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. The more 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, for hereditary 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 for occasional 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 of Rab 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 at long 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.