Insanity.

by Henry Putnam Stearns.

PREFACE.

It is something more than two years since I read a paper, ent.i.tled "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 s.n.a.t.c.hes of time and with many interruptions, so that there exists less uniformity of style than there would otherwise be. Moreover, some of the subjects presented have been discussed by me in papers 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_.

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 interest 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 pract.i.tioners of medicine and philanthropists, who are ever seeking to improve the conditions of society.

This results from two causes: 1, the change which has taken place in the public mind in relation to the nature of the disease, it no longer being regarded as something for which an individual is responsible in a larger measure than for other diseases, 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 portions of the system, bearing with it neither more nor less of responsibility or disgrace; 2, and, as a result in part from this change, a more clear realization on the part of the public, that there exists an obligation 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 cla.s.s in the community.

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 unfortunate cla.s.s appeals even more strongly for sympathy and aid than any other, more especially by reason of the consequences which result to the individual himself, as well as to his family, and the community in which he resides.

The lower we 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 invades the brain, and the individual no longer holds sway over the purposes evolved from his mental operations, he becomes the most helpless of creatures. 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 pa.s.sed 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 promoting both the happiness and the recovery of the patient. But in the case of the insane the opposite 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 circ.u.mstances 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 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 indications as may arise in the progress of their diseases.

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 necessary 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 controlling 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 circ.u.mstances, the vast majority of insane persons cannot be cared for in private homes, except at greatest disadvantage to other members of the family as well as themselves, renders it imperative for the highest interests 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. Hospitals and asylums have been erected and equipped at large expense, and physicians, selected with reference 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; physicians 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 importance, affecting all cla.s.ses 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 large 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 hopeful indication. So far as it goes, it indicates a diminution 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 present time.

CHAPTER II.

INCREASE OF INSANITY.

If the general tendency of movement in relation to the public interest in the care and management of the insane during the last twenty-five years, has been such as I have intimated in the preceding chapter, I think there exists at least a probability, 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 apparent, I think, from the evidence of statistics now to be presented. But, as preliminary to this, I propose 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.

1. It appears almost trite to remark that there have come large changes over the conditions of civilization 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 especially 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 const.i.tute 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 territories, const.i.tuted the great business of life among these nations, and furnished the themes of which historians wrote; while the conditions of life, pertaining to the great body of the common people, as to education, modes of living, occupations, and health, were of almost no account. Education related chiefly to military matters, and was practically confined to the higher cla.s.ses, 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 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 cla.s.ses, 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 compared 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 constantly to still further diminish it. Large numbers are congregated in factories and mills, and are engaged 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 atmosphere of the factory, store, or counting-house, and, what is not unfrequently worse, that of the illy ventilated 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 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, manufacturing 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 whole system.

In the former conditions of life, persons were, to a much larger degree, governed, and their requirements provided for, by legal, or arbitrary, enactments, 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 artificial wants created, bring increased care and individual 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, the force or tendency of disease seems to be carried over (if I may so speak) into the nervous system, so that diseases affecting this portion of the body are much more frequent than formerly. People are more sensitive and nervous; indeed, nervousness has become exceedingly common among all cla.s.ses, and modifies many forms of disease, thereby inducing an asthenic type, which requires the use of vastly larger quant.i.ties of those tonic medicines which act on the nervous system, than would have been tolerated fifty years ago. And the keen compet.i.tions in business, the intense mental activities which pervade all the vocations of modern life, the ruling pa.s.sion for wealth which extends through almost all cla.s.ses 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 would be antic.i.p.ated from the increase of the general population.

The increased demand for hospital accommodation 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 insane has greatly improved everywhere within the last forty years: buildings, grounds, and the general external appearances have become more attractive; halls and rooms have been better furnished, lighted, heated, and ventilated, and consequently more cheerful and inviting in appearance to patients and friends. There is much less of mechanical restraint used than was formerly considered 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 asylum treatment, and have lost, in a large measure, the distrust formerly existing in relation to these inst.i.tutions, 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 cla.s.s in the community can have, and, consequently, very large numbers who were formerly detained in almshouses and in county poorhouses, 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 cla.s.ses, also, in asylums, where they may be under the care of persons who have been educated for the purpose, and consequently understand better 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 pa.s.s 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 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 acc.u.mulation of persons who may be considered as asylum inhabitants. It is a general rule, with few exceptions, that persons who have once pa.s.sed through the experience of a serious illness never are in quite as perfect a state of health afterward, and in many cases are more likely to be again affected; and in reference to insanity this is especially 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 numbers 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 disease of the brain as may cause insanity, tend to shorten 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, tends largely to explain the increase of numbers who appear to be so rapidly acc.u.mulating in the asylums and hospitals of the country.

In forming an opinion, therefore, as to the increase of insanity, from indications based on the _numbers_ which are now provided for by the public, it becomes necessary to take into the account all the above considerations, and perhaps some others. Indeed, 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. .h.i.therto 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 spa.r.s.eness 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 Boards of Commissioners in Lunacy for England and Scotland; and do so with the a.s.surance 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 population is much more h.o.m.ogeneous; 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 cla.s.ses are readily reached and their conditions of health determined.

In these countries, so favorably const.i.tuted in these respects, there have existed Boards of Commissioners in Lunacy, for many years, whose duties are concerned solely with the insane, and their system of inspection appears to be wellnigh perfect. I therefore propose to introduce some of the statistics 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 1859 to 1868, inclusive, and the second, from 1869 to 1878, inclusive; giving 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 England: first, as to private patients, the whole number was, in 1859, four thousand nine hundred and eighty (4,980): and there was an _increase_ of this cla.s.s in registered hospitals, during the first decade, to the number of two hundred and thirty (230); and in licensed houses, to three hundred and twenty-six (326).

Of this cla.s.s of patients residing with relatives and others, there has been an _increase_ of one hundred and fifty-two (152); and in naval and military hospitals, of eighteen (18).