accepted classification of mental diseases, and the same terms even
are used by different writers to convey entirely different meanings.
The classification according to the causes of insanity was suggested
by Morel of Paris, and fully elaborated by Skae of Edinburgh, as
follows: (1) Moral idiocy; (2) intellectual idiocy; (3) moral
imbecility; (4) intellectual imbecility; (5) epileptic insanity; (6)
insanity of masturbation; (7) insanity of pubescence; (8) hysterical
mania; (9) amenorrhœal mania; (10) post-connubial mania; (11)
puerperal mania; (12) mania of pregnancy; (13) mania of lactation;
(14) climacteric mania; (15) ovario- and uteromania; (16) senile
mania; (17) phthisical mania; (18) metastatic mania; (19) traumatic
mania; (20) syphilitic mania; (21) delirium tremens; (22) dipsomania;
(23) mania of alcoholism; (24) post-febrile mania; (25) mania of
oxaluria and phosphaturia; (26) general paralysis; (27) epidemic
mania; (28) idiopathic sthenic mania; (29) idiopathic asthenic mania.
In a large proportion of cases the causes of insanity are so many and
so complex that it is not within human power to say which of a number
has been the most important, or the assigned and classified cause may
be only an accidental complication or the most striking, but by no
means most potent, cause.
The classification, according to the functions interfered with, is
that adopted by Maudsley and by Bucknill. According to Bucknill, we
have
(1) Insanity of the intellect or ideas: Idiocy, imbecility, dementia,
delusional insanity, monomania, mania.
(2) Insanity of the feelings and the moral sentiments: Moral
imbecility, moral insanity, melancholia, religious insanity,
hypochondriacal insanity, nostalgic hypochondriacal insanity,
exaltation regarding religion, pride, vanity, ambition.
(3) Insanity of the propensities, instincts, or desires: Mania,
homicidal mania, suicidal mania, erotomania, dipsomania.
Maudsley's classification, according to the faculties thought to be
affected, {106} is also inconsistent: I. Affective insanity: (1)
Simple mania; (2) simple melancholia; (3) moral insanity. II.
Ideational insanity: (1) General (acute and chronic mania and
melancholia); (2) partial (monomania and melancholia); (3) dementia
(primary and secondary); (4) general paralysis; (5) idiocy and
imbecility.
The classification according to symptoms is most generally adopted,
being used, more or less modified, in Germany, generally in France,
and more commonly than any other in this country and in England. It
has been suggested by different writers in a dozen different forms,
differing only in details. Griesinger's is as follows:
(1) States of mental depression: Hypochondriasis; simple melancholia;
melancholia with stupor; melancholia with destructive tendencies;
melancholia with persistent excitement of the will or impulse (moral
insanity).
(2) States of mental exaltation: Mania; monomania.
(3) States of mental weakness: Chronic mania; dementia; idiocy;
cretinism.
As important complications of insanity he places general paralysis of
the insane and epilepsy, and various disorders of sensation and
movement, such as convulsive gait, general cramps, choreic movements,
hyperæsthesia of the skin, etc.
A classification according to the morbid condition of the brain has
thus far proved unsuccessful. Up to the present time this remains
largely a field of speculation, and even with the immense progress of
the past dozen years it is a subject upon which there is now little
definite to be said. Voisin's system is purely visionary—namely: I.
Idiopathic insanity, due to vascular spasm. II. Insanity dependent on
brain lesions: Congestive insanity; insanity from anæmia; atheromatous
insanity; insanity from brain tumors. III. Insanity from alterations
of the blood: Diathetic insanities; syphilitic insanity.
In basing his nomenclature on the clinical history of the various
forms of insanity, Clouston makes his classification as follows:
(1) States of mental depression (melancholia, psychalgia): (_a_)
Simple melancholia; (_b_) hypochondriacal melancholia; (_c_)
delusional melancholia; (_d_) excited melancholia; (_e_) suicidal and
homicidal melancholia.
(2) States of mental exaltation (mania, psychlampsia): (_a_) Simple
mania (folie raisonnante); (_b_) acute mania; (_c_) delusional mania;
(_d_) chronic mania.
(3) States of regularly alternating depression and exaltation (folie
circulaire, psychorhythm, folie à double forme, circular insanity,
periodic mania, recurrent mania).
(4) States of fixed and limited delusion (monomania, monopsychosis):
(_a_) Monomania of pride and grandeur; (_b_) monomania of unseen
agency; (_c_) monomania of suspicion.
(5) States of mental enfeeblement (dementia, amentia, psychoparesis,
congenital imbecility, idiocy): (_a_) Secondary (ordinary) dementia
(following acute or subacute disease, ending in chronicity); (_b_)
primary enfeeblement (imbecility, idiocy, cretinism), the result of
deficient brain development or of brain disease in very early life;
(_c_) senile dementia; (_d_) organic dementia (the result of organic
brain disease).
(6) States of mental stupor (stupor, psychocoma): (_a_) Melancholic
{107} stupor (melancholia attonita); (_b_) anergic stupor (primary
dementia, dementia attonita); (_c_) secondary stupor (transitory,
after acute mania).
(7) States of defective inhibition (psychokinesia, hyperkinesia,
impulsive insanity, volitional insanity, uncontrollable impulse,
insanity without delusion): (_a_) Homicidal impulse; (_b_) suicidal
impulse; (_c_) epileptiform impulse; (_d_) animal impulse; (_e_)
dipsomania; (_f_) pyromania; (_g_) kleptomania; (_h_) moral insanity.
(8) The insane diathesis (psychoneurosis, neurosis insana, neurosis
spasmodica).
Some of the German mental pathologists have endeavored to combine in
their classification the clinical history with the little that is
known of its morbid anatomy. Meynert has gone so far in this direction
as to have constructed an ideal mental pathology belonging to the
sphere of brilliant speculation rather than exact science. Schüle has
well summarized our knowledge on these points, as follows:
I. States of mental defect or degeneration. (1) States of mental
defect: (_a_) Microcephalism; (_b_) idiocy. (2) States of mental
degeneracy, chiefly as the result or further development of (_a_)
Hereditary insanity, impulsive insanity, moral insanity; (_b_)
insanity from the severe neuroses, epileptic insanity, hysterical
insanity, hypochondriacal insanity; (_c_) periodic and circular
insanity.
II. Insanity in persons of full mental and physical development:
(_A_) The cerebral neuroses causing mental disease, affecting
primarily the mind alone (psychoneuroses): (1) The acute or subacute
typical cerebral neuroses in healthy neurotic persons and with a
vaso-motor origin: (_a_) Primary form, melancholia, melancholia
agitata, simple mania; (_b_) secondary form, chronic mania and
monomania, dementia. (2) The chronic cerebral neuroses giving rise to
mental disease founded on degeneration and of neurotic origin
primarily (delusional insanity): (_a_) Primary monomania of
persecution, with a condition of pure mental depression or with
exaggerated and exalted ideas; (_b_) delusional insanity, strictly
speaking, psycho-convulsive form (maladie du doute), psycho-cataleptic
form (delusional insanity attended with anomalies of sensation).
(_B_) The organic mental diseases affecting the psychic functions
(cerebro-psychoses), differing from (_A_) chiefly in being
deeper-seated: (1) With motor symptoms of excitement (acute mania):
(_a_) Mania furiosa (including mania transitoria); (_b_) mania gravis;
(_c_) acute delirious mania. (2) With motor neuroses and symptoms
resembling catalepsy, tetanus, and anergic stupor, or the various
forms of Spannungsneurosen: (_a_) Melancholia attonita; (_b_)
delusional stupor; (_c_) primary dementia (stupor), acute and chronic.
(3) With progressive paralysis, the typical form of paralytic
dementia.
(_C_) The distinct lesions of the brain, giving rise secondarily to
psychical disturbances. The modified paralyses or cerebral diseases in
which dementia and paralysis are both observed clinically: (_a_)
Meningo-periencephalitis, chronic and subacute; (_b_) pachymeningitis
and hæmatoma; (_c_) diffuse encephalitis with sclerosis, without
mental excitement and with mental excitement; (_d_) diffuse
encephalitis with local softening, apoplexy, capillary aneurisms in
groups or singly, multiple sclerosis; (_e_) diffuse encephalitis
arising from foreign growths in the brain; (_f_) chronic {108}
periencephalitis, with previous tabes dorsalis; tabic paralysis: (_g_)
primary atrophy of the brain, with accompanying spinal tabes, tabic
dementia; (_h_) syphilitic encephalitis, with disturbances of the
mind.
Krafft-Ebing's classification is as follows:
_A_. Mental Diseases of the Normal Brain.—I. Psychoneuroses: 1.
Primary, curable diseases: _a_, Melancholia—_α_, Simple melancholia;
_β_, melancholia with stupor; _b_, Mania—_α_, Maniacal exaltation;
_β_, acute mania; _c_, Stupidity (primary dementia) or curable
dementia; _d_, confusional insanity (Wahnsinn). 2. Secondary,
incurable diseases: _a_, Chronic delusional insanity; _b_, terminal
dementia—_α_, with agitation; _β_, with apathy.
II. Conditions of Mental Degeneration.—_a_, Constitutional affective
insanity (folie raisonnante); _b_, moral insanity; _c_, primary
monomania—_α_, With delusions of persecution; _β_, with delusions of
ambition; _d_, with imperative conceptions; _e_, insanity from
constitutional neuroses—_α_, epileptic; _β_, hysterical; _γ_,
hypochondriacal; _f_, periodic insanity (folie circulaire).
III. Diseases of the Brain with Mental Disturbances
Predominating.—_a_, Paralytic dementia; _b_, cerebral syphilis; _c_,
chronic alcoholism; _d_, senile dementia; _e_, acute delirium.
_B_. Conditions of Arrested Mental Development.—Idiocy and cretinism.
Krafft-Ebing agrees with Schüle in dividing mental diseases into two
classes—those of a degenerative nature arising from the development of
an hereditary or congenital neurotic tendency, or from injury, sexual
or alcoholic excess, etc., and those which occur from what may be
called accidental causes in otherwise healthy persons, in whom mental
disease would not be anticipated, and from which the late Isaac Ray
said that, with sufficient exciting cause, no one has any privilege of
exemption. The essential distinction between them was pointed out by
Moreau and Morel, and is best stated by Krafft-Ebing:
Degenerative insanity is a constitutional disease arising from slight
exciting causes, even physiological conditions (puberty, menstruation,
the puerperal state, climacterium), but for the most part from
pathological conditions, chiefly hereditary predisposition, injury to
the head, acute disease, etc., occurring during development of the
sensitive brain, forming often the last in a series of neuropathic
disorders, such as spinal irritation, hysteria, hypochondria,
epilepsy. The tendency to recovery is slight, and generally there is
only temporary return to the primary condition. Relapses and
progressive development of graver forms of disease are common. There
is progressive hereditary mental degeneration or a strong tendency to
appear in descendants in progressively severer form. All forms of the
psychoneuroses occur, but of severe type and irregular course, with
sudden and rapid changes in the character of the disease, which does
not follow any particular course and cannot be definitely classified,
rarely ending in dementia, and often lasting in some form through
life. The tendency to periodicity is strong. Delusions are chiefly
physio-pathological as direct creations of the diseased brain,
entirely without apparent cause, to the astonishment of the person and
independent of his frame of mind at the time. They appear and
disappear, to be replaced by morbid impulses or mental weakness.
Delusions are strange, mysterious, monstrous, without possible
explanation from the {109} nature of the disease. There is, for the
most part, an inseparable transition from pathological predisposition
to actual disease, with a strange mixture of lucidity and diseased
mental perversion. Acts are often from impulse. There are sudden
outbursts or short attacks; as, for instance, in periodic, hysterical,
and epileptic insanity.
In psychoneuroses developed in persons of previously normal
brain-function heredity is only a latent predisposing cause. The
tendency is to recovery; relapses are infrequent. They are not so
readily transmitted to later generations. The disease follows the
course of some well-defined type. There is not a tendency to
periodicity. Delusions arise chiefly from psychological sources as the
result of diseased mental conditions. They are usually not early
symptoms, and in general they correspond with the prevailing state of
the mind. Delusions correspond with the mental state. The change from
health to disease is well defined.
These are the main features of the two classes of mental disease, but
the line between them is not a hard and fast one, and it is not seldom
impossible to place a particular diseased person definitely in the one
or the other.
The objection to all of the classifications of insanity now in use,
that they have not an accurate scientific basis, and that a diagnosis
must often be delayed or changed as symptoms develop, applies,
although in a less degree, to other diseases than of the mind.
HISTORY.—The history of insanity is probably as old as the human race,
although its rarity among savage nations at the present day, and its
greatest prevalence where there are the widest extremes of wealth and
poverty, indicate that it is essentially a disease of the high
civilizations. It is found even in the lower animals. It is described
in the early writers on medicine from Hippocrates and Plato down. The
ancient Egyptians had temples dedicated to Saturn, where they cared
for the insane with music and dancing. The Greeks and Romans treated
the sick, and probably some of the insane, in rooms adjoining their
temples. The monks of Jerusalem built an asylum for the insane of
their number in the sixth century. There were several asylums in
existence among the Moors in the seventh century, and it is thought
that at the time of their invasion of Spain they introduced them into
Western Europe. The monks, who were the chief depositaries of medical
knowledge in the Middle Ages, treated the insane, as they did to a
less extent each other, by flagellations, until St. Vincent de Paul
and the Knights of Malta proclaimed insanity a disease and treated it
as such. It would be idle to estimate how many were put to the rack,
burned, and otherwise maltreated as possessed of the devil or as
witches—how many were called prophets or saints.
As late as the last quarter of the last century the insane, when not
starving or neglected, were for the most part confined in jails and
poorhouses or kept in chains. In Scotland a farmer reputed to be as
large as Hercules was said to cure them by severity. In England the
practice of exhibiting the inmates of Bethlehem Hospital (Bedlam) to
the populace for a small fee was given up only in 1770. In Paris a few
of the insane were treated in general hospitals, and the asylums were
considered as receptacles for chronic cases, where the attendants,
often convicts serving out their time, were allowed to whip them. Van
Helmont recommended the sudden immersing of the insane into cold water
and keeping them {110} there for several moments—a remedy brought even
to this country. Rush says, as late as 1812, that by the proper
application of mild and terrifying modes of punishment (the strait
waistcoat, the tranquillizer chair, privation of customary pleasant
food, pouring water under the coat-sleeve so that it may descend into
the armpits and down the trunk of the body, the shower-bath continued
for fifteen or twenty minutes, and a resort to the fear of death)
chains will seldom, and the whip never, be required to govern mad
people. The intelligent ideas of the Egyptians, Greeks, and Romans
regarding insanity were degraded first by the Jewish, and then by the
Goth and Vandal, influences in Europe, until, after sixteen centuries
of perverse teaching, the stimulus given to all medical work by John
Hunter and Bichat, and to humanity by John Howard, prepared the way in
France for the philosopher-physician Pinel and his pupil the clinical
observer Esquirol. In Italy, Chiarruggi; in Germany, Langemann; in
England, Tuke; in America, Rush,—began the reform. Up to that time the
metaphysicians had nearly usurped the study of insanity. Hospitals for
the treatment of curable mental disease were built in Germany besides
the asylums for the chronic insane, but still sudden plunges in water,
rapid whirling around, and all sorts of shocks and surprises formed a
part of the treatment, while Heinroth, Pinel's leading pupil in
Germany, thought that all insanity began in vice, that its source was
a conscious neglect of God's will, that its best treatment consisted
in a pious life, and the only means of prevention to be in the
Christian religion. From that time to this, especially since the
metaphysical theory of insanity was abandoned, and more particularly
during the last quarter of this century, during which the theory of
physical disease as the basis of insanity has prevailed, there has
been a great and rapid advance in our knowledge of the pathology and
treatment of the diseases of the mind, so as to place them beyond the
pale of mystery, but on the same footing with other diseases, to be
treated on the general principles of common sense and medical science.
PREVALENCE.—It would be idle to attempt to say what proportion of the
population was insane at any time or in any country of the world until
the most recent years. In Massachusetts in 1820 there were under
custody in the one insane asylum in the State 50 patients, or 9.55 in
each 100,000 of the population. This number had increased to 11.34 to
every 100,000 people in 1830, 61.99 in 1840, 84.97 in 1850, 97.90 in
1855, 122.17 in 1860, 121.24 in 1865, 134.83 in 1870, 138.50 in 1875,
and 177.67 in 1880, in six State, one county, one city, one corporate,
and six private asylums. The number of the insane in asylums had
increased sixty times, and the rate proportionately to the population
had augmented more than eighteen times.
In the United States, even after due allowance for the fact that the
enumeration of the insane was quite complete for the first time in
1880, the following table shows a recent large increase in their
numbers. Of the 91,997 insane reported in 1880, there were 40,942 in
lunatic hospitals, 9302 in almshouses without special departments for
the insane, and 417 in jails. There are no statistics of the insanity
prevalent among the 265,565 Indians living in tribal relations by the
enumeration of 1883.
{111} CENSUS OF THE UNITED STATES.
_Population_.
-----+------------+------------+-----------+------------+-----------
Year.| Total. | Native. | Foreign. | White. | Colored.
-----+------------+------------+-----------+------------+-----------
1860 | 31,443,321 | 27,304,624 | 4,138,697 | 26,922,537 | 4,441,830
1870 | 38,558,371 | 32,991,142 | 5,567,229 | 33,589,377 | 4,880,009
| | | | | [2]
1880 | 50,155,783 | 43,475,840 | 6,679,943 | 43,402,970 | 6,580,793
| | | | | [3]
| | _Insane_. | |
1860 | 24,042 | 17,399 | 5,784 | 23,276 | 766
1870 | 37,432 | 26,205 | 11,227 | 35,610 | 1,774
1880 | 91,997 | 65,651 | 26,346 | 85,840 | 5,998
| | | | |
| | _Idiotic_. | |
1860 | 18,930 | 17,685 | 1,125 | 16,952 | 1,978
1870 | 24,527 | 22,882 | 1,645 | 21,324 | 3,188
1880 | 76,895 | 72,888 | 4,007 | 67,316 | 9,490
| | | | | [4]
-----+------------+------------+-----------+------------+-----------
[Footnote 2: Unknown, 55.]
[Footnote 3: Unknown, 148.]
[Footnote 4: Unknown, 1.]
INSANE AND IDIOTIC POPULATION IN THE UNITED STATES BY THE CENSUS OF
1880.[5]
--------+---------+----------+---------+--------+---------+--------
| | | | Negro | |
Total. | Native. | Foreign. | White. | and | Native | Foreign
| | | | Mixed. | White. | White.
--------+---------+----------+---------+--------+---------+--------
| | Insane. | |
91,997 | 65,651 | 26,346 | 85,840 | 5,998 | 59,600 | 26,240
| | | | | |
| | Idiotic. | |
76,895 | 72,888 | 4,007 | 67,316 | 9,490 | 63,314 | 4,002
| | | | | |
| | Of unsound mind. | |
168,892 | 138,539 | 30,353 | 153,156 | 15,488 | 122,914 | 30,242
| | | | | |
| | Population to 1 insane. | |
545 | 662 | 253 | 505 | 1,097 | 618 | 250
| | | | | |
| | Population to 1 idiotic. | |
652 | 596 | 1,666 | 644 | 693 | 581 | 1,642
| | | | | |
| Population to 1 of unsound mind. |
297 | 314 | 220 | 283 | 425 | 299 | 217
--------+---------+----------+---------+--------+---------+--------
[Footnote 5: Total population, 50,155,783; native, 43,475,840;
foreign, 6,679,943; white, 43,402,970 (unknown, 148); negro and mixed,
6,580,793; native white, 36,828,640; foreign white, 6,574,330;
civilized Indians, 66,407; Chinese, 105,465. Among the Indians there
were 53 insane, 84 idiotic, 137, or 1 in 485, distributed over 30
States and Territories; among the Chinese, 105 insane, 5 idiotic, 110,
or 1 in 959.]
In England and Wales in 1860, with a population of 19,902,713, there
were known to the lunacy commissioners 38,058 persons of unsound mind,
including the insane, idiots, and imbeciles, or 523 persons to 1 of
unsound mind. In 1870 this number had increased to 1 in 411. It seems
by the census of 1871, however, that there were 39,567 insane and
29,452 idiots and imbeciles, in all 69,019 of unsound mind, or 1 in
330 of the population. In 1880, with a population of 25,708,666, there
were known to the lunacy commissioners 71,191 persons of unsound mind,
or 1 to 362 of the population. The census returns of 1881 are not
available. The most recent statistics in Ireland indicate 1 person of
unsound mind to each 260 of the population by the census, and in
Scotland 1 in 362, according to the returns (not complete) to the
lunacy commission.
In the following list, after the original States, of which Vermont,
Maine, and West Virginia were parts later separated, the others are
given in the order of their having been admitted as States to the
Union, and finally the eight Territories. The States maintaining
slavery up to the time of the civil war are printed in italics. The
large proportion of insane persons in the District of Columbia is due
to the fact that the {112} government hospital contains so many
officers and privates who really belong to the several States; and in
California the insane hospitals have been used to a considerable
extent by the adjoining States and Territories.
By the United States census of 1880 there was 1 person of unsound mind
(insane and idiotic) in the United States to each 297 of the
population; in the _District of Columbia_, 1 in 169; Connecticut, 1 in
245; _Delaware_, 313; _Georgia_, 373; _Maryland_, 294; Massachusetts,
249; New Hampshire, 197; New Jersey, 326; New York, 251; _North
Carolina_, 270; Pennsylvania, 289; Rhode Island, 301; _South
Carolina_, 368; _Virginia_, 290; Vermont, 182; _Kentucky_, 261;
_Tennessee_, 259; Ohio, 232; _Louisiana_, 457, Indiana, 239;
_Mississippi_, 415; Illinois, 330; _Alabama_, 337; Maine, 226;
_Missouri_, 324; _Arkansas_, 371; Michigan, 328; _Florida_, 433;
_Texas_, 414; Iowa, 334; Wisconsin, 305; California, 286; Minnesota,
416; Oregon, 312; Kansas, 478; _West Virginia_, 263; Nevada, 1270;
Nebraska, 561; Colorado, 1104; Arizona, 1263; Dakota, 839; Idaho, 836;
Montana, 529; New Mexico, 434; Utah, 481; Washington, 412; Wyoming,
3464.