INCREASE OF INSANITY.
If the general tendency of movement in relation to the public interest in
the care and management of the insane during the last twenty-five years,
has been such as I have intimated in the preceding chapter, I think there
exists at least a probability, that there will be an increase of this
public interest and consequent action in the years to come. The ground of
such probability will be more apparent, I think, from the evidence of
statistics now to be presented. But, as preliminary to this, I propose to
mention several points for consideration, which have a bearing, of more or
less importance, upon the discussion of the subject, and which may serve
to indicate the tendency and general drift of influences in operation in
the present and recent past.
1. It appears almost trite to remark that there have come large changes
over the conditions of civilization since the beginning of the nineteenth
century, and yet, I think, we generally fail to realize how great many of
them, of such a character as especially to influence mental as well as
physical health, have been.
Previous to, and during the early part of this period, the history of
those nations with which we are most familiar, especially of those
portions which now constitute the Empire of Germany, and of France and
England, had been one of wars, which were waged in the interests of the
few in distinction from those of the many.
Kings, and generals of armies, and rulers of petty nationalities and
clans, were the personages who stood out in bold relief; their plans,
intrigues, and movements, and the marshalling of their armies for combat,
together with the results which followed in the way of conquering and
re-conquering of territories, constituted the great business of life among
these nations, and furnished the themes of which historians wrote; while
the conditions of life, pertaining to the great body of the common people,
as to education, modes of living, occupations, and health, were of almost
no account. Education related chiefly to military matters, and was
practically confined to the higher classes, while the well-being of the
common people was of little concern, except so far as it might prove to be
of service in the battles of conquest.
The manufactories, commerce, machinery; the law, and politics as now
existing, and which play so large a part and exert so great an influence
on the lives of the common people of to-day, were then practically
unknown. The people were divided, for the most part, into two classes,
those who fought the battles, and those who tilled the soil, to obtain the
wherewithal to sustain both. These conditions immensely simplified the
problem of life, as compared with that of the present time, and, moreover,
necessitated an existence out-of-doors for the vast majority of persons.
2. At the present time a much smaller number till the soil and follow
out-door occupations, and the improved agricultural machinery now so
largely used, and the numerous other avenues of life which have been
opened so freely to all, are tending constantly to still further diminish
it. Large numbers are congregated in factories and mills, and are engaged
in mechanical occupations, counting-houses, mercantile and in-door
pursuits. Instead of being in the open air, and breathing it in its
freshness and purity, they are, for twenty or more hours of the
twenty-four, in the confined and vitiated atmosphere of the factory,
store, or counting-house, and, what is not unfrequently worse, that of the
illy ventilated sleeping-room. In the one case, the blood is purified and
nourished by the influence of a large supply of oxygen which it bears to
every portion of the system, and especially the brain, while in the
other, it is only partially decarbonated, and bears a taint during its
whole round of circulation. The thousands who are, in the present,
immersed in the dense atmosphere of cities, large towns, manufacturing
establishments, and mines of various kinds, were accustomed, in former
times, to live largely out-of-doors, and were engaged in such pursuits as
tended to develop and strengthen the whole system.
In the former conditions of life, persons were, to a much larger degree,
governed, and their requirements provided for, by legal, or arbitrary,
enactments, so that there existed less care on their part, as to obtaining
those things necessary for self and family, while in the present, the
larger degree of personal liberty enjoyed, and the multiplied artificial
wants created, bring increased care and individual responsibility.
3. Again, there has, within quite a recent period of time, come a
considerable change in the human system itself, attributable in a measure,
probably, to some or all of the above causes, in relation to the character
and tendencies of diseases. During the former period, it is believed that
diseases affected more often the circulatory system, and that they were
largely of a more sthenic character; that they were treated in a manner
much more heroic than would be well borne at the present time is quite
plain, whether it was judicious or otherwise. Now, the force or tendency
of disease seems to be carried over (if I may so speak) into the nervous
system, so that diseases affecting this portion of the body are much more
frequent than formerly. People are more sensitive and nervous; indeed,
nervousness has become exceedingly common among all classes, and modifies
many forms of disease, thereby inducing an asthenic type, which requires
the use of vastly larger quantities of those tonic medicines which act on
the nervous system, than would have been tolerated fifty years ago. And
the keen competitions in business, the intense mental activities which
pervade all the vocations of modern life, the ruling passion for wealth
which extends through almost all classes of society, and the consequent
neglect of those laws which govern health, all tend to further increase
it. From these causes, there can but result, on the whole, a much less
vigorous system and one less able to resist the effects of strain and
anxiety, and much less robust families of children, many of whom have,
from the beginning, in their nervous systems, weaknesses which cling to
them through life.
These considerations, and others which may be referred to more fully
hereafter, would appear to indicate the probability that there have been
in operation such powerful influences as would tend toward an increase of
insanity beyond that which would be anticipated from the increase of the
general population.
The increased demand for hospital accommodation for the insane, which has
been so great within recent years, has been thought, by some, to indicate
a certainty of such increase of insanity. While there may be some show for
such an inference, I do not think it very conclusive, as this demand may
be readily accounted for by other reasons, of which the following may be
mentioned.
1st. The general condition of asylums for the insane has greatly improved
everywhere within the last forty years: buildings, grounds, and the
general external appearances have become more attractive; halls and rooms
have been better furnished, lighted, heated, and ventilated, and
consequently more cheerful and inviting in appearance to patients and
friends. There is much less of mechanical restraint used than was formerly
considered necessary, and a larger amount of personal freedom; while the
introduction of labor among the inmates more generally has served to
render life in asylums more like that at home, especially for the chronic
insane. In consequence, or partly in consequence, the public have come,
more fully than ever before, to appreciate the good results which arise,
both directly and indirectly, from asylum treatment, and have lost, in a
large measure, the distrust formerly existing in relation to these
institutions, and are now more ready to place their friends and relatives
in them for care.
2d. The view has become more general, that those who are so unfortunate as
to become insane, have claims upon the public, more obligatory than any
other class in the community can have, and, consequently, very large
numbers who were formerly detained in almshouses and in county poorhouses,
have been removed and placed under the more favorable conditions of
hospitals better adapted to their humane care.
3d. Formerly it was considered necessary to place only the more acute and
violent forms of disease in asylums for treatment, while the chronic
insane, especially those in a demented and quiet condition, were retained
at home; but more recently persons are inclined to recognize the
importance of placing these classes, also, in asylums, where they may be
under the care of persons who have been educated for the purpose, and
consequently understand better how to manage and care for them; and also
for the purpose of leaving the productive members of the family free to
engage in ordinary industry.
4th. It has also come to pass that many who were formerly considered only
as _eccentric_ or _singular_ in their general conduct and relations with
others, are now recognized as partially insane, and consequently society
is less tolerant of their presence, and more urgent that they be removed
to places of greater safety, and where their general influence may be less
harmful.
Further, 5th. Allowance has to be made for ordinary accumulation of
persons who may be considered as asylum inhabitants. It is a general rule,
with few exceptions, that persons who have once passed through the
experience of a serious illness never are in quite as perfect a state of
health afterward, and in many cases are more likely to be again affected;
and in reference to insanity this is especially true. Every one who has
once been insane is more likely to become so again; so that the fact that
from thirty to fifty per cent. of the insane recover once, renders the
probability of larger numbers hereafter greater. Then, of the numbers who
do not recover and do not die, many live on for a much longer period than
formerly. There can be no doubt that the existence of even such functional
disease of the brain as may cause insanity, tend to shorten life in the
vast majority of persons so affected, while the lack of care and
treatment, and too often long-time neglect and abuse formerly prevalent
among the insane, served to shorten the period of life still more. The
fact that under the more favorable conditions of hospital life these
persons live for much longer periods than would otherwise be the case,
tends largely to explain the increase of numbers who appear to be so
rapidly accumulating in the asylums and hospitals of the country.
In forming an opinion, therefore, as to the increase of insanity, from
indications based on the _numbers_ which are now provided for by the
public, it becomes necessary to take into the account all the above
considerations, and perhaps some others. Indeed, the item of _numbers in
asylums_ is but one of the factors of the problem, which embraces a large
field for observation.
Bearing the above preliminary considerations in mind, we may now refer to
something more definite in the way of statistics, for the purpose of
answering our inquiry.
It is evident that the usual census, if it could be made frequently
enough, and also accurate, would go far toward a solution of the problem,
but this has hitherto not been practicable in this country. Owing largely
to the migratory character of large portions of the populations, the great
extent of the country, and the sparseness of population in many sections,
and for other reasons, any conclusions from it can be only proximate.
But, while we do not at present possess the data requisite to determine
the question with accuracy in this country, we may refer to the statistics
which have been yearly published since 1858, by the Boards of
Commissioners in Lunacy for England and Scotland; and do so with the
assurance that what may be found to be true there, will, at least, be good
evidence as to what exists with us.
Both these countries have vastly greater facilities for accurately
determining the number of insane persons living at any one time within
their borders, than are possible in the United States. The population is
much more homogeneous; it is greatly more dense, there being about
25,000,000 of people on a number of square miles less than are contained
in some of our single States. The people are not accustomed to frequent
change of residence from one portion of the country to another, and all
classes are readily reached and their conditions of health determined.
In these countries, so favorably constituted in these respects, there have
existed Boards of Commissioners in Lunacy, for many years, whose duties
are concerned solely with the insane, and their system of inspection
appears to be wellnigh perfect. I therefore propose to introduce some of
the statistics furnished by these Boards, from which we may learn in what
direction has been the tendency of insanity there. In this procedure I
shall divide those which I use from both Boards into periods of ten years
each, the first, from 1859 to 1868, inclusive, and the second, from 1869
to 1878, inclusive; giving the numbers of increase and decrease of both
_private_ and _pauper_ patients, as they appear in the reports,
distributed in asylums, licensed dwellings, and with relatives and
friends.
From the report of the Commissioners for England: first, as to private
patients, the whole number was, in 1859, four thousand nine hundred and
eighty (4,980): and there was an _increase_ of this class in registered
hospitals, during the first decade, to the number of two hundred and
thirty (230); and in licensed houses, to three hundred and twenty-six
(326).
Of this class of patients residing with relatives and others, there has
been an _increase_ of one hundred and fifty-two (152); and in naval and
military hospitals, of eighteen (18).
Of this class of patients in county and borough asylums, there was a
_decrease_ of eight (8).
Second, as to pauper patients;[1] there has been an _increase_ of these,
in county and borough asylums, amounting to nine thousand eight hundred
and forty-four (9,844); and in registered hospitals, of one hundred and
ninety-six (196); and in workhouses, of twenty-seven hundred and
twenty-one (2,721); and residing with relatives and others, of one
thousand and thirty-one (1,031).
There has been a _decrease_ of this class residing in licensed houses, of
six hundred and ninety-eight (698).
By adding together the several sums of _increase_ which have occurred in
both classes, and the increase in the number of criminal lunatics, three
hundred and forty-two (342), who have been provided for, since 1864, in a
special asylum at Broadmoor; and deducting the sums of _decrease_ which
have occurred by removals and redistribution of patients among the several
asylums and registered houses, we have, as a grand total of _increase_
during the ten years, fourteen thousand two hundred and thirty-eight
(14,238).
I have presented the above statistics somewhat in detail, in order that it
may be more apparent among what classes of society this large increase has
mainly occurred. It will accordingly be observed that, while it has been
only seventeen (17) per cent. among the private patients, it has been
about seventy (70) per cent. among the pauper class.
It is apparent that the above statistics present only the total number of
increase, without relation to the increase of the population. To enable us
to appreciate their full significance, another statement, therefore,
becomes necessary.
The ratio of the insane to the sane, the total number of the population
being estimated at the middle of the year, for the several years of the
decade, was as follows:
In 1859 one in 535
" 1860 " " 523
" 1861 " " 507
" 1862 " " 495
" 1863 " " 478
" 1864 " " 466
" 1865 " " 460
" 1866 " " 449
" 1867 " " 441
" 1868 " " 430
exhibiting a higher ratio of the insane to the sane for every year of the
decade.
I now introduce the statistics of the second decade, viz., from 1869 to
1878 inclusive; and perhaps it is fair to assume that these will be more
nearly perfect than those of the former period, as the system employed had
been longer in operation, and the conditions of the problem somewhat
simplified, as the result of previous labors. For convenience, I shall
group together the private and pauper patients.
In 1869, there were of both private and pauper patients in the county and
borough asylums twenty-six thousand eight hundred and sixty-seven
(26,867); in 1878, there were of the same classes of persons, thirty-seven
thousand seven hundred and sixty-three (37,763): exhibiting an _increase_
of ten thousand eight hundred and ninety-six (10,896).
There were in registered hospitals, in 1869, of both private and pauper
patients, twenty-three hundred and fifty-two (2,352); and in 1878,
twenty-seven hundred and seventy-eight (2,778): showing an _increase_ of
four hundred and twenty-six (426).
In licensed houses, there were, in 1869, four thousand seven hundred and
ninety-six (4,796); and in 1878, there were four thousand two hundred and
two (4,202): exhibiting a _decrease_ of five hundred and ninety-four
(594).
In naval and military hospitals, in 1869, there were two hundred and nine
(209); and in 1878, three hundred and sixty (360): an _increase_ of one
hundred and fifty-one (151).
In the Criminal Lunatic Asylum at Broadmoor, in 1869, there were four
hundred and sixty-one (461); and in 1878, four hundred and eighty-two
(482): an _increase_ of twenty-one (21).
In the workhouses there were, in 1869, eleven thousand one hundred and
eighty-one (11,181); and in 1878, sixteen thousand two hundred and
sixty-five (16,265): equal to an _increase_ of five thousand and
eighty-four (5,084).
Residing with relatives and others, there were, in 1869, seven thousand
three hundred and eleven (7,311); and in 1878, six thousand six hundred
and eighty-eight (6,688): giving a _decrease_ of six hundred and
twenty-three (623).
By the addition of these several sums of _increase_, and deducting those
of _decrease_, we have a total of _increase_ during these ten years of
fifteen thousand three hundred and sixty-one (15,361).
The increase, therefore, as between the first and second decade, amounts
to one thousand one hundred and twenty-three (1,123).
The ratio this increase bears to the total number of the population, from
year to year, appears from the following table:
In 1869 one in 417
" 1870 " " 411
" 1871 " " 401
" 1872 " " 396
" 1873 " " 387
" 1874 " " 381
" 1875 " " 375
" 1876 " " 373
" 1877 " " 364
" 1878 " " 362
It will be observed from the above statistics, that there has been a
considerably uniform increase of insanity, greater than that of the
general population, but that it has been less rapid during the second
decade than the first. By reference to the last Report of the
Commissioners, I find that in 1880 there is one insane person to every
three hundred and fifty-seven (357), which indicates that insanity
continued to that time to increase more rapidly in proportion than the
general population.
I have presented the above numbers somewhat more in detail as to classes
and methods of distribution than was necessary, thinking the lay reader
may be interested to understand something as to these points, in the care
of the insane in England. As these methods are quite similar in Scotland,
I shall, in some measure, omit this detail in presenting the statistics
relating to that country.
From the Reports of the Board of Commissioners in Lunacy for Scotland, it
appears that in 1860 there were of insane persons:
1. Of paupers in asylums and poorhouses, three thousand three hundred and
seventy-nine (3,379); of the same class in private dwellings, eighteen
hundred and forty-seven (1,847).
2. Of private patients in asylums, nine hundred and seventy-one (971); and
in private dwellings, twenty-one (21): making a total of both classes of
six thousand two hundred and eighteen (6,218).
These numbers are understood to be exclusive of criminals and imbecile
children.
In 1869 there were under observation:
1. Of pauper patients in asylums and poorhouses, four thousand four
hundred and ninety-four (4,494); and in private dwellings, one thousand
and five hundred (1,500).
2. Of private patients in asylums, one thousand one hundred and
twenty-eight (1,128); and in private dwellings, thirty-five (35): making a
total of both classes of seven thousand one hundred and fifty-seven
(7,157).
During these ten years, therefore, from 1860 to 1869, inclusive, the total
number of insane persons in Scotland, of which the Board had cognizance,
advanced from six thousand two hundred and eighteen (6,218) to seven
thousand one hundred and fifty-seven (7,157), giving a net increase
amounting to nine hundred and thirty-nine (939).
I introduce the table as before to show the relation this bears to the
number of the population:
In 1860 one in 487
" 1861 " " 487
" 1862 " " 480
" 1863 " " 490
" 1864 " " 490
" 1865 " " 487
" 1866 " " 480
" 1867 " " 473
" 1868 " " 467
" 1869 " " 458
It will be observed that the increase has not been uniform, as was the
case in relation to that of England. There was a decrease for two of the
ten years, 1863 and 1864, but from that time forward an increase.
Referring next to the second decade, from 1870 to 1879, inclusive, it is
found that in 1870 there were:
1. Of pauper insane persons in asylums and poorhouses, four thousand seven
hundred and twenty-eight (4,728); and in private dwellings, one thousand
four hundred and sixty-nine (1,469).
2. Of private insane persons, in asylums, one thousand one hundred and
sixty-three (1,163), and in private houses forty-nine (49): making a total
of the private and pauper insane of seven thousand four hundred and nine
(7,409).
In 1879, there were:
1. Of pauper lunatics in asylums and wards of poorhouses, six thousand two
hundred and ninety two (6,292); and in private dwellings, one thousand
three hundred and ninety-eight (1,398).
2. Of private lunatics in asylums, one thousand three hundred and
fifty-eight (1,358); and in private houses, one hundred and ten (110):
making a total of both classes of nine thousand one hundred and
fifty-eight (9,158).
The advance, therefore, during this decade was from seven thousand four
hundred and nine (7,409), to nine thousand one hundred and fifty-eight
(9,158); which equals one thousand seven hundred and forty-nine (1,749),
as against nine hundred and thirty-nine (939) during the preceding decade,
or nearly one hundred per cent. larger.
In relation to the general population it was as follows:
In 1870 one in 448
" 1871 " " 440
" 1872 " " 438
" 1873 " " 434
" 1874 " " 436
" 1875 " " 432
" 1876 " " 420
" 1877 " " 408
" 1878 " " 400
" 1879 " " 392
exhibiting a decrease in relation to the total of population for one year
only of the decade, and on the whole a steady increase for the whole
twenty years.
It further appears from the tables of statistics, that the number of
_insane_ paupers per 100,000 of the population, which was one hundred and
fifty-seven (157), January 1, 1858, advanced to two hundred and seventeen
(217) per 100,000, January 1, 1880, notwithstanding the fact, that during
this period the number of pauper-persons per 100,000 of the general
population diminished from two thousand six hundred and thirty (2,630) to
one thousand seven hundred and eighteen (1,718).
It thus appears that insanity is, both absolutely and relatively, a much
larger element in the pauperism of the country than ever before.
In considering the force of the above statistics there is one element
which may, I think, properly be referred to as entering into the
calculation, to which I have nowhere found any allusion, namely,--that of
emigration. I have not at hand the statistics to show how great this has
been from England and Scotland during the last twenty years, but we know
that it has been very considerable from both countries to Canada,
Australia, and the United States; and I think it fair to assume that this
emigration has generally been from those who have been in good mental
health, at least at the time of leaving these countries; and if at this
time they had relatives who were insane, these would be left behind.
Therefore, so far as this would have an effect upon the statistics of
insanity, it would be toward exhibiting a higher ratio of the insane to
the whole population than would otherwise appear.
Having made due allowance for this, and other considerations, which were
alluded to in connection with the statistics of asylums, I still think the
evidence all points toward a large increase of insanity, both absolute and
relatively to the population, in both England and Scotland.
At the time of this writing, the statistics of the census for 1880, for
the United States, have not been so far completed and published, that
evidence from them can here be presented, but I think there can be no
doubt that, when they appear, they will tend to confirm very strongly
those already presented, which have been prepared with so great care, and
collected under such very favorable conditions, and which demonstrate, or
so nearly demonstrate, both the absolute and relative increase of
insanity.