Читать книгу Insanity: Its Causes and Prevention - Henry Putnam Stearns - Страница 5
CHAPTER II.
ОглавлениеINCREASE 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 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 territories, constituted 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 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 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 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 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 mental activities which pervade all the vocations of modern life, the ruling passion for wealth which extends 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 would be anticipated 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 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 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 classes, 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 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 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 considered 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 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 accumulating 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 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 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 population 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 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 class 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 class 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).
Of this class of patients in county and borough asylums, there was a decrease of eight (8).
Second, as to pauper patients;[1] 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 licensed houses, of six hundred and ninety-eight (698).
By adding together the several sums of increase which have occurred in both classes, and the increase in the number of criminal lunatics, three hundred 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 observed 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 decade, was as follows:
| In | 1859 | one in | 535 |
| " | 1860 | "" | 523 |
| " | 1861 | "" | 507 |
| " | 1862 | "" | 495 |
| " | 1863 | "" | 478 |
| " | 1864 | "" | 466 |
| " | 1865 | "" | 460 |
| " | 1866 | "" | 449 |
| " | 1867 | "" | 441 |
| " | 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 decade, 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 system 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 hundred 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 thousand seven hundred and ninety-six (4,796); and in 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 of five thousand 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 and 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 hundred and twenty-three (1,123).
The ratio this increase bears to the total number of the population, from year to year, appears from the following table:
| In | 1869 | one in | 417 |
| " | 1870 | "" | 411 |
| " | 1871 | "" | 401 |
| " | 1872 | "" | 396 |
| " | 1873 | "" | 387 |
| " | 1874 | "" | 381 |
| " | 1875 | "" | 375 |
| " | 1876 | "" | 373 |
| " | 1877 | "" | 364 |
| " | 1878 | "" | 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 Report 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 continued to that time to increase more rapidly in proportion than the general population.
I have presented the above numbers somewhat more in detail as to classes and methods of distribution 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 presenting the statistics relating to that country.
From the Reports of the Board of Commissioners in Lunacy for Scotland, it appears that in 1860 there were of insane persons:
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 hundred and seventy-one (971); and in private dwellings, 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 1860 to 1869, inclusive, the total number of insane persons in Scotland, of which the Board had cognizance, advanced 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).
I introduce the table as before to show the relation this bears to the number of the population:
| In | 1860 | one in | 487 |
| " | 1861 | "" | 487 |
| " | 1862 | "" | 480 |
| " | 1863 | "" | 490 |
| " | 1864 | "" | 490 |
| " | 1865 | "" | 487 |
| " | 1866 | "" | 480 |
| " | 1867 | "" | 473 |
| " | 1868 | "" | 467 |
| " | 1869 | "" | 458 |
It will be observed that the increase has not been uniform, as was the case in relation to that of England. 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 poorhouses, 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 thousand one hundred and sixty-three (1,163), and in private 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:
1. Of pauper lunatics in asylums and wards of poorhouses, six thousand two hundred and ninety 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 (110): making a total of both classes of nine thousand one hundred and fifty-eight (9,158).
The advance, therefore, during this decade was 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 |
| " | 1871 | "" | 440 |
| " | 1872 | "" | 438 |
| " | 1873 | "" | 434 |
| " | 1874 | "" | 436 |
| " | 1875 | "" | 432 |
| " | 1876 | "" | 420 |
| " | 1877 | "" | 408 |
| " | 1878 | "" | 400 |
| " | 1879 | "" | 392 |
exhibiting a decrease in relation to the total of population for one year only of the decade, and on the whole a steady increase for the whole twenty years.
It further appears from the tables of statistics, that the number of insane paupers per 100,000 of the population, which was one hundred and fifty-seven (157), January 1, 1858, advanced to two hundred and seventeen (217) per 100,000, January 1, 1880, notwithstanding the fact, that during this period the number of pauper-persons per 100,000 of the general population diminished from two thousand six hundred and thirty (2,630) to one thousand seven hundred and eighteen (1,718).
It thus appears that insanity is, both absolutely and relatively, a much larger element in the pauperism of the country than ever before.
In considering the force of the above statistics there is one element which may, I think, properly be referred to as entering into the calculation, to which I have nowhere found any allusion, namely—that of emigration. I have not at hand the statistics to show how great this has been from England and Scotland during the last twenty years, but we know that it has been very considerable from both countries to Canada, Australia, and the United States; and I think it fair to assume that this emigration has generally been from those who have been in good mental health, at least at the time of leaving these countries; and if at this time they had relatives who were insane, these would be left behind. Therefore, so far as this would have an effect upon the statistics of insanity, it would be toward exhibiting a higher ratio of the insane to the whole population than would otherwise appear.
Having made due allowance for this, and other considerations, which were alluded to in connection with the statistics of asylums, I still think the evidence all points toward a large increase of insanity, both absolute and relatively to the population, in both England and Scotland.
At the time of this writing, the statistics of the census for 1880, for the United States, have not been so far completed and published, that evidence from them can here be presented, but I think there can be no doubt that, when they appear, they will tend to confirm very strongly those already presented, which have been prepared with so great care, and collected under such very favorable conditions, and which demonstrate, or so nearly demonstrate, both the absolute and relative increase of insanity.
INSANITY AND CIVILIZATION.
