The dominant feature of moral insanity is profound egoism combined with complete indifference with regard to good and evil.

The exclusive aim of such an individual is his .pleasure or his own interest (and very often he has but poor judgment as regards even his own interest), and to reach this aim he does not hesitate to use any means or any expedient. He has neither sentiment of honor nor respect for the truth. His unique preoccupation is to escape conviction and punishment.

Cruel and malicious toward his inferiors and toward the weak in general, he is cowardly toward anybody who is above him. In the asylum or prison he quite readily submits to the rules and to the discipline and does not abandon himself to his morbid propensities until he regains his liberty.

Undoubtedly there are cases of moral insanity with a sane judgment and a strong will. These, freed from the scruples which might interfere with their liberty of action, occasionally have a brilliant career.

Almost always, however, other psychic anomalies are present in addition to the disorders of the moral sphere. The most frequent are:

(a) Weakness of judgment: the subject realizes but imperfectly the possible consequences of his acts, and in spite of all his precautions he ultimately comes into conflict with the law. The thoughtlessness of criminals is well known.

(b) Absence of perseverance: this prevents the utilization of any aptitudes which the patient may possess and which are in some instances very considerable.

(c) Impulsiveness: the moral insane readily yield to the first impulse, so that it is quite difficult in practice to distinguish them from the impulsive criminals. The best criterion is the existence of subsequent remorse in the latter. Unfortunately, it is impossible to determinate its true degree of sincerity. It is well known with what consummate art hardened criminals simulate the most touching

remorse.

(d) Diverse psychic anomalies: obsessions, morbid emotionalism, etc.

Commitment is in most cases necessary. Agricultural colonies, properly conducted, are admirably suited for this class of patients.

CHAPTER VIII.

HUNTINGTON'S CHOREA.

HUNTINGTON'S chorea, a constitutional affection in the strictest sense, occurring on a hereditary basis, forms a group apart from and apparently entirely independent of the other constitutional disorders thus far considered. Arrests of development, epilepsy, dementia præcox, paranoia, manic-depressive psychoses, involutional melancholia, hysteria, and allied conditions often enough present a history of similar heredity, but at least as often, if not more so, they present a history of dissimilar heredity, so that we find instances of two or more of them existing in the same family. For this reason it is generally held that these conditions, though forming clinically fairly distinct entities, are nevertheless in some manner related to each other. The case is different with Huntington's chorea. In all cases in which a complete family history has been secured the heredity which was found has been similar. Instances of other neuropathic conditions are, indeed, occasionally observed in the families of patients suffering from Huntington's chorea, but they are relatively so infrequent as to be readily accounted for as coincidences essentially without relationship to the chorea itself.

Another reason for assigning to Huntington's

chorea an independent position among the constitutional disorders is the special manner in which it is transmitted by heredity. Such evidence as is available indicates that the neuropathic conditions enumerated above are transmitted in the manner of Mendelian recessives. (See Part I, Chapter I, Etiology.) Theoretically, then, the development of a case requires a convergent heredity, and in practice such heredity is very frequently found where a complete family history is available; furthermore, the hypothesis of recessiveness offers an explanation of the frequently observed fact of atavistic heredity in connection with cases of these conditions. Pedigrees in cases of Huntington's chorea practically never show either convergent or atavistic heredity; even in families heavily charged with this condition an individual who happens to be free from it is also free from the risk of transmitting it to his offspring; in other words this disease does not skip a generation as other neuropathic conditions frequently do. Thus Huntington's chorea, considered as a biologic trait, behaves, unlike the large general group of other neuropathic conditions, not as a Mendelian recessive, but as a dominant in relation to the normal condition.1

The disease is comparatively rare, yet most institutions for the insane can show one or more cases. Both sexes are about equally affected. The age of onset in typical cases is between thirty-five and fifty.

1 C. B. Davenport. Heredity in Relation to Eugenics. New York, 1911. P. 102.

The development is gradual, beginning with slight irregular movements of the face and upper extremities which extend slowly over the rest of the body, at the same time becoming more severe; the movements are almost constant, ceasing only during sleep; the patient's speech becomes affected, eventually growing indistinct and unintelligible. There are no disturbances of sensation. Mental symptoms appear in almost every case sooner or later; "a weakness of judgment and initiative, absent-mindedness, general dissatisfaction with surroundings, a growing selfishness and irritability are among the earliest symptoms observed." 1 The fully developed mental picture is characterized by marked irritability, ideas of persecution, and a slow but progressive deterioration; the latter consists mainly in a "disinclination toward mental exertion, which is so pronounced that the examination becomes very difficult; in the marked cases it interferes even with such simple reactions as stating whether it is summer or winter, and seems to give rise to the fact that the patient does not respond at all, or responds in a perseveratory manner; in the milder cases it shows itself in calculation, in giving time relations, and in giving the substance of a simple story read to them, leading to the excuse that the memory is bad, that they are unable to tell it, etc.; whereas, on the other hand, in the orientation, even in the worst cases, there is remarkably little interference; the memory of actual facts, if sufficiently

1 A. S. Hamilton. A Report of Twenty-seven Cases of Chronic Progressive Chorea. Amer. Journ. of Insanity, Jan., 1908.