The Encyclopedia Americana (1920)/Insane, Statistics of

INSANE, Statistics of. Statistical data relating to the insane in the United States are found principally in Federal census reports, the reports of State commissions charged with the supervision of the insane, reports of individual State hospitals and special studies. In 1904 and in 1910 the United States Census Bureau issued a special statistical volume relating to the insane and feeble-minded. Prior to 1904 the data concerning the insane were made a part of the general decennial census report. Beginning with 1850 and continuing to 1890 an attempt was made at each decennial census of the population to secure a complete enumeration of the insane by inserting a question relative to insanity in the general population schedule. The results down to 1880 were unsatisfactory as it is generally believed that only a small portion of the people suffering from mental disorders were enumerated as insane. At the tenth census, 1880, the returns of the enumerators were supplemented by special reports from physicians. The latter reported about 17 per cent of the total number of insane enumerated in that year. In taking the census of 1890 no attempt was made to secure supplemental data from physicians. Consequently, the number of insane enumerated in that year did not show an increase commensurate with the growth of the population. In the census of 1900 and of 1910 the question relating to the insane was omitted from the general population schedule. In 1904 a census of the insane in institutions was taken by special enumerators appointed for such purpose. A similar census was taken again in 1910. In 1917 the National Committee for Mental Hygiene made a special census of the insane in institutions, the data being obtained from schedules filled out by hospital superintendents.

These various enumerations of the insane, while in part incomplete, give a general view of the increase in insanity in the United States since 1850. The following tabulation shows the total insane enumerated at each of the several censuses, together with the number of insane per 100,000 of the population:

	Total insane enumerated
YEAR OF CENSUS	Number		Per 100,000 population
1917[1]	234,055		227.6
1910[1]	187,791		204.2
1904[1]	150,151		183.6
1890	106,485		170.0
1880	91,959		183.3
1870[2]	37,432		97.1
1860[2]	24,042		76.5
1850[2]	15,619		67.3

1. No enumeration of insane outside of institutions.
2. Enumeration believed to have been seriously deficient.

The data for the years 1904, 1910 and 1917, which relate to the insane in institutions only, show a remarkable increase of this class of unfortunates as compared with the increase of the general population. The ratio of the insane in institutions to the general population in 1904 was 1 to 545, in 1910, 1 to 490 and in 1917, 1 to 439. It is probable that the actual increase in insanity has not been as great as these figures would indicate. During the last 15 years the practice of placing the insane under institutional care has been greatly extended. As the institutions for the care of the insane have improved they have won a greater degree of public favor, and more mild cases of mental disorder have been admitted thereto. As the incidence of mental disorder increases with advancing age, the lengthening of the average period of human life in recent years has increased the insanity rate by bringing a larger proportion of the population into the advanced age periods. The rate of insanity is found to be much higher in cities than in rural districts. The trend of the population from country to city during the last three decades have therefore been an important factor in causing the upward trend of the rate. After all allowances have been made, however, it is believed by those who have given careful attention to the subject that the insane are increasing more rapidly than the general population, but that the difference in rate of increase is too slight to be alarming.

Insanity in the Several States.— Owing to various factors, such as institutional provision for the insane, distribution of urban and rural population, the composition of the population with respect to age, nativity and race, marked differences in the ratio of the insane to the general population are found in the various States. The following table shows the insane in institutions in the United States by divisions and States in 1910 and 1917, together with the number per 100,000 of general population in each of the two years:

Insane in Institutions in the United States by Divisions and States 1 Jan. 1910 and 1 Jan. 1917.

	Number				Rate per 100,000 of general population
DIVISIONS AND STATES	1 Jan. 1910		1 Jan. 1917		1 Jan. 1910		1 Jan. 1917
United States	187,791		234,055		204.2		227.6
New England	19,580		23,542		298.8		326.7
Maine	1,258		1,493		169.5		192.7
New Hampshire	909		1,098		211.1		247.6
Vermont	990		1,110		278.1		304.7
Massachusetts	11,601		14,096		344.6		376.1
Rhode Island	1,243		1,565		229.1		252.4
Connecticut	3,579		4,180		321.1		333.1
Middle Atlantic	52,380		65,145		271.2		296.9
New York	31,280		38,117		343.2		367.7
New Jersey	6,042		7,592		238.1		254.7
Pennsylvania	15,058		19,436		196.4		226.2
East North Central	41,246		49,686		226.0		251.1
Ohio	10,594		12,307		222.2		237.5
Indiana	4,527		5,769		167.6		204.1
Illinois	12,839		16,354		227.7		264.0
Michigan	6,699		7,377		238.4		239.9
Wisconsin	6,587		7,879		282.2		313.4
West North Central	22,683		27,516		194.9		219.3
Minnesota	4,744		5,857		228.5		255.1
Iowa	5,377		6,367		241.7		286.2
Missouri	6,168		7,512		187.3		219.6
North Dakota	628		1,079		108.8		143.4
South Dakota	864		1,059		148.0		149.6
Nebraska	1,990		2,485		166.9		194.5
Kansas	2,912		3,157		172.2		171.5
South Atlantic	19,952		24,758		163.6		185.0
Delaware	441		484		218.0		225.9
Maryland	3,220		4,035		248.6		294.9
District of Columbia	2,890		3,082		872.9		840.6
Virginia	3,635		4,398		176.3		199.7
West Virginia	1,722		2,127		141.0		152.0
North Carolina	2,522		3,446		114.3		142.5
South Carolina	1,541		1,642		101.7		100.5
Georgia	3,132		4,062		120.0		141.2
Florida	849		1,482		112.8		163.8
East South Central	9,759		11,231		116.0		124.9
Kentucky	3,538		4,348		154.5		182.2
Tennessee	2,204		2,518		100.9		109.7
Alabama	2,039		2,341		95.4		99.7
Mississippi	1,978		2,024		110.1		103.0
West South Central	8,413		11,971		95.8		116.1
Arkansas	1,092		1,628		69.4		92.9
Louisiana	2,158		2,552		130.3		138.5
Oklahoma	1,110		2,758		67.0		122.8
Texas	4,053		5,033		104.0		112.5
Mountain	3,574		4,887		135.7		148.8
Montana	697		1,083		185.3		232.3
Idaho	388		540		119.2		123.6
Wyoming	162		220		111.6		120.7
Colorado	1,199		1,613		150.1		165.4
New Mexico	219		302		66.9		72.4
Arizona	337		411		164.9		158.3
Utah	342		474		91.6		108.0
Nevada	230		244		280.9		224.4
Pacific	10,204		15,319		243.4		283.8
Washington	1,987		3,312		174.0		211.5
Oregon	1,565		2,309		232.6		272.0
California	6,652		9,698		279.8		325.0

Insane in Foreign Countries.— Available statistics of the insane in foreign countries are very unsatisfactory. The classifications of mental disorders in the various nationalities are dissimilar and wide variations exist in the provision made for the care of the mentally afflicted. In some cases the insane are enumerated with the feeble-minded and epileptic and the number of the separate classes is not given.

On account of shell shock and the stresses of army life, it is believed that insanity has greatly increased in the belligerent countries of Europe since the beginning of the present war, but the conversion of hospitals for the insane into military hospitals has reduced the number of civil insane in institutions in these countries. Current statistics of the civil insane in the European countries at war are therefore misleading.

According to the report of the Commissioners in Lunacy, published in 1914, the insane in England and Wales increased from 36,762 in 1859 to 140,237 in 1914, an increase of 281.5 per cent. During the same period the general population of these countries increased 89.5 per cent. The ratio of insane to the general population in England and Wales on 1 Jan. 1914 was 1 to 266, or 376 per 100,000. During the year 1913 there were 18,407 first admissions and 3,896 readmissions to institutions, for the insane in these countries. The rate of first admissions during 1913 was 49.9 per 100,000.

The report of the Inspectors of Lunatics for Ireland for the year ending 31 Dec. 1915 gives the number of insane in institutions in Ireland on 1 Jan. 1915 as 25,180, or a ratio of 575 per 100,000 of estimated population. The number of first admissions in 1914 was 2,798, a ratio of 64 per 100,000 of estimated population. The readmissions numbered 730.

In Scotland, on 1 Jan. 1914, there were 18,682 insane patients in institutions, a ratio of 394 per 100,000. The admissions in 1913 numbered 2,908, a ratio of 61.4 per 100,000 of estimated population.

In Australia, on 1 Jan. 1913, there were 16,439 insane persons under care, a ratio of 347 per 100,000 of estimated population.

In the Netherlands, on 1 Jan. 1914, there were 13,975 insane persons in institutions. The admissions during the preceding year numbered 2,897.

The following table gives a comparison of the increase of insane patients under treatment in various countries from 1890 to 1910, together with the ratio of the insane to the general population in 1910. Owing to the reasons above stated the ratios must be taken with some allowance.

Comparison of Increase of Insane Patients under Treatment in Various Countries, 1890-1910.

(Compiled from official yearbooks and census reports).

	Insane in institutions						Number per 100,000  of population  in 1910
COUNTRIES	1 Jan. 1890		1 Jan. 1900		1 Jan. 1910
United States	74,028		[1]150,151		187,791		204
England and Wales	86,067		106,611		130,553		262
Scotland	[2]. . . . .		15,229		17,792		376
Ireland	16,139		21,014		24,269		553
France	57,418		64,938		74,404		188
Prussia	30,686		57,503		86,007		217
Italy	[3]24,118		[4]36,845		[5]45,009		130
Belgium	10,515		14,603		18,182		245
Netherlands	6,079,		8,139		11,746		200
Norway	1,369		1,707		2,679		112
Sweden	2,555		4,269		6,897		125
Switzerland	4,454		6,648		8,910		238
Australia	[2]. . . . .		[4]12,427		15,565		285

1. 1904.
2. Data not available.
3. 1892.
4. 1902.
5. 1908.

Switzerland on 1 Jan. 1916 was caring for 9,916 insane patients in its 24 hospitals. The admissions of the preceding year totaled 4,070.

In Sweden, in 1914, the 18 hospitals for the insane housed an average patient population of 9,610. In 1910 the average number housed was 7,866. There were 1,978 admissions in 1910.

In Denmark, on 31 Dec. 1916, the insane in institutions numbered 4,644, a ratio of 168 per 100,000 of the general population.

The insane in public and private institutions in Germany increased from 78,155 in 1891 to 120,872 in 1901. Since 1901, the data in the German yearbooks concerning the insane have included feeble-minded, epileptics, etc.

The total population of the hospitals for the insane in France on 31 Dec. 1912 was 77,237.

Sex of Insane.— The total number of insane, enumerated in institutions in the United States on 1 Jan. 1910, included 98,695 males and 89,096 females; the total number of insane admitted during the year 1910 included 34,116 males and 26,653 females. The rates per 100,000 of the general population were: Males, 72.1; females, 59.7; total, 66.1. The ratio of males to females among patients in institutions was 110.8 to 100; and among admissions, 128 to 100. In the general population of the United States in 1910 the ratio of males to females was 106 to 100.

In New York State where the sexes are nearly equally distributed in the general population, on 30 Tune 1917, there were 18,422 males and 20,342 females in institutions for the insane, a ratio of 90.6 males to 100 females. Among the first admissions to all institutions for the insane in the State in 1917, there were 3,878 males and 3,462 females, a ratio of 112 males to 100 females.

The excess of males among first admissions is largely due to the greater prevalence of general paralysis and alcoholic insanity in this sex. As patients with general paralysis have a high rate of mortality and patients with alcoholic insanity improve rapidly, the average duration of hospital life is less for males than for females. In the New York civil State hospitals in 1917 the average duration of the hospital life of the male patients who died in the hospitals was 5.5 years, and of the female, 7.2 years.

Age of the Insane Mental diseases occur principally during the period of adult life, the rate of incidence increasing with advancing age. The age distribution of the 6,877 first admissions to the New York civil State hospitals in 1917 as compared with the age distribution of the general population of the State in 1910 is given in the following table:

Comparison of Age Distribution of First Admissions, 1917, and of the General Population of the State, 1910.

AGE	First admissions 1917		Per cent of total first admissions 1917		Per cent of general population of New York 1910
Under 15 years	12		0.2		27.3
15 to 19 years	317		4.6		9.2
20 to 24 years	721		10.5		10.3
25 to 29 years	833		12.1		9.7
30 to 34 years	835		12.1		8.4
35 to 39 years	797		11.6		7.8
40 to 44 years	639		9.3		6.6
45 to 49 years	604		8.8		5.5
50 to 54 years	518		7.5		4.6
55 to 59 years	405		5.9		3.2
60 to 64 years	342		5.0		2.6
65 to 74 years	490		7.1		3.2
75 years and over	332		4.8		1.4
Unascertained	32		0.5		0.1
Total	6,877		100.0		100.0

Causes of Insanity.— Causes of mental diseases are multiple rather than single. Several factors may operate together to cause the onset of a psychosis. Alcohol has always been a prominent factor in the causation of mental disease but its influence seems to have declined in recent years. Syphilis is the primary cause in all cases of general paralysis and of psychoses with cerebral syphilis. Opium and its derivatives, cocaine and other habit-forming drugs cause psychoses in comparatively few cases. Arteriosclerosis by shutting off the blood supply to important parts of the brain prevents this organ from performing its natural functions and thus causes various forms of mental disorder. Blows on the head cause insanity in a similar way by injuring brain tissues. Fevers and exhausting physical diseases often give rise to mental disease.

Insanity may also be due to mental causes, such as fear, joy, anger, grief or anxiety.

Abnormal mental make-up in either the temperamental or intellectual sphere is a predisposing cause in many cases. The abnormal mind gives way to unusual stress while the normal mind is able to withstand it. When the stress is prolonged or of extraordinary severity, as in army life, even the normal mind may give way.

The following table shows the relative prominence of the principal definite causes among males and females as reported by the New York State hospitals.

Causes of Mental Disease among First Admissions to the Civil New York State Hospitals for the Insane, for the Year Ending 30 June 1917.

CAUSES	Number of Cases			Per cent
	Males	Females	Total	Males	Females	Total
Alcohol	655	209	864	18.2	6.4	12.6
Syphilis	750	212	962	20.8	6.5	14.0
Drugs	5	12	17	0.1	0.4	0.2
Abnormal make-up	1,047	1,037	2,084	29.0	31.7	30.3
Injury to head	30	6	36	0.8	0.2	0.5
Physical illness	55	73	128	1.5	2.2	1.9
Senility	247	371	618	6.9	11.3	9.0
Arteriosclerosis	462	334	796	12.8	10.2	11.6
Epilepsy	78	73	151	2.2	2.2	2.2
Pregnancy, childbirth and lactation	......	122	122	......	3.7	1.8
Death in family	25	123	148	0.7	3.8	2.2
Loss of employment and financial loss	71	46	117	2.0	1.4	1.7
Disappointment in love	18	24	42	0.5	0.7	0.6
Other specified causes	212	523	735	5.9	16.0	10.7
Unascertained	696	821	1,517	19.3	25.1	22.1
Total first admissions	3,605	3,272	[1]6,877	......	......	......

1. As each cause reported was enumerated, the number of causes exceeds the number of patients.

Insane Classified with Reference to Psychoses.— No nation-wide census of the insane in the United States with reference to psychoses of mental diseases has ever been taken. The accompanying table gives the result of a census of the 36,357 patients in the New York State hospitals taken by psychoses on I July 1917. As the patients of the New York State hospitals have been carefully classified with reference to psychoses for the past 10 years this census may be considered representative of the distribution of insane patients in institutions in the various clinical groups. As the duration of hospital life of patients in some groups is much longer than in others the distribution of the patients in the hospitals with respect to psychoses varies considerably from that of the newly-admitted cases. This is shown clearly in the accompanying table.

Distribution by Psychoses of Insane Patients in Civil State Hospitals in New York State and of First Admissions to such Hospitals in 1917.

PSYCHOSES	Patients in civil State hospitals.  30 June 1917		First admissions year ending  30 June 1917
	Number	Per  cent	Number	Per  cent
Traumatic	53	0.15	18	0.3
Senile	1,238	3.41	585	8.5
With cerebral arteriosclerosis	469	1.29	395	5.5
Dementia paralytica	1,370	3.72	866	12.6
With cerebral syphilis	122	0.34	43	0.6
With Huntington's chorea	24	0.06	10	0.1
With brain tumor	14	0.04	8	0.1
With other brain or nervous diseases	127	0.35	38	0.5
Alcoholic	1,788	4.92	594	8.6
Drug and other toxic	29	0.08	15	0.2
Infective-exhaustive	52	0.14	99	1.5
Allied to infective-exhaustive	27	0.07	20	0.3
Autotoxic	15	0.04	19	0.3
Manic-depressive	2,716	7.47	833	12.1
Allied to manic-depressive	1,116	3.07	303	4.4
Involution melancholia	785	2.16	201	3.0
Symptomatic depressions	25	0.07	17	0.3
Dementia precox	19,544	53.76	1,475	21.5
Allied to dementia precox	1,273	3.50	311	4.5
Paranoic conditions and paranoias	1,634	4.49	135	2.0
Epileptic	1,223	3.36	142	2.1
Psychoneuroses	162	0.45	77	1.1
Constitutional inferiority	503	1.38	108	1.6
Mental deficiency	1,319	3.63	179	2.7
Unclassified	705	1.94	297	4.3
Not insane	24	0.06	89	1.3
Total	36,357	100.00	6,877	100.0

Movement for Uniform Statistics of the Insane.— As previously pointed out, statistics of the insane until recent years dealt principally with the number enumerated in various States and countries without regard to the kinds of mental disease with which they were afflicted. In fact, the absence of a generally accepted classification prior to 1917 prevented the collection of national statistics of mental diseases. The first bureau of statistics for the study of mental diseases was established in 1908 by the New York State Commission in Lunacy (now, the State Hospital Commission). The Commission adopted a uniform classification of mental diseases for use in its 13 State hospitals, and required the medical officers of each hospital to submit to the Commission's statistician a statistical card report concerning each case admitted, readmitted, discharged, or deceased. From such cards yearly statistical reports have been prepared and published, and the cards have been filed according to identification number and psychosis. The Commission now (1918) has a file of uniform cards of about 60,000 first admissions — the largest collection of systematic data concerning mental diseases in the world. By combining the cards received from all the hospitals for a series of years, the bureau is able to make intensive studies of the separate mental diseases.

The success of New York's pioneer work led the American Medico-Psychological Association to undertake a movement for uniform statistics of the insane throughout the United States. At the meeting of the Association held in Niagara Falls in June 1913, a special committee was appointed to devise ways and means of securing uniform statistical reports from institutions for the insane. This committee, after prolonged conferences, submitted its final report to the Association at the annual meeting held in New York in May 1917. The report recommended the adoption of a new classification of mental diseases and submitted outlines of 18 statistical tables for use in the annual reports of institutions for the insane. The committee stated that “the lack of uniformity in hospital reports at the present time makes it absolutely impossible to collect comparative statistics concerning mental diseases in different states and countries, and extremely difficult to secure comparative data relative to the movement of patients, administration and cost of maintenance and additions”; and that the “importance and need of such uniform data have been repeatedly emphasized by officers of the association, by statisticians of the United States Census Bureau, by editors of psychiatric journals and by administrative officers in various states.” “Such data,” the committee adds, “should serve as the basis for constructive work in raising the standard of care of the insane, as a guide for preventive effort, and as an aid in the progress of psychiatry.” The report of the committee was unanimously adopted and a standing committee on statistics was appointed to secure the adoption of the new classification and statistical system by Federal and State authorities. In February 1918, such standing committee affiliated with the National Committee for Mental Hygiene which had received a special gift for statistical work.

Through the co-operative work of the two organizations a uniform system of statistics of mental diseases was put into operation in nearly all the State hospitals for the insane in the United States during the summer of 1918. The surgeon-general of the army, in September 1917, adopted practically the same system for use in the Division of Neurology and Psychiatry.

The Association's classification of mental diseases which forms the basis of the new statistical system consists of 22 groups of principal psychoses, some of which are subdivided into more or less distinct types. The classification is not regarded as final, but it constitutes the first successful attempt to secure uniformity in the designation of mental diseases in the United States.

Bibliography.— Census reports, Insane and Feeble-minded in Institutions, 1904 and 1910; ‘Insane, Feebleminded, Epileptics and Inebriates in Institutions in the United States, Jan. 1, 1917,’ by Horatio M. Pollock, Ph.D., and Miss Edith M. Furbush, A.B., B.S.; New York State Hospital Commission Reports 1908 to 1917; Report of Committee on Statistics of the American Medico-Psychological Association, 1917; Statistical Manual for use in Institutions for the Insane, published by the Bureau of Statistics of the National Committee for Mental Hygiene, 1918; Statistical yearbooks of foreign countries.

Horatio M. Pollock.