Part 27

_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 classification 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 prone 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 advertisement 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 institution. 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 class 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 illustration 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-knob, 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.

_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 acquaintanceship which alone will justify judgment of their actions, to have many other peculiarities of mind besides the shiftlessness 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 hardships, 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 classes 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 passer-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 assure 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 competitions, 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 shield 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 prone 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 pronounced as to be a little beyond the bounds of ordinary rationality.

Other so-called monomaniacs have the same characteristic and are associated 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, associated symptoms are never lacking. It is not improbable that in Jack the Ripper's case a sexual element was present, because the victims were always of one low class, 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 classes of persons ordinarily considered to be quite responsible for their actions are yet so circumstanced 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 hardships 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 attitude 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 modicum 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 attitude towards indulgence in spirituous liquors. Others find it almost impossible to resist their cravings in this direction. One might go through the list of passionate 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 circumstances 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.