# The Increase of Insanity, 1907/Lecture 1

THE INCREASE OF INSANITY
LECTURE I
Mr. President, Fellows, and Gentlemen,—I have little doubt that each of my predecessors has in turn experienced similar feelings before he has delivered the Lumleian lectures. In my own case the feeling of pride at the honour bestowed on me by the selection of our President was immediately succeeded by some uncertainty as to the precise subject which I should select, and the apprehension which still persists lest I should, in any way, fail in my duty or fall short of my responsibility to you. Wishing to do my best, I have naturally selected the subject which my special experience of forty years should enable me to treat with some authority. But as I have not thought it desirable on this occasion to hazard any new theory or treat any special point with all the detail of thought and illustration which it would undoubtedly require, I trust that the apparently somewhat discursive nature of my remarks upon the wider issues may be ​attributed to a desire to lay before you facts which are of general rather than highly specialised significance. At the present time the subject of the increase of insanity is being very carefully considered, not only in England, but in all civilised countries, and I feel that the very fact that it is being so considered has increased my difficulty. In all directions, both in the medical and lay press, articles have appeared on the subject, so that I have little doubt that the opinions which are the result of my own experience will frequently be found to coincide with the opinions already expressed by other observers.
At the outset I must acknowledge my own definite conviction that there is a steady increase in the numbers of the insane, and that this increase shows a definite relationship to the progress of civilisation. I do not myself think that this estimation necessarily implies the hopeless degeneration of the race, nor do I think that it furnishes an authentic basis for dread as to the future of the minds and bodies of our successors. With the multiplication of rules and regulations it becomes more and more difficult to fall into all varying social requirements, and my own particular experience indicates that many cases are attributable rather to social misfits than to material brain disease. In describing these and similar cases I may say that I rely upon my own observation, supported by such statistics drawn from official sources as I may find it ​necessary to employ in connection with the more recognised groups of the insane.
Let me now indicate the lines on which I propose to move. First of all, before studying the question of the increase of insanity, it is essential that we should recognise what we mean by insanity. Of course, I take primarily the medical standpoint, but I have my doubts as to whether the social one is not, after all, the more practically important of the two. We find ample evidence that with no merely medical criterion on unsoundness of mind is the public easily satisfied; no doubt it would often be much better if it were. Next I will examine briefly into the more generally accepted causes and endeavour to show if it is possible to find amongst them any indication of the actual lines of increase. So that in a word the question will be, What are the special forms of insanity which are increasing? What are the causes which are more in evidence now than formerly were? And what hitherto unrecognised moral or physical causes are tending to produce, or to reproduce, mental unsoundness? And the evidence which I can offer in reply to these questions will, I hope, enable you to form conclusions as to the validity of the reasons given for the increase of the certified and uncertified insane.
To begin with, in judging the conduct of any person supposed to be of unsound mind it must be recognised that similar conduct may arise from totally different disorders ​or circumstances and also that the mind is a very complex thing which has many ways of expressing the same feeling. Take, for example, the exaltation of ideas in a patient believing himself to be a king or a person of distinction. Such an idea may correspond with a temporary increase of pulse rate, and I have seen it prominent or suppressed as the pulse varied. It may succeed the loss of judgment and the feeling of buoyancy met with in general paralysis of the insane; it may be associated with the temporary disorder produced by brain-poisoning—say by lead or alcohol; or it may be a slow growth in some “mute inglorious Milton” or lonely idealist, who, possibly building on the “might have been,” finally recognises in himself or herself a scion of royalty or an inspired poet. Or again, perhaps in a more advanced stage of degeneration of mind the patient, who may have begun by feeling that he was watched or spied upon, is convinced at length that he has discovered that all this was merely the protection essential to the movements of a royal personage—himself. In each case the conduct of the patient is similar, though the underlying ideas are so different. Similarly, I have often had to point out that what might be a reasonable act in one person would be insane extravagance in another. I mention these facts here because in determining what is meant by insanity, or what is to be done for it, the circumstances and environment have always to be considered. And notwithstanding their mutual points of resemblance, ​no one pathology or treatment is applicable to all similar cases.
A question which I am often asked is whether I believe that certain persons only can be driven insane, whether the rest can never become mad—whether, in fact, there are many in whom nothing in the form of exciting causes will produce insanity. My reply is that almost anyone may have delirium, which is temporary insanity; that almost anyone, given certain physical causes, may have general paralysis, and also, it is sufficiently evident, that with advancing years the powers of the mind, both on the motor and sensory sides, may be impaired or disabled before the other functions of the body. Yet this notwithstanding, I still believe there are some persons who can hardly be driven mad by any outside stress or emotional cause. And surely it is worthy of consideration that so many very aged persons retain their senses and reasoning power almost unimpaired until the very last. On the other hand, that there is a class of persons accurately described as “neurotic” is very evident ; and it is equally certain that it is this class which provides the largest number of sufferers from insanity and allied disorders. It is in regard to these that I have stated my belief that there is no ground for supposing the increase to be of an alarming extent.
But it may be well here to consider what I mean by ​“neurotic,” for I find it regarded as such a convenient term that it has frequently been made to include almost every nervous or mental disorder which has ill-defined symptoms. To be civilised, as a sane person, implies the capability of reacting normally to the changing conditions of one’s surroundings, so as to interfere as little as possible with the interests, safety, and welfare of other persons living under similar conditions. With increasing complexity there must be an increasing power of adaptation, and, as might be expected, there will often be found a deficient or an undue social mobility. It is in this abnormality of reaction to surroundings that we find the true empirical basis of neurosis. Now this may arise from many diverse conditions. It may be a result of weak, degenerating, or insane parentage, or it may arise from causes which materially interfere with the nutrition of the higher nervous organs, from toxic influences, for example, or from generally debilitating causes, such as excesses of any kind. The point to consider is whether any of these influences have been acting so forcibly as to render the civilised races at the present time more likely to break down along nervous lines. In regard to this tendency the reports of the Commissioners in Lunacy for England, Scotland, and Ireland will be found most instructive. We are fortunate in this respect that the Irish Commissioners last year, taking it for granted that there was an increase in the numbers of ​the insane, addressed special inquiries to the various medical officers of the asylums on this point and elicited their individual opinions in regard to it. Special stress, I may remark incidentally, was laid upon the danger of hereditary predisposition and excessive indulgence in alcohol. I think, therefore, that conclusions based on these reports, in so far as they agree, may be taken as the composite opinion of asylum physicians as to the causes of any such increase.
And now to speak a little more definitely on my first point. I still believe that what Hughlings Jackson said many years ago is true—viz., that we physicians connected with insanity resemble gardeners rather than botanists, that the fact must be recognised that we classify for convenience rather than upon a scientific basis, because in point of fact no such basis, or finality of mode, has as yet been discovered. And perhaps little wonder, since many have to be treated as lunatics in whose brains and nervous systems no change whatever can be found. Unfortunately, this necessity of definition and classification to which I have referred may sometimes lend itself to misinterpretation, as in the pseudo-legal idea—which I regard as neither reasonable nor convenient—that every person of unsound mind is a lunatic. Obviously there are many persons of unsound mind who are neither dangerous to themselves nor to others—why, therefore, regard them as aliens? The true difficulty is that a ​disease “insanity,” as a definite entity, does not exist. Yet one might almost conclude from the elaborate articles which have appeared in our leading daily journal that it does, and that it is as definite in its symptoms and its origin as cancer or pulmonary tuberculosis. It is impossible for the physician to view abnormalities of mind, whether congenital or acquired, as having a common origin and requiring a similar treatment. There is no such thing as a bacillus of insanity. I have dwelt upon this point because one of the many difficulties which the study of the insane involves is the necessity of regarding them from so many different standpoints. The medical man concerns himself chiefly with the evidences of bodily disease to be discovered in the brain or one of its servants; the lawyer looks not so much to symptoms as to the questions of reason and responsibility, whether, in fact, the individual can recognise what he is doing and the consequences of it. The public at large considers chiefly questions of conduct, asking whether a person is dangerous to himself or to others. Apropos ot the latter, we constantly meet with statements that many people are placed in asylums because they are troublesome rather than because they are dangerous; and it is also worthy of remark that there are many who desire that the feeble-minded and eccentric should have greater or even perfect liberty, so long as they are not a social danger. This point is, I think, rather well illustrated in ​the peculiar distinctions recognised on the popular side thus, persons are spoken of as being “ beside themselves," or “out of their senses,” or “ out of their minds. To these you will note that I have already added my own conviction that many are really “out of their surroundings” and thus are aliens.
The conclusion then follows that, there being no definite entity of insanity, there can be no one comprehensive definition of it. And that the person is sane or insane in relation to his own standard and not to any existent arbitrary one, except the conventional arbitrament of civilisation. And as this varies the truth of my former remark becomes evident, that what is reasonable conduct in one man under certain conditions, may be plain madness in another differently situated. I often think of a splendid young animal whom I saw— the son of a distinguished father, who rightly judged his son to be an anachronism—out of place in fact; and considered that he would have made a fine knight in the Middle Ages, and perhaps even now might make a good cowboy in America. It becomes evident from such a case that there may be some who have a reason for attributing the causes of their insane position to their wrong surroundings. And here I would point out that there is a sense in which insanity is merely a question of degree. For example, a small amount of miserliness may be all right; but, when you find it developed into the habits of the ​recluse, who starves himself, though he has plenty of money, avoids all society, and neglects cleanliness and all the simpler conventions of life, he may be treated as insane. I knew such a recluse, with plenty of money, who lived a hermit’s life for thirty years or more, prowling about the streets at night, and lying in bed during the day; yet no steps were taken, as he did not interfere with society. But when called to see a similar case not so well off, I found that the authorities had already been called in. His small house being neglected was regarded as insanitary and he was removed to an asylum. Thus we see that similar conduct is, or is not, practically regarded as insanity according to the conditions. And if there should be some who regard this view as of little importance from the practical or statistical standpoint—as referring, in fact, to a very small area in the wide field to be covered by the specialist—as not affecting in a vital degree the estimated sum-total of the insane, I am not in agreement. I still maintain that very many of the chronic insane owe their position largely to their surroundings, and the part which their surroundings and circumstances have played as factors in the determination of that position is precisely what it is often important to consider before any reliable statistics can be built up in regard to the mental evolution or degeneration of the race.
With regard to a certain degree of a particular habit ​or feeling being considered normal, but its excess insanity, I may give the example of a very devoted husband, who, with advancing years, dreaded the absence, even for a very short time, of his wife. Later he began to suspect that she was more absent than was necessary. Finally, though there was not the slightest ground for suspicion, he demanded from her a confession of her misconduct, calmly observing that he would forget and forgive. Thus, the overgrowth of natural affection, and the suspicion of an imaginary sin have led, I fear, to a permanent delusion, wrecking two lives. Where are we to look for the material basis of such a delusion? The conditions are still more complicated when the person proves to be a social misfit. There are some, like my cowboy youth, who are out of harmony with their surroundings from the first. There are others who, as a result of education, disease, or other circumstances or causes, pass into a social grade different from their own. I have known public school and university men who have proved quite unfit for their natural homes and yet they have done admirably as artisans. Are we to have a pathology for such conditions? Of course, a certain number of these social failures add to the numbers of the insane in our infirmaries and asylums. Undoubtedly, some may say there is some brain defect in these persons to account for their degradation; but how about the change of reformation, and in regard to those who have been ​converted, are we to have a pathology of conversion as well as of perversion? At any rate, the fact remains that not only from the social but from all other standpoints insanity is judged rather from conduct than from any known mental symptoms.
I will now proceed in order to consider the insanity of brain disease, the insanity of brain intoxication, the insanity of the truly neurotic type, the insanity of habit or association, and the insanity of function, simple disharmony, or want of accommodation. In considering these points I will give my experience as to the relative increase among them. First, then, there is a considerable amount of insanity depending upon natural decay of the nervous centres chiefly represented in the brain. The Commissioners give a table showing a considerable increase of longevity among the surviving senile insane. The chronic insane in asylums are like pensioners; they are removed from the stress and anxieties of life, they are carefully tended, and sometimes their very mental defect will lend itself to a calm which itself is favourable to a long life. Again, it is certain that, whereas in a former generation the old people were kept and guarded by their relatives, these latter are now more easily persuaded that they would, in their indifferent or mindless states, be better in an asylum than elsewhere. And the infirmaries, on their part, are only too ready to transfer to asylums those who are not able to be of service in the wards ​and for whom they can get a bigger grant from public funds if they are sent to an asylum. Hence, the insanity of old age does certainly represent a considerable increase of the insane population. The forms of insanity associated with old age are not special in character, though many of them exhibit analogous features associated with loss of memory and loss of the senses of time, place, and relation. The insanity associated with premature decay, with toxic brain infection, is best represented by general paralysis of the insane. Here again, without doubt, there is considerable increase. In England, Scotland, and Ireland, all three, the Commissioners’ reports prove this. Although we are at present unable to say that this disease proceeds from one definite source, there seems to be little doubt that syphilis added to alcoholic indulgence in city residents constitutes the chief cause. In England the progress is steady, and it is interesting to note that this disease is now more prevalent among women than it used to be. This is markedly observable in Scotland. Women will have men’s rights and with them they incur further risks.
Forty years ago the medical officers of asylums in Ireland often came to Betlilem Hospital to see cases of general paralysis because they wished to assure themselves that they were not overlooking the disease. Personally I visited many Irish asylums in those days and I found very few cases of the disease, which now is common enough, particularly in the Irish asylums near cities.
​In America a similar experience has been recorded among the negroes, who before the Civil War rarely provided cases of general paralysis. Now these are common enough. In the last Scotch report general paralysis is stated to be increasing more rapidly in Edinburgh than in Glasgow. This seems hard to explain, but I am inclined to think this must depend on some difference in the diagnosis, many cases appearing as brain syphilis and not as simple general paralysis.
The next group to which I call attention is in many ways important and interesting, particularly at the present time, when toxins are the favourite explanation of most morbid states. I would recall what Sutton said many years ago, that though there was doubtless much to be learnt from an observation of the relationship between micro-organisms and disease, yet, as effective causes, their importance might be over-estimated and their operation misunderstood, that just as we lived on, and aided by, them when healthy, so it was when we began to fail in any direction that the microbes were ready to prey on us. That mental disorder amounting to insanity may depend upon toxic influences is too well known to require much illustration on my part, yet it is perhaps worth while to note a few of the special forms of disorder which follow intoxications of one kind or another. First, then, there is generally a progressive affection beginning with the most highly specialised parts leading to defect in the last and most complex attainments, the con​tinuance of such infection leads to further loss of power, and, as Hughlings Jackson has pointed out in his “Factors of Insanities,” a letting loose of functions dependent on what he has called the lower or subordinate mental strata. It is thus that Ave get Avith loss of power, restlessness and deliria. A still further exposure to the toxin leads to destruction of the parts and the annihilation of the functions. The result is a complete parallel to the decay met with in old age, which, I suppose, justifies Metchnikoff in his suggestion that senile changes depend on micro-organisms.
I have already spoken of neuroses and given some description, if not a precise definition, of them; and now, in natural order, I propose to consider the special forms of insanity which may be said to possess this common factor, that they are usually associated with insane or degenerating parentage. This class provides the largest number of long-live residents in asylums, who used to be grouped together lents. They generally come of insane stock and tend to trasmit their neurosis, in one form or another, to their decendants. They are more liable than others to break down under slight stresses ; ceteris paribus, then' neuroses appear at the critical periods of life, such as adolescence, liberty, and, in the case of women, with child-bearing and the menopause. These patients show a special liability to relapse after recovery, and, as a sequence, to establish a habit of recurring mental disorder—mania, melancholia, as the case may be. This morbid habit may become more ​and more organised and pass into regular circular insanity. The ease with which morbid mental processes are started in such cases is exemplified in the manner in which hallucinations of the various senses appear and develop; having appeared, they lead on in natural order to delusions of various kinds, to some extent coloured by the age, sex, education, and surroundings of the patient. But that persons even with fully-organised delusional insanity have any specially recognisable affection of their brain I doubt. I daresay that in many there is some change of condition and in many also a defect of the highest powers; but as yet I am convinced we shall not learn much even from most careful histological observation. Without being a pessimist, I fear my experience is that such persons are slowly increasing in number and that no amount of drug treatment will have any effect upon them. If any good is to be done it seems to me that it is rather to be hoped for from the methodical and contemned treatment followed in asylums. What cannot be cured must be endured, and I fear that persons suffering from fully-organised delusions are as little likely to lose them in many cases as they are to change their features.
With the above we have to consider, as depending upon a neurotic heredity, those who furnish examples of certain, often recondite morbid modes of mental association—persons, in fact, suffering from so-called obsession. No reasoning seems to affect the beliefs or tendencies of these ​persons, yet in all other relationships their conduct may appear to be perfectly sane. Thus, a patient told me he knew it was a mistake, yet he dare not touch anything without gloves; another was afraid to sit in a chair without a preliminary dusting. He admitted that this was useless even if there were infection in the chair, all the same he must go through with it. Another patient, having been once bitten by a dog was never free from the dread of hydrophobia, and though no signs existed of the dog ever having suffered from rabies, yet he could not go near the city where the accident happened. That with some of these morbid associations a physical basis bears a part I must admit, for this latter gentleman only comes to consult other physicians or myself when he is suffering from general symptoms of ill-health. On the whole I am not prepared to say whether there is any material increase among those suffering from obsessions.
To complete this part of the subject I must name the allied sufferers from the folie de doute. This may be seen to depend on different causes in different persons. The highly-trained legal mind may be so evenly poised that it cannot come to a conclusion; and the individual who suffers from this condition, or from its allied state of Grilbelsucht, is suffering from a disorder which I cannot associate with brain disease. The manner in which a simple natural idea may pass into a morbid one is shown in the following case. A well-educated man of good social position fell in love with a lady of good birth who, in ​consequence of the ruin of her father, found it necessary to give dancing lessons in order to earn money. The idea that she might expose her ankles to strangers so possessed him that he felt life intolerable, and no amount of argument that the lady was only teaching girls produced any effect. Again I have met several doctors’ wives who have developed an insane jealousy in consequence of their husbands attending midwifery cases. Thus, obsessions developed after the manner I have indicated have had serious practical effects, though in the cases to which I have referred the seclusion of the sufferers was not required.
Again, the perfectly natural way in which ordinary feelings may lead to insane developments is well illustrated in such cases as the following. A young man early in life becomes deaf; at first he feels the loss to be a very real and personal one, but he is content to do his best under the new limitations. Later he experiences several disappointments, for example, in love; no doubt depending on his defect. Slowly he builds up a delusion that people shun him; gradually he becomes convinced that there is an organised system of annoyance. An insane or violent act may be the first indication of the progressive mental disorder. In this example marked physical defect is the starting point, but one constantly meets with patients affected by a mere peculiarity which they think influences people against them. For example, a man with a scar on his nose believed that this was looked upon as the “mark ​of the Beast.” Another, who had led a seafaring life, was certain that everyone recognised in his scar evidence that he had had syphilis. Apart from personal defects or peculiarities one meets with many in whom a disharmony with the social environment has given rise to a morbid mental growth. A widow with small means has to reduce her expenditure. She believes her neighbours shun her ; from this she develops a whole system of suggestion, innuendo, and annoyance, which may cause her to injure herself or her children, or perhaps to appeal to the police. Such cases are of everyday occurrence, and I rather presume they tend to increase with the complexity of urban life.
Allied to such cases are those which I place under the heading “conscientious.” Almost daily I see cases, generally young, of both sexes who, living their home-life and regarded as most quiet and well-behaved persons, have nevertheless slowly withdrawn from all intimate friendships, they have taken to self-improvement, they lead laborious days and often studious nights. They are said to be scrupulously conscientious. They are only very morbidly sensitive. Often they go on thus for years before it is discovered that brooding has led to the hatching of delusions of persecution. Here I suppose there is probably an unhealthy nervous system, but I do not think it is such a one as will in the material part of the brain be shown to be defective. This kind of case is frequently illustrated in the only sons of widows who live their quiet life surrounded ​only by female relations. This class includes a large number of persons who drift into delusional insanity. I am fully aware of the fact that there are hundreds or thousands living similar lives who do not break down nervously, and that there are other elements in the situation. What I wish to enforce from the standpoint I have chosen is that such persons must be treated by change of condition and not merely by drugs alone.
It will be seen that in all the cases to which I have been referring I seem to deny the existence of any material pathology. I merely say that in those cases where the mutual reaction shows a distinct degrading influence in the surroundings of the individual it is more or less hopeless to look for any real uniform material cause in the person himself. Of course, I allow that variable bodily states may dispose a person to be more readily affected by his surroundings and therefore more unstable. But I shall have failed altogether if I have not shown that there are many nervous conditions in which the visible defect is one of arrangement and accommodation rather than destruction of any portion of the material basis of mind. I cannot therefore accept much that Hughlings Jackson has written in his “Factors of Insanities,” because while he regards mental symptoms as the morbid product of the brain he does not sufficiently recognise them as a resultant of the forces of the environment. That every idea and every delusion have a representative in some material change in ​some part of the nervous system of course I do not deny : but that there are always definite changes which are the equivalent of insanity, I do deny. Before leaving this part of my subject I must refer to functional mental disorders. I cannot admit that all these have any material pathological basis. In fact, I still maintain that there are such things as functional mental and nervous disorders.
Let me quote what the late Dr. H. G. Sutton wrote on this matter : “ Failure of function leads to organic destruction. It used to be taught that structure makes function, but it is the reverse, just as the blacksmith makes the horseshoe, fitting the iron for service. In nature it is evident that all function is making union—a living and a loving— while in disease there is disunion.” Finally, unless we admit the supreme importance of surroundings both in giving rise to and in sustaining mental perversion, we can-not fully recognise the equally supreme necessity of judiciously modifying those surroundings and conditions in order to effect a salutary change.
Take this example. There was a girl admitted into Bethlem Hospital suffering from acute mania. After some weeks, quite suddenly, all the maniacal symptoms disappeared, but she was paraplegic. The state of paralysis lasted for some weeks, to be again replaced by mania, which in its turn was again followed by paraplegia. Eventually the paraplegia slowly passed off, leaving the patient sane in body and mind. Certain other cases in which neuroses are interchanged are ​interesting : thus, sufferers from asthma or hay fever will lose these affections while suffering from another form of neurosis. I cannot find anything but a dynamic pathology for some of these cases of sudden cure. I have known patients apparently demented for years suddenly, without any bodily change, wake up perfectly sane and with no loss of mental power. A watch may lie inactive, for want of winding up, for years and yet not decay. The mind seems capable of resting in the same way. In this case we must fain call it apparent dementia.
The next part of my subject—a brief reference to what may be called the ordinary forms of mental disorder–is, I think, less likely to give rise to any differences of opinion. First there is mania, the loss of higher mental control, which really extends from delirium to hysteria. As Jackson has pointed out, the removal of the higher control facilitates the demonstration of the lower activites of mind and also allows them to assert themselves in an abnormal manner. I am inclined to think there is an increase, though not a very large one, in the cases of acute delirious mania—grave delirium, as it has been called. This disease is doubtless the result of some toxic influence and will furnish evidence of what I have said elsewhere, that anything which will produce temporary delirium may give rise to delirious insanity. It may follow infectious fevers, alcohol, or some auto-toxins, arising, I have little doubt, in many cases from initial brain changes. I think, judging from my ​own personal experience, that the result—or, at any rate, one of the results—of reduced consumption of alcohol is that there are found fewer cases of grave delirium arising from or following delirium tremens. As to ordinary mania, the general opinion I find among the metropolitan asylums is that there are fewer cases of simple mania than formerly, and that certain forms of mental disease which used to begin with mania are now more commonly seen in a melancholic state. This is said to be the case in adolescent insanity and also in general paralysis of the insane. This conclusion has by some been attributed to the part played by influenza in starting the neurosis, for there is no doubt that, as a rule, melancholic states are more common after this disease.
Next as to melancholia. You will gather from what I have just said that my own experience, which appears to be supported by that of most asylum physicians, is that there is an increase of melancholic patients and also of melancholic symptoms in the various forms of insanity. The self-conscious youth is religiously depressed. The girl with amenorrhoea is contrite and self-accusing. Middle-aged men and women are suspicious and doubtful as to their social position or their conduct in the past; with advancing years comes a dread of poverty and the workhouse, and perhaps the desire to leave a world where they feel that they have already begun to outlive their welcome.
The next general form of insanity, to which I have ​already several times referred, is so wide and so far-reaching that I am not surprised to find an almost universal belief in its increase. Dementia is the termination of many forms of insanity. As I have already pointed out, we have to deal with the fact that the insane live much longer than they did : they remain till the end in asylums and are thus recognised in census statistics. Again, a tendency to senile disorders leads naturally to an increase of senile dementia. So there are more old people to become insane and the insane live long enough to become old. I have little doubt that the various types of youthful disease tend more rapidly to mental weakness than they did in former years, but this is rather a belief than a proved fact. As to the various forms of dementia—such as those depending on syphilis, general paralysis, or alcohol—some are increasing, others are stationary, at present.
Under the head of “functional disorders” I referred to the truly neurotic insanities and I stated my conviction that they were increasing. I would point out that here again we ought to be on our guard. For it is pretty certain that these persons also accumulate in the asylums and live longer lives there. I certainly think myself that many among such persons might be allowed to live free, at least from asylum control. I have not referred to the large class of idiots, imbeciles, etc., as I do not personally claim enough knowledge to speak about them. I do not, however, think it can be denied that there is a very large and probably ​increasing group of social failures, the failure depending on some nervous want. Some of these are physically unfit, others are wanting in their senses, while many are morally weak and unfit for ordinary social life. Whether these are increasing in proportion to the population I cannot say, but that in the future they will have to be seriously considered I do not doubt.
And now to sum up shortly what I have been aiming at to-day. I have desired to make it clear that I cannot accept any definition of insanity as a disease. I have endeavoured briefly to delineate its social, legal, and medical aspects, each of which differs from the other. I have referred, in the time at my disposal, to the forms of mental disorder which appear to be the most interesting and worthy of consideration at the present moment. I have expounded my belief in the existence, or the non-existence, of a pathology for such cases, and I have given a few details here and there as to the increase of the various groups. If I should be considered to have expressed too hasty a conviction in regard to certain cases, which, being out of harmony with their surroundings and obnoxious to society, are in our day treated as aliens, I would nevertheless repeat my opinion that although insanity cannot be predicated of that which is neither a mental nor a physical organism, although I cannot go so far as to say that the insanity lies in the environment itself, yet in not a few cases the actual source, and especially the sustenance, of the disorder, do lie in the surroundings ​rather than in the patient ; and to a judicious and well-advised modification where possible of the surroundings and circumstances only can those interested look, with any prospect of success, for the desired safety, convalescence, or cure.