Religious delusions are found in para noia, epilepsy, and melancholia. In paranoia and epilepsy they are nearly al ways of an expansive character. The subject fancies himself or herself an ex alted religious personage, and may even claim the attributes of the Diety. In other cases he or she holds communica tion with God, the Saviour, the Virgin Mary, or some prominent saint. In these persons hallucinations of hearing and vision are always present. The religious delusions of melancholia are usually per meated with a profound sense of un worthiness of the subject, while the para noiac is saturated, so to speak, with the sense of his own importance and power, and is always convinced that he is en titled to more honor than the world renders him; the melancholiac, on the other hand, constantly and loudly pro tests his utter unworthiness, his sinful ness, the impossibility of ever regaining the lost grace of God.
Sexual delusions of an expansive char acter are present in the early stages of general paresis, in mania, and in para noia. In the latter they are combined usually with persecutory delusions. The persistent doubts of sexual power so often found in neurasthenics cannot be regarded as delusions.
Morbid Impulses. Impulsive Acts.— When an epileptic during an hallucina tory aura attacks another person, a para noiac under the influence of his perse cutory delusions commits murder, or a sexual pervert cohabits with animals or with dead bodies, the acts are said to be impulsive, and committed in obedience to an imperative impulse, conception, or idea. The Germans call these impulses "Zwangsvorstellungen," literally coercive conceptions. The French term is "obses sions." The numerous so-called mono manias and monophobias of authors be long to this class of symptoms. Thus suicidal and homicidal mania, dipso mania, pyromania, kleptomania, eroto mania, onomatomania, are not special varieties of insanity, but are merely coercive impulses, often irresistible.
An impulsive tendency to suicide does not constitute a special variety of in sanity; it is merely a symptom of a de pressive mental state. It is most fre quently a symptom of melancholia, but may be present in other forms of mental disturbance.
General Diagnosis.—The differentia tion of the individual forms of insanity is often difficult, but it is still more diffi cult at times to say with positiveness that a person under examination is sane or in sane. This is largely due to the fact that there is no absolute standard of sanity. The outward expression of insanity of thought and feeling is manifested through conduct, but as there is no gen eral standard of sane conduct, it is neces sary to compare the conduct of the person in question with the conduct of the generality of persons living under the same environments or to compare the conduct of the subject with his own previous mode of life. The behavior of
a thief, a tramp, a drunkard, or a prosti tute is not approved by society, but the thief and his proscribed companions are not considered as insane, either by ciety in general or by each other. But if a clergyman becomes a thief; a million aire, a tramp, an ascetic, a drunkard; or one who has hitherto been a model of womanly virtue a prostitute, there are grave reasons for suspecting the sanity of the person thus offending. The gen eral diagnosis of insanity must take into account not only the subject's conduct at the time being, but his previous his tory and his environment. Specific de tails will be given in the consideration of the special forms of insanity General Prognosis.—Contrary to com mon belief, insanity is curable in a con siderable proportion of cases. If appro priate treatment is promptly instituted the recovery-rate of all cases should reach at least 40 per cent. If certain groups that are incurable, such as imbe cility, paranoia, general paresis, and epileptic and other secondary dementias are excluded, the proportion of recoveries should be much larger. It is not un reasonable to expect recovery in 75 per cent. of the psychoses due to nutritive disturbances or toxic conditions.
The insane succumb in hut a small proportion to infectious disease as com pared with the general population. Of 15,248 deaths in Italian asylums, 8.46 per cent. were due to tuberculosis, 4.16 per cent. to pneumonia, and 1.75 per cent. to typhoid fever. Of 307,477 deaths in the general population, 12.22 per cent. were from tuberculosis, 15.50 per cent. from pneumonia, and 2.95 per cent. from typhoid fever. Gucci (Centralb. f. Ner venheilkunde, etc., No. 26, '89).
The prognosis of insanity in childhood is, on the whole, favorable if there is no neuropathic ancestry. lf, however, the child shows evidences of psychopathic heredity, the prognosis is bad. Moreau de Tour (Annales d'Hyposologie et de Psych., Dec., '91).
Of 2176 insane persons admitted into the Eastern Michigan Asylum, 378, or 17.3 per cent., recovered without relapse, 91, or 4.1 per cent., recovered, relapsing one or more times; 256, or 11.1 per cent., were discharged improved, remaining at home without again resorting to the asylum; and 522, or 23.9 per cent., died. The low absolute-recovery rate is due to the fact that all sorts of cases in various stages of chronic insanity are admitted. E. A. Christian (Amer. Lancet, May, '94).