CENSUS OF THEUNITEDSTATES.Population.
CENSUS OF THEUNITEDSTATES.Population.
2Unknown, 55.
3Unknown, 148.
4Unknown, 1.
INSANE ANDIDIOTICPOPULATION IN THEUNITEDSTATES BY THECENSUS OF1880.5
INSANE ANDIDIOTICPOPULATION IN THEUNITEDSTATES BY THECENSUS OF1880.5
5Total 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 thegovernment 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 theDistrict 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.
The proportion of the enumerated insane in asylums was—District of 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. Themore 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, forhereditary 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 foroccasional 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 ofRab 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 atlong 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 organicmental 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:
6Excluding 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,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:
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.
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.
A relation between pulmonary consumption and mental disease is frequently observed—partly, perhaps, due to general anæmia, in part to circulation of diseased blood in the brain, and partly from tubercular deposits. Other diseases act directly upon the brain and nervous system, as leptomeningitis, pachymeningitis, sclerosis, capillary aneurisms, embolisms, cerebral hemorrhage, tumors, disease of arteries, syphilis, caries, exostosis, abscess, internal otitis, sunstroke; still others by disturbances in the cerebral circulation, as diseases of the heart and kidneys; others by vitiating the blood circulating in the brain, as in the acute stage of febrile disorders; others in some general unknown way, as chorea, hysteria, epilepsy, gout, rheumatism, malaria, pneumonia; and still others during the period of convalescence or of general exhaustion, which is often associated with infectious diseases or chronic disease attended with general anæmia. The more violent and curable psychoses occur at the height of acute diseases, those of longer duration and of less favorable result during convalescence. Among other recognized causes are prolonged and obstinate dyspepsia, the psychological changes, if morbidly developed or attended with accident, at puberty, during pregnancy, at childbirth, during the puerperal state or lactation, and at the climacterium, and rarely various affections of the abdominal and pelvic organs.
Chronic alcoholism produces disease of the small blood-vessels of the brain and the consequences of that condition, causing insanity in a considerable proportion of cases, and almost always some mental impairment. Insanity occurs under conditions of cerebral hyperæmia and of cerebral anæmia, although their relation as cause and effect is very obscure. The habitual use of hasheesh gives rise to a disagreeable form of dementia, and so does opium, but more rarely. The effects of poisoning from iodoform, lead, mercury, bromide of potassium, hydrate of chloral, belladonna, tobacco, when reported as producing insanity, are usually transitory.
Cases have been reported of two persons being exposed to the same causes and having similar attacks of insanity (folie à deux), and also of folie induite or folie communiquée, where several persons have adopted the delusions of a person of influence among them, one of the most remarkable instances of which was the case of the seventeen grammar-school-taught Adventists of Pocasset, who accepted the insane belief of their leader, Freeman, that, like Abraham, he had been commanded by the Lord to kill his child, that she was to rise on the third day after hehad killed her, and that he was to become a great evangelist. So-called epidemic insanity, choreomania, and demonopathy belong in this class.
From untrained, ill-balanced men and women, whose lives are ill regulated, the ranks of the insane are largely filled. Insanity is often the ultimate wreck of a life ill guided, directed chiefly by caprice and passion and weakened by indulgence. In that case it is, like much habitual drunkenness, as much a fault as a disease. The individual will not behave with decency and propriety for so long a time that, finally, especially after the age when the brain begins to fail, he cannot.
SYMPTOMATOLOGY ANDCOURSE.—The distinguishing symptoms of insanity are mental. In some forms of insanity they are mental only; in others these symptoms are associated with others, such as also occur in diseases not necessarily affecting the mind. The earliest mental symptoms are change of character, increased irritability, less feeling of accountability, a lower moral tone, moral perversion, diminished stability, loss of interest, lessened power of concentration and self-control, impulsive acts, anxiety or the opposite condition of mind, perverted or exaggerated force of the emotions, restlessness, apprehension, sleeplessness, impaired will, slight depression or barely noticeable exhilaration: things and persons seem changed in some vague, unexplained way. There is an alteration in the way in which the person is affected by his surroundings.
The next symptoms are more purely intellectual. Delusions are often at first based upon some fact, and are merged into insane delusions only as the mind, in becoming weakened, loses power of comparison and judgment. Often they arise out of the disordered condition of mind. Hallucinations of any of the special senses, illusions, perverted ideas, mental confusion, mental hyperæsthesia or anæsthesia, delirium, stupor, exaltation, depression, impairment or loss of memory, quickened or dulled conception and perception, increased or diminished intellectual activity and acumen, distorted association of ideas, imperative conceptions, all sorts of anomalies of consciousness and free will, uncontrollable and uncontrolled insane impulses, are common. The intellectual and moral symptoms appear nearly or quite together in very acute disease, and they together increase in intensity, and finally entirely control the individual. Many of the insane recognize the fact of their insanity. Some of them understand the nature of their disease quite well, discuss their cases intelligently, and frequently ask why they, automaton-like, are impelled by a force which they cannot resist to constantly do things which their intelligence and better nature condemn. Not a few are confined in places of safety by their own preference.
The physical symptoms of insanity are perverted sensations of almost every conceivable kind, resulting in depraved instincts and acts, psycho-motor excitability, convulsive action, choreic movements, uncontrollable muscular agitation (springing, shouting, swearing, dancing, running, destructive tendencies, etc.), elevation or depression of pulse, respiration, or temperature, loss of appetite, digestive disturbances, pain, fever, tetanic and cataleptic rigidity, paralysis, tremor, ataxia, epileptic seizures, convulsions, muscular contractions, increased or decreased secretions and excretions, disturbances of general nutrition.
The course of the various mental diseases is to a great extent chronic, some forms being incurable from the beginning, others curable to suchan extent that of recent cases from one-half to nine-tenths recover, of whom a considerable proportion remain well to their death. The duration of the mental diseases is from a few days to a lifetime, sometimes not even shortening life. The termination is oftenest in incurable chronicity or dementia, less often in permanent recovery without recurrence, and still less often in death from the first attack. Unfortunately, the essentially incurable and the curable forms of mental disease are classed together in statistics of insanity. While many types are absolutely fatal or certain to end in hopeless chronicity or dementia, others tend to recovery. In some forms relapses and recurrent attacks are to be expected: in others they seldom occur. In many cases there is no more probability of transmission to children than in Bright's disease, and no more likelihood of subsequent attacks than in typhoid fever.
MORBIDANATOMY ANDPATHOLOGY.—It is thought by the best observers that insanity depends upon a functional brain disturbance, or at least upon a disordered condition which it is beyond our present power to discover, and that the normal working of the mind depends upon a brain healthy to such an extent that its millions of functional activities, in their endless relations to each other, preserve a state of equilibrium; or, in other words, that the higher centres maintain their power of control over the lower. It is doubtless true that this relation depends in general upon a healthy brain, but it is not yet known to what extent. Disease of the brain or its membranes, apparently slight, often seems to cause insanity, and often there is marked disease without insanity. We certainly cannot place all the pathological conditions found in the brain of a person dying insane in direct causal relation to his insanity. The anæmia observed by Meynert in melancholia and the hyperæmia of maniacal excitement, even if proved to be universal in those conditions, may be only symptoms of the underlying disease or caused by it. It is certain that there are indications of as great anæmia or hyperæmia in other states without insanity.
Insanity in its initial stage does not, as a rule, involve a recognizable deviation from the normal structure of the brain, and the patient may die before such pathological changes are so manifest that we can detect them. But if the disease has been of long standing, in the majority of cases the brain shows evident marks of disease, and there may be found no striking indication to the naked eye of deviation from a healthy condition, when a microscopic examination reveals signs of advanced cerebral disease. The limited knowledge of the cerebral structure and function which pathologists possess, and the consequent difficulty in detecting changes from the healthy state, indicate that the failure to find them is attributable in not a few instances to the fault of the investigator rather than to the nature of the disease. Certain it is that the better acquainted we have become with the anatomy of the brain and with its functions and sensible qualities, and the more thorough and painstaking we have been in our examinations, the rarer it has become to find a case of insanity where no organic changes are observed after death, although it is true that we do not understand all the relations between these changes and the symptoms observed during life.
A large abscess of the brain, a hemorrhage, a tumor, or a wound of the cortex or other portion of the brain, various degrees of inflammation,meningitis, are sometimes followed by insanity and sometimes not; and we do not yet understand the reason for the difference. Indeed, nearly every pathological condition of the brain known in insanity—in kind, if not in extent and degree—may be found in diseased or injured brains where there has been no mental disease in consequence. There is only one disease, general paralysis of the insane, in which the morbid appearances discoverable after death with our present knowledge bear a definite relation to the most constant manifestations during life. And yet, with pathological changes so similar that we are not able to detect their essential difference, the mental symptoms of the first stage of general paralysis may be most various. Rosenbach has found in the brains of starved dogs and guinea-pigs as extensive changes as in well-marked primary dementia, in which the pathological conditions are more extensive than in any other form of acute insanity.7That is to say, when we have discovered and described all the morbid appearances in the brain of an insane person we have taken only the first step in accounting for his insanity.
7Centralblatt für Nevr. Psych. und ger. Med., 1884, p. 33.
The localization of many of the cerebral functions, the discovery of a psychomotor tract, and the constant accessions to our knowledge of the physiology of the brain are throwing much light on the subject. But all efforts to localize the intellectual and moral functions of the brain, except generally to agree with the teachings of a century ago and to place them for the most part in the anterior and antero-lateral portions of the cortex, have thus far failed of success, the most careful observers still thinking that local lesions when apparently causing insanity do so by injuring the action of the brain as a whole, and not of any particular part.
In some cases of insanity, with never anything like acute disease, where death occurs from the weakness of old age or some intercurrent malady, the brain does not present any recognizable difference from those of sane people whose brains have worn out with their bodies. In those forms of mental disease where changes are found, the most important and constant are in the cortex of the brain, especially in the fore, upper, and middle parts of the periphery, involving usually also the membranes. In beginning acute mania the condition of the blood affecting the brain or the pathological changes are probably as nearly identical with those in the acute stage of pneumonia, certain forms of typhoid fever, cerebro-spinal meningitis, and other diseases as the symptoms of the mania are now and then difficult to differentiate from those of the other diseases just mentioned. In rheumatism, syphilis, malarial poisoning, and Bright's disease with mania we find no distinctive pathological conditions to account for the maniacal symptoms.
If asked whether there is a fixed lesion of the brain or any of its parts corresponding to given psychological changes, we should be obliged to say no, except in the case of incurable dementia. If asked whether there are important morbid changes corresponding with all cases of insanity, we can only say yes, sooner or later, in the majority of cases, and that there are certain destructive lesions, chiefly inflammatory, atrophic, and degenerative, which invariably mean marked deterioration of the mind. As regards diseases of other organs than the brain, the insane, like the sane, die of all of them, and in especially large numbers of pulmonary consumption.