COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD f HX641 30010 RC601 .St3 Insanity: its causes RECAP Columbia ®mher)SJttp ^ttnma SItbrarg i %*- INSANITY: ITS CAUSES AND PREVENTION BY HENRY PUTNAM STEARNS, M.D. SUPERINTENDENT OF THE RETREAT FOR THE INSANE, HARTFORD, CONN.; LECTURER ON INSANITY IN THE MEDICAL DEPARTMENT OF YALE COLLEGE, ETC., ETC. " It is the mynde that makes good or ill, That maketh wretch or happie, rich or poore." Spenser — Faerie Queene^ Book XI, Canto IX. NEW YORK G. P. PUTNAM'S SONS 27 & 29 WEST 23D STREET 1883 Copyright by G. P. PUTNAM'S SONS 1883 Press of G. P, Ptitnams Sons New York TO JOHN SIBBALD, M.D., F.R.S.E., COMMISSIONER IN LUNACY FOR SCOTLAND, IN PLEASANT REMEMBRANCE OF A PORTION OF OUR STUDENT-LIFE PASSED TOGETHER, THIS BOOK IS INSCRIBED WITH SINCERE REGARD BY HIS FRIEND, THE AUTHOR. Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/insanityitscauseOOstea PREFACE. IT is something more than two years since I read a paper, entitled "The Insane Diathesis," at a meeting of the Connecticut Medical Society. The numerous requests received for copies of that article have led me to think that something more in detail in relation to the prevention of insanity might be desired by the reading public both lay and professional. Hence this little book. It has not been written for specialists exclusively, though it is hoped it will not prove wholly uninteresting to them, but rather for those in the general practice of medicine, educators, and the more intelligent lay members of society. It has been written during odd snatches of time and with many interruptions, so that there ex- ists less uniformity of style than there would otherwise be. Moreover, some of the subjects presented have been discussed by me in papers v which have already been published. These papers, however, so far as they have been introduced into this work, have been rewritten, and, it is thought, improved. H. P. S. Hartford, Dec, 1882. CONTENTS. CHAPTER I. PRELIMINARY. PAGE. Increase of interest in the subject of insanity, resulting from, first, more intelligent views concerning its nature ; and, second, the obligation to make provision for the care of the insane in a larger measure than for other unfortunate classes — ■ — Results in the way of hospitals — Asylum attendants — Change in the modes of management, and care of the insane . . 3 CHAPTER II. INCREASE OF INSANITY. Indications which point to the probability of its increase in a greater ratio than that of the population : (i) in relation to the general conditions of society ; (2) in occupations ; (3) in the character or tendency of disease — Increased demand for hospi- tals for the insane not a conclusive evidence of increase of in- sanity ; other reasons exist for this — Improvements in hospitals — The chronic as well as the acute insane now provided for more generally than formerly — Accumulations in asylums — Statistics — Those of England and Scotland — Their character and import as presented in the yearly reports of the Boards of Lunacy Commissioners . . . . . . .11 CHAPTER III. INSANITY AND CIVILIZATION. Prevalence of disease among savage nations — Conditions of life not such as to produce insanity — Definitions of civilization — Several conditions attending civilization combine to increase diseases of the brain — Increase of brain activity — Over-stimu- lation of the brain in schools and by the use of alcoholic beverages — A community of interests exists in savage life vii VI 11 CONTENTS. which is lost in civilized life — In the latter the strong thrive at the expense of the weak — Monopolies in land and other forms of property — Inference to be drawn from the tendency of in- sanity to increase — The primary condition of insanity one of the brain — Investigations should relate to the nature and causes of this condition ......... 33 CHAPTER IV. THE INSANE DIATHESIS. The ideal human system — The actual human system — Physical and mental differences among persons in health — Periods during which there exist considerable changes in the character of mental action in the case of many persons while in a state of health — Excitement and depression of mental activity — This tendency to unstable activity of the nervous system may be in- herited or acquired — Illustrations from the effects of over- exertion, " writer's cramp," chorea — A similar condition of that portion of the brain which is concerned in mental operations may exist — Illustrations — The effects of sudden mental shocks and long-continued mental application — Recapitulation — The condition which we term the Insane Diathesis is the prime factor in the causation of insanity 53 CHAPTER V. THE INFLUENCE OF EDUCATION. The higher conception of education — The ordinary course pur- suicd in schools — Too many subjects studied at one time, and too large a number of scholars under the supervision of one teacher — Little opportunity to study individual characters and tendencies — Numerous subjects of study tend to confuse the mind rather than invigorate it — Illustrative cases — Teachers only in part to blame — Courses pursued in colleges — The im- portance of avoiding over-stimulation of any portion of the system in the period of youth — Ball clubs ; rowing clubs — A similar tendency to over-stimulation of the brain in study prevalent in England— Over-exertion in the use of the brain tends strongly to create weakness and instability of action, and a condition which may be transmitted to children . . 73 CONTENTS. IX CHAPTER VI. INDUSTRIAL EDUCATION. I'AGE Occupations of persons admitted to State asylums — Percentage of those having no education in industry, or regular occupation — Importance of industrial education to the brain — Difficulty of obtaining it greater than formerly — Education of the brain has taken the place of industrial education, and with unfavor- able results — The education of the schools does not qualify the mass of people to earn a living : it tends rather to unfit them for industrial labor — The interests of society require that the largest number be educated to be self-supporting — To secure this it is necessary to begin early in life — The same principles apply to education for domestic labor . . . . • 95 CHAPTER VII. MORAL EDUCATION. Examples of deficient moral education — It more especially per- tains to the influence of home and relates to obedience — Respect and obedience toward persons in authority essential to any effi- cient system — This must be learned in early life if at all — Self- control essential to the growth of mental strength and discipline — The tendencies in the modes of home and school education 115 CHAPTER VIII. HEREDITY. Its importance as a factor in causing physical and mental characJ teristics in families and nations — Illustrations — Tendencies to morbid action, both mental and physical, may also be trans- mitted — Insanity — Dipsomania — How may unfavorable ten- dencies be avoided ? — The influence of heredity acts toward elimination of unfavorable tendencies when existing on one side of the family — Importance of understanding this in relation to marriage — Education may do much toward aiding in the removal of unfavorable tendencies — Weak-minded children — Those bom with peculiarities of physical and mental constitutions . . . . . . ... 125 X CONTENTS. CHAPTER IX. CONSANGUINEOUS MARRIAGES. PAGE Different views in relation to the influence of consanguinity — The customs of the ancient Egyptians, Syrians, and others — Experi- ments in the inter-breeding of cattle — Popular impressions as to its effects — Opposite views explained by understanding the laws of heredity — Favorable as well as unfavorable tendencies are increased — Hence unfavorable ones may be eliminated . 145 CHAPTER X. ALCOHOL. General considerations concerning its effects upon the nervous sys- tem — Its use at the present time as compared with that of the past — Society now reaping the effects of its use in the past — Physiological effects of alcohol upon the system — Experiments of Dr. Parkes and Count Wollowicz — Its effect upon the ac- tion of the heart — Its effect upon the circulation of the brain, the blood-vessels, and cells, resulting in a less sensitive condition of these parts, and ultimately in organic changes — Its effect upon the character of mind ; upon the electrical currents of the brain ; upon other portions of the body ; upon the brains of children and young persons — The alcoholic di- athesis likely to be transmitted 153 CHAPTER XI. TOBACCO. Opposite views as to its general effects upon individuals — The physiological effects upon the mucous membranes, the heart, and the nervous system — Nicotin — Its eliminatiom from the system by the lungs, skin, and kidneys — Its effects those of a narcotic and not of a stimulant — Its effects upon the brains of children and young persons — The use of tobacco by children should be forbidden by law — Its general effects upon society, socially and politically, as presented by M. Fievee — It is not directly responsible in any large degree for producing insanity — Creates a diathesis which causes a diminu- tion of intellectual and moral power I73 CONTENTS. . XI CHAPTER XII. sex: in relation to insanity. PAGE. Relative frequency of the occurrence of insanity in the sexes — The sexual system in the female exerts a larger influence upon the nervous system in certain ways than that of the male — Sexual derangements dependent upon the debility of the nervous system — They are generally consequents and not causes of nervous debility — Functional derangements of sexual organs rare among the insane — A tendency to recovery in case they do exist — Other conditions not favorable to mental health 187 CHAPTER XIII. POVERTY. Physical labor one of the largest promoters of health — Sudden in- crease of wealth often results most unfavorably — Too constant application to labor and household cares — A case illustrative — In the contests of life the weaker go to the wall — They are often surrounded by most unfavorable sanitary surroundings, im- pure air, poor tenements — They become the psychological windfalls of society — Have been and will continue to be de- pendent when stricken down by disease .... 199 CHAPTER XIV. RELIGION. Influence of religious belief upon man — Not a cause of insanity — Religious belief natural to man — It is found in all nations — Man instinctively looks up to a Superior Power in hours of suffering and need — He needs such a belief to sustain and give hope — The laws of health and a religious life are in harmony — A religious belief tends toward health — So long as the present conditions of life exist, man will require its sustain- ing influence ......... 2ii CHAPTER XV. INSUFFICIENT SLEEP. Conditions of the brain which, are supposed to produce sleep — Congested state of the blood-vessels — An anaemic state — Suffer- Xll CONTENTS. ing when a person is for any cause deprived of sleep — Persons usually sleep too little rather than too much — Physiological reasons why children require more sleep than adults — They gen- erally sleep too little, especially when living in cities — The im- portance, of sleep for the brain learned from its universality in nature and especially from the functions of other portions of the body — In this state it recuperates its exhausted ener- gies and stores them up for use when in a state of activity — Inability to sleep a precursor of insanity . . . .223 CHAPTER XVI. CONCLUSION. The primary causes of few diseases are fully understood — Pre- vention of insanity must come mainly from education received at home and in the school — Difficulties in the way of securing any efficient preventive measures — Educational processes may be improved in several ways : (i) by securing a larger degree of individttality ; (2) more attention to industrial education ; (3) more efficient home education — Changes in certain habits ; (i) in reference to the use of alcoholic bev- erages ; (2) in the use of tobacco ; (3) the importance of longer periods of rest and recreation ; (4) improved sanitary sur- roundings in those portions of cities occupied by the poor and laboring classes of society — The importance of systematic measures toward the prevention of insanity .... 237 PRELIMINARY. CHAPTER I. PRELIMINARY. THE subject of insanity, in its relation to both individuals and society, is becoming of greater importance every year. A larger measure of inter- est 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 im- prove the conditions of society. This results from two causes : i, the change which has taken place in the public mind in relation to the nature of the disease, it no longer being re- garded as something for which an individual is re- sponsible in a larger measure than for other dis- eases, 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 por- tions of the system, bearing with it neither more nor less of responsibility or disgrace ; 2, and, as a re- 3 4 INSANITY. suit in part from this change, a more clear realization on the part of the public, that there exists an obli- gation 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 com- munity. 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 un- fortunate class appeals even more strongly for sym- pathy and aid than any other, more especially by reason of the consequences which result to the in- dividual himself, as well as to his family, and the community in which .he resides. The lowerwe^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 in- .vades the brain, and the individual no longer holds PRELIMINAR Y. 5 sway over the purposes evolved from his mental operations, he becomes the most helpless of creat- ures. 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 pro- moting both the happiness and the recovery of the patient. But in the case of the insane the oppo- site 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 O INSANITY. 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 In- dications as may arise in the progress of their dis- eases. 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 nec- essary 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 con- trolling 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 disadvan- tage to other members of the family as well as themselves, renders it imperative for the highest in- PRELIMINARY. 7 terests 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. Hos- pitals and asylums have been erected and equipped at large expense, and physicians, selected with ref- erence 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; physi- cians 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 importaace, 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 larg-e 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 hope- o INSANIl'Y. ful indication. So far as it goes, it indicates a dim- inution 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 pres- ent time. INCREASE OF INSANITY. CHAPTER II. INCREASE OF INSANITY. IF the general tendency of movement in relation to the public interest in the care and manage- ment of the insane during the last twenty-five years, has been such as I have intimated in the pre- ceding chapter, I think there exists at least a proba- bility, 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 ap- parent, I think, from the evidence of statistics now to be presented. But, as preliminary to this, I pro- pose 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. I. It appears almost trite to remark that there have come large changes over the conditions of civiliza- tion 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 espe^ II 12 INSANITY. cially 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 territo- ries, constituted the great business of life among these nations, and furnished the themes of which historians wrote ; while the conditions of life, per- taining to the great body of the common people, as to education, modes of living, occupations, and health, were of almost no account. Education re- lated 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 INCREASE OF INSANITY. 1 3 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 com- pared 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 con- stantly to still further diminish it. Large numbers are congregated in factories and mills, and are en- gaged 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 atmos- phere of the factory, store, or counting-house, and, what is not unfrequently worse, that of the illy ven- tilated 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 14 INSANITY. 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, manufactur- ing 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 w^hole system. In the former conditions of life, persons were, to a much larger degree, governed, and their require- ments provided for, by legal, or arbitrary, enact- ments, 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 arti- ficial wants created, bring increased care and individ- ual 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, INCREA SE OF INSA NITY. 1 5 the force or tendency of disease seems to be car- ried over (if I may so speak) into the nervous sys- tem, so that diseases affecting this portion of the body are much more frequent than formerly. Peo- ple are more sensitive and nervous ; indeed, ner- vousness 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 men- tal activities which pervade all the vocations of modern life, the ruling passion for wealth which ex- tends 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 1 6 IX SANITY. would be anticipated from the increase of the gen- eral population. The increased demand for hospital accommoda- tion 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 in- sane has greatly improved everywhere within the last forty years: buildings, grounds, and the gen- eral external appearances have become more at- tractive ; halls and rooms have been better fur- nished, lighted, heated, and ventilated, and conse- quently more cheerful and inviting in appearance to patients and friends. There is much less of mechanical restraint used than was formerly con- sidered 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 asy- lum treatment, and have lost, in a large measure, INCREASE OF INSANITY, 1/ 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 for- merly detained in almshouses and in county poor- houses, 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 bet- ter 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 1 8 INSANITY. 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 con- sidered 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 after- ward, and in many cases are more likely to be again affected ; and in reference to insanity this is espe- cially 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 num- bers 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 dis- ease of the brain as may cause insanity, tend to short- en 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, INCREASE OF INSANITY. 1 9 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 in- crease of insanity, from indications based on the minibers which are now provided for by the public, it becomes necesary to take into the account all the above considerations, and perhaps some others. In- deed, 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 20 INSANITY. 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 popu- lation 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 Com- missioners in Lunacy, for many years, whose duties are concerned solely with the insane, and their sys- tem of inspection appears to be wellnigh perfect. I therefore propose to introduce some of the statis- tics 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 185910 1868, inclusive, and the second, from 1869 to 1878, inclusive; giv- INCREASE OF EY SANITY. 21 ing 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 Eng- land : first, as to private patients, the whole num- ber was, in 1859, ^°^^ thousand nine hundred and eighty (4,980) ; and there was an increase of this class in registered hospitals, during the first dec- ade, 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 hun- dred 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 ;^ 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 li- censed houses, of six hundred and ninety-eight (698.) ^ The whole number was 31,782, 22 INSANITY. By adding together the several sums of increase which have occurred in both classes, and the in- crease in the number of criminal lunatics, three hun- dred 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 ob- served 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 dec- ade, was as follows : INCREASE OF INSANITY. 23 In 1859 one in 535 In 1864 one in 466 •♦ i860 " " 523 " T865 " " 460 " 1S61 " " 507 " 1866 " " 449 " 1862 " " 495 " 1867 " " 441 •• 1863 " " 478. " 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 dec- ade, 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 sys- tem 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 hun- dred 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 thou- sand seven hundred and ninety-six (4,796) ; and in 24 INSANITY. 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 oi five thou- sand 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 nnd 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 hun- dred and twenty-three (1,123). INCREASE OF INSANITY. 25 The ratio this increase bears to the total number of the population, from year to year, appears from the following table : In 1S69 one in 417 In 1874 one in 3S1 " 1870 ( ( C ( 411 " 1875 < I < ( 375 " 1871 (( ( ( 401 " 1876 ( ( (( 373 " 1872 (( (( 396 " 1877 (( ( < 364 " 1873 ( ( < ( 387 " 1878 i< (( 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 Re- port 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 con- tinued to that time to increase more rapidly in pro- portion than the general population. I have presented the above numbers somewhat more in detail as to classes and methods of distri- bution 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 present- ing the statistics relating to that country. From the Reports of the Board of Commissioners in Lunacy for Scotland, it appears that in i860 there were of insane persons : 26 INSANITY. 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 hun- *dred and seventy-one (971) ; and in private dwell- ings, 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 i860 to 1869, inclusive, the total number of insane persons in Scotland, of which the Board had cognizance, ad- vanced 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). [n iS6o one in 487 In 1865 " iS6i ( < (1 487 " 1S66 " 1S62 ( t t ( 480 " 1867 " 1S63 t ( ( ( 490 " 1868 " 1S64 II 1 1 490 " 1869 INCREASE OF INSANITY. 2/ I introduce the table as before to show the relation this bears to the number of the population : one in 487 ♦' " 480 " " 473 " " 467 " " 45S It will be observed that the increase has not been uniform, as was the case in relation to that of Eneland. 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 poor- houses, 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 thou- sand one hundred and sixty-three (1,163), and in pri- vate 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: I. Of pauper lunatics in asylums and wards of poorhouses, six thousand two hundred and ninety 28 INSANITY. 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 (no): making a total of both classes of nine thousand one hundred and fifty-eight (9,158). The advance, therefore, during this decade v/as 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 In 1875 one in 432 " 1871 ((