the semi-tropical regions, which are relatively free from the sudden changes of weather so common in the northeastern and northern central regions, is comparatively low. If we turn to the seasonal influences the same criticism applies, though the changes take a somewhat longer time. As regards climate and seasons, Berkley,* an eminent American authority, says: These are factors of very minor importance in the evolution of insanity. The harmful effects of heat in the south are more than counterbalanced by the more prevalent abuse of alcohol in colder regions. In a general insane asylum, where the middle and lower classes of the population are received, a study of the records will show that a larger number of admissions in one year may occur during the winter, whereas in other years the same holds good for the spring, summer, or autumn. Hence one is obliged to conclude that the seasons have little to do with the evolution of insanity.'

In the last analysis, however, the effects of all these agents which collectively I have spoken of as constituting man's physical environment upon his mind must be only secondary, mediate and not immediate. If we will study the effects of any one of them-for example, temperature, humidity, altitude-we will find them expressed in terms of respiration, pulse rate, evaporation from the cutaneous surface, blood pressure, &c. -effects which I grant you are potent, but which, nevertheless, are not primarily mental.

This whole matter reminds me very forcibly of the learned judge who could not understand why the expert called upon to testify as to the mental condition of the defendant should have measured his feet. The medical profession have been largely responsible for this

Henry J. Berkley. Insanity: General Etiology, Reference Handbook of the Medical Sciences, Vol. V.

conception, especially our misguided friend, the gynecologist. This gentleman has insisted that all forms whatsoever of mental disease affecting the female were traceable to an affection of the uterus or its appendages, and has devised all manner of operations to relieve such conditions. True, the insane female who may have a local pelvic condition which is amenable to surgical interference is just as much entitled to the relief that can be obtained from that source as her more fortunate sister, and it is quite conceivable that the relief of a local condition which was painful or debilitating by reason of frequent hemorrhages, or other cause, would place the organism in a better condition to rally from any abnormal state. the sort of stuff that mind is made of is not to be found in the abdominal cavity.

But

This brings us again to the basis of our argument. If we are to seek for an adequate cause to explain the conditions to which I have directed your attention, we must seek for a mental cause, not a physical one.

If we look back over organic nature we shall see that in the progress of evolution the nervous system has come to play a progressively more and more important part until we get to the higher animals-the vertebrates-in which the brain comes to be of paramount importance.

Still, in the lower races of men, although the brain is of such great importance in the struggle for existence, that struggle is, after all, in the main and relatively a physical struggle; it consists largely of collecting food which is often ready at hand in the tropics, of pursuing and killing game, and often of personal encounters with his fellowman, as a result of which the conquered is killed or reduced to slavery. When we get to civilized man, however, the picture is different. Here the struggle for existence has become an essentially mental struggle, and success is a func

tion of intellectual capacity. I can in no better way illustrate the severity of this struggle than by calling your attention to the fact that it takes twenty-five years of preparation nowadays before a young man is considered equipped to cope with his fellows.

The brain then becomes, as it were, the storm center in the organism. Here, in the habitation of the mind, do all the problems of subsistence meet their solution, and here also do all those mighty emotions which ever and anon stir the soul take their origin. It is here in the brain that vaunted ambition has its sway, and here that the sweet pains of love tune one soul in harmony with another.

The mind, delicately adjusted as it is to its environment, responding as it does to the slightest changes therein, occupies a dangerous position and becomes at once liable to great stress and to the multiplicity of disorders that result therefrom. The savage in his simplicity does not know what it is to suffer from the cares and worries which are the daily portion of the average European, and it is little wonder that the latter, beset by all manner of disappointments and vexations, should more frequently break down in mind than his less-gifted brother.

If you have followed me thus far, you will note that in my attempt to account for the geographical distribution of insanity in the United States I have discarded the influences of the physical environment as being efficient causes because of their indirectness, and have appealed to the immediate results of mental stress, the results of the contact of man with man in the struggle for existence; in short, the results of that struggle itself as exemplified in civilization.

If my contention is true, that insanity is the result of the stresses incident to the progressive civilized state, it must be possible to educe further proof of this by a study of some of the phenomena

that accompany civilization. We would thus expect to find that in those localities where civilization was furthest advanced, where the social institutions were stable, where class distinctions had crystallized-in short, where the stresses of intellectual life were greatest-the proportion of insanity was highest. Let us see if this is so.

One of the most marked results of civilization is the concentration of population in certain areas. Let us study this condition in the United States with reference to the distribution of insanity. The census for 1890 shows that for the different regions of the United States the population per square mile is as follows:

North Atlantic Division .
South Atlantic Division.
North Central Division.
South Central Division..
Western Division....

107.37

32.98

29.68

1894

2.58

The North Atlantic Division, comprising the New England States, with New York, New Jersey, and Pennsylvania, has more than three times the number of inhabitants per square mile of any of the other divisions—in fact, more than all the rest put together. Of these states, Rhode Island, the smallest, has the greatest density of population, with 318.44 to the square mile; then comes Massachusetts with 278.48, Connecticut with 154.03, and down the coast, New York with 125.95, New Jersey with 193.82, and Pennsylvania with 116.88. From this center of density the proportion of inhabitants to the square mile diminishes regularly in every direction. If we go south, we find Maryland with 105 and Delaware with 86 per square mile, until in the extreme south we find but 30 or 40. Westward from Pennsylvania, however, we find a belt bordering the Ohio River, containing Ohio with 90, Indiana with 61, and Illinois with 68 per square mile, and from here the diminution is rapid to Louisiana with but 24, Minnesota with only

16, and the extreme West, where the proportion is less than 1.

Here, you see, we have an almost exact parallel with the distribution of insanity.

Closely connected with this peculiarity of civilized communities to concentrate in certain areas in fact, a part of the same phenomena-is the growth of great cities. The Eleventh Census shows that the percentage of the population of the United States living in cities of 8,000 or more inhabitants for the different regions was as follows:

North Atlantic Division...
North Central Division..

South Atlantic Division.

South Central Division. Western Division.....

51.58 25.91 16 03 10.45 29.99

Here again we see the same parallelism between the degree of manifestation of a phenomena of civilization and the proportion of insanity. The North Atlantic Division contains almost twice the percentage of urban population of

any of the other divisions, and here, as we know, we find the highest percent-1 age of insane.

If we calculate the proportion of insane per 100,000 in all cities of the United States containing 50,000 or more inhabitants, we will find that in 1880 the ratio was 231.6 as against 183.3 for the whole country, while in 1890 the ratio was 242.7 as against 170 for the whole country. Thus we find that the ratio of insane in cities of this size has not only increased in the decade from 1880 to 1890, but that the ratio for the whole country has decreased. It is also significant that, while in 1880 there were only 35 cities containing 50,000 or more inhabitants, in 1890 there were 58 such cities. We further find that of these 58 cities 26, or nearly one-half, are located in the North Atlantic Division. Of these 26, 6 are in Massachusetts, 7 in New York, 5 in New Jersey,

in Pennsylvania, 2 in Connecticut, I in Rhode Island, and none in Maine,

New Hampshire, and Vermont, so that our findings thus far are still further harmonized by these additional facts, for the density of population in Maine, New Hampshire, and Vermont is very much lower than for the other states in this region. (See outline map No. III.)

If, now, we study the movement of population during the past century we meet again the same confirmation for our views. *Mayo-Smith makes the statement that in 1790, 95 per cent of the population were on the Atlantic seaboard, with an average depth of settlement at right angles to the coast of only 255 miles. The stream of population spread westward along three lines-one the valley of the Mohawk, one from Virginia southwest into Kentucky and Tennessee by way of the Appalachian Valley, and one over the Alleghenies to the Ohio River. This latter course was the

* Richmond Mayo-Smith, "Statistics and Sociology."

principal one, and from the junction of the. Ohio with the Mississippi we find further westward migration occurring along the valleys of the Missouri, Arkansas, and Red Rivers. This course of the westward spread of population has been maintained, for, though river valleys furnish the natural highways for migration, when railroads come to be built they are built in the valleys, and the general course of events is not materially changed thereby.

See how closely these facts correspond with the distribution of insanity. From the northeastern coast states-Massachusetts, Connecticut, New York, and New Jersey-there is a progressive decrease southward along the Atlantic coast. There is also a decrease as we go southwest along the Appalachian Valley; but we find the ratio of insane continues high in the Virginias, Kentucky, Tennessee, and North Carolina, and does not show a marked falling off