ALCOHOLISM AS A CAUSE OF INSANITY

BY CHARLES L. DANA, M.D., LL.D.,

New York City; Professor of Nervous Diseases, Cornell Medical College.

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The case against alcohol as a cause of insanity is of the kind which really has only one side. I have no need to make an argument to prove that alcohol is a cause of insanity. However it is not the only cause, and as a cause of insanity it has to be regarded in perhaps a little different way than sometimes has been supposed. Alcohol causes we are told about 15 per cent of insanity, but if we think by simply wiping alcohol right out of society at once we would thereby also reduce by 15 per cent the amount of insanity, we would probably be mistaken. For insanity is not usually caused by any single factor, and alcohol does not do its work in a simple way.

Alcohol acts in producing insanity in three ways. First, through the intemperance of the person using it; second, indirectly through hereditary influence, and, third, indirectly through its effect on the environment. As I have said, alcohol produces about 15 per cent of all the insanities in this country. It affects men very much more than women in a proportion of three to one in this country, and about two to one in other countries. As an indirect cause, that is, acting through heredity, alcohol is not so important as I think it has sometimes been stated. In going over my statistics of personal cases, and I am relying mainly on those, I find that it acts as an hereditary factor in about 5 or 6 per cent. In the poorer classes the percentage is somewhat larger. The importance of alcohol in producing insanity indirectly through disturbance of environment is no doubt great. Taking it altogether, some observers have asserted that alcohol is directly or indirectly the means of inducing nearly one-half the cases of insanity.

Alcohol is the cause of idiocy and imbecility, acting indirectly through the parents, in about 5 per cent of the cases, in New York and the region with which I am familiar. In France, Switzerland

and foreign countries the percentage of epilepsy and imbecility, caused by alcohol, is put as high as 40 or 50 per cent.

There are some other interesting facts regarding the influence of alcohol as the cause of insanity according to age, sex, race, social condition, etc. I have already said that alcohol does not induce insanity in women as much as in men, but in the proportion of about one tc three. The immediate reason is that women do not drink as much as men, because they do not like the effects. It has not for them the social stimulus which men get from it. Statistics show that in New York and also in England and Europe there is more alcoholism and alcoholic insanity among women in the urban than in the rural populations. In other words, city women drink more than country women. A very important fact has been established, viz., that alcohol habits which lead to insanity are almost always begun in early life.

There are some very curious differences in the way alcohol affects different races. The Jews have hardly any alcoholism. The proportion is given by some as low as one to thirty. It is rarely seen among them in our hospitals in New York. On the other hand, insanity is twice as common amongst the Jews as amongst the other races with which we live. The Italians, according to the statistics. which are not very good, have not much alcoholic insanity, though they drink more alcohol than Americans. In Eastern countries, like India, the insanity from alcoholism is very rare, but insanity from drugs takes its place. This is true at least of the Punjaub and of Egypt.

Alcohol is consumed throughout the United States and European countries at about a certain amount per capita yearly. This varies from eight or nine litres of absolute alcohol per head per year in England, and about the same in this country, to fourteen or fifteen litres in France, which stands at the head of alcoholic drinking countries; other nations range between these.

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Insanity does not vary exactly in proportion to this. example, there is as much insanity in England as in France, though the consumption of alcohol is twice as great in the latter country. So much for the statistics in the, case against alcohol.

I want to call attention now to a few things which are rather curious, in view of the fact that alcohol appears to cause so much insanity. One of the things I have already referred to is that in

some of the countries where the consumption of alcohol is large, the amount of insanity is not proportionately large. The statistics of Italy are very inadequate, but all those obtainable show that the percentage of alcohol insanity is not more than 3 or 4 per cent among Italians, though they drink more alcohol than is done in countries like the United States or England. The history of the consumption of alcohol, however, shows that where it goes up to an excessive amount per head per year, the amount of crime, insanity and poverty increases very rapidly.

It seems to me then that there is kind of an automatically working drink law to this effect: Each country has a certain "normal" per capita consumption of alcohol, say seven or eight litres per head yearly. Now when by special effort you get the consumption below this point, it does not make much difference in the amount of insanity. But when by neglect it goes above this normal, there is a great increase in insanity, crime and pauperism. For example, in England there is a less proportion of insanity in the heavy drinking counties on the seacoast which are prosperous than there is in the inland counties, which are rather poor and much more temperate. English alienists explain it by the fact that they substitute strong black tea for alcohol. A laborer will drink one or two quarts of strong black tea every day. It indicates that one cannot easily rid a community of intemperance of some kind.

I have already referred to racial statistics, showing that insanity may be very prevalent in races where alcoholism is not very great. The statistics in the prohibition and non-prohibition states throw as yet no light on the effect of this kind of legislation on insanity. In Vermont, for example, the percentage of insanity is greater than in some of the non-prohibition states, but we cannot say that there is not as much liquor drunk there as in any other state. The same is true of other states. So that nothing can be said as to the effect of prohibition on the insanity rate until figures are better studied out.

Another thing which I think ought to be known in connection with those statistics published to show the baneful effects of alcohol, is that in some countries these statistics include delirium tremens as a form of insanity. So it is technically, yet this and most other "alcoholic insanities” are rather a class by themselves, and are of a mild and more curable type. As a matter of fact the chronic

incurable and more serious forms of insanity are not often caused directly by alcoholism.

I have thus very briefly summed up some of the facts showing the relations of alcohol to insanity. It seems to me in conclusion that what we need to do in this matter is to fight the increased use of alcohol, and fight the abuse of alcohol in every possible way. I think we can probably do it more successfully by appealing to the sense and reason of people, by bringing up children in the way of self-control and wisdom, than by actual legislation; I mean in so far at least as the control of insanity is concerned. I do not believe that as long as the consumption of alcohol per head does not rise above what I have called the normal rate, legislation against it will lessen insanity, although it may do a lot of other good. I think if we legislate at all we should legislate against the use of it by anyone under thirty years of age, and I think if such a law could be enforced we would cut out the evils of alcoholism better than in any other way.

It seems to me that by pursuing in addition to this some methods of education and training which will make us a stronger or less neuropathic race, we will have less alcoholism and less alcoholic insanity, because in the majority of cases alcoholism is not a disease so much as it is a symptom of a neuropathic constitution. In fact the test of a neuropathic constitution is the inability to use alcohol at all, or to use it wisely or moderately. Alcoholism is in reality only a symptom, the expression of an unstable constitution. It is really this unstable constitution which blossoms out in alcoholism. and which is perhaps through this led into an insanity. Therefore we must legislate against alcohol to some extent and educate against alcohol, but it is still more our duty to train our children and ourselves to habits of wise living and habits of self-control, so as to eliminate the feeble souls and oversensitive constitutions. The flowing bowl would do little harm if it were not for the shallow pate.

THE IMPORTANCE OF THE ENFORCEMENT OF LAW

BY CHAMPE S. ANDREWS, Esq.,
New York City.

The reformers interested in the progress of the public health divide themselves into two camps-those who believe that legislation is a cure-all, that all that is necessary to reform an evil condition is to pass a prohibition law, and those who take a cynical attitude towards the law and say that laws do not help in the solution of public health problems, and that we must educate each individual so as to make laws unnecessary. Both points of view contain essential

errors.

Instead of saying that laws are absolutely necessary to prevent all public health evils, I would say that in most instances the passage of laws to correct these abuses is a necessity, but that we must not stop with the mere enactment of the law. We must also provide a means for its enforcement. That part of the law which provides the means by which it shall be enforced is of as much importance as the law itself. Many recalcitrant and criminal legislators pass laws at the request of the reformers of our community, and the reformers go away satisfied with what has been done, yet we may read the statistics after the passage of that law and find no convictions under it and no good accomplished.

In my particular work, in the service of the Medical Society of the County of New York, for the enforcement of the laws against the illegal practice of medicine, we have had some six or seven hundred convictions. There is a little book published, showing that every state in the Union has a law on the subject, almost as good as the New York law, and some better; and yet, in one New York county one person, aided by the Medical Society and the legal corporation charged with the enforcement of this law, has succeeded in securing seven or eight hundred convictions, whereas all the rest of the United States has not succeeded in securing twenty-five. It is not because there are not enough laws, but because there are no persons charged with their enforcement.

Take the prolific laws regulating physical environment. What