being expressed. The existence of such rather noticeable peculiarities may lead to the suspicion of mental disequilibration in young people.

The most important warning may well be the occurrence of suicide in any other member of the family for several generations before. The tendency of suicide to repeat itself in families is now well known and recognised. During the year 1901 in New York City, in one case other members of the immediate family had committed suicide in six instances. The subject has taken on additional interest because of the suicide of a well-known gambler who was the fourth of his family in two generations to take his own life. In another case, reported within the last five years, the suicide was the last of a family of nine children, every one of whom had committed suicide. There is the record in the German army of four generations of a n.o.ble family, the eldest son of which committed suicide during the 5 years from 50 to 55.

In these cases the tendency to suicide is not directly inherited, but there is a mental weakness that makes the individual incapable of withstanding the sufferings life may entail. In the later members of the family there is also a suggestibility that the frequent contemplation of the idea of suicide finally leads to the putting off of the natural abhorrence at the thought of its commission. In such families, therefore, it is particularly important to warn medical attendants and members of the family of the possibilities of unfortunate acts so as to prevent if possible the execution of any impulse to self-murder.

JAMES J. WALSH.

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XXVIII

VENEREAL DISEASES AND MARRIAGE

Syphilis is a disease that is contagious, inoculable, and transmissible by heredity. It may be acquired innocently, and it is so acquired in about 4 per centum of cases according to good authority, but the other 96 per centum is venereal. The disease attacks any part of the body within and without from the soles of the feet to the hair and finger-nails. The first evidence, where the case is not hereditary, is a hardened sore called a chancre; next the lymphatic glands swell, and many forms of skin-eruption occur; then follows a chronic inflammation of the cellulo-vascular tissues and the bones, and small tumours, called gummata, may develop in almost any part of the body. The disease may vary from a light attack to malignancy.

There are periods in the course of the disease.