INSANITY 299 was supposed by the more ignorant to be one of necessity. Lunatics were not looked upon then as unfortunate sufferers from disease, but rather as subjects of demoniacal posses- sion, or as self-made victims of evil passions. The exposure of the abuses aroused the public mind, and medical men not only felt called but were forced to pay more attention to the study of humane methods of treating the insane, and to emulate the example of the Tukes at the retreat. Causes. The causes of insanity may be divided into predisposing and exciting. The more general predisposing causes are sex, age, social position, education. The question as to the influence of sex has not been definitely set- tled. Alienists are agreed that the existing statistical tables do not settle the question, and that asylum reports are apt to mislead, as the minority of female patients in asylums may be owing to the greater unwillingness of friends to send them from home than males. The statis- tics of Esquirol embrace about 70,000 patients of all countries, and show a small majority of females, and he and also Haslam thought in- sanity more frequent among women than men. It has been said that women are more liable than men to inherit insanity, and Dr. Maudsley is inclined to this conclusion. In regard to the influence of age, cases of insanity are rare in childhood. The greatest number become insane between 25 and 50. It is difficult from statis- tics to determine the effect of social position. In England there are about 9,000 poor and 1,300 members of wealthy families in public and private asylums, and this is probably about the proportion of the poor to the rich ; but it is probable that a state of poverty is more pro- ductive of mental disease than one of affluence. Insanity has been found more frequent among unmarried men and married women. Its great- er frequency among married women is proba- bly owing to care, anxiety, and over-exertion of body and mind, and difficulties in gestation, lactation, and menstruation. Of the more special predisposing causes, heredity plays a most important part. Jacobi in 220 cases of mania found hereditary predisposition in about one ninth. Hagen in 170 cases found it in about one third. Esquirol found it among the poor in more than one fourth ; in the rich, about three fifths. Webster found at Bedlam, in 1,798 patients, hereditary predisposition in about one third, oftener in females. Skae of Edinburgh, in 248 admissions, found it in a lit- tle over one third. In a large number, from English and Irish asylums collected by Dr. Jar- vis of Massachusetts, it was found among 44,- 417 men in the proportion of 3*-, and 43,093 women of among ^. At Bloomingdale asy- lum the proportion was found to be about one sixth. It was advanced by Esquirol, and con- firmed by Baillarger in the examination of 453 cases, that insanity is more frequently trans- mitted from the mother than from the father. It was found that the transmission from the mother to the sons was only about equal to that of the father; but the transmission to the daughters was twice as frequent. This would indicate that women inherit insanity oftener than men, a point previously alluded to. It is also found that children who inherit insanity sometimes manifest the disease before the pa- rents do ; but they are more likely to inherit it if born after its appearance in the parents. There is also a tendency in hereditary insanity to show itself in much the same way in the dif- ferent individuals of the family ; thus it has been observed that a whole family of brothers and sisters have become insane at about the same age, and committed suicide. The disposi- tion may be removed by marriage with healthy stock, or may be increased by intermarriage. The exciting causes of insanity may be di- vided into moral or psychical and physical. The principal psychical causes are grief, fright, anxiety, care, or an excited state of any pas- sion, particularly if recurring often or pro- longed; the emotions aroused by disappoint- ment, by unfortunate love, by jealousy, by re- flecting on misfortunes that have ruined the prospects of life ; excessive or prolonged em- ployment of the intellectual faculties, particu- larly when connected with the emotions, as the composition of poetry or romance, or the prolonged excitement attending the manage- ment of difficult legal cases. Anything which will produce a hyperamia of a portion or of the whole of the brain, by which the nutrition and consequently the normal function is inter- fered with, may become an exciting cause. From the number of cases of insanity in men of business, who have broken down in the struggle to amass fortunes, it is fair to assume that the prominence given by Maudsley to the eager desire to get rich as a cause of insanity is amply justified. He says : " The occupation which a man is entirely engaged in does not fail to modify his character, and the reaction upon the individual's nature of a life which is being spent with the sole aim of becoming rich is most baneful. If one conviction has been fixed in my mind more distinctly than another by observation of instances, it is that it is ex- tremely unlikely that such a man will beget healthy children ; that, in fact, it is extremely likely that the deterioration of nature which he has acquired will be transmitted as an evil heritage to his children. In several instances in which the father has toiled upward from poverty to vast wealth, with the aim and hope of founding a family, I have witnessed the re- sult in a degeneracy, mental and physical, of his offspring, which has sometimes gone as far as extinction of the family in the third or fourth generation." The principal physical causes are drunkenness and the use of narcotic or poisonous drugs ; want of food ; want of sleep and over-exertion; other nervous dis- eases, such as epilepsy, chorea, and hysteria, particularly the first ; severe injuries to the head, particularly from blows, causing fracture of the skull or concussion of the brain ; sun-
