COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD RC605.R14 HX641 30339 Insanity; its nature COLORADO BULLETIN Vol. xin. No. 11 Published Monthly by the Regents of the University of Colorado. Entered at the Post Office, Boulder, Colorado, as second-class mail matter. INSANITY ITS NATURE, CAUSES AND PREVENTION Boulder. Colorado. November. 1913 UNIVERSITY EXTENSION DIVISION General Series No. 12 Hygiene Series No. 1 fie (oO^ RiV Columbia 5Hntt)ersttp College of ^fjj'gicians! anb burgeons; Hihtaxv Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/insanityitsnaturOOrama UNIVERSITY OF COLORADO BULLETIN Vol. XIII. No. 11 Published Monthly by the Regents of the University of Colorado. E-itered at the Post Office, Boulder, Colorado, as second-class mail matter. INSANITY ITS NATURE, CAUSES AND PREVENTION BY FRANCIS RAMALEY Professor of Biology Boulder, Colorado, November, 1913 UNIVERSITY EXTENSION DIVISION General Series No. 12 Hygiene Series No. 1 Copyright, 1913, BY Francis Ramaley. INTRODUCTION If one were to take quite seriously the warnings , of popu- lar writers, it would be easy to become convinced that the entire American people is quickly tending toward insanity. The large number of patients in hospitals for the insane is pointed out as proof positive that mental disease is rapidly increasing. Indeed, figures from all communities where the insane are given adequate care, show that governments are constantly called upon for greater and greater appropriations for hospital maintenance. There are, however, certain reasons for this condition which are not fully understood by the average citizen: (1) With im- proved conditions in hospitals there is less objection to commit- ment than formerly, whether from patients themselves or from relatives. (2) With better care, patients live longer than when they were less well provided for. (3) With more knowledge of insanity on the part of physicians, cases are recognized earlier and the victims of suicidal mania are committed before they reach the stage in which they are ready to accomplish self-destruction. (4) The greater proportionate number of persons residing in cities makes it increasingly difficult for families to conceal cases of in- sanity, as was formerly much done in country districts. The importance of mental disease as a sociological factor is very great. Withdrawal of large numbers of persons from pro- ductive occupations is in itself bad enough; but the sufferings of the patients themselves and the worry and anxiety to their fami- lies are even worse. The public still looks upon insanity as a disgrace and the members of a patient's family feel this condi- tion keenly. Insanity is not always incurable, as so many imagine. Even with inadequate facilities for the care of the insane, about one- third of all cases in the best hospitals are either completely cured, or else benefited to such extent that the patient is able to return to his family and become partially or wholly self-supporting. And while the possibility of cure cannot be held out to all the insane much is now known concerning prevention. If the average person knew as much as he easily might, and would live in the light of 4 UXIVERSITY OF COLORADO. that knowledge, insanity would soon become of less than one-half its present importance. Many people im'agine that all "lunatics'" are the same — they are "raving maniacs," likely at any and all times to kill either themselves or their keepers. The facts are, however, quite other- wise. Except for a comparatively small number of violent individ- uals, the patients in modern hospitals are permitted to attend sim- ple entertainments given in the institution; many assist in the necessary work of the garden and farm, dairy, laundry and kitchen. In some state hospitals the meals are served in large dining rooms and there is little difficulty in maintaining good order. Indeed, the inmates, with certain exceptions, are likely to be as well be- haved as the boys of an average boarding school or academy. One difficulty that the public experiences in understanding about insane people results from the fact that the names of the various mental diseases are generally unfamiliar. To the lay mind such terms as schizophrenia, paresis, paranoia, and catatonia, mean lit- tle. They have such a technical and scientific sound that most peo- ple would pass by a magazine article in which they were noticed. In the present article technicalities will be avoided; stress will be laid upon the importance of insanity to the community and to the individual, and particular attention will be called to methods of prevention, THE MYSTERY OF INSANITY The behavior of the insane has always seemed so entirely be- yond the bounds of reason that the supposition naturally came about that no explanation of insane conduct could be made. Re- cently, however, it has been shown that the various delusions and hallucinations are definitely related to previous mental experience. Sometimes the connection is very clear, as when a man who has had great struggles with poverty, on becoming insane, imagines himself immensely rich. Or one of an over-sensitive nature, after brooding over an insult, becomes violent and wishes to kill every- one about him. In this latter case he has the idea of revenge, but is ready to injure those who never brought him any harm. The self-accusations of some of the mentally unbalanced no doubt arise through the magnification in their own minds of some slight fault, EXTEXSIOX BULLETIX. 5 perhaps of long ago — even back in early childhood. In any case of insanity, there is some reason for the symptoms which appear; although without more information than is usually at hand, there is necessarily much of mystery involved. Mental disease is of slow development. Onlookers see a sud- den otitbreak, btit the patient himself probably knew weeks or even months before that he was ""'not himself. '" In many cases the origin of an attack is fotmd in some infection dating back ten or twenty years. If the early manifestations of mental breakdown affect only the individual himself, it may be a long time before even his friends and family suspect any trouble. This is especially true with those of a reticent disposition, who may not be in the habit of exposing their inmost thoughts to others. A man might imagine himself to be the lawful heir to the British throne, yet if he told no one about it and contintied in his regular occtipa- tion he wotild pass as a normal person. If. however, he should attempt to assassinate the king, his madness would be at once apparent. Much of the mystery of insanity restilts from the long period dtiring which the disease makes insiduotis progress, but in which there are no visible signs of mental alienation. MANIFESTATIONS OF MENTAL DISEASE Many of the pectiliarities of the insane are but exaggeration of characteristics seen in ordinary people. The common manifesta- tions are: excitement, depression, apathy, obsessions, delusions, hal- lucinations. Excitement is well enough known to all. Some people are in a constant state of excitement. Trivial incidents affect them greatly. The mentally tmbalanced often show this same symptom: they talk incessantly, go rapidly from one thing to another: are now in the seventh heaven of bliss and again in the depths of despair. States of depression are likely to alternate with periods of excitement, as in the very common "maniac-depressive insanity." Just as some people not in asylums take little interest in their surroundings, so with many insane patients. This condition of apathy may become so pronounced as to result in what appears to be true dementia (loss of mental power), but sometimes the apa- thetic condition disappears and the patient is once mere able to 6 UNIVERSITY OF COLORADO. carry on ordinary mental processes. True dementia is incurable and as a rule becomes progressively worse and worse. Obsessions show themselves in impulses which the person may know to be foolish or wrong, but which it is well-nigh impossible to withstand. Many crimes are committed under the compelling influence of an obsession. The person knows he is doing wrong, but cannot help it. Other obsessions lead only to absurd and fan- tastic actions such as washing the hands a hundred times a day, exam- ining the number of every bank note, looking a dozen times to see whether the door is locked or the clock wound. Delusions and hallucinations are the true marks of insanity. The former are false ideas, the latter false sense impressions. One who feels that he is the pope or a king or a millionaire, when this is not a fact, is the victim of a delusion. The seeing of snakes or dogs or the hearing of voices which have no existence, the smell- ing of certain odors which no one else can detect — these are classed as hallucinations. No doubt, delusions and hallucinations may not be known for some time even to the family and friends of the patient, yet sooner or later they are likely to lead to abnor- mal conduct. The person is considered insane when his acts be- come anti-social, i. e., inconsistent with the social conditions under which he lives. Arrogance, conceit, melancholy, excitement or apathy may be unpleasant to other members of the family, but these characteristics are not entirely unbearable, as are homicidal or suicidal mania, destructiveness, filthy personal habits, or acts which bring ridicule upon the patient or his family. These soon lead to legal proceedings for the commitment of the offender. THE NUMBER OF INSANE In Colorado the state hospital for the insane has a greater enrollment than the state university and a like condition exists wherever there is adequate provision for the insane. Following are the number of insane in institutions in a few representative states: Pennsylvania 16,992; California 7,904; Michigan 6,082; Indiana 5,- 378; Minnesota 5,329. The foregoing figures are taken from the latest available reports. It is probable that the total number of insane for the United States is greater than the attendance in all the universities and colleges of the country. EXTENSION BULLETIN. 7 The claim has heen made that immigration of undesirable Europeans is responsible for much insanity, and it is true that the proportion of insane among the foreign-born is very high. It must, however, be kept in mind that insanity strikes most fre- quently in the age period from twenty to thirty and that young men and young women make up a large part of the immigrant ar- rivals each year. Statistics show the frequency of insanity to be nearly twice as great among the foreign-born as among natives, but it is not likely that this is the true proportion for corresponding ages. We are so accustomed to blame the poor foreigner for his shortcomings, that there is danger of being too severe with him in this instance. Estimates of experienced alienists place the number of the in- sane at about four to each 1,000 of the population. This number is about equalled by the epileptics, who. let it be understood, should not be classed with the insane. Idiots, imbeciles, and other feeble- minded persons are much more numerous than the insane. Care- ful tests of children of school age suggest that about two per cent, (twenty to the thousand) of most populations are distinctly feeble- minded. Up to the present these mental defectives have not re- ceived proper state care and every institution for the feeble-minded has a long waiting list. There is great need for better provision for these unfortunates, especially the segregation of all feeble-minded women of child-bearing age. It is well here to point out that feeble- mindedness is chiefly hereditary and incurable. The condition de- pends upon original lack of mental capacity; insanity, on the other hand, appears in those who were at one time normal, but who later developed aberrant mental processes. Hospitals for the insane usually have a larger number of men than women patients. This is partly due to the greater amount of alcoholism among men, so that probably a somewhat greater number of men than women become insane. Another reason for the presence of more men patients is that "queerness"' in a man soon Incapacitates him for employment while a woman at home may be quite irrational and yet not unbearable to the other mem- bers of her familv. 8 UNIVERSITY OF COLORADO. SOCIOLOGICAL IMPORT OF INSANITY Like any other illness, insanity .contributes to poverty; it is often connected with crimes of violence; it has much to do with the fantastic political and religious "movements" of every age. The contributions of the mildly insane to literature and the other fine arts are well known. In these days of cash estimates perhaps the cost of caring for the insane will be of interest. It is impossible to learn of the ex- pense to individuals and families, to counties and cities, but the maintenance of state institutions requires large sums of money. In New York over twenty per cent, of the revenues of the common- wealth go to the support of the insane. No doubt this is a pro- portion which should also be maintained elsewhere. In every state where the insane are well cared for at least one-fifth of the revenues will probably need to be spent on their care. But this enormous expense is to a large degree unnecessary, or would be unnecessary if measures of prevention were thoroughly understood and employed by the individual and the state. This topic will be given consideration later. Suffice it to say at this point that investigation under state aid is much needed. The real causes of insanity should be thoroughly studied and more and bet- ter methods of prevention developed. HEREDITY IN RELATION TO INSANITY There is a common belief that heredity is a true cause of insan- ity. Nearly all hospitals, in stating the causes of disease in their patients list from twenty to thirty per cent, as hereditary. A part of the victims of "hereditary insanity" are, however, epileptics and imbeciles. With the true insane, family "taint" is likely to show itself in a "predisposition," and mental disease may "run in fam- ilies" just as tuberculosis does. But with tuberculosis there must be other factors than heredity to bring on disease, so also with insanity. What is inherited is not the insanity itself, but rather an unstable mental constitution. Instability of mental make-up, or psychopathic constitution, acts in inheritance as a so-called "negative character." It seems EXTEXSIOX BULLETIX. 9 to result from the lack of something^ in the person (perhaps a chemical substance), something which normal individuals possess.* The following are the rules of heredity as applied to the in- heritance of mental instability. 1. Two normal parents coming from normal families will have only normal children. 2. A normal person of a perfectly stable family married to a per- son mentally unstable will have children all apparently normal, but really with a hidden "defect" or "taint" which may appear in a later generation. 3. Two mentally abnormal parents cannot have normal children. If the parents are insane, all the children are likely to be men- tally unstable and may "go insane." 4. Two apparently normal but really "tainted" parents may have one child in four abnormal. 5. An apparently normal but really "tainted" person mated to a mentally unstable person will have one-half the children nor- mal, the other half unstable. Certain exceptions may occur in the cases enumerated above, but for the most part these rules apply. The conditions may be shown, perhaps more clearly, by means of diagrams. Parents: Case 1 Normal, of Normal, of norm-al X normal family family Children: All normal Case 2 Parents: Normal, of Mentally normal X unstable family Children: All apparently normal but really with a hid- den "defect"' * For discussion of positive and negative characters the reader is referred to Charles B. Davexport's "Heredity in Relation to Eugenics" (New Yorlv. 1911), pp. 16-21. A special account of insanity appears in pages 77-SO. 10 UNIVERSITY OF COLORADO. Parents: Children : Parents : Children: Parents: Children: Case 3 Mentally unstable X All mentally unstable Case 4 Mentally unstable Apparently normal Apparently normal but really with hidden defect ormal; ^ unstable X but really with hidden defect like the parents; 14 Mentally Case 5 Apparently normal but really with X hidden defect 1/^ like one parent; i/^ Mentally unstable person like the other parent Unstable mental make-up is, without doubt, transmitted in the way indicated in the diagrams just given. One who comes into the world with such a constitution is unfortunate, but is not necessarily doomed to the lunatic asylum. Perhaps in some few cases a bad heredity cannot be counteracted even by the best hygienic condi- tions. This is, however, not really known with certainty. In con- stitutional psycopaths, head injuries, infectious diseases, under- nutrition, or perhaps even psychic traumata (mental or emotional shocks) may bring on mental disease, but if these can be escaped, insanity can probably also be escaped in most instances. CAUSES OF INSANITY Insanity may result from the abuse of alcohol or other poi- sons. Many cases appear in persons with an early infection of syphilis; sometimes from an infection that dates back as much as ten or twenty years.- Both of these causes seem to be purely ex- trinsic, and it is not known that any constitutional peculiarity is originally present in those who develop insanity in these ways. EXTEXSIOX BULLETIN. 11 About twenty per cent, of insanities seem directly related to intem- perance and about ten per cent, to disease resulting from immorality. Injuries to the brain bring on insanity at times, but not every person receiving a brain injury becomes insane. Mucb, no doubt, depends upon natural mental make-up, something upon previous state of health both bodily and mental. Infectious diseases, lead poisoning, pellagra, arteriosclerosis, child-birth and other influences tending to reduce general vitality may be classed as contributing factors in many insanities, yet it is doubtful if any one of these is the sole element in the causation of any particular case. It seems likely that most cases of insanity develop very slowly. The integrity of the mental mechanism is not easily nor quickly destroyed. There must have been something wrong before this so-called "cause" appeared. Perhaps there was some faulty construction of the brain, or possibly only a functional mental disorder of long standing. These questions are not fully understood, and students of insanity are not agreed as to the im- portance of various assigned "causes." In considering the so-called "mental" and "moral" causes of insanity much the same comment may be made as with reference to physical diseases and injuries. A man may "go insane" follow- ing business reverses, or domestic difficulty, or the death of wife or child. Yet these calamities befall thousands of other men, and they do not lose their minds. One can hardly escape the convic- tion that here too the "causes" are but contributing factors. The original cause must be something far more deep-seated. A theory which has many adherents is that much insanity re- sults from an "auto-intoxication," that is, a self-poisoning due to failure of the body organs to eliminate promptly the poisons which develop in the ordinary course of body activity. Many patients give a history of long-continued constipation; some have kidney disorders; with many there are recurrent headaches which have caused trouble for years. These various symptoms certainly sug- gest some kind of bodily derangement. Certain kinds of insanity seem associated with particular men- tal dispositions. There are people with the "shut-in-personality," others of a gloomy cr a fault-finding disposition, still others char- acterized by conceit and suspicion. Each of these three types of persons contributes largely to a particular corresponding form of insanity. It may be that the person who falls into bad mental 12 UXIVERSITY OF COLORADO. habits thus predisposes himself to mental alienation, or perhaps these habits are merely expressions of an underlying defect which later shows itself in true insanity. Whichever is the real state of affairs it behooves all those who are "queer" or "peculiar" to at- tempt as best they can to get into right habits of thought and be- come like other people. To sum up briefly the causes of insanity is difficult. The vari- ous students of the subject do not agree. Yet, in spite of conflicting views, the following statements may be made: 1. Heredity is a large factor in unstable mental make-up, although it cannot be said that insanity is itself really hereditary. 2. Alcoholism and syphilitic infection are definitely responsible for about one-third of all cases. 3. Bodily disorders, sometimes seemingly only trivial, but often of long standing, occur in the history of a great many patients. 4. Mental peculiarities, showing themselves long before the insane condition is reached, frequently are known. 5. In a considerable number of cases no previous indication of approaching disease is seen and at present no satisfactory ex- planation of these cases can be made. PREVENTION OF INSANITY The reader who has followed the discussion in the foregoing pages is already in possession of the facts and theories which may now be employed in developing a program for prevention of insan- ity. Because so many types of disease are called by the one name it is natural that many different methods of attacking the problem will be necessary. Measures which seek to control the consumption of alcoholic liquors do not apply to eradication of lead poison or of arteriosclerosis. Sanitary and safety regulations by the state, while reducing the number of head injuries, can have little influence on auto-intoxication or heredity. Since two causes of insanity are thoroughly understood — alcoholism and syphilis — the first point of attack in controlling insanity should be an attack on these factors. Any and all measures which may aid men to lead temperate and moral lives shculd be encouraged. Facts need to be known and appreciated. It should be understood, for example, that alcohol is a narcotic and anaesthetic, not a true "stimulant" at all — as so many believe. The pleasurable feeling induced is not due to a stim- EXTEN8I0X BULLETIX. 13 iilating effect, but to the temporary deadening of the higher nerve centers. A person who has taken a drink of whiskey no longer appreciates his true condition. If he is tired, the nervous mechan- ism which would make him aware of the fact is thrown ' otit of gear and he imagines himself refreshed and strengthened. Btit peo- ple attempting to work under the "stimulus" of whiskey do their work badly. They soon tire and must have recourse to ever increas- ing amounts of alcohol. Another matter of which the public shotild know more is the danger of immoral living. "• Sowing wild oats" is hardly the trifling fault that many young men imagine. There is almost a certainty of contracting venereal disease. Stich disease is, in a considerable ntimber of cases, followed by insanity — and syphilitic insanity is incurable. Concerning these two catises of insanity mtich can be done through suitable laws, faithfully enforced, but unless the ptiblic is interested in enforcement, the laws will be inoperative. Education of the public to an appreciation of the great menace of insanity should encourage a right public sentiment. It is a disgrace that the states should be called upon to spend great sums in caring for pre- ventable cases of mental disease. Such insanity as is associated with infectious disease shotild decrease with the better control of infections by health depart- ments and improved methods of medical treatment and nursing. If auto-intoxication is involved, changes in the daily life of the in- dividual, leading to more hygienic living, may have important re- sults. Persons troubled with constipation, headaches, or kidney dis- ease should have a thorough medical examination and full and ra- tional treatment, both medical and hygienic. Indeed, any one suf- fering from chronic disease, no matter how seemingly trivial, ought to secure the best available medical advice and treatment. The cultivation of proper emotional and mental states is highly desirable in every one, but this seems especially important with those of psychopathic make-up. Whether by such methods alone a threatened attack of insanity can be warded off is difficult of proof. There is, however, little doubt that they furnish a valuable adjuvant to hygienic meastires. More attention might well be given in the home to proper training of children predisposed to nervous- ness. The interested reader may well consult Dr. Barker's little pamphlet on this stibject, mentioned in the note at the close of this paper. 14 LXIVERSITY OF COLORADO. Most of the insane who recover at all do so within a few months of their commitment to a hospital. Hence, when mental disease is detected there should be no time lost in applying the best methods of treatment. It is of great importance that cases be recognized at their onset, when chances of recovery are best. To accomplish this result it is necessary that there be a more gen- eral knowledge of the facts of insanity and of the possibility of cure. Voluntary commitments, although rather infrequent now, would then become more common. There would be less feeling of disgrace in connection with mental disease and a better and more healthy attitude toward those who have recovered from an attack. If medical schools would give more attention to mental disease the general practitioner would be able at an early period to recog- nize oncoming insanity in his patients. By this means many cases which are now allowed to progress to the incurable stage might be sent promptly to a suitable hospital and recovery be made possi- ble. Medical students would find a thorough course in psychology of great advantage to them. All hospitals for the insane and all large general hospitals might well provide special clinics or dispensaries for psycopathic cases. No doubt many persons who fear the development of insanity would go to such clinics. At present most people do not know which way to turn for help. Courses of training for teachers should include study of the principles of mental hygiene as applied to the training of children. This would seem to be a field of great possibilities. Indeed, a knowledge of personal hygiene in all its branches is highly desirable in the teacher. Universities and colleges may contribute much to the preven- tion of insanity through scientific investigation; also by offering courses in hygiene to undergraduates. There needs to be a wide- spread knowledge of how to keep in good health. Measures which have been found of value in the prevention of tuberculosis will un- doubtedly prove useful in protecting from nervous and mental dis- orders. The importance of sunlight, fresh air, good food and mod- erate exercise can hardly be overestimated. If the "intelligent pub- lic" could be made really intelligent as to health-preservation, a large part of the insanity problem would be solved. The work of prevention of insanity should not and cannot be thrown entirely upon the state. At any rate the acts of the state EXTENSIOX BULLETIX. 15 must always rest upon public opinion. Intelligent public opinion can have its foundation only in accurate knowledge. The follow- ing are adapted from a set of suggestions made by the National Committee on Mental Hygiene: 1. Let every one become informed as to tbe causes of mental dis- ease and make the facts known to others. 2. Let each lead a hygienic life, physically, mentally, and morally. 3. Let all speak and think of insanity as a disease; not as a crime. No family should feel disgraced because some member hecomes insane. 4. If relative, friend or acquaintance seems to be in poor health physically or mentally, let him be informed of the value of prompt medical care. 5. When philanthropists or hospital superintendents ask for im- proved facilities for the detection and treatment of insanity, let every intelligent person lend his aid. While it is seldom safe to prophesy there seems good reason to hope for a decrease of insanity in the coming years. Many forces are at work which make for temperance, morality, intelligence, and hygienic living. These should bring about in time a better average condition of both physical and mental health. Note : The following' three are excellent popular works on personal hygiene. (The last two have well-written chapters on the nervous sys- tem) : HrxcHixsox, "Woods.. The Conquest of Consumption, Boston, 1910. Ptle, TV alter L.., Personal Hygiene; Philadelphia, 1907. WooDWORTH, R. S., The Care of the Body; Xew York, 1912. TVorks dealing with insanity are chiefly technical and quite beyond the understanding of the ordinary reader. The following, are, however, not only readable, but highly interesting : Beers^ Clifford TV., A Mind that Found Itself; New York. 1912. Hart^ Berxard^ The Psychology- of Insanity; Cambridge,- Eng., 1912. The National Committee on Mental Hygiene has issued a number of pamphlets which may be secured on application to the Secretary of the committee at 50 Union Square, New York City. Following- are the titles: No. 1. Origin, Objects and Plans of the National Committee for Mental Hygiene ; the mental hygiene movement ; state societies ; informa- tion regarding the problem of mental health and the care of the insane. No. 2. Principles of Mental Hygiene applied to the Management of Children predisposed to nervousness. By Dr. Lewellys F. Barker. (Is- sued March, 1912.) [This is an exceedingly valuable paper for parents and teachers.] No. 3. Summaries of the Laws relating- to the Commitment and Care of the Insane in the United States, compiled by John Koren. Price, ?1.00. (Issued September, 1912.) No. 4. Some Phases of the Mental Hygiene Movement and the Scope of the Work of the National Committee for Mental Hygiene. By Lewellys F. Barker. (Issued November, 1912.) COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special arrange- ment with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C28(i14i)m100 RC605 R14 Raraaley