INSANITY
41
INSANITY
cause it seems impossible to increase accommodations
in proportion to the increasing numbers of the insane.
There are two reasons for this increase. One is an
actual increase in the proportion of the insane to the
total population because of the strenuous life. An-
otlier is that in our busy modern life there is less in-
clination to keep even the mildly insane at home.
Apart from the State institutions, there is a reaction to
the old monastic system of care for the insane, and
there are many large and well-known insane asylums
in America under the charge of roligi<nis. The tra-
dition establi.sheil liy Mailann- Cras at the foundation
of the Sisters of Charity of St. \'incent de Paul has
borne fruit. In America they have large asylums
for the insane at Baltimore, New Orleans, Madison,
N. J., and New York.
HriM.Kri, Ih'siiilals and As!/hii,i>s •>)' l\u- World (London, !s:ili, li hi, II ,ilary of thelnsan, ,1, Ih, Hnli.h Isles (iMadon, ISSLM, (I M,K, M.inoir of Dr. Con.,lhi :r,lh sl.l.h of the Treal- mrnl of Hi, Inane in Europe and Amrrin, ( I,ondon, 1869); KiRciioFK, (Irunilriss einer Geschichte der drutschen Irrenpfiege (Berlin, 1890), bigoted; Esqoirol, Memoirc hislorique sur Charenlon (Paris. 1835). JaMES J. WaLSH.
Insanity. — .411 writers on this subject confess their inability to frame a strictly logical or a completely satisfactory tlefinition. The dividing line betw'een sanity and insanity, like the line that distinguishes a man of axcrage height from a tall man, can be de- scribed only in terms of a moral estimate. There is a borderland l>ct\vccn the two states which is not easily identiticil as belonging certainly toeither. Henceadef- inition that aiuisat rigorous comprehensiveness is liable toinchule such non-insane conditions as livsti'ii:!, febrile delirium, or perverted passions. The driiiiil ion gi\ .'ii by the " Century Dictionary" is prolialily as salisiac- tory as any: "A seriously ini|iaircd (■(irnliliou of the mental functions, invoking the inti'llcci, eiiiof ions, and will, or one or more of tinsr faculties, exclusive of temporary states proilucetl l>y and accompanying intoxications or acute febrile diseases." Not less difiicult is the prolilem of classification. No classifi- cation based on a single principle is entirely satis- factory. Anatomical changes are an inadequate basis because they are absent from many forms of insanity; the causes are so numerous and so frequently com- bined in a single case that it is impossil^le to say which is pretlominant; and the symptoms are so manifold that the accidental cannot alwaj's be distinguished from the essential. Intleed, the nervous system and the mental functions are so complex and so inade- quately known that any attempt at an accurate classification of their abnormal states must of necessity be a failure. In this article only the most important forms will lie enumerated, namely, those which are most prevalent and those which are clearly distin- guished from one another.
One of the oldest ilivisions of mental disorders is into melancholia aTid mania. In the former the domi- nant mood is depression; in the latter, exaltation. The former differs from sane melancholy only in degree, and its chief characteristics are mental an- guish and impulses to suicide. It includes probably one-half of all the cases of insanity, and is more frequently cured than any other form. In mania the morl )idly elated mood may vary from excessive cheer- fulness to violent rage. Monomania, which may ex- hibit characteristics of both melancholia and mania, is a perversion of the intellective rather than the affective faculties. Its chief manifestation is delu- sions, very frequently tlelusions of persecution. Mono- mania corresponds roughl.v to the later and more precise term paranoia. In this form the delusions are systematized and persistent, while the general intellectual processes may remain substantially un- impaired. When the attacks of melancholia or mania occur at regular intervals they are frequently named periodical insanity. The term partial insanity com- prises chiefly those varieties known as impulsive,
emotional, and moral. These are characterized bj' a
loss of self-control, on account of which the patient
performs acts that are at variance with his prevailing
disposition, ideas, and desires — for example, murder
and suicide. Somewhat akin to these forms are those
associated with such general diseases of the nervous
system as epilepsy, hysteria, and neurasthenia. When
insanity takes the form of a general enfeeblement of
the mental faculties as a consequence of disease, it
is called dementia. It is usually permanent. Its
principal varieties are senile, paralytic, and syph-
ilitic. Paresis is one kind of paralytic dementia.
All the above-mentioned forms of insanity are ac-
quired, in the sense that they occur in normally
developed brains. Congenital insanity, or feeljle-
mindedness, is divided chiefly, according to its degrees,
into imbecility, idiocy, and cretinism.
That insanity is on the increase, seems to be the general verdict of authorities, although the absence of relialile and comprehensive statistics makes any satisfactory estimate impossible. Whatever be its extent, the increase is undoubtedly due in some meas- ure to our more complex civilization, especially as seen in city life. In general, the causes of insanity may be reduced to two: predisposing causes and ex- citing causes. The most important of the former are insane, neurotic, epileptic, drunken, or consumptive ancestors; great stress and strain, and a neuropathic constitution. Among tlie exciting causes must be mentioned shock, inlense emotion, worry, intellectual overwork, diseases of tlie nerMius system, exhausting diseases, alcoholic and sexual excesses, paralysis, sinisticike. and accidental injuries. It has been esti- Mialed that the physical causes, whether predisposing or exciting, stand to the moral causes, such as afflic- tion and losses, in the ratio of four to one. Of 2476 ca.ses due to physical causes which were admitted to the asylums of New York during the twelve months preceding .30 September, 1900, alcoholic and sexual excesses and diseases had brought on 684. The majority of cases of insanity, however, are traceable to more than one cause.
Inasmuch as insanity almost always involves some perversion of the will, either direct or indirect, it raises interesting and important questions concerning moral responsibility. Every impairment of mental function must impede the freedom of the will, either by restricting its scope, or by diminishing or tlestroy- ing it outright. Ignorance, error, lilinding passion, and paralysing fear all render a person morally irre- sponsible for those actions which take place under their influence. This is true even of the sane; ob- viously it happens much more frequently among the insane, owing to delirium, delusions, loss of memory, and many other mental disorders. Is it, however, only in this general way, that is, through defective action of the intellect, that freedom and responsibility are lessened or destroyed in persons who are of un- sound mind? May not the disease act directly upon the will, compelling the patient to do things that his intellect assures him are wrong? The English courts and almost all the courts of the United States answer this question in the negative. Their practice is to regard a defendant in a criminal case as responsible and punishable if at the time of the crime he knew the difference between right and wrong, or at least knew that his act was contrary to the civil or moral law. For example, a man who, labouring under the insane delusion that another has injured his reputation, kills the latter is presumed to be morally accountable if he realized that the killing was immoral or illegal. In a word, the rule of the courts is that knowledge of wrong implies freedom to avoid it. Medical author- ities on insanity are practically unanimous in rejecting this judicial test. Experience, they maintain, shows that many insane persons who can think and reason correctly on every topic except that which forms the
