by Mark Stevens
We appreciate that classification is impossible beyond a simple statement of your symptoms. Insanity is a most peculiar state and defies attempts to contain it within one label or another. Modern alienists recognise this, and your diagnosis will present you only as experiencing one of a few, widely accepted conditions. The greater proportion of patients – as many as eight in every ten – will usually be considered to have mania or dementia, while of the remainder, around half are considered melancholic. These are the principal diagnoses of lunacy, though others are available.
A smaller sub-group of our patients are not really lunatics at all: these are the mentally defective, the idiots and imbeciles who were born lacking part of their mental capacities. Members of all these groups can be found on any one ward.
Mania
The poor wretch raving, oblivious in his madness, is a traditional representation of insanity. Acute mania is easy for the layman to understand, for it acts as a shaft of moonlight directly illuminating the lunatic from his saner cousins. The behaviour associated with mania is distinctive, and the disease brings with it a passion that is uncontrollable and prolonged.
Many sufferers of mania will barely sleep, unable to rest long enough for darkness to quell the turbulence within their minds; while conscious, they tend to speak franticly, spewing out words and making wild gestures almost without cease. Their torrent of ideas, noise or actions informs the physician of his patient’s state. Language may be fanciful, foul or free-flowing; words flee from the pen; bedding or clothing may be ripped and cast aside. The manic tirelessly seek satisfaction, yet can find none. No imposter would try to fake acute mania for they would exhaust themselves in the attempt.
This state of excitement chiefly characterises the disease. Amongst our patients is E.B., 34, who is suffering from an acute attack of mania. She is a recently-widowed housewife with three young children, and was brought in after trying to commit suicide, first by biting herself and then by banging her head against the wall of the workhouse ward. She talks constantly, throws herself about and tears at any fabric within reach.
Sometimes an acute attack of mania can be deduced very promptly. A quickened pulse may be used as evidence for its arrival, while often the appetite is increased. Once mania has settled and become chronic, then the symptoms of an acute attack are joined by others peculiar to each case. J.T., a 29-year-old schoolteacher has been suffering from mania for over five years. On the ward you will find him talking incoherently to himself and making incessant gestures. His bowels are uncontrolled and he is liable to break things in the day-room. He has also developed a voracious appetite for grass and, more worryingly, coal, and if left to himself outside he will forage for either delicacy. We have found that he becomes calm only when listening to music or singing.
There is no guarantee that delusions may be present in mania for, though you may be restless, your mind is not necessarily distorted. You may dance, or sing, or fight in a futile attempt to dissolve your energies, rather than because you are hearing music or because imaginary devils are upon you. Nevertheless, the result for sufferers is the same level of disorientation as may be experienced by a delusion. At the extremity of mania there is some connection with acute melancholia, and it is not uncommon for the physician to determine a patient as manic with melancholic tendencies, or the reverse. Suicidal patients are often considered to be suffering from mania, even if they are in a melancholic phase. The other disease associated with mania is the general paralysis of the insane (further discussed below), which may include a manic phase during its progression. A paralytic maniac will calm down within a month or so of onset; the illness of the true maniac will continue far beyond such a point.
Mania may take other forms that stop short of such extravagant behaviour, and in this modern age diagnosis is subject to a process of constant refinement and distinction. We now recognise mania regarding a particular aspect of normal functions and urges: insanitary habits, such as the consumption of faeces or urine; an inappropriate libido; gorging on food or vomiting. Similarly, compulsions considered morally wrong may find themselves described as manic if the individual is consumed by them and unable to stop their behaviour: compulsive thieving, fire-starting or erotic tendencies are all sub-classes of the disease. Observation will allow us to conclude whether such appetites and perversions have become indecorous.
In a significant minority of cases mania is found to be relapsing but recurrent. Many patients have left asylum care as rational men and women and contentedly rejoined their previous lives, only for another attack to occur, followed by the inevitable return journey to the asylum. Hysteria is a prime example of such cases, where a female crisis can quickly bring about a new onslaught of disease. J.B., a middle-aged field-worker has had many attacks of mania during the past ten years. When she is unwell, she sleeps barely an hour at night in the dormitory, while she shouts continuously during the day. When she is better, she is able to work on her ward or in the laundry; but these periods of good health never last long. For patients like this, the wide range of potentially exciting causes render it very difficult to predict with any certainty whether a temporary recovery will become permanent. All too often, respite is brief.
Eventually, the maniac is so exhausted that few vestiges of the self remain. In this, the raving madman differs from the sufferer whose mania takes on more subtle forms. These subtleties are often assigned to the epithet of monomania, and we will discuss them under that name.
Dementia
The concept of dementia is equally easy to understand: it is one of loss. The capacity that once existed for rational thought is now compromised in some way. Unlike an idiot or imbecile, who has never enjoyed that capacity, the sufferer of dementia is able to feel the lack of the facility they formerly had. Thus the demented may act as an infant in knowledge, actions or responses but they are most certainly adult, and once operated in an adult form.
Sometimes sufferers from dementia are aware of the advance of their condition. The disease can be slow to take hold, progressing gently over a number of years. The patient may experience occasional forgetfulness or incoherence for long periods before it becomes a noticeable problem. The unfortunate sufferer is then able to appreciate their descent into the slough of nature’s vacuum. Once the disease has fully taken hold, patients will forget even such details as their own names and how to care for themselves; they seem increasingly dreamlike and distracted. They have regressed to a state of nativity, though lacking the purpose of enquiry that is found in the young. Often patients relive their own childhood emotions, so that the contented child becomes a placid and friendly patient; while one who experienced unhappiness may find their adult mind becoming filled with anger.
On our male side there are dementia sufferers such as J.N., aged 61, who was a general labourer in his previous life. Now he does not know where he is, or what year we are in. He knows that he has children, but he no longer believes they are his. Instead he paces the ward anxiously, convinced that he has committed a crime and asking the staff whether he is to be hanged. On the female side you may meet S.J.A., 52, who worked as a dressmaker and for many years cared for her elderly mother alone. She recently attempted to strangle herself with a bandage and was removed here. Prior to that point, she had suddenly begun to neglect her household chores, to collect rubbish from the streets and to fill her cupboards with it. Here, her loss of memory has become apparent; she takes no notice of life on the ward, and struggles to find answers to questions put to her.
We will always probe for symptoms such as these, and it has long been held that the use of numbers and letters can assist in diagnosing cases of dementia. Should we fear that you may be suffering from the condition, we may ask you questions based on the recognition of numbers, or whether you can write a simple sentence. Such abstract questions draw out the loss of memory in the dementia patient.
Sadly, some demented persons suffer from disagreeable symptoms. Many patients forget how to care for themsel
ves or to perform the most basic routines of hygiene, while the disease is also attended by a general relaxation of the muscles. Patients lose control of their bladder or bowels, or become prone to the vices of masturbation and exhibitionism. As a result, dementia patients usually require a higher degree of care than other lunatics.
In some cases of dementia affecting younger persons it is not memory but judgement that is impaired. The enfeeblement of the intellect wears down the patient’s understanding of what is real and what is imagined. Delusions are present though without the extreme agitation associated with mania. These cases are often found to have their origin in a particular event of happiness or sorrow, which can be recounted with unusual clarity by the patient. J.H., for example, is an ex-soldier whose disease came on when he was 33 years of age. He says that during his service he was put into a black hole together with a roaring lion. Throughout his time here he has become increasingly still and silent. At first he would do a little scrubbing in the wards, though he complained at night that a great snake was placed in the bed beside him. Now he is listless and vacant. He sits all day, performing imaginary actions, picking things up from the floor, the table or the air and then eating them. He is prone to wet himself or soil his clothing and must be washed regularly.
Dementia such as this is sometimes perceived to follow either mania or melancholia, and a firm diagnosis may not be made for some months, until an acute attack of the other symptoms has subsided.
Melancholia
Melancholia was, for many years, seen as the twin of mania. It shares a similar emotional intensity to the latter condition, though rather than inspiring excessive gaiety and energy, melancholia gifts its victims only despondency, sloth and fear. A sufferer may become withdrawn and unable to cope with life; they may seek solitude or even their own destruction. Essentially, not only are they cheerless in mind but the mind itself is consumed intently with the fact of its own cheerlessness; melancholia is, therefore, as exhausting a disease as mania.
It has often been theorised that melancholia stems solely from the moral causes of insanity: that grief, anxieties and reverses of fortune are the trigger. The disappointment then clings to the person and they cannot free themselves of it. In this, melancholia differs from the normal passing phase of sorrow. Melancholia grips a person until their will is lost. W.S.’s case would seem to illustrate this: he is 45 and has suffered a series of reverses in life. He was married for twenty years and had several children, but all save one died young. When his wife died two years ago, W.S. suddenly lost all his energy and strength. He could no longer be persuaded to work, and his surviving daughter felt obliged to hide his razor as he was so frequently asking for it. Now he resides here.
Nevertheless, it is rare indeed that a case of melancholia has a sudden onset. The disease generally has a lengthy progression, and at first may seem no more than a slight exaggeration of a patient’s underlying character. It is only with the passage of time that one can see the melancholic’s thoughts drawn back constantly towards the source of gloom, as if he were a shadow continually trying to escape the pull of the dark. It is at this point that delusions or hallucinations can be observed in the conversation of many a melancholic patient, while the most severe cases become almost paralysed and unable even to speak.
H.T. is a 50-year-old housewife. When she came to us her hair was thick, grey and matted, and her clothes were filthy. She had evidently neglected herself for some time. If you see her on the ward now, you will find her both depressed and nervous, worried for her personal safety and awaiting what she believes to be her reckoning. She says that she has stolen many things and begs to be taken to the police so that they might arrest her. She looks distracted as she waits for the officers to arrive and spirit her away. She is a woman at a certain time of life, and this may well be the underlying cause of her desperation. The acute onset of her illness was brought about, however, by an article she read in the newspaper about the Shipton rail disaster, when so many passengers on the Great Western Railway lost their lives. She is convinced that she caused the tragedy and for this reason she believes her suffering is inevitable.
Melancholia such as this may be accurately diagnosed through observation. The grip of sadness leads to a stooped and drooping posture, engulfed in slow and painful movement, while the face is bereft of any sparks of life. Sufferers of melancholia are additionally by far the most aware of any member of our patient cohort. They are able to describe both the causes and the symptoms of their disease, while they can also anticipate the foreboding of an attack and perceive the inevitability of each setback. If you wish to articulate your unworthy life, your affliction with a deadly ailment, or your suspicion that some person or institution has set out to ruin you, then we will be happy to listen to you expound your tale of woe.
An interview with a melancholic is therefore likely to be lengthy. While the maniac is too flighty to focus on conversation, we can ask a depressed patient about their health, their friends and family, their expectations, their spiritual or emotional beliefs, and expect a full response. We will observe their rest too, for the restorative powers of sleep are often denied to the melancholy, for whom a silent night provides space for further brooding. S.C. is one of our nocturnally troubled patients. She is the wife of a cellarman and mother to a young child. She has exhausted herself with suckling her infant, lost her faith and abandoned herself to the hopelessness of existence. She seeks only to bring about her own destruction, and it is at night and in the morning when this suicidal impulse is strongest; her mood lightens quickly once she begins work.
S.C. demonstrates another notable feature of the melancholic: the ability to live within a system of sadness without it having an obvious impact on daily life. Even the delusions of the melancholic may be faced inward, so that they do not affect those around him. Since the flame of hope has been extinguished, a melancholic’s false beliefs do not necessarily lead to any subsequent action. As a result, the melancholic can successfully disguise their insanity, and may even deny it if confronted by it. Patience is the virtue of the physician who works with melancholia.
Monomania
As research into the nature of insanity continues, so alienists have begun to uncover more conditions. It is to this group of newly identified illnesses that the epithet of monomania belongs.
Monomania always results in a most particular delusion: one solitary, irrational falsehood is taken as a truth upon which the disordered mind builds further schemes and actions. This fantasy building is of a most logical nature, but it is unstable because the foundations are wrong. The nature of the initial delusion will vary, but it usually places the patient in a position where he must act either to bring about some great event or to prevent one. An element of conspiracy is also often present. Thus, a patient may feel themselves quite right to warn society of impending doom – an act that any responsible citizen might consider – but if that source of doom is imaginary, then the patient can do nothing but harm in pursuing his quest.
At its most creative, monomania can include full sensory hallucinations, such that serpents might be seen to lurk beneath the floors or spectres to be perched above the roofs; equally, the illness may fixate itself on real beings, who can then find themselves at risk. Whatever the nature of the delusion, it will be localised, and is unlikely to cross over into other aspects of the patient’s life.
Consider the case of F.S., an ex-soldier of 37 years who has served in India. He has monomania of suspicion: he believes that sexual irritants are being placed in beer, that both he and his wife took this contaminated drink, and that persons unknown continue to poison him. To escape his persecutors F.S. believes his only option is to flee to America, where he will be safe. He is wary of the asylum food. However, if he can be diverted from his passion, the patient is happy and content, working in the kitchen garden and apparently enjoying his occupation.
F.B. is a middle-aged farmer who has become obsessed with his financial affairs. He has latel
y encountered money troubles, and now believes that he is entitled to an allowance from the Duke of Cambridge. He also believes that he has been wronged by his brother, who obtained a court judgement against him for a payment owed. He intended to shoot his brother but, finding him not at home, shot one of his cows instead. Ever since he came here it has become apparent how this delusion spreads. If spoken to today, he will assure you that his debts are partly due to his investment in a fictitious grammar school, to his spotting defects in the old Westminster Bridge, and to the building of this asylum, the construction of which he believes results from a dispute between him and his neighbours. Yet, on all these matters his speech is utterly coherent, and he is polite, orderly and industrious; in many ways the model patient.
The monomaniac is thus a man whose insanity is only ever partial. To the layman, the patient appears no less sane than his neighbour, as he is able to converse on a number of topics and to act rationally in relation to them. His intellect and reasoning seem undimmed by illness, and it is only by touching on the nature of the delusion itself that the disease becomes apparent. In consequence, many months of careful observation may be necessary to prove the disease. Equally, it might often seem that an otherwise rational person could be challenged about the basis of such a limited delusion, yet the monomaniac is by their very nature unable to disprove it. Their legs may not resemble wood, but that does not mean that if you cut them they would not be wood inside.