INSANITY

CHAPTER XL

Insanity - Causes-Classification-Diagnosis-Hallucinations, illusions and delusionsMania - Melancholia -- Dementia - Delusional insanityMoral insanity-Impulsive insanity-General paralysis of the insane - Epileptic insanity— Periodical insanity-Insanity in relation to childbearing-Toxic insanity-Idiocy.

It is not proposed to enter into a full discussion of the subject of insanity in this book. The medico-legal relations of insanity will be fully considered, together with the methods of determining its existence and degree; the important question of the civil and criminal responsibility of the insane will be discussed, and directions will be given as to the legal obligations devolving on medical practitioners in connection with the certification of persons of unsound mind, for the purpose of placing them under restraint.

Definitions. From the point of view of the physician, insanity must be regarded as a disease of the brain or a disorder of the mind, apart from the consideration of the responsibility of the individual. The medical jurist, however, has to consider the important question of responsibility. No satisfactory definition of insanity, which includes all forms of unsoundness of mind, can be given; this is not surprising when it is remembered that mental disorder varies in its degree as well as in its characters, and that no two cases are precisely similar. The common notion of insanity is that it necessarily consists

in an entire deprivation of reason; this, however, is incorrect, as the insane certainly reason upon their feelings and impressions. Savage considers that no standard of sanity can under any circumstances be considered definitely to exist. 'Sanity and insanity, as recognised by the doctor, and, in fact, by the general public, must be but terms of convenience. No person is perfectly sane in all his mental faculties, any more than he is perfectly healthy in body. A man, in fact, must be considered as sane or insane in relation to himself. The old and oft-repeated statement that insanity is a perversion of the ego is absolutely true. Sanity and insanity, then, are to be measured by differences or changes of habit, taste, and disposition in the individual, as well as by other symptoms of change in the nervous centres' (Savage 1).. Bucknill and Tuke define insanity as a disease of the brain (idiopathic or sympathetic) affecting the integrity of the mind, whether marked by intellectual or emotional disorder, such affection not being the mere symptom or immediate result of fever or poison. The indication of insanity, as required by law, is not so much the proof of the existence of delusion in the mind of a person, as the proof that such a person is either incapable of managing his or her affairs with ordinary propriety, or is liable to endanger his own life or the lives of those around him. Insanity may be either congenital or acquired. In congenital insanity the mental powers or moral character are, from the first, much below the average standard at the same age. In acquired insanity the original character of the person becomes morbidly altered.

Causes of insanity. These are divided into the predisposing and the exciting causes The principal predisposing causes of insanity are the following: (i) Sex.-There is a rather larger proportion of cases of insanity among males than among females. (ii) Age.-The tendency to insanity increases with the development and employment of brain and mind. The

Insanity and Allied Neuroses.

greater number of cases arise in the period between twenty-five and forty years of age. (iii) Heredity.—An inherited tendency to neurotic disorder is a great predisposing as well as exciting cause of insanity. (iv) Condition of life.-Insanity is more common among civilised than barbarous races, but the vices and failures of civilisation are responsible for this greater proportion. Poverty and bad hygienic surroundings and excessive alcoholic drinking are among the conditions of life that predispose to insanity.

The exciting causes of insanity may be divided into physical and moral causes.

Classification.-Various classifications of the different types of insanity have been attempted, but most of them are open to the objection of fostering the tendency to regard each class as a distinct disorder. Savage classifies the different forms of insanity according to age occurrence-viz. insanity of early development, of childhood, of adolescence, of maturity, of climacteric, and of old age.

The following is the nomenclature and classification adopted

by the Committee of the Royal College of Physicians, London,

The following are the principal types of insanity :-(i) Maniacal states. The association of mental weakness with loss of control. (ii) Melancholic states. The association of mental weakness with excessive self-consciousness. (iii) Delusional insanity. In this form the patient is misled by false sense impressions. (iv) Dementia.-A combination of mental weakness with defect in the mental functions. (v) Idiocy.-A deficiency of the mental faculties, either congenital or acquired very early in life. (vi) States of weak-mindedness.

INDICATIONS AND DIAGNOSIS OF INSANITY

There are many difficulties that may present themselves in connection with the diagnosis of an alleged mental disorder. It may be feigned, or the real disorder may be artfully concealed, or there may be considerable difficulty, or even impossibility, in discovering the motive of some extraordinary action. Although the absence of all rational motive generally indicates an insane act, yet, in any particular case, its absence must not be too readily inferred, since the motive may be most artfully and successfully concealed. The duties of the medical jurist in connection with a case of insanity relate to the questions of (a) the civil responsibility of the individual, and (b) his criminal responsibility.

Civil responsibility means the capability of an individual to manage his own affairs with propriety, and to conduct the

ordinary duties and affairs of civil life according to the usual social rules. The question of civil responsibility is specially raised in connection with the making of wills and entering into contracts.

Criminal responsibility refers only to criminal acts, and raises the question as to whether an individual, at the time of the commission of some particular crime, was or was not in such a mental condition as to render him responsible for the act.

The onset of insanity may be sudden or gradual. If it begin very insidiously, the first noticeable change is frequently an alteration in temperament; the emotions become affected before the mind is impaired, and the individual is different to what he formerly was. Either he becomes more quiet and dull than usual, or, on the other hand, more restless, excitable, or noisy. The dulness may deepen to gloom and despondency, which may alternate with periods of excitement. The degree of excitement varies considerably, and may be accompanied by outbursts of gaiety, or of anger and violence, which appear to be uncontrollable by the will. This change in the disposition. of the individual generally lasts some time before delusions are discoverable, and is generally apparent to members of his own family before it is noticed by others. The outbursts of irritability or anger are called forth by the most trifling circumstances, and are generally associated with extreme impatience of contradiction. The feelings of the patient become reflected in his acts. He either looks upon everything despondingly, and neglects his duties and amusements, or, on the other hand, he conducts his business rashly and foolishly, is extravagant, and may indulge in drinking or frivolous pursuits. The emotions frequently change, so that the individual may acquire a dislike or hatred for persons to whom he was formerly attached. This condition is generally accompanied by suspicion of one or more individuals around him, the suspicion generally taking the form of an idea that there is a conspiracy against his person, property, or liberty. These emotional changes and