Essays In Pastoral Medicine Part 25

This is an aspect of criminology with which the Christian clergyman can be in sympathy, and that does not smack of the utter materialism which was at the foundation of much of the discussion of the so-called criminal type. The {281} recognition of moral perversion as a form of insanity requiring treatment and then constant observation for many years, just as in the case of mental disequilibration would be a distinct advance over our present crude methods of dealing with criminals.

JAMES J. WALSH.

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XXVI

PARANOIA, A STUDY IN CRANKS

Of late years the crank, in the various forms in which he or she may occur, has became a subject of great popular as well as scientific interest. As a matter of fact, the queernesses of people are a more absorbing study to the neurologists and psychologists than are any forms of insanity. It not infrequently happens that individuals of peculiar tendencies are p.r.o.ne to have special affinity for religious ideas, and strange applications of Christian formulae of thought. Even when they do not become absolutely insane in their religiosity, they may often go to extremes. It must be remembered, too, that some cranks are mentally affected in but mild form, and it may be difficult to determine whether their oddity is really the result of a certain amount of mental torsion, or merely intellectual tension.

Such persons are more likely to be brought in close contact with their pastors and other clergymen and with religious Superiors of various kinds than even normal individuals. They often put their confessors, particularly, in serious quandaries in the matter of spiritual advice.

A review, then, of the accepted ideas of experts with regard to such people is likely to be of special service to those who would understand these cases as well as possible, though the present state of medical knowledge, here as elsewhere, leaves much to be desired.

A distinguished authority in mental diseases once said, half in jest though he meant it to be taken at least half in earnest, that a great many more of us are cracked than are usually thought to be, only that most of us succeed in concealing the crack quite well. The frequency of the crank adds to the {283} interest of his study, which is by no means a department of medical science of recent growth. While interest in this cla.s.s of persons has become much more intense in recent years, eccentric individuals have been an object of close observation and of serious study almost as far back as history goes. When Quintilian said that genius was not far separated from insanity, he meant to record the conclusion of his time, that men of genius are apt to seem inexplicable in their ways to those who come closely in contact with them. Eccentric persons, however, are by no means always undesirable members of a generation. It has been noted by historians in all ages that to the refusal of eccentric individuals,--often thought at the beginning, particularly, to be little better than insane--to accept the traditions of the past, we owe many of the privileges which we enjoy at the present time. Their refusal to think along old lines of thought often makes them valuable pioneers in progress.

Definite knowledge with regard to the pathological basis of crankism, or eccentricities, has not yet been obtained. What has been learned, however, has enabled the neurologist to distinguish various forms of mental perturbation, to recognise the probable influence of certain conditions and environments on the future action of eccentric individuals, and to foretell the probable outcome of the cases. All of this information is of very practical importance to religious Superiors and others in positions of religious confidence, who are sure to be brought, even more than the rest of the community, in contact with the eccentric cla.s.s. It has seemed advisable, then, to condense some of the recent knowledge on this subject into popular form for the use of confessors, spiritual directors, and those in religious authority.

How recently medical knowledge on this important subject has developed along strictly scientific lines may perhaps best be appreciated from the fact that Professor Mendel of Berlin, to whom we owe the term _paranoia_, the recognised scientific designation for crankism, is yet alive and continuing his lectures on neurology at the great German university. The term, from the Greek word [Greek text], meaning alongside of, and {284} [Greek text], mind, expresses the fact that the mental faculties of individuals designated by it are beside themselves, that is, the mental powers are not entirely under the control of the individual, so that they only come near voluntary intellection in its highest sense. In a word, the term contains a series of expressive innuendos by its etymological derivation.

Professor Berkley of Johns Hopkins University says that the word paranoia was first adapted by Mendel from the writings of Plato, to indicate an especial form of mental disease occurring in individuals capable of considerable education, at times of brilliant acquirements, yet possessing a mental twist that makes them a cla.s.s apart from the great ma.s.s of humanity.

Professor Peterson, the President of the New York State Commission of Lunacy, gives a very good definition of the condition which, though couched in somewhat technical terms, furnishes the most definite idea of the essential properties of paranoia. He says: "Paranoia may be defined as a progressive psychosis founded on a hereditary basis, characterised by an early hypochondriacal stage, followed by a stage of systematisation of delusions of persecution, which are later transformed into systematised illusions of grandeur." He continues: "Though hallucinations, especially of hearing, are often present, the cardinal symptom is the elabourate system of fixed delusion."

In a word, the paranoiac is a crank usually descended from more or less cranky ancestors, with an overweening interest in his health to begin with, who later develops the idea that many people are trying to do him harm, or at least to prevent his rise in the world, and who finally becomes possessed of the notion that he is "somebody," even though those around him refuse to acknowledge it and pay very little attention to the claim. Such people not infrequently hear things that are not said. That is, not only do they hear the voices of the dead, of spirits good and evil, but also the voices of living persons, who are at a distance from them and sometimes even when those living persons are present, but have said absolutely nothing. These delusions of hearing, however, are not so important as the self-deception forced upon them by their {285} mental state with regard to their importance in the world and their relations to other people.

The most significant consideration with regard to paranoia is the fact that it is practically always hereditary. Krafft-Ebing said that he never saw a case of true and reasonably well developed paranoia without hereditary taint. This does not imply, of course, that the same symptom of delusions exists in several generations, but some serious mental peculiarity is always found to exist in the preceding generation. Other authorities are not quite so sweeping in their a.s.sertion of heredity for these cases, though practically all are agreed that in over 80 per centum of the cases, some hereditary element can be traced without overstretching the details of family history that are given.

Paranoia occurs a little more commonly in females than in males. As it is of hereditary origin, it is not surprising to find that the peculiarities are noticed very early in life, though they may not be sufficiently emphasised to attract the attention of any but acute observers, who are brought closely in contact with the patients. Even in childhood, patients who subsequently develop serious forms of paranoia, usually have been shy, backward, inclined not to play readily, irritable, peculiar, precocious, p.r.o.ne to spend much time in study at an age when they ought to be interested mainly in sports, and they are generally old beyond their years. A typical example of this was Friederich Nietzsche, the German philosopher, who died a few years ago in an insane asylum.

Olla Hanssen, Nietzsche's biographer, who carefully collected the family accounts of the philosopher's childhood, said that he did not talk until much later in childhood than is usual. "As a boy he was retiring and solitary in his habits. During his school days he was always interested in books not in sports, in lonely walks not in young companions." A history of this kind will be found in the early career of many queer folk. Very often these old-fashioned traits are a source of pleasure to parents and sometimes even to teachers. During childhood, however, the sports of childhood should satisfy the child, and abnormalities of interest in things outside of childhood's sphere are always suspicious. The growing {286} organism needs, first of all, muscular exercise, and after that the freedom of mind that comes with spontaneous play. It may be said, in pa.s.sing, that the walk of a city child with its maid, when even the child's choice in the matter of where it shall walk is not consulted and the maid's will is constantly imposed, is the worst possible training for spontaneous action or volition in later life.

In the cases that develop early in life it will practically always be found that infantile cerebral disorders of some kind are a prominent feature of the history. The mother's delivery was difficult perhaps, and the child was for some time after birth unconscious, or infantile convulsions occurred. It may be remarked here that a history of convulsions in childhood is now considered by physicians as of serious import for the future nervous and mental life of the child. It has recently been announced, for instance, that so-called idiopathic epilepsy,--that is, epilepsy without some directly immediate cause,--very seldom develops later in life in persons who have not had in childhood convulsive seizures as the result of some extreme irritation. This does not imply that every child that has convulsions will suffer from some serious nervous or mental condition later; but every child whose mental and nervous equilibrium is not stable, because of hereditary elements of weakness, will almost certainly suffer. Injuries to the head in childhood are nearly of as great importance as the actual occurrence of convulsions.

There are usually three stages of paranoia described by authorities in mental diseases. These have been called the prodromal or initial period, which is also, because of the set of symptoms usually most prominent in it, often called the hypochondriacal stage of the disease. The patient occupies himself with his feelings and his sensations. He is concerned very much about the state of his health and is p.r.o.ne to think himself affected by diseases that he reads about or hears described. This set of symptoms, by itself alone, is not an index of enduring mental disturbance, but may be only a manifestation of a pa.s.sing mental perturbation in sympathy with some slight physical ailment. This state may indeed be nothing more than the result of too persistent introspection. {287} Most medical students suffer from a certain amount of hypochondria during their early acquisition of a knowledge of the symptoms of disease.

In the true hypochondriac, however, every bodily sensation, or as it is technically called, somaesthetic sensation, is translated to mean a significant symptom of serious disease. A slight feeling of fatigue becomes to the patient's mind the "tired feeling" of a dangerous const.i.tutional disorder. Any peculiar feeling, such as that of the hand or foot going to sleep, is set down at once as a symptom of a serious nervous disease, or if the patient has heard that in old people numbness of the extremities is a forerunner of apoplexy, he is sure to conclude that apoplexy is threatening in his own case.

Subjective sensations of heat and cold set him to taking his temperature and his pulse, and even slight variations in these are magnified into important physical signs of disease.

Very often such slight symptoms as pa.s.sing lapses of memory are magnified into approaching complete failure of memory, and la.s.situde becomes a permanent loss of will power, evidently due to disease in the patient's mind, and there begins the persuasion that nothing can overcome it. Morbid introspection becomes, after a time, the favourite occupation, and every slightest sensation or feeling sets up trains of thought that lead to far-reaching conclusions with regard to physical weakness. The patient is apt to be greatly preoccupied with himself, to neglect his duty towards others, to be utterly selfish, to fail to realise how much sympathy is being wasted on him.

Some people never pa.s.s beyond this preliminary stage of the mental disorder. Usually, however, after a time the patient misinterprets not only his own sensations, but the actions of other people in his regard; he becomes suspicious and distrustful of everybody around him, sometimes even of his best friends. He is pa.s.sing on to the second stage of the disease, in which he is sure to feel that he is the object of persecution. Just as he misunderstood his physical symptoms, so he misconstrues the actions of his friends. He is sure that they look at him curiously, that they smile {288} ironically. Sometimes he thinks that they wink at one another with regard to him, or make signs behind his back that are meant to be derisive. Even harmless pa.s.sing observations may be morbidly perverted into severe and inimical criticism of himself and his actions.

The paranoiac is now apt to enter fully upon the second or persecutory stage of his mental disorder. His distress and discomfort he attributes to those around him and he is sure that he is the subject of persecution. At first his persecutors are not very definitely recognised. No particular person is picked out and even no particular set of persons. There is just a vague sense of persecution. A distinguished neurologist once said that no sane person in this world, outside of a novel or a play, has time to make it his business to persecute anyone else. When people come, then, with stories of persecution, either they themselves are not in their right mind and are deluded as to the source of the persecution, or else their persecutor is not in his right mind and the case needs seeing to from the other standpoint.

After a time, longer or shorter in individual cases, the paranoiac begins to recognise definitely who his persecutors are. As a rule, it is not some single individual, but a combination of individuals.

Already there is the beginning of the third state of the disease--the grandiose stage of the disease, in which the patient feels an extreme sense of his own importance. It would be derogatory to his self conceit to consider himself the subject of persecution by an individual, and so it is usually some society, or the government, or its officials, or some secret organisation that is persecuting him, and perhaps also persecuting those who are near and dear to him.

Sometimes it is the Odd Fellows, or perhaps the Masons, who are the persecutors. If the newspapers have recently had some account of the disappearance of Morgan years ago, and this subject crops up periodically in the papers, then the Masons become a favourite subject for paranoiacs' delusions of persecutions. Just after the Cronin murder in Chicago, the Clan-na-Gael became an extremely fearsome spectre for paranoiacs who thought themselves persecuted. It is of some {289} importance to know, as a rule, what the usual reading matter of a patient is, and what things are likely in his past history to have impressed him, in order to realise what the real source of his delusions of persecutions are.

It is curious how rational these patients may be on all other subjects except the special topic of their delusion. During the past year a paranoiac has been under observation, who is considered a reasonably rational individual by those who know him well, who follows his daily occupation, that of clerk, without intermission and with business ability, who is a faithful attendant at church, and who is very kind to his family, but who is sure that he is the subject of persecution by the Clan-na-Gael. He never belonged to the organisation. He is not able to give any good reason why he should be persecuted, except perhaps the fact that, though an Irishman, he never did belong to them. He is perfectly sure, however, that they are planning to poison him and his family. He finds peculiar tastes in the tea and the coffee at times. He throws out these materials and insists on his wife getting others at another grocery store. He sometimes brings groceries home from a distance and yet finds that if he ever buys materials a second time in the same place, they are sure to have been tampered with in the meantime by emissaries of this secret organisation. He feels sure that he has seen these secret agents, but he is only able to give vague descriptions. Not a little of the prejudice against these organisations is really founded on such morbid suspicions.

Another form that the idea of persecution sometimes takes, in this second stage, is the delusion that the patient is neglected by those who should specially care for him or her. A woman insists that she is neglected by her husband. She may become intensely jealous of him and make life extremely miserable for him without there being any good reason for her jealousy. These cases are not nearly so rare as might be thought. On the other hand, men suspect their wives of unfaithfulness. This suspicion may go to very serious lengths in persecution at home, though the man all the time keeps his suspicions to himself, in order not to make a laughing stock of himself outside of the house. It is this curious mixture of {290} rationality and delusion that is the characteristic feature of the disease. It is for this reason that these conditions were sometimes called monomanias, as if patients were really disturbed only on one point. As a matter of fact, however, patients are mentally wrong on a number of points, though there is some one mental aberration so much more prominent than other peculiarities that it overshadows the others.

It is not long after the persecutory stage sets in before patients are apt to become themselves persecutors of others as a result of their belief that they are being persecuted. The French have a suggestive expression for this. It is _persecutes persecuteurs_, that is to say, "persecuted persecutors,"--patients who are trying to repay supposed persecutors by persecution on their own part. Such patients, of course, very easily become dangerous. They need to be carefully watched. As a rule, the persons whom they are p.r.o.ne to select as the persecutors upon whom they must avenge themselves are absolutely innocent parties. At times they are even dear and well meaning friends.

After the persecutory stage in paranoia, comes the third, or so-called expansive period of the disease. It has been remarked that sometimes this develops as a sort of logical sequence from the patient's ideas of persecution. If he has too many enemies and if important secret organisations are trying to be rid of him, he must be a person of some importance. As a consequence he evolves for himself a royal or aristocratic descent, or hints that he is the unacknowledged son of great personages. In a kingdom royalty is, of course, a dominant idea.

In a republic like our own, he may consider himself to be the President or the politician to whom the President owes his office.

_Paranoia Religiosa_.--Not infrequently the first hint of their supposed greatness comes to such patients suddenly in a dream or in a vision; when their expansiveness takes a religious turn, this is especially apt to be the case. They may believe themselves to be especially chosen by the Almighty, a new Messiah or even Christ Himself, come once more to earth. Such people may retain much of their rationality on most of the points relating to practical life, and yet have this {291} hallucination as to their close relationship with the divinity. Not only may they retain their mental equilibrium on other points, but they may even give decided manifestations of great genius.

This is, I suppose, one of the most interesting features of this form of mental disease, but it is well ill.u.s.trated in the lives of many modern founders of religious sects, even in our own generation.

Such religious reformers as Mahomet and Swedenborg seem undoubtedly to have been afflicted with this third stage of expansive paranoia. In our own day there is no doubt that many of the founders of new religious sects, many of the heaven-sent apostles or reincarnations of patriarchs and prophets, the miraculous healers and the like, are afflicted in this same way. It is useless and entirely contrary to the known facts to put such people aside as mere imposters. Imposters they are, but they have imposed on themselves as well as on their followers. They are sincere as far as they go, and the mental twist that gives them their power has occurred in the midst of the manifestation of the intellectual faculties of a highly practical character and of executive ability, with wonderful capacity for the direction of complex affairs. A prominent neurologist said, not long ago, that the most interesting feature of Christian Science is to contemplate in the study of the movement how near people may come to insanity and yet retain their faculty to make and handle money and even acc.u.mulate fortunes.

_Paranoia Erotica_.--After the _paranoia religiosa_, the most common form of the disease is the _paranoia erotica_. There are authorities in mental diseases who do not hesitate to say that an excess of religiosity and of erotic sentimentality are more or less interchangeable. This declaration represents, however, the unconscious exaggeration of a mind unsympathetic towards religious ideas. But it must not be lost sight of that the two forms of excesses, erotic and religious, are more nearly related than would be ordinarily supposed, and that erotic manifestations may be confidently looked for in patients who have been afflicted by a too highly wrought religious sentimentality. St. Theresa seems to have realised this very well and has touched on the subject in one of her letters.

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Ordinarily erotic paranoia manifests itself by the patient imagining himself or herself to be beloved by some one of superior station. This love is of rather a platonic character and the "lover" cranks are p.r.o.ne to pick out as the object of their attention and annoyance some young woman rather prominently in the public eye, but whose reputation is of the very highest. Mary Anderson was the subject of a good deal of this sort of persecution. At the present moment the well and favourably known daughter of a great millionaire is the subject of many such attentions.

These paranoiacs are apt to become dangerous if they are prevented from paying what they consider suitable attention to the object of their affection. In hospitals they have to be carefully watched, and more than one accident has taken place as the result of relaxation of vigilance on the part of their attendants. If kept from the object of his affection, delusions of persecution become prominent in the amorous paranoiac, and he may become a persecutor in turn and thus a dangerous lunatic. He can not be made to understand that the sending of flowers and photographs and letters is entirely distasteful to the chosen one. Fortunately, after a time, in many of these cases, a state of dementia sets in, and then the patients become mild-mannered imbeciles whom it is not at all difficult to manage.

As a rule where the patient has pa.s.sed through the various stages of paranoia, dementia, with symptoms of imbecility, closes the scene. The paranoia may not always follow the course mapped out for it. Stages may be skipped, several forms of delusions may become prominent in the life of the individual at about the same time. The main feature of the disease is its progressive character, and its diagnosis depends on the queerness exhibited all during the course of life, as well as on the presence of hereditary neurotic influences.

_Special Forms of Paranoia_.--There are besides the two types described a number of special forms of paranoia, some of which aroused attention first under the form of monomanias, that seem to merit brief treatment by themselves. In their extreme forms they are easy of recognition. Milder types, however, may easily escape cla.s.sification under the {293} head of paranoia, because they are considered to be individual oddities and not due to any physical or mental incapacity.

Undoubtedly, however, the study of these peculiar "types," as the French call them, from the standard of the alienist or expert in mental diseases, will serve to make clearer the real significance of many otherwise almost unaccountable actions. There is no doubt, that the consideration of these eccentrics as paranoiacs makes the charitable judgment of many of their acts much easier, and at the same time is of service in managing them. They are likely to be of much less harm to the community and to their friends, when it is realised that they are not to be taken too seriously, but that, on the contrary, there is ample justification for a benevolent combination of interests to keep them from injuring themselves and their friends.

_Paranoia Querulans_.--One of the most important and familiar forms of the special types of paranoia is what is known scientifically _paranoia querulans_, that is, the peculiarity of those who insist on going to law whenever there is the slightest pretext. It is pretty generally recognised that a goodly proportion of the civil suits that crowd our law courts are due to the peculiarities of these people who insist on having their rights, or what they think their rights, vindicated for them by a court of justice. There are very peculiar characters in this line, some of whom make themselves very much feared and detested by their neighbours. There are some individuals to whom the slightest injury or show of injury means an immediate appeal to the law.

Not infrequently these patients, for such they are in the highest sense of that word, waste their own substance and even the means of support of wife and children, on their foolish law schemes. When their queerness reaches a certain excessive degree its pathological character is readily recognised. In a less degree _paranoia querulans_ may be a source of very serious discomfort to friends and neighbours without exciting a suspicion of its basis in mental abnormality. Not infrequently such patients become more irrational at times when their physical condition is lower than normal, and a return to their ordinary health makes them {294} more amenable to reason and less p.r.o.ne to appeal to expensive litigation.

It is evident that the irrationality of frequent appeals to expensive and bothersome litigation should arouse suspicion. Such patients need to be cared for quite as effectually as those who have tendencies to gamble away their substance or to waste it in the midst of inebriety.

Unfortunately it is extremely difficult to frame laws so as to meet such conditions. Severer forms of the affliction are readily recognised and the sufferer is properly restrained. I remember once seeing a patient in Professor Flechsig's clinic in Leipzig, who had been sent to the asylum because of his tendency to go to law on the smallest possible pretext. This patient's incarceration in the asylum was due to a very striking manifestation of his _paranoia querulans_.

He answered an advertis.e.m.e.nt for a clerk, published by one of the large commercial houses. He found himself one of a row of applicants for the position, and as the member of the firm whose duty it was to engage the clerk was at the moment busy, he had to wait several hours before his application was heard and refused. He tried to secure a warrant for the firm in order to have them indemnify him for the time he had spent while waiting for his application to be heard, at the rate of wages they would have been bound to pay him had he obtained the vacant clerkship; only as they had spoiled a day he claimed a full day's wages.

This patient had been in the asylum several times before because of his tendency to go to law. He always gained in weight while in the asylum, became much more tractable and less querulous as his physical condition improved, and usually after some months could be allowed to leave the inst.i.tution. He was, however, one of the inept. With the help of asylum influence he usually obtained some occupation more or less suitable, but was not able to retain it for long. When out of a situation he worried about himself, usually did not take proper food, and then soon his litigious peculiarities began to manifest themselves once more in such form that if he could get the money to retain an attorney, or if he could persuade one to take his case on a contingent fee, and he was very ingenious at this, he soon became a veritable nuisance to {295} those around him. When in poor health he was never contented unless he had at least one lawsuit on his hands, and only really happy when he had several.

_The Gambler Paranoiac_.--A form of paranoia that inflicts almost more of human suffering on the friends of the patient than any other is that in which the sufferer is possessed of the idea that he can, by luck or by ingenious combinations, succeed in winning money at gambling. Milder forms of this paranoia are so common that it is the custom not to think of even the severer forms of the gambling mania as a manifestation of irrational mentality. When a man thinks, however, that he can beat a gambler at his own game, or when by long lucubration he comes to the conclusion that he has invented a system by which he can beat a roulette wheel, he is, on this subject at least, as little responsible as the man who thinks that he has discovered perpetual motion.

This form of paranoia inflicts suffering mainly on the near relatives of the patient. There is no doubt that when extreme manifestation of the gambling mania becomes evident, patients should be legally restrained from further foolishness. One difficulty with regard to the proper appreciation of gambling has been an unfortunate tendency to cla.s.s gambling among the malicious actions. There are many people for whom only two sins seem to have any special importance, drunkenness and gambling. As a rule, there is not the least spirit of malice in the ordinary gambler; not meaning, of course, by this the sharpers, who try to make money at the expense of others, but the man who believes that, somehow, chance and fate are going to conspire to enrich him at the expense of others, though it must be confessed that he does not usually even think of this latter part of the proposition which he accepts so readily.

We have had in recent times so many manifestations of the practical universality of the gambling spirit, the belief by people that brokers and banking concerns are ready to make them rich quick, that we have in it perhaps the best ill.u.s.tration of the partial truth of the proposition that "half the world is off, and the other half not quite on."

_The "Phobias."_--Sometimes the special form of queerness {296} takes on a very harmless aspect. Patients are worried because of the fact that they can not keep themselves clean. They want to wash their hands every time they touch any object that has been handled by others, whether that object seems to be specially dirty or not. Such patients may wear the skin off their hands washing them forty or fifty times a day. They almost absolutely refuse to touch a door-k.n.o.b, because it is handled by so many people. They will consent to take only perfectly new bills. It is almost amusing to see the efforts they make to avoid shaking hands with people, without giving direct offense. When it comes to shaking hands with their physician, they are apt candidly to declare that he must not ask them to do so, because they can not overcome their feelings as to the possibility of contamination from hands that come in contact with so many patients. This fear of dirt has received the name Misophobia.

There are a number of other "phobias," and the patient's fears are manifested at the most peculiar objects. Agoraphobia, for instance, is the fear of crossing an open place. These patients begin to tremble as soon as they get away from the line of buildings in a street, in their way across the square. This trembling becomes actual staggering, with a sense of oppression over the heart that makes locomotion almost or quite impossible. Claustrophobia, the opposite of Agoraphobia, is the fear of narrow places, and prevents some people from going through a narrow street with high buildings. Many of these "phobias" have a physical basis in some organic or nervous heart affection.