Degenerative insanity is a constitutional disease arising from slight exciting causes, even physiological conditions (puberty, menstruation, the puerperal state, climacterium), but for the most part from pathological conditions, chiefly hereditary predisposition, injury to the head, acute disease, etc., occurring during development of the sensitive brain, forming often the last in a series of neuropathic disorders, such as spinal irritation, hysteria, hypochondria, epilepsy. The tendency to recovery is slight, and generally there is only temporary return to the primary condition. Relapses and progressive development of graver forms of disease are common. There is progressive hereditary mental degeneration or a strong tendency to appear in descendants in progressively severer form. All forms of the psychoneuroses occur, but of severe type and irregular course, with sudden and rapid changes in the character of the disease, which does not follow any particular course and cannot be definitely classified, rarely ending in dementia, and often lasting in some form through life. The tendency to periodicity is strong. Delusions are chiefly physio-pathological as direct creations of the diseased brain, entirely without apparent cause, to the astonishment of the person and independent of his frame of mind at the time. They appear and disappear, to be replaced by morbid impulses or mental weakness. Delusions are strange, mysterious, monstrous, without possible explanation from the nature of the disease. There is, for the most part, an inseparable transition from pathological predisposition to actual disease, with a strange mixture of lucidity and diseased mental perversion. Acts are often from impulse. There are sudden outbursts or short attacks; as, for instance, in periodic, hysterical, and epileptic insanity.
In psychoneuroses developed in persons of previously normal brain-function heredity is only a latent predisposing cause. The tendency is to recovery; relapses are infrequent. They are not so readily transmitted to later generations. The disease follows the course of some well-defined type. There is not a tendency to periodicity. Delusions arise chiefly from psychological sources as the result of diseased mental conditions. They are usually not early symptoms, and in general they correspond with the prevailing state of the mind. Delusions correspond with the mental state. The change from health to disease is well defined.
These are the main features of the two classes of mental disease, but the line between them is not a hard and fast one, and it is not seldom impossible to place a particular diseased person definitely in the one or the other.
The objection to all of the classifications of insanity now in use, that they have not an accurate scientific basis, and that a diagnosis must often be delayed or changed as symptoms develop, applies, although in a less degree, to other diseases than of the mind.
HISTORY.—The history of insanity is probably as old as the human race, although its rarity among savage nations at the present day, and its greatest prevalence where there are the widest extremes of wealth and poverty, indicate that it is essentially a disease of the high civilizations. It is found even in the lower animals. It is described in the early writers on medicine from Hippocrates and Plato down. The ancient Egyptians had temples dedicated to Saturn, where they cared for the insane with music and dancing. The Greeks and Romans treated the sick, and probably some of the insane, in rooms adjoining their temples. The monks of Jerusalem built an asylum for the insane of their number in the sixth century. There were several asylums in existence among the Moors in the seventh century, and it is thought that at the time of their invasion of Spain they introduced them into Western Europe. The monks, who were the chief depositaries of medical knowledge in the Middle Ages, treated the insane, as they did to a less extent each other, by flagellations, until St. Vincent de Paul and the Knights of Malta proclaimed insanity a disease and treated it as such. It would be idle to estimate how many were put to the rack, burned, and otherwise maltreated as possessed of the devil or as witches—how many were called prophets or saints.
As late as the last quarter of the last century the insane, when not starving or neglected, were for the most part confined in jails and poorhouses or kept in chains. In Scotland a farmer reputed to be as large as Hercules was said to cure them by severity. In England the practice of exhibiting the inmates of Bethlehem Hospital (Bedlam) to the populace for a small fee was given up only in 1770. In Paris a few of the insane were treated in general hospitals, and the asylums were considered as receptacles for chronic cases, where the attendants, often convicts serving out their time, were allowed to whip them. Van Helmont recommended the sudden immersing of the insane into cold water and keeping them there for several moments—a remedy brought even to this country. Rush says, as late as 1812, that by the proper application of mild and terrifying modes of punishment (the strait waistcoat, the tranquillizer chair, privation of customary pleasant food, pouring water under the coat-sleeve so that it may descend into the armpits and down the trunk of the body, the shower-bath continued for fifteen or twenty minutes, and a resort to the fear of death) chains will seldom, and the whip never, be required to govern mad people. The intelligent ideas of the Egyptians, Greeks, and Romans regarding insanity were degraded first by the Jewish, and then by the Goth and Vandal, influences in Europe, until, after sixteen centuries of perverse teaching, the stimulus given to all medical work by John Hunter and Bichat, and to humanity by John Howard, prepared the way in France for the philosopher-physician Pinel and his pupil the clinical observer Esquirol. In Italy, Chiarruggi; in Germany, Langemann; in England, Tuke; in America, Rush,—began the reform. Up to that time the metaphysicians had nearly usurped the study of insanity. Hospitals for the treatment of curable mental disease were built in Germany besides the asylums for the chronic insane, but still sudden plunges in water, rapid whirling around, and all sorts of shocks and surprises formed a part of the treatment, while Heinroth, Pinel's leading pupil in Germany, thought that all insanity began in vice, that its source was a conscious neglect of God's will, that its best treatment consisted in a pious life, and the only means of prevention to be in the Christian religion. From that time to this, especially since the metaphysical theory of insanity was abandoned, and more particularly during the last quarter of this century, during which the theory of physical disease as the basis of insanity has prevailed, there has been a great and rapid advance in our knowledge of the pathology and treatment of the diseases of the mind, so as to place them beyond the pale of mystery, but on the same footing with other diseases, to be treated on the general principles of common sense and medical science.
PREVALENCE.—It would be idle to attempt to say what proportion of the population was insane at any time or in any country of the world until the most recent years. In Massachusetts in 1820 there were under custody in the one insane asylum in the State 50 patients, or 9.55 in each 100,000 of the population. This number had increased to 11.34 to every 100,000 people in 1830, 61.99 in 1840, 84.97 in 1850, 97.90 in 1855, 122.17 in 1860, 121.24 in 1865, 134.83 in 1870, 138.50 in 1875, and 177.67 in 1880, in six State, one county, one city, one corporate, and six private asylums. The number of the insane in asylums had increased sixty times, and the rate proportionately to the population had augmented more than eighteen times.
In the United States, even after due allowance for the fact that the enumeration of the insane was quite complete for the first time in 1880, the following table shows a recent large increase in their numbers. Of the 91,997 insane reported in 1880, there were 40,942 in lunatic hospitals, 9302 in almshouses without special departments for the insane, and 417 in jails. There are no statistics of the insanity prevalent among the 265,565 Indians living in tribal relations by the enumeration of 1883.
CENSUS OF THE UNITED STATES.
Population.