Columbia, 90.6 per cent.; Connecticut, 39; Georgia, 36.8; Maryland,
49.1; Massachusetts, 60.1; New Hampshire, 27.1; New Jersey, 67.8; New
York, 57.2; North Carolina, 13.2; Pennsylvania, 36.1; Rhode Island,
57.3; South Carolina, 38.2; Virginia, 45.5; Vermont, 44.7; Kentucky,
50.7; Tennessee, 16; Ohio, 48; Louisiana, 44.9; Indiana, 26;
Mississippi, 33.7; Illinois, 42.7; Alabama, 24.5; Maine, 26.1;
Missouri, 40.7; Michigan, 41.5; Florida, 30; Texas, 22.3; Iowa, 37.8;
Wisconsin, 48.6; California, 80.3; Minnesota, 61.8; Oregon, 65.5;
Kansas, 31.9; West Virginia, 40.1; Nebraska, 38; Colorado, 34.3. In
Arkansas and in Nevada there was no insane asylum in 1880, and in
Delaware the insane were sent to a Pennsylvania asylum or to the
almshouse. In the Territories the provisions for the insane are very
incomplete.
The statistics just given indicate an enormous increase in the numbers
of the insane who become a public charge, and the figures gathered
from all countries prove conclusively that more insane people are
known to be in existence proportionately to the population from decade
to decade. The question naturally arises, Is insanity increasing as
fast as appears at first sight to be the case, or is the increase
apparent rather than real?
In the first place, the definition of insanity has so widened of later
years as to include vastly greater numbers of the population than
hitherto. The nice adjustment of social relations in a high order of
civilization and greater medical skill make insanity easier of
detection. Large numbers of persons now confined would have been
considered far from being fit subjects for insane asylums a half
century ago. Again, it is hardly a generation ago that we began taking
proper care of the insane. Some States have hardly commenced yet, and
even in the oldest parts of our country many of unsound mind are kept
neglected and squalid in town almshouses or county jails. Wherever
humanity has demanded improved accommodations for the insane they have
accumulated enormously, from the simple fact that they are protected
like children, and kept from dying of neglect, suicide, and
exhaustion. In other words, science and humanity have prolonged their
lives of illness, in some cases to as much as tenfold their natural
length if they had been left to themselves, even where nothing can be
done but to prolong their misery. The {113} more intelligent views now
held of insanity as a physical disease rather than a family disgrace
have led people to be less backward in reporting their insane
relatives as such, while the increasing number of insane asylums and
the growing confidence in them have brought many of the insane to
notice who formerly would have been concealed in attics and cellars
and never mentioned.
Whether or not more persons become insane each year in proportion to
the population we have no methods of determining statistically. The
mortality returns in Massachusetts for the last five census years show
that the deaths from insanity, paralysis, apoplexy, softening of the
brain, and unspecified diseases of the brain, including cephalitis,
were 12.06 per 10,000 inhabitants in 1860, 14.39 in 1865, 14.95 in
1870, 16.42 in 1875, and 17 in 1880; which would probably indicate an
increase, even after allowing for a considerable source of error due
to inaccurate diagnoses, imperfect registration, and the influx of a
large foreign population. It is claimed that the table on page 111
indicates a direct importation of insane persons from Europe. It is
certainly a curious fact that the proportion of idiots and of the
insane differs so little in the native population, and that among
foreigners the idiots, who could not easily be sent here without being
detected and sent back, are less than one-sixth of the number of their
insane. But it is also true that the amount of insanity among
strangers in a foreign land would naturally be greater than among
those who are at home.
The prevalence of insanity as compared with other diseases at the
present time may be fairly estimated from the statistics of
Massachusetts for twenty years, where there were 604,677 deaths
reported, including 2145 from suicide, 1995 from insanity, 1838 from
delirium tremens and intemperance. The reported deaths from pulmonary
consumption are fifty times as many as from insanity; from diarrhœal
diseases, thirty times; from pneumonia, twenty times; from diphtheria,
including croup, fifteen times; from scarlet fever, heart disease, and
typhoid fever, each eleven times; from accidents, ten times; from
cancer, five times; from childbirth and measles, each more than twice
as many. The average death-rates reported from insanity per 100,000
inhabitants were 6.24 from 1861-70, and 7.12 from 1871-80, whereas the
increase in the number of admissions to Massachusetts insane asylums
in the twenty years was from 846 to 1610. The total number of insane
people living in the State is less than the number of consumptives
dying each year, and far less than the number of syphilitics.
CAUSATION.—It is clear that only a small proportion of the human race
is liable to become insane, and one can only wonder that so few brains
are overthrown by the multiplicity of causes in modern life which tend
to disturb those “invisible thoroughfares of the mind which are the
first lurking-places of anguish, mania, and crime.” When we come to
investigate the causes of mental disease, we find that they are of two
kinds—remote or predisposing and immediate or exciting. They are also
moral or mental and physical.
Among the predisposing causes heredity includes nearly or quite 75 per
cent. of all cases, and is easily first; in considering which not only
the immediate parents are to be taken into account, but also the
collateral branches, grandparents, uncles, aunts, sisters, brothers,
and cousins, for {114} hereditary insanity often skips one generation,
and even appears, sometimes, first in the child, then later in the
parent. An insane parent may have several children, of whom some may
be exposed to the exciting causes of insanity and become insane,
transmitting their disease, intensified or not, to their children,
while others may avoid the exciting causes of mental disease, escape
insanity, but yet transmit to their children a temperament
predisposing them to disorder of the mind, which becomes the
starting-point for actual mental disease as soon as the exciting
causes are sufficient to develop the taint. If the exciting causes do
not appear, however, in that generation, and wise marriages are made,
the stock returns to the normal healthy standard and the disease
disappears from the family. The same form of disease, too, is
frequently not transmitted from parent to child or grandchild, but the
neuroses, the psychoneuroses, and the cerebro-psychoses, the
degenerative forms and the developed forms, are interchangeable. In
the ancestry of insanity we find not only actual cerebro-mental
disease, but epilepsy, brain disease due to syphilis, habitual
drunkenness, any of the severe neuroses, apoplexy, pulmonary
consumption, a closely-allied disease, and suicide. Very often the
patient's friends think that there is no hereditary predisposition to
mental disease, when the physician trained to study such cases would
discover so strong a taint that he would not expect all of several
children to escape insanity or some of its allied diseases even in a
case where there had not been actual insanity in the family for
several generations. For instance, where one parent is habitually
using alcoholic liquors to such a degree as never to be drunk, and yet
rarely quite himself, with the other a sufferer from one of the severe
neuroses or cerebral diseases, a single child from such a marriage
might stand a fair chance of inheriting and retaining mental health,
but if several children should be born the chances that all would
escape mental disorder are few. Again, if one parent were the victim
of that intense intellectual strain and moral perversion so often seen
in the eager pursuit of position and wealth, and the other, straining
to keep up in the race, died early of pulmonary consumption, if there
had been in the family cases of convulsions, chorea, apoplexy, or
suicide, and if some member were hysterical or, without sufficient
external cause, unreasonable, anxious, irritable, full of baseless
fears, there might have been no insanity in the family, and yet a
tendency to insanity might be transmitted to a considerable proportion
of the offspring. On the other hand, the existence of a number of
cases of insanity in a family may be due to external or accidental
causes, and not indicate any general taint.
It is true that there are families in which insanity occurs where the
allied neuroses do not often appear, and that various diseases of the
nervous system may be frequent in a stock in which insanity is rare or
absent. A person who has recovered from an acute attack of
cerebro-mental disorder, if previously healthy and without hereditary
predisposition to such diseases, may marry and not transmit to
offspring either insanity or any of its allied diseases, while it is
not uncommon for an individual seemingly the least liable to mental
disease of a whole family to become insane, leaving several brothers
and sisters with ill-balanced minds to get through life without
breaking down, the morbid energy in the latter case expending itself
in irregularities of conduct and of mental operations as fast as it is
created, instead of being stored up for {115} occasional outbreaks.
The degree to which insanity may be expected to follow any given
antecedents can only be estimated very approximately, as the laws of
heredity are very little known, and as there is a tendency in nature,
so strong that it is constantly asserting itself, to return to the
healthy type if it has a chance. But, in general, it may be said that
the more individuals of both branches in whom insanity and its allied
diseases are found, just so far may a larger proportion of the
children be expected to suffer. The character of the particular
disease or tendency to disease which is likely to develop from any
given antecedents is still a very obscure matter. But the case is
often clear enough to justify the remark that if childhood has any
rights it has the right to be born healthy.
It must be admitted that geniuses and men of extraordinary talent
appear in families tainted with insanity, and, indeed, that
comparatively few families have had distinguished men among them for
several generations without also showing a considerable number of
insane members. Schopenhauer, “mad Jack Byron's son,” and Johnson—who
said that his inheritance made him mad all his life—are conspicuous
examples of this well-known fact; and it is also observed that
children and grandchildren of men distinguished for their great
intellectual powers are subjects of degenerative mental disorders, or
at least are of less than ordinary mental capacity and moral force.
The sound and the unsound, too, may exist together in the same mind,
each acting in certain ways independently of the other, and
cerebro-mental disease not seldom, occurs in persons of the highest
intellectual attainments. Dean Swift, with his delusion that parts of
his body were made of glass; Bishop Butler, tormented all his life by
his morbid fancies; Chatterton, committing suicide in an attic;
Rousseau, Tasso, Pascal, Comte, Beethoven, Charles Lamb, John Bunyan,
the author of _Rab and His Friends_, Schumann, Shelley, Cowper,
Swedenborg, and the epileptics Julius Cæsar, Mohammed, and
Napoleon,—are only a few of the many illustrations of this law. In the
descending scale from insanity we find also crime, drunkenness, and
all sorts of moral perversions, which may be its antecedents also.
Even a man's self-indulgences may be intensified as mental or moral
degeneration in his children. The degenerative processes may go on
where there is intellectual stagnation in small communities, with the
vices of civilization, as well as in the crowd, producing a large
class of persons for whom doctors have only compassion, considering
them as invalids although treated as responsible by law and society.
It is difficult to estimate the influence of intermarriage as
predisposing to insanity. The history of the early Ptolemies, of
numerous savage or uncivilized races, and of many selected cases in
the enlightened world may be quoted to show that it is often attended
with no evil results; and there are other causes of degeneration in
the royal families and aristocracies of Europe and in the cases of
individuals where intermarriage of relations has resulted in
deterioration of stock. It is, at all events, certain that marriages
may be made so as to intensify morbid tendencies or so as to eliminate
them—to produce a race of clear heads with sober judgment, or a race
part of whom shall be great sufferers from neuralgia or mental pain;
another part ill-balanced or explorers in fields of thought and action
never tried by calmer intellects, perhaps with now and then at {116}
long intervals a genius; a third part morbid and brilliant or stupid
and imbecile; and still a fourth part near enough to the normal
standard of mental health.
Undoubtedly, a great portion of the mental and nervous disorder
commonly attributed to heredity is largely caused or aggravated by
imitation and by vicious training of children. Schopenhauer says that
the normal man is two-thirds will and one-third intellect—in other
words, two-thirds made by education and one-third by inheritance. The
intellect is often trained so as to enfeeble the will as well as to
hinder the development of the physical man. Self-culture may so
degenerate into self-indulgence as to destroy individuality and force;
and mental health, as a rule, depends upon bodily health and the
exercise of self-control.
In the uncivilized and half-civilized races of the world insanity is
rare; in the early civilizations the insane perished from neglect,
were hanged and burned, starved and died in famine and pestilence, and
fell among the foremost in war. Some of the tribes of North American
Indians shoot the insane, considering them possessed of evil spirits,
while their white neighbors keep them in chains and squalor.
Civilization brings better food, clothing, and shelter, and less
danger from war, famine, and pestilence than savage or mediæval times.
In the struggle for existence, however, physical strength no longer
wholly wins the day, but also those faculties that involve great
mental and bodily strain in mines, factories, crowded tenements,
counting-rooms, offices; in the eager, excited over-study for prizes
or rank in overheated, badly-ventilated schools, and, indeed, in every
walk of life. People with marked neuroses, who would have gone to the
wall a couple of centuries ago from want of physical strength, now
support themselves by indoor light work, marry, and reproduce their
kind. Minute division of labor involves monotonous toil and increases
the impairment of the body's resistance to mental and nervous strain,
and abuse of the nerve-stimulants tea, coffee, tobacco, or, worst of
all, alcohol and narcotics, add to the evil. Degeneration due to the
reproduction of poor stock is intensified by intermarriage. Luxury,
idleness, excesses, syphilis, debility, drunkenness, poverty, disease,
and overwork produce vitiated constitutions in which varying types of
insanity appear in various nations and climates, but, so far as is
known at present, not in very different degree under similar
conditions. One of the great problems of the day is whether the many
conditions incompatible with health in our crowded populations can be
overcome so as to prevent the degeneration going on thereby.
In early life chiefly the degenerative or the hereditary type of
insanity occurs, or some modification of it. The prevalent forms
coming next are insanity of puberty and adolescence and the curious
morbid psychological developments of lying, stealing, running away
from home, all sorts of perversity of action and thought—impulse
overpowering reason; often resulting in cure if wisely treated, but
not seldom ending in various forms of so-called moral insanity,
suicide, epilepsy, hysteria, primary insanity, prostitution, and
offences against the laws. It is largely a matter of accident rather
than a result of any established principle whether such boys and girls
are sent to reformatories and prisons or to insane asylums. In the
progressively advancing years of life organic {117} mental disease and
the psychoneuroses are more common, the favorable or unfavorable type
of which depends largely upon the degree of degenerative tendency in
each case.
The exhaustion and the disturbed cerebral circulation arising from
acute and chronic diseases, profound anæmia, or prolonged mental
strain, associated with emotional disturbance from any cause, are
among the antecedents of insanity. By our asylum reports ill-health is
second only to intemperance as an exciting cause of insanity, and
ill-health comes probably more largely from poverty than from any
other direct cause. Diseases and accidents to the mother during
gestation and injuries to the infant's head during parturition may
reasonably be supposed to so affect the fœtal brain as to predispose
to insanity in later life.
Of 18,422 admissions tabulated from reports of Massachusetts asylums,
the prevalence of insanity by ages was approximately as follows:
------------------+-------------+-----------------+---------------
| | | Admissions per
Age. | Number of | Population by | 100,000 of
| Admissions. | Census of 1875. | Population.
------------------+-------------+-----------------+---------------
15 and under | 366 | 312,103[6] | 117
15 to 20 | 1,380 | 165,936 | 832
20 to 30 | 5,269 | 310,861 | 1695
30 to 40 | 4,632 | 240,966 | 1922
40 to 50 | 3,372 | 182,823 | 1789
50 to 60 | 1,797 | 126,430 | 1421
60 to 70 | 976 | 79,186 | 1106
70 to 80 | 382 | 38,283 | 997
Over 80 | 58 | 11,167 | 519
Age not reported | 190 | 10,302 |
+-------------+-----------------+--------------
Total | 18,422 | 1,478,057[6] | 1246
+----------------------------------------------
Total of all ages | —— | 1,651,912 | 1115
-----------------------------------------------------------------
[Footnote 6: Excluding those under five years of age.]
Of the 36,762 persons of unsound mind known to the English lunacy
commission in 1859, there were 31,782 paupers, or 86.45 per cent., as
compared with 4980, or 13.55 per cent., supported by themselves or
their relatives. At the close of 1880, of 73,113 insane, 65,372, or
89.41 per cent., were paupers, and 7741, or 10.59 per cent., were
private patients or self-supporting. The increase in the number of the
latter from 1859 to 1883 was from 2.53 to 2.96 per 10,000 of the
population, or 17 per cent., and of the pauper insane from 16.14 to
25.72, or 59 per cent., while general pauperism had rapidly diminished
from 43.7 to 29.5 per 1000 inhabitants.
Similarly, of 9541 admissions to the State hospitals for the insane in
Massachusetts from 1871 to 1880 inclusive, there were 4166 State
patients, 4050 supported by cities and towns, and 1325 private
patients; in other words, 86 per cent. were supported by public
charity. Of 7963 admissions in the same time in which the nationality
was stated, 4532 were natives and 3431 foreigners, respectively 57 and
43 per cent., whereas by the census of 1875 the natives were 74.64 per
cent. of the population, showing more than twice as great a percentage
among foreigners (chiefly laborers) as among natives. It is quite
clear, therefore, that insanity is more prevalent, or at least
increasing more rapidly, {118} among the lower parts of the social
scale than higher up; but it is impossible to say how many people have
dropped from higher planes of life to lower.
Although women are probably more predisposed to insanity than men, and
men more exposed to its objective causes than women, it is not certain
that more insanity occurs in either sex. It is somewhat more prevalent
in single and widowed and divorced people than in those married. The
period of greatest prevalence is earlier in women than in men.
Insanity prevails not only at a time of life when the strain on mind
and body is great, as is shown by the preceding table, but also in
those places where the effort is most intense. That fact is well shown
in the distribution of insanity over the State in the large and small
towns, being greatest where the concentration of population brings
with it extremes of poverty and wealth, as indicated by the following
table, showing the number of admissions accredited to cities and towns
in the McLean, South Boston, and State hospitals for the insane per
100,000 inhabitants from 1871 to 1880, the difference being
exaggerated by the proximity of the hospitals and greater ease of
commitment in the larger towns:
-------+------------------+-------------+-----------+--------------
| | | | Insane
Number | | Inhabitants | | Patients
of | Population. | by Census | Insane | per 100,000
Towns. | | of 1875. | Patients. | Inhabitants.
-------+------------------+-------------+-----------+--------------
341 | The State | 1,651,912 | 5689 | 344
1 | Boston | 341,919 | 1987 | 581
12 | 20,000 to 50,000 | 405,655 | 1486 | 367
42 | 5000 to 20,000 | 367,957 | 1193 | 324
286 | 5000 and under | 536,381 | 1023 | 190
-------+------------------+-------------+-----------+--------------
Of 9381 men and 9041 women admitted to our asylums, 7435 were married,
8193 single, and 1620 widowed or divorced. Of the 9381 males, 2215
were laborers, 1357 farmers, 313 clerks, 62 clergymen, 59 physicians,
43 lawyers, 201 students, of whom 114 were in school. Of 4673 females,
52 were school-girls.
The exciting or immediate causes of insanity are usually so complex
that many of the statistics on that point conform to the preconceived
views of the various compilers of them, as it is very easy to pick out
a few from the many; but out of a large number of persons exposed to
the alleged causes of insanity, one can never feel certain how many,
nor indeed what, individuals will become insane.
It is not always easy to say how and when the furrows left in the
brain by the mental and so-called moral causes of insanity have
deepened into actual mental disease. Prolonged emotional and mental
strain or severe mental shock often are directly associated with the
immediate appearance of insanity. In armies, among people separated
from their homes, in prisons, insanity oftener occurs than among the
same people at home. Severe grief, disappointment, great and sudden
joy or success, chagrin, fear, religious or political excitement,
wars, pestilences, domestic or business troubles, poverty, and
misfortune are among the commonly-reported moral causes of insanity,
as are certain occupations involving steady and monotonous toil,
especially if involving mental worry or necessitating unhappy
relations.
{119} Of the physical exciting causes of insanity, intemperance in the
use of alcohol is easily first: luxury and excess in eating, drinking,
and sexual indulgence, especially if associated with overwork or
physical inactivity and mental anxiety, are also dangerous. It is
difficult to estimate the influence of syphilis except when giving
rise to coarse disease of the brain. Masturbation acts as an exciting
cause, chiefly by creating a morbid psychical state and by exalting
the sensibility of the nervous system, but probably not often, even
with the young. Injuries to the brain and nervous system are usually
slow in their operation, unlike the severe mental shock which is at
once followed by insanity. Pain also, if intense, like great loss of
blood, acts slowly by wearing out the powers of resistance, or rapidly
by producing delirium.