The Causes Of Insanity
83 Art. IX.?
The extent to which insanity prevails amongst civilised peoples, and the rapidity with which its increase is registered, are serious questions to occupy the attention of thinkers. On what is dependent the visible yearly multiplication of those to whom the treatment of asylums is requisite ? What are the elements of insanity? What are the causes that primarily excite it? It is hardly to be expected, perhaps, that much in the way of reply to these questions will be obtained from a study of pathological changes in the organs chiefly affected. We shall learn but little respecting that which drove A, B, and C to the shelter of the madhouse by a study, howsoever closely conducted it may be, of the brain and body of A, B, or C on the post-mortem table. Such inquiries as this give us only the most valuable information as to structural changes brought about during the course of the illness, and present a view of that which had occurred in its progress. Nothing is revealed to tell why A, B, or C became mad, rather than developed any other of the numerous acute diseases capable of producing absolute decay and death of the organism. Many there are who will not, probably ever, resign the vain expectation of finding definite knowledge in the evidences the dead subject may present?knowledge that will guide him more or less surely to a discovery of that which first initiated the lesions, of which he has the proof before him. This objective mode of looking for what it is possible to gather only by invoking the additional assistance afforded by retrospective inquiry, can hardly be expected to produce any very considerable results. The facts of pathology are simply facts, and the aid they render towards elucidating the conditions to which they are due, will, so long as it is sought in them alone, be of the most illusory description. We are unquestionably justified in assuming of any given case of mental disease that three principal factors have been concerned in its production, viz.: 1st, an exciting cause ; 2nd, a predisposition to disease; and 3rd, inability, chiefly physical, partly psychical, to make progress against the influences once brought to bear on the organism. The researches of later years have done very much to clear up the former obscurity which surrounded the history of the two latter of the three essentials above stated; but, spite of every effort, it remains still for anything more definite than conjecture to be suggested concerning the exciting causes of 84 the causes of insanity.
insanity. In a paper by Dr George M. Beard, of New York, in defence of a National Association for the Protection of the Insane, a line of inquiry is pursued which, if persistently followed by those who possess opportunities of investigating the questions it opens up, may in time lead to the accumulation of really invaluable information. Dr Beard boldly attacks the problem, and indicates the direction whence enlightenment will come, in the following cogent paragraph :?
“This augmentation of the numbers of the insane, and development of novel symptoms and forms of insanity, are most notably seen among the English-speaking people. Insanity is a part of the cost of liberty ; it is a tax on our freedom, that so many must be deprived of their freedom. In the great despotisms there is little need of societies for the protection of the insane ; where the sane are all oppressed, the number of the insane lias never been very great. The Czardom of Russia oppresses its subjects, but does not make them crazy, and the Turks, with all their weaknesses, are mostly sane. England, the spawning ground of empires, sends out her children through all the earth, carrying with them the seeds both of liberty and nervous disease. Liberty implies responsibility; responsibility leads to worry, and worry is attended always with disappointment. Out of the throes and agonies and manipulations and calculations of the last month, two men have been nominated for the supreme office of this nation, to the disappointment of thousands upon thousands of candidates, their followers and friends. A solid despotism and established religion are partly redeemed by this? that they keep the asylums empty ; if we think for ourselves and govern ourselves, thousands must go down in the struggle. Nature knows nothing of disinterested benevolence : she never gives anything: she may often trust for a time, but sooner or later we have got to pay, principal and interest. As a philosopher has said, all progress is in waves?a motion without any advance.”
Civilisation, with the attendant excitement of life it entails in those countries where continual changes mark the progress of events, is in its effect more of a curse than a blessing. The fault, however, is not in itself so much as in the feverish anxiety, the unreasoning ambition, of those whose aspirations are fostered by whatever alters the ordinary current of everyday occurrences. The tendency of the time is to stimulate desires that had better been left unroused; the exigencies of political situations, and of mercantile, necessitate the co-operation of a vast proportion of the community in measures that, under a more subdued and less ambitious regime, would be an object of concern only to those entrusted with the exciting conduct of state affairs. Wide-reaching political schemes, however, entail a national sympathy with ideas of a more extended nature than such as are familiar to simpler-minded nations. And, as is now very generally recognised, the character of a great people as a whole is visibly affected by the kind and degree of the operations in which they are involved. Greatness is of many kinds, moreover, and as each country grows in wealth and in importance, so do the matters of internal concern to it grow in complexity and in number. Its government, religion, morals, educational code, &c. &c., all become centres of fixed interest to more or fewer of the people composing it; and, accordingly as these latter are more or less absorbed in, and influenced by, the conditions affecting their chosen objects of regard, so are they liable to succumb at any moment of extraordinary pressure to influences reacting on them for ill. In some the consequences take on the form of physical disease; in many they exhibit themselves in the shape of mental alienation; and when in the latter way, it is to be accepted as certain that there has been a preparatory weakening of the organisation, in such wise as to admit the ready action of disturbing causes sufficiently strong to destroy the harmonious relations of health. These causes, their nature, influence, initial and continued, need to be studied carefully and exhaustively to the end, that any real and reliable, useful knowledge about exciting causes of insanity may be gathered ; generalisations in plenty have been made, and the rough outline of the study has again and again been sketched. What is wanted now is such an aggregation of facts as could be obtained, for instance, by bringing together the histories, as fully as possible, of every patient at present in confinement. From a cursory examination even of the few that one has been able to learn much about, it is all but certain that it will be possible by and by, when evidence has vastly increased, to formulate a series of expressions which shall have all the value of laws, and be serviceable for the purpose of predicating the course, and thereby suggesting the treatment, of any and every given case of disease.
The ” protection ” of the insane has been taken as the object with which an American Society has begun existence. Its president is Dr H. B. Wilbur, and Dr Gr. M. Beard holds the office of treasurer. As a first contribution to ” protection ” it has issued a small work containing papers by Drs. Beard, Shaw, and Seguin, in which the need for such an association as the new club is demonstrated. The aims held in view by the Society are fair and useful, judging from the following draft of its constitution :
86 the causes of insanity. ” This Society shall be known as the National Association for the Protection of the Insane and tiie Phevention of Insanity.
“The methods by which the Society proposes to attain its end are: “First. By the encouragement of special and thorough clinical and pathological observations by the medical profession generally, as well as by those connected with asylums. ” Second. By enlightening public sentiment as to the nature of the malady, the importance of early treatment, improved methods of management and treatment at home and abroad.
” Third. By recommending an enlightened State policy, which, while neglecting no one of its insane population, shall so administer relief and protection as not to lay unnecessary or undue burdens upon the tax-payers.
” Fourth. By holding public meetings, wherever needed, to stimulate legislation that will secure efficient State supervision of all public institutions for the care of the insane, as a mutual safeguard for the protection of Society?the patients, as well as those who have them in charge.
” Fifth. To further the perfection of laws relating to the treatment of the insane, and their rights while patients in the asylum.
” Sixth. By efforts to allay the public distrust in relation to the management of insane asylums, by placing them on the same footing as that of other hospitals, both in the matter of freer communication with the outside world, and the privilege of a consulting medical staff of general practitioners.” If the intentions shadowed forth in this somewhat comprehensive scheme are at all efficiently carried out, there will accrue a very considerable increase to the knowledge we possess respecting the causes of insanity. Of all the six methods suggested for developing the resources of the association the most important, and that which will most probably be productive of good, is the first: ” Encouragement of thorough and special .clinical and pathological observations.” will bring to light a good deal likely to explain the many incomprehensible facts of lunacy ; and in the way of ” protection ” it is no doubt a legitimate application of the redundant energy so apparent in our Trans-Atlantic brethren. The association, however, is in fault in omitting to include among its aims the further extension of its inquiries to those causes which are primarily potent in the causation of the diseases it seeks to exert an iniluence over. The examination of resulting conditions, of actual results will not, we consider, lead beyond a certain limit of discovery; they can do little or nothing to tell how and why they have been developed rather than any other series of changes consequent on the co-operation of the three essential factors of disease ; and in the state of our present understanding the first desire of every student of insanity is to know what produced it.
It has been frequently pointed out that intense intellectual labour is not a fertile agent in the production of insanity. The most arduous and constant brain workers of every age have by no means helped greatly to swell the ranks of the mentally unsound; we may at any moment find in asylums a proportion of men of exalted intellectual capacity, but they will as a rule be found to be persons of intellectual habit rather than intellectual occupation; and though a few professional thinkers are scattered among the lunatics of every country, they are always of a type that is itself a tolerable explanation of their condition. For example, highly educated and highly intellectual men who engage in the worry and concern of mercantile pursuits, who are subject from day to day to the exciting responsibilities of vast commercial enterprises, are pre-eminently those whom we expect to find, and do find, among the insane inmates of our asylums. They are men of nervous, susceptible temperaments ; men who have become exquisitely sensitive by education to the influence of absorbing interests, and men too, who, relieved from the cares incident to business life, had been capable of the loftiest intellectual achievements. Such as these are the first victims to fall before the exciting causes brought to bear on them ; and though, fortunately, their number is not considerable, they are the most instructive cases that present themselves. Under other circumstances, living the life of one following the inclinations natural to cultivated minds, these same patients would certainly not have succumbed to the shock against which, in the life they did lead, they were unable to stand. Naturally, they would not have been affected, in different relations, by the same associations of circumstances ; but this fact is a valuable one to us in pursuing an inquiry into the connections of insanity. It must be that the conditions of existence are eventually chargeable with the initiation of nervous changes which result at length in total mental disablement. The question, however, is not thus easily settled.
There are to be considered, as having an appreciable share in the total result, a complicated series of minor assisting agencies that together materially affect it. The conditions of a merchant’s existence are very unlike the conditions of a philosopher’s, or even a statesman’s life. There is surrounding the one at all times a personal uncertainty of consequences that carries with it interference with bodily processes eminently inj urious to the general health. Digestion is imperfectly performed ; the secretions are defective or vitiated, and as a necessary consequence the nervous system suffers at a time when the calls on its special powers are constant and considerable. In this case the exciting cause may with propriety be said to be either one of two ; either that is, the inappropriate nature of the occupations engaged in, or the continued physical disturbance engendered through the occupation. The ultimate result is the same whichever is considered; but the mode of arriving at it deductively will differ as one or the other is taken as a point to start from. The detail of especial importance in this connection is, that there is a definite and fixed agreement between certain definable and marked conditions and their resulting consequences. The exact nature of this relation, its kind and degrees, and its susceptibility to influences brought to bear on it, together with the particular nature of these influences themselves ; these are the questions that present themselves, and to which answers must be given ere we can hope to advance very much past the point to which mental medicine has attained.
In honest desire to improve the condition of patients brought to them, and anxious to relieve them as speedily as possible, professional students of lunacy have directed themselves to the task of cure without reflecting how much the success of remedial measures must depend on their adaptation to the condition they are invoked to aid, and that this must be immediately dependent on the nature of the causes producing them. It is always a somewhat thankless duty to peer backwards, but in this instance it is imperative, and may well be expected to be abundantly productive. The method of investigation would afford excellent opportunities for the employment of members of such an association as the new American guild for the protection of the insane. It will require for its successful prosecution not only considerable patience, and some technical acquaintance with the individual aspects of insanity, but also such a constant intercommunication of those engaged on it as can only be secured by association of numbers with a common object in view. Single-handed endeavours will do a good deal in the way that is here suggested, but of itself it cannot do all that is required to secure an exhaustive work.
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