PRIMARY INSANITY (primäre Verrücktheit, primordiale Verrücktheit, {152} originäre Verrücktheit) is usually a further development of an hereditary predisposition to mental disease. The term primary monomania, although used as an equivalent for primäre Verrücktheit, seems to me too narrow for a disease in which the leading delusion may change so many times. Primary insanity is sometimes congenital, and may be developed also by injury or by disease involving the brain early in life or during the physiological changes at puberty, possibly by self-abuse, in persons of an unstable mental organization. It often develops so slowly with the character as to almost seem part of it, until it reaches such a degree of insane delusion of self-importance and expansive ideas as to be unmistakable insanity. There are also delusions of persecution, distrust, and suspicion, erotomania, and moral perversion, in spite of high claims to superior character, and indeed in spite of a high standard of life in some particulars. Perhaps the most striking symptom of primary insanity is the great variety of imperative conceptions (Zwangsvorstellungen) by virtue of which the individual is impelled, by a force often irresistible, to commit various offences against propriety and the laws, even to murder, as well as to perform countless acts of unwisdom or folly. There are usually physical indications of chronic or old cerebral disease, or of defect or degeneration in the incomplete or asymmetrical development of the brain, which, however, may be no more than are found in persons who might not be classed as of unsound mind. Attacks of simple mania (mental excitement) of short duration are quite common, and there is a progressive impairment of the higher faculties of the brain—those which come last in a high order of civilization—although there may be acuteness of memory, perspicacity, and shrewdness which seem altogether phenomenal as compared with the other mental qualities. There is no form of mental disease which is better expressed by the word craziness than primary insanity, no other in which the victim is more thoroughly in the grasp of his malady, and yet no other in which he is more likely to be held responsible for the crazy acts which he may perform, because his inherent mental state, out of which his generally deluded frame of mind is evolved, gives rise to delusive ideas of such a character that they are not universally recognized, even by physicians of experience in mental disease, as insane delusions, but are considered by some of them as the prevarications of a criminally-minded person. When these persons commit crimes, too, they often do so with methods and motives quite like those of the ordinary criminal.