Insanity: Its Causes and Prevention

The subject of insanity, in its relation to both individuals and society, is becoming of greater importance every year. A larger measure of interest in relation to it has been manifest, not only in the writings of specialists, who have made it a study, and the care of its subjects a profession, but also in those of general practitioners of medicine and philanthropists, who are ever seeking to improve the conditions of society.

This results from two causes: 1, the change which has taken place in the public mind in relation to the nature of the disease, it no longer being regarded as something for which an individual is responsible in a larger measure than for other diseases, or as entailing a stigma upon those who are so unfortunate as to have experienced it, but rather a disease which invades the brain in the same way that diseases of another character affect other portions of the system, bearing with it neither more nor less of responsibility or disgrace; 2, and, as a result in part from this change, a more clear realization on the part of the public, that there exists an obligation to make provision for care and treatment of those who are deprived of reason, and consequently unable to care for themselves, to a larger extent than for any other unfortunate class in the community.

The obligation resting upon the strong to provide for those who become helpless from the effects of other forms of disease has long been acknowledged, but it is only within recent times that this obligation concerning those who become helpless from the effects of insanity has come into general recognition. Now, however, it is readily conceded that this unfortunate class appeals even more strongly for sympathy and aid than any other, more especially by reason of the consequences which result to the individual himself, as well as to his family, and the community in which he resides.

The lower we descend in the scale of existence, the less importance does the nervous system sustain in its relation to other systems of the entire body; and conversely, the higher we rise in the scale, the larger importance does it hold, until, in man, it reaches its highest relation, crowning all the others, and making its possessor supreme in the world of animal-life. When, however, disease invades the brain, and the individual no longer holds sway over the purposes evolved from his mental operations, he becomes the most helpless of creatures. Thought no longer follows the dictation of the will; designs or plans, for the present and future, are no longer possible. That intellectual power on which he so much prided himself, and on which his highest happiness and usefulness depended, has passed into darkness and confusion. Henceforth, if he is to be cared for at all, or treated for the amelioration of disease, or for recovery, it must be by friends on the ground of obligation, or by the public, in virtue of that charity which is the growth of civilization and religion.

Persons affected with other forms of disease may be cared for, in the most part, at their own homes and by members of their own family better than elsewhere, while the indirect influence of such care and surroundings is often of much service in promoting both the happiness and the recovery of the patient. But in the case of the insane the opposite is true: the atmosphere of home and the care of friends are unfavorable conditions. More often than otherwise, the disordered mind regards the oldest and dearest friends as the worst enemies, while the circumstances of home and scenes long familiar, are those which are the least calculated to improve the mind.

In most other forms of disease, individuals may exercise their own judgment or preferences in the selection of medical attendants, nurses, and such appliances as may be thought necessary to comfort and recovery; they more or less fully realize their own condition and requirements, are capable, in some measure at least, of controlling their desires and feelings, and of explaining their experiences, and are generally influenced by such favorable indications as may arise in the progress of their diseases.

But in the case of the insane all this is generally reversed. Individuals have little or no judgment by which to be guided, as to those appliances necessary for their care and treatment; they rarely recognize their conditions fully enough to feel the necessity for doing any thing, beyond yielding to those impulses which may be uppermost for the time being; they are not generally capable of controlling their own feelings, restraining their desires, or of intelligently realizing and describing their condition, or of caring for themselves.

These conditions, so peculiar and opposite to those existing in many other forms of disease, and the fact that even under favorable circumstances, the vast majority of insane persons cannot be cared for in private homes, except at greatest disadvantage to other members of the family as well as themselves, renders it imperative for the highest interests of society, that governments interpose and make provision for their care as wards of the State, in a greater or less degree.

It appears to have been only within the last half century that this obligation has become more fully recognized, and, in consequence, society seems to be striving to make amends for past neglect. Hospitals and asylums have been erected and equipped at large expense, and physicians, selected with reference to experience and efficiency, have been placed in the care of them. In some countries commissioners have been appointed whose duty it becomes to see that kindness and sympathetic care take the place of former neglect and cruelty; physicians and others, influenced by professional and philanthropic motives, have been active in efforts to secure measures for the most enlightened treatment and the most humane care for these unfortunate members of society, so that, in process of time, this charity has become one of the largest importance, affecting all classes and conditions of society, and influencing, directly or indirectly, every property-holder and every voter.

And, while it is a most melancholy truth that so large a number become insane and dependent on society for care, yet the fact, that society is so ready to recognize its obligation and respond so generously to it, appears to be a cheering and hopeful indication. So far as it goes, it indicates a diminution of selfishness and a growth of charity. It indicates that the more humane, sympathetic, and finer qualities of character are having a larger measure of influence in the tendencies of the present time.

* * *

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.

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INSANITY AND CIVILIZATION.

Information in reference to the character of the diseases which formerly existed among the aborigines of North America, or among uncivilized peoples of other countries, in the past, is both meagre and indefinite.

Legends concerning widespread epidemics of some forms of disease, especially the yellow fever and small-pox, among those tribes which formerly lived on the territory which now constitutes New England, have been handed down, and there must have occurred cases of insanity, to a greater or less extent, among all savage nations, arising from injuries to some portion of the nervous system; but, for the most part, those conditions and experiences of life which appear to predispose or excite the nervous system into diseased action, were probably absent.

Those who were born with weakened or defective organizations, either physical or mental, would, under the exposed conditions and the rude experiences of uncivilized life, hardly attain to adult age, even if they were not intentionally left to perish, so that the vast majority of those who did arrive at those periods of life during which insanity generally manifests itself, would probably possess such nervous organizations as would be little liable to become insane.

Their modes of living, also, being for the most part in the open air, and without excessive labor or exertion, except on occasions, and during short periods; and living in comparative freedom concerning those uncertainties of business and property which exist so generally among some classes, and even nations, under the conditions of civilized life; having few needs, and those of such a nature as to be easily supplied, would all be unfavorable to the development of insanity.

Again, uncivilized persons have but little sensitiveness, and are easily satisfied in reference to that long range of sentiment and feeling which holds so large a sway, and wields so strong an influence, in the lives of their brethern and sisters in civilized life; and, moreover, experience few of the annoyances, disappointments, and vexations which result from the habits and customs of our forms of domestic and business conditions.

Yet it appears to be a humiliating admission to make, that, with all the increase of mental power and range of thought, with acquired power over the forces of nature, with ability to convert the hidden treasures and forces of nature, into the means of supplying wants and ministering to comfort, and, with the vast storehouse of mental wealth which comes into the possession of mankind through the influences of civilization, there should, somehow, necessarily come with them, greater liability to such a calamity as insanity. This is, however, but one of many evils which invariably come into existence under the changed relations and circumstances of life, not only while passing from the habits of uncivilized life to those of a high state of civilization, but especially while living in the latter condition.

It is exceedingly difficult to differentiate, and accurately state in few words, what is signified by either insanity or civilization. Both are terms, the general signification of which, for practical purposes, is supposed to be well enough understood, but when we are called upon to give a clear and at the same time a fully comprehensive definition of them, there is much difficulty in doing it.

As has been very clearly shown by Dr. Arthur Mitchell,[2] civilizations may differ in different countries, as well as at different periods of time in the same country; they may be old or new, high or low, one thing in this century, and another in the next. That of the ancient Greek certainly differed widely from that of the Roman, while both differed largely from the European civilization of the present time.

In one view of the subject, that which regards it as something separate and distinct from those unfavorable conditions which always accompany its progress, we may say that civilization may be considered as the measure of perfection reached by society as a whole, toward living in harmony with its environments, in a civil condition.

But, inasmuch as no civilization has yet appeared among any people, so far as we know, or is soon likely to appear, free from those imperfections which affect even large numbers, some other more practical idea of its character will be necessary. For my present purpose it may be considered as the sum of results, which follow from the total of activities in operation among any people, while living under those conditions which always have pertained to civil life.

These results will vary even largely from one period of time to another, and will be partly good and partly bad. Indeed, I think it will be found that, in the degree in which nations have passed from those conditions which pertain to life in the savage state, upward toward those which abound in civilized life, in that measure has the sum total of diseased conditions, in both body and mind, increased; in this measure have there resulted degenerations of nerve element, and consequent failure to attain to and live in harmony with those artificial arrangements and conditions with which society in the civil state has, thus far in its history, uniformly surrounded itself.

In other words, while man has largely gained in some directions; while his mind has become more active and far-reaching in its range of thought, and many-sided in its activities; while the comforts and luxuries of life have become many times larger, by abandoning those conditions of life which pertain to the savage state, and assuming others of a vastly higher and more complex nature, yet, thus far in his history, he has not succeeded in surrounding society by such regulations, and in securing obedience to such laws, as will suffice to preserve and retain the health and strength of body which existed while in the savage state, except among the few.

That many of the conditions pertaining to modern civilization prove to be highly conducive to physical diseases, needs hardly to be said, and that they are no less productive of insanity and other diseases of the nervous system, will be evident from some considerations to be alluded to in connection with this discussion.

1. At first thought it might appear that the development and extension of civilization, which carries with it so many and great advantages in many other respects, should also be favorable to mental health. It is a law of the human system that the various organs become strong and maintain a high standard of health, only while under a considerable degree of activity, and this is especially true of the muscular and nervous systems. Inactivity and disuse tend toward degeneration, therefore, such circumstances and surroundings of life as will conduce to harmonious activity of these organs and parts, would, ceteris paribus, be most favorable to health.

Now the various portions and faculties of the human brain are brought into a state of full development and activity only under the conditions and influences of civilization; all of those higher and finer manifestations of thought, sentiment, and feeling, which pertain only to man; the satisfaction which comes from the results of mental activities both in relation to mechanics, education, governments, and the social amenities; the increase of strength pertaining to thought, and consequent self-reliance, and ability to rise above the adverse circumstances and experiences of life; freedom from the conditions of uncertain and limited supply, with attainment of those of a fairly certain and abundant character; the results which come from travel, and intercourse with persons of other nationalities; from trade, commerce, and intellectual pursuits; together with the possession of knowledge, which is power,-all come only from the conditions and influences of civilization, and should rather have a tendency to confirm and make strong mental health.

And this would undoubtedly be the result, if these were all, or indeed mainly, the effects attendant on living under the influences of civilization.

But, unfortunately, these are only some of the beneficent results of this change. Other influences, customs, and practices, and those of a character highly adverse to the maintenance of healthy mentality, have also come into operation, to a greater or less extent, and are especially potent in modern civilization.

With the increase of mental activity alluded to, there have come into a fuller range of activity those portions of the brain which are concerned with thought, and which, in the narrow limits and simple conditions before experienced, had been comparatively inactive. Consequently, a larger supply of blood has been summoned to these parts of the brain to repair the loss incurred by this increased activity. This change and consequent disturbance in the relative blood-supply, as between the brain and other parts of the system, would be of little importance if sufficient care be exercised that it comes in the right degree, and does not cause too great activity in the organ of the mind; indeed, there might be expected favorable results from a larger exercise of function, or at least not unfavorable ones.

In the experience of modern times, however, this has not proved to be the case. With the measure of mental power and scope which attends the change, there has been a large tendency to over-stimulate the intellectual faculties, which has been aided and thought to be necessary, in consequence of the immense competitions and business activities of modern civilization.

This tendency to stimulation has been manifest even to a much larger extent than formerly, first, in the matter of education. The new conditions and employments of life, rendered prominent by some of the discoveries which pertain to science, agriculture, commerce, and the general conduct of business pursuits, have developed requirements on the part of those who are called upon to conduct them, which have been heretofore unknown. To meet these requirements it has been thought necessary to pursue such courses of education, and to present such special incentives to study on the part of the young, by the use of prizes and grades of scholarship, and public exhibitions, as will bring into operation the largest possible activity, and secure the highest discipline of the brain, even at a very early period of life. At this time all the forces of vitality and physical growth are in the fullest activity, so that the strain comes upon the brain at the period when it has the least of ability to bear it, and at expense to other portions of the system.

And again, in the use of stimulants, especially alcohol, in some of its forms, and tobacco, during the period of growth and early manhood. The use of these substances, as well as the subject of education, in their effects upon the nervous system, will be discussed more fully in future chapters, and are only mentioned, in this connection, as causes of nerve degeneration, which have come into operation more fully through the influence of modern civilization.

2. One of the conditions of savage life, is that of a community of interests and supplies, to a large extent. Families and tribes seek for and possess supplies in common; the weaker depend upon the strong, and the strong aid the weak, so that when privations, from failure in the chase and other causes, may come, they affect all together, and generally in like degree. The passion of avarice is in a latent state; those who are strong do not thrive at the expense of those who are less so, while the latter depend upon aid from the former. Wealth and poverty and such distinctions as arise from these civil conditions are unknown.

Under the conditions and customs which pertain to civilized life, how great the contrast! All, or nearly all, is changed. Individuality appears at once. Each and every person, or family, is expected to rely upon his, or its, individual effort for success in obtaining such things as are necessary to comfort and well-being. In this he stands, in a large sense, isolated, and fails, or succeeds, by himself, alone, or with his family.

In other words, community of interests, except in some very indefinite and limited measure, is lost sight of, and swallowed up in those of the individual. In the conduct of life, the strong are almost sure, not only to neglect the weak, but often to tyrannize over them; they become selfish and not unfrequently covetous, and require much for little. The distinctions and conditions of society incident to wealth and poverty, knowledge and ignorance, appear, and the latter too often surrounds its unfortunate victim with such hardships and exposure, as tend rapidly, in too many cases, toward bodily and mental disease.

In this way the struggle incident to the conditions of civilized life, becomes tenfold greater than in savage life, for one portion of the community, and in this struggle, the weaker ones, sooner or later, tend toward the wall. The strong become stronger from the very conditions and influences which surround them, while the weak tend to become weaker, and many are almost sure to fall by the way. Ignorance, poverty, and unhealth are long-time companions, and lean strongly toward immortality.

Under the complicated conditions and antagonizing interests of civilization, the strong make the laws and establish the customs, which become obligatory upon all alike, and these will invariably be of such a character as will, in the long run, discriminate in their own favor. This has been apparent in all the older civilizations, especially in reference to the tenure of land; so that, once owned, always owned, might be considered as the law. Land, once in possession, continues in families for long generations, or indefinitely, unless it revert to the government. In either case its resources in ameliorating the conditions of the poor, and ministering to the productive wealth of the country, are greatly diminished, while under the influence and laws of a larger community of interests, it could be made productive toward the support and comfort of thousands who now live and die in poverty, want, and ignorance, and who, all their lives, from infancy to death, are in those circumstances of privation which render them specially liable to disease of mind.

But not only in respect of land does the tendency to unequal conditions manifest itself; it becomes apparent in reference to property in nearly all its other forms. In the conduct of commerce, manufactures, trade and exchange, in government itself, there exist vast ranges of opportunity unknown to savage life, for the strong to triumph over the weak: To him that hath shall be given, and he shall have an abundance, while from him that hath not shall be taken away even that which he appeareth to have. The rich have an abundance and surfeit, while the poor become poorer, and suffer for the requisites wherewith to become strong, or even to remain in physical health. To the one class pertain all those conditions which serve to invigorate and strengthen, while to the other pertain the opposite ones. To the one belongs abundance in the way of food, clothing, shelter, warmth, pure air, change, and education, while to the other pertain privation, insufficiency of food, impure air, overwork, ignorance, and a never-ending monotony and drudgery of life.

And in the history of the world, thus far, there has never appeared any high states of civilization without these unequal and inharmonious developments. No peoples have as yet ever learned the art of living under the conditions of civilization without them; no peoples have ever passed from the community of interests and possessions, which exists so largely in savage life, up to those conditions which pertain to civil life, except with attendant results similar to those already indicated; and these results are plainly those which tend largely toward the development of mental disease.

If the views presented in the preceding chapter and also in this, in reference to the tendency of insanity to increase, and which statistics appear to confirm, are correct, we perceive at once how important, in relation to both political economy and the future health and happiness of society, becomes the problem of this disease.

As a subject of science and philanthropy, it has for some years engaged the study and interest of many who have been desirous more fully to understand its bearing in both these respects; but in the no distant future, it will become the disease of paramount importance and interest to legislators and political economists; and as there exist reasons for supposing that, under the changing conditions of our modern civilization, it will more surely tend to invade the homes of many who have heretofore been exempt, and will in the future even more surely than in the past, affect all ranks and conditions of society, the increasing importance of making its causes a subject of investigation, and of endeavoring to prevent its increase, even in a limited degree, becomes at once apparent.

It may be remarked at the outset that many of the exciting causes of insanity are uncontrollable. We can do little, or nothing, toward changing or modifying the demands which are made upon us by the business operations of the present; nor toward modifying those great activities which are so loudly calling for development and conduct in life; we cannot do much toward changing the unequal conditions which pertain so largely in relation to property, occupations, and modes of living; or in avoiding the sufferings which result from the bereavements and disappointed expectations of life; we cannot, nor is it desirable, in all respects, if we could, do much to promote community of interests in property. But it is important to bear in mind that, after all, the prime condition of insanity lies, to a large extent, back of these exciting causes. Thousands have passed through such conditions and experiences, have suffered from disappointment and failure in respect to their plans and purposes; have endured exposures and hardships all their lives; all, without becoming insane, and thousands more will continue to do so in the future. It is evident, therefore, that there must exist back of these experiences, a state of the nervous system which renders it susceptible of the disease. This, it is, which is the prime factor in the problem of insanity; and it becomes of the first importance to discover, so far as we may be able to do so, in what this predisposing tendency may consist, or, at least in what ways, or through the operation of what causes, it more especially tends to come into existence and operation to so large an extent at the present time, and by what means it maybe avoided.

In this study we are proceeding along the same road we follow in investigations concerning other diseases. In a philosophical sense, there lies back of all manifestation of diseased action, an antecedent condition, which is the soil from which morbid actions spring. There exist the scrofulous, the phthisical, the gouty, the rheumatic diatheses, and, hence, the question of heredity is of the utmost importance in reference to many forms of disease.

"To many intents and purposes, we are born one generation at least, and generally more, before we come into the world. The soil whence the protoplasm of our grandfathers was formed, has a large significance in reference to ourselves. We limp, because they were gouty; we groan with rheumatic pains, because they slept in damp rooms; the neuralgic twinges of their fifth pair of nerves extend over into ours. The acid of the grapes, which our fathers ate, has acted on the enamel of our bicuspids and molars. That intangible tendency to weakness, to unhealth, so indefinable, so delicate, so inappreciable to our senses, is yet the mightiest factor in our being, and measures the amount of our physical pains and sufferings with a greater delicacy than we have been wont to think. It is the match, which needs only to be rubbed,-or the tinder waiting for the spark,-or the acid for the alkali.

On no other theory are we able to explain the effects, or absence of effect, from the exciting causes of disease. For instance: in one case cold produces neuralgia, in another rheumatism, in another pneumonia, in yet another bronchitis, and in the fifth person no morbid action at all. Now in these several persons there must have existed a primary or induced condition of the several parts affected, of such a nature, that a common cause, acting upon all alike, yet produced widely different results.

"Again, two persons may be exposed to the same atmospheric conditions, or be brought within a similar miasmatic influence, resulting in the one case in fever; in the other, in nothing. The miasm or poison was doubtless present in both systems alike, and, perhaps, in similar quantity, and yet in one case with no appreciable effect, and in the other, creating an illness which may continue for weeks or months. It is evident that there must have been, in the last case, a condition of the system which rendered the action of the miasm possible, and without which, it would have been entirely, or nearly, inert. In fact, strictly speaking, this cause, or antecedent condition, is rather a part of the disease itself, and cannot, in fairness, be separated from it. For, if disease be abnormal action, either in the structure or function of an organ, whether sufficient to be recognized or not, subjectively or objectively, then this weakness, inherited or acquired, becomes the chief factor, and those changes, which are sufficiently gross to be observed by our senses, and which we are accustomed to term disease, are only the remaining factors of it."[3]

I apply the same course of reasoning in relation to that necessarily antecedent condition of the brain, which renders it especially liable to become diseased through the operation of those ordinary exciting causes, which, to a greater or less extent, surround the lives of all persons, and which we term the Insane Diathesis. It becomes necessary, therefore, to study this peculiar condition of the brain, first, as to its nature, and, second, as to some of those causes which tend especially to create it.

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THE INSANE DIATHESIS.