The Increase of Insanity

by F. B. Sanborn, of Massachusetts: A Presentation at the Twenty-Second Annual Session of the National Conference of Charities and Correction, May 24-30, 1895 

 Editor’s Note: Franklin Benjamin Sanborn was born in Hampton Falls, New Hampshire, the fifth of seven children of Aaron and Lydia (nee Leavitt) Sanborn.  Aaron Sanborn was a farmer and town clerk, and was direct descendant of New Hampshire settlers of 1640. From 1852 to 1855, he attended Harvard College.  During his college years, Sanborn was strongly influenced by Theodore Parker and Ralph Waldo Emerson.  They encouraged him to move to Concord, Massachusetts, after graduating from Harvard. For a quarter century he was officially connected with the work of public charity and correction in the Commonwealth of Massachusetts. When the Massachusetts Board of State Charities was organized in 1863, he was made its first secretary by the appointment of Governor John A. Andrew. In recognition of this position as a leader in reform movements in Massachusetts,  Mr. Sanborn was elected president of the National Conference of Charities and Correction, in 1881 when it convened in Boston.

Ever since a few of us met in the city of New York in May, i874, at the call of the American Social Science Association, and there formed the nucleus around which this great deliberative body has grown,-yes, for more than twenty-five years,- the problem of the constant increase of insanity has forced itself on the attention of all those who, like myself, had an official connection with the commitment and care of the insane. For we had noticed, and our reports had shown (mine began in 1864, when I was secretary of the Massachusetts Board of State Charities), that the number of the insane under public care was growing rapidly. It was apparently checked a little in the United States by the Civil War (1861 to 1865), for many of the insane were in the great armies then contending; but no sooner did the war end than insanity began to increase again here. It had been steadily gaining ground in Great Britain and Ireland, from the first dates that furnished reasonably exact statistics; and now the same remark is true, I think, of every civilized country. So great has the increase been – far beyond the gain in population that some alarm has been felt lest insanity should become a dominant element in our recent civilization. Indeed, a whimsical but trenchant German writer, Max Nordau, seems to have taken that view in his work on ” Degeneration” (Degenerescence), lately translated, and now extensively read in America and England. At all events, the experts of insanity in Great Britain and elsewhere have been called on to explain why it is that, with all their improved apparatus for the treatment of the insane,- costly hospitals, trained attendants, special medical care, study of brain disease and brain function,- nevertheless insanity goes on doubling itself.

Various and conflicting explanations have been given for the past twenty years. We have been first told that all the appliances of high civilization, specially in cities and other places of dense population, favor and promote the access of insanity; and then we have been assured that there was no actual increase of new cases (what is called “occurring insanity”), but only an accumulation of unrecovered cases and of persons not formerly reckoned insane, but now swept into the count by closer and more recent classification. Both these statements are true to some extent, though they tend to contradict each other. The appliances and tendencies of high civilization do develop insanity beyond the measure of past centuries; and, in my opinion, they do more than counteract the improvements made in treating insanity. It is also true that, as compared with half a century ago, the classification of mental disease and impairment has become more strict; and many persons are now returned as insane in England, for instance, who would not have been included in that class in 1845, when Lord Ashley, since better known as Lord Shaftesbury, carried through his act establishing a Lunacy Commission. But can this change alone account for the registered fact that the reported insane increased from about 25,000 in 1849 to more than 90,000 in 1894,- that is, they nearly quadrupled,- while the population of England and Wales hardly doubled,– that is, gained from 16,000,000 in 1849 to about 31,000,000 in 1894?

In Scotland, where exact statistics have only been collected since i859, when the admirable Scotch Commission in Lunacy, established in part through the efforts of our countrywoman, Miss Dix, began its Reports, the proportionate increase has been nearly as great. In 1859 there were reported 5,795 insane persons, and in 1894 13,300; that is, 192 in every 100,000 Scots at the first date and 325 in every 100,000 last year. In Ireland a still more striking fact is reported; for, while population there has been fast decreasing (from 5,798,960 in I862 to 4,704,750 in 1892), the reported insane have gone up from 8,055 in 1862 to 16,689 in 1892.

These startling figures have led several Irish experts to consider seriously the causes of what is taking place in that island; and at the last annual meeting of the British Medico-Psychological Association, in Dublin last June, Doctor Conolly Norman, its president, declared against monster asylums, and in favor of the methods of family care and detached buildings, by which Saxony, Belgium, and some parts of Germany are checking the increase of insanity. And Thomas Drapes, an asylum superintendent at Enniscorthy, showed, by an interesting paper, that first admissions (occurring insanity) had increased 32 per cent in Ireland from 1868 to 1892. His exact words are: “The ratio of first admissions to population has increased considerably, and this must be regarded as indicating a decided increase in occurring insanity. The official inspectors of asylums in Ireland in 1893 came to the same conclusion. Their language was, “The annual increase, in the face of a shrinking population, of the number of first admissions, including, as it does, such a large proportion of first attacks of insanity, almost irresistibly points to some increase of occurring insanity in particular districts.”

Now, if this increase is found anywhere, it may be assumed to exist elsewhere. Why do I say this? It would not be true, because cholera is found every year in Russia and Turkey, that therefore it exists constantly in Ireland and Connecticut. Nevertheless, I believe it to be true that the proof of an increase in new cases of insanity, pro rata, in Ireland and Massachusetts does furnish a strong presumption that a similar evil exists in all countries where the accumulation of the chronic insane goes on so fast as we know it does,– in the whole United States, in Great Britain, in Germany, France, Italy, and wherever we have careful returns of the yearly situation.

In an article published by my good friend Doctor Tuke (whose recent death we all lament) in his Journal of Mental Science (London, April, 1894) I showed conclusively that new cases of insanity had been increasing in Massachusetts in the fifteen years from 1878 to 1893, or ever since the new tables of statistical return prepared by the late Doctor Earle and myself had been in use. These tables, for the first time, made it possible to discriminate between new hospital cases of insanity and those repeated readmissions which, until Doctor Earle exploded the fallacy, had served to raise the alleged rate of recoveries far beyond the real fact. They also, after a period of years, have enabled us to reach a fairly accurate conclusion as to the length of the insane life, the death-rate of the insane as compared with the sane of the same ages, and several other points of much importance.

Another feature of my London article was the proposition that, so long as the death-rate of the insane (confessedly twice or thrice that of the sane) and the recovery-rate, taken together, do not prevent the great accumulation of the chronic insane in asylums or in the general population, there must be an increase in new cases beyond the ratio of population-increase; since otherwise this accumulation could not be kept up. I see no escape from this reasoning. If the death-rate does not fall, it must be from the accession of new cases, since we know that it is in acute insanity that the mortality is much the largest; but, if the accumulation does not cease, it must be because new cases furnish more material of chronic insanity than even this high death-rate can diminish.

A singular confirmation of this reasoning appears in a paper read by Doctor T. A. Chapman, of the English County Asylum in Hereford, at the Dublin meeting of last summer, just mentioned. Hereford is a little county on the border of England and Wales, in extent less than Rhode Island, and in population less than Delaware; yet it has more paupers than either (4,458 in a population of 113,39I), and more insane in proportion to its population than any English county. By the census of 1891, while all England had 325 insane for every 100,000 inhabitants, Hereford had 460 pauper lunatics in every 100,000, and enough more who were not paupers to bring the rate up to 520 insane for every 100,000. Hereford also had 328 out of every 100,000 in asylums as against 196 in all England, so that its admission and death-rate, as well as its age-tables, could be more exactly computed. Now, the average age of all these Hereford insane in asylums was nearly 51 years for both sexes and 52 1/2 years for women; while in all England it was nearly 46 years only, and for women less than 47. Consequently, there is a lower death-rate in Hereford than in the rest of England; for it is among the insane of less than forty years that new cases and deaths are most frequent. Now, in eleven years past, in Hereford, the average age of the resident insane has increased by three years; while the death-rate, naturally, has decreased. Yet, low as the present death-rate is among the Hereford insane, it is nearly three times as large as among the whole population of England, sane and insane, the exact figures given by Doctor Chapman being 50.6 in every 1,000 for his insane, and only 19 for the corresponding ages in all England.

Now, assuming what is not far from the fact, that there are 100,000 insane persons in England and Wales, and 30,700,000 persons of all sorts, of whom 10,000,000 are children below the age to be attacked with insanity; and seeing that, of the 100,000 insane, at least 5,000 (probably 7,000) die in a year, while, of the 20,600,000 sane persons exposed to insanity, only 400,000 die in a year, — it will be seen that the proportion of the insane to the sane must continually diminish, unless new cases increase. For, while from 5 per cent to 7 per cent of the insane yearly die, only 2 per cent of the sane die. Add to this high percentage of insane deaths the number who recover annually (from 7,000 to 10,000), and it will be seen how rapid must be the increase of new cases, in order to keep the English insane even from diminishing. But in fact, during the twenty years from 1871 to 1891, they did increase from 69,009 to 97,383,– more than 40 per cent, or at the average rate of 2 per cent a year. In Massachusetts, as shown by the table in my London article, the resident insane increased in fifteen years more than 6 per cent annually, and the new cases increased 6 1/2 per cent, the population in the same time gaining about 3 per cent.

Doctor Drapes, speaking for Ireland, says: ‘”Will the increase of insanity ever reach its limit? Not,” he answers, “until the discharges and deaths come to equal the admissions. Our death-rate is increasing, our discharge-rate remains fairly constant; but our admission-rate continues to rise.” Doctor Tuke, using the Irish figures of Doctor Drapes, and combining them with the English tables published by him in the same journal that contained my article, added some startling deductions at the Dublin meeting. He showed that, while in England the rate of first admissions above population in the seventeen years, 1875-93, was but 6 per cent, and seemed to be slightly decreasing in the last five years, in Ireland the rate had increased in the last five years by 60 per cent, after allowing for the Irish decrease of population. Where Ireland increased 36 per cent in twenty years, in her insane (admissions), England had increased but 6 per cent; and in mere accumulation, where Ireland gained 60 per cent of insanity, England gained but 22 per cent. It further appeared in the Dublin debate that in the Irish county (Kerry) which showed the largest emigration (20.3 emigrants for every 1,000 inhabitants) there had been the greatest gain in first admissions of the insane; for while in the ten years, 1872-82, there were but 538 first admissions in Kerry, there were 826 in the ten years, 1882-92. One explanation of the more rapid accumulation of the Irish insane as compared with England was the small number of general paralytics in Ireland; the Cork asylum, for instance, with 1,200 patients, having only 4 paretics and only 85 epileptics. Doctor Conolly at the end of the discussion made this Bunsby-like remark: ” Changes in the condition of life are really at the bottom of the increase of insanity in Ireland, be it apparent or be it real.” To which all the people will say “Amen,” and “God forbid! ”

Having reached the conclusions above named, —that is, (1) that occurring insanity has increased beyond the gain in population both in Ireland and in Massachusetts, as shown by careful statistics; and (2) that, so long as the death-rate of the insane is double that of the sane, any considerable accumulation of the chronic insane must be due to a corresponding increase in new cases, — I own I was disappointed at finding that a recent Special Report of the Scotch Lunacy Commissioners (Dec. 24, 1894), devoted wholly to the question of the increase of insanity in that country, does not show any evidence that occurring insanity is gaining in Scotland beyond the ratio of increasing population. This is a Board of great authority and of careful research; and this particular Report was the work of Sir Arthur Mitchell, who has just retired from the Board after many years’ service, of Doctor John Sibbald, who has also had many years’ experience, and, finally, of Mr. T. W. L. Spence, the accomplished secretary of the Board, who pursued a new and interesting line of inquiry concerning the increase of private patients among the Scotch insane. The opinion of either of these gentlemen, in a matter which he had investigated, is entitled to great respect; and, when they agree in one opinion, the probability that they are correct is much increased. Nevertheless, I believe that their method of inquiry is so impaired by a lack of complete statistical data, and by a prepossession in favor of the conclusion at which they arrived, that their verdict, otherwise entitled to great weight, need not be accepted even for Scotland, while it has little or no bearing on the facts collected and put in evidence in Ireland and Massachusetts.

Two things are obviously needful to a full statistical investigation of the prevalence of insanity at a given date as compared with its prevalence at a later date. The first is a complete register of all cases of the disease at the two dates taken: the second is a similar register of the incidence and disposal of all cases occurring between the two dates,- how many came under observation for the first time, how many recovered, how many died, and how many disappeared from view without either death or permanent recovery. For instance, if the Scotch gentlemen could state exactly the whole number of insane persons anywhere in Scotland in 1874, the corresponding number in 1894, and then all the first admissions, deaths, recoveries, and other disappearances in the whole kingdom between these two dates, it would not be hard to say, knowing the population as a whole in 1874 and 1894, whether insanity in Scotland (new cases) was gaining or losing ground. No such fulness of data being even claimed for Scotland (or as yet for any country or region), the best that can be done is to approximate to this desired but unattainable exactness. This Sir Arthur Mitchell and his colleagues undertake to do; and their several methods are ingenious, sincere, and laborious. But they all start with a belief that they shall not find any increase of new cases, beyond the population-rate, in the twenty years; and, as we generally find what we look for, and only now and then come upon the unexpected, so here they could find no considerable gain in new cases.

But let us suppose that they or we or any other inquirers into this important but perplexed question should have taken certain fixed points from which to reckon,-for instance, all the visible population, both sane and insane, at a given date,-then consider the actual deaths in this classified population for twenty years, and the visible number living at the end of that time,- and see what conclusion is forced upon us by the computation. It will appear in Scotland, for example, that the sane population in I855 was about 2,970,000, and the insane 7,400; that in 1894 the sane had increased to 4,111,000, or 39 per cent., while the insane had grown to nearly 14,000, a gain of 85 per cent. Yet in this period of nearly thirty years the insane had been dying at a rate more than twice as large as the sane deaths of the same ages. They had also been recovering at a still higher rate; and yet so many were the new cases, or those for the first time visible, that the insane, who should have decreased, actually gained faster than the sane. Where could this gain have come from for the past dozen years, if not from an increasing number of new cases? In the years immediately following 1874 it might be supposed that a stricter classification of the insane would lead to an apparent increase; but this could not long continue to offset the natural decrease by the double death-rate, which, from figures given by Doctor Sibbald in his paper, was for Scotland at least a treble death-rate, being more than 60 in 1,000 cases of the insane. The average death-rate for the sane of all ages above ten years in Scotland is not before me; but it cannot well have exceeded 20 in 1,000, and was probably less than this. Therefore, if three insane persons died for every sane man and woman in Scotland, it could not be many years, unless new cases of insanity also increased fast, before the accumulation of the chronic insane of that country would cease, and a diminution would begin, since all the while recoveries would be going on, and would still farther reduce the material for chronic insanity.

A presumption in favor of the increase in new cases of insanity –not necessarily of acute cases–is therefore raised by the mere fact of the accumulation of chronic insanity; and this presumption is strengthened by the fact, which will hardly be questioned, that the insane die much faster than the sane, while yet the accumulation steadily continues, and shows no sign of material diminution. But in certain regions (in Massachusetts, for example), where an actual count of new cases has been made for fifteen years, with some approach to accuracy, it is found that they do increase beyond the gain in population. That is to say, the increase which accumulation and inference make highly probable is found, in fact, to exist, and to continue from year to year. Hence we reason (and there seems to be no flaw in the argument) that, if the same pains were taken as in Massachusetts to compute the exact number of new cases of insanity, it would be found even in Scotland, as it has been found in Ireland, that occurring insanity, not less than chronic insanity, is really gaining ground. It is not necessary to suppose that it gains equally fast everywhere; but, until some reasonably exact registration is made of cases which are actually new,- that is, appear for treatment for the first time,- we have no right to say that such new cases are not increasing beyond the natural gain in population. It is difficult to prove a negative, especially when all reasonable inference from observed facts tends to an affirmative.

A single word as to the real causes of the increase of insanity, which, in the form of accumulation, everybody admits, and which I have shown also to exist in Ireland and in Massachusetts, in the form of new cases.

It is within the observation of most physicians who have the care of the insane that the insanity of physical degeneration, resulting from syphilis, paralysis, intemperance, under-feeding, epilepsy, etc., is growing more and more common. These are the least hopeful forms of insanity; and it is their prevalence which seems to have caused a diminution in the rate of recoveries, almost everywhere noticed within the last twenty years. Cases really acute, and not complicated with these forms of disease and degeneracy, recover as easily and as fast as ever; and there is even a tendency to virtual recoveries of the chronic insane, which was not so much noted until recent years. But the crowding of population into cities in all civilized countries, and the growth of vice and disease consequent upon this rapid growth of city populations, have increased those degenerative tendencies noticed by Nordau and other writers, and have thus made certain forms of insanity not only more frequent, but less curable. There is a natural limit to this melancholy state of things, and there are limitations and palliatives which science can apply; but it does not seem that we have yet reached that limit or that those remedial agencies have yet been effectively applied. Till that is done, insanity must continue both to accumulate and to increase actively.

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Source: Proceedings Of The National Conference Of Charities And Correction at the Twenty-Second Annual Session Held in New Haven, Conn. May 24-30, 1895 pp 186-194. (Accessed: October 16, 2014). The proceedings of annual meetings of the NCSW, 1874-1983, are available on the web thanks to a digitization project undertaken by the University of Michigan Library, with assistance from the Social Welfare History Archives at the University of Minnesota.  The web site for this resource is: http://www.hti.umich.edu/n/ncosw/