ALCOHOL AND INSANITY

The unscientific and therefore untruthful character of the assertion, constantly repeated in the propagandist literature, that the greater part of insanity is caused by alcoholism, is finely illustrated in a paper entitled Insanity Among the Jews, by A. A. Brill, Ph.B., M.D., and Morris J. Karpas, both of New York City. The article was read before the New York Neurological Society in April, 1914, and reprinted in the Medical Record of October 3, 1914.

Whether the Jews, as sometimes stated, show a greater tendency to become insane than other races is probably an unsettled question. It is an admitted fact, however, that the Jews contribute a very large quota to the insane population of our institutions, but only a correspondingly small part of it is ascribed to alcoholic psychoses. Yet the Jews, as a rule, are not abstainers; one might rather describe them as moderate users of intoxicants. This condition among the Jews would be wholly inexplicable if alcohol were responsible for insanity to the extent habitually claimed. Stated differently, insanity may be exceedingly prevalent among peoples quite independent of alcohol as a factor.

The authors of the paper under consideration refer to "Sichel's careful investigations based upon the records of the Frankfort Hospital for the Insane," and say among other things:

"He also found that the Jews contribute a very small percentage to the number of cases of alcoholic psychoses.

"Similar deductions have been reached by Kirby, who examined the admissions of the Manhattan State Hospital from October I, 1907, to September 30, 1908. He says: "The figures for the Jewish race bring out several interesting facts. One notices, first of all, that the Hebrews are practically free from alcoholic psychoses. The figures 0.32 per cent. (cf. author's statistics) represent a single case which occurred in a series of 182 cases of alcoholic insanity. I must also add that this particular patient, a man, is still under observation, having been over a year in the hospital, and certain features in the development of the psychosis, as well as the course of the disorder, suggest the possibility that the case may, after all, belong to the paranoid dementias. We notice the further interesting fact that the absence of alcoholic insanity in the

Hebrew is accompanied by the lowest figure for senile dementia and psychosis with organic disease. The most noteworthy fact gathered from the second column is that the Hebrew race shows by far the greatest percentage of manic-depressive cases (28.43) and the Jew also stands highest in the psychoneuroses and constitutional inferiorities and in involution melancholia. In dementia præcox, with the exception of the English people (28.57 per cent.), the Hebrews are again foremost (27.47 per cent.). In the undifferentiated depressions they are next to the highest. We thus see that in the large group of the so-called functional psychoses, by which we mean those disorders in which certain endogenous or psychogenetic factors seem most important as upsetting causes, the Jewish people outnumber enormously any race.'

"Pilcz states that adolescent dementia (dementia præcox) and dementia subsequent to acute psychoses and psychoses depending on hereditary and degenerative bases are more frequent (periodic insanity, 28.8 per cent.; secondary dementia, 33.3 per cent.) among the Jews than non-Jews; he, too, found that alcoholic insanity is very rare among the Jews. Thus he quotes Seckinger as saying that, in his six years' service in the Allgemeine Krankenhaus in Vienna, he observed only one case of delirium tremens in a Jew, and that in his experience alcoholism plays no rôle in the etiology of other forms of insanity among Jews. His statistics of Jewish paretics are 18.75 per cent."

The authors have examined the statistical data of admissions to the Manhattan State Hospital (New York) for four consecutive years, 1908-1912. "The total number of admissions was 5,710 (2,803 men and 2,907 women), of which there were 1,203 Jews (588 men and 615 women). The Jews thus constituted 21 per cent. of the total admissions." Yet, in the diagnostic grouping of the patients, only eight of the men and none of the women were found insane from alcoholic psychoses. The percentage of admissions (Hebrews) classified under alcoholic psychoses is therefore 2.5 for the men and 0.0 for the women.

No doubt the striking immunity of Jews to insanity attributable to the abuse of alcohol is due, among other things, to their moderate habits, but not to their abstinence. The point to be emphasized, and one too often lost sight of, is that an unusually high note of insanity may be found among people quite independent of any influence of alcohol.

WHO ARE THE INEBRIATES?

Among the world-wide authorities on the subject of inebriety perhaps no one holds a higher rank than Dr. R. W. Branthwaite, Inspector of Retreats and Reformatories under the English Inebriates Acts. Added to his thorough equipment as a scientist he has the great advantage of a long experience of dealing with inebriates and unusual opportunities for observing them. Therefore he has gained a wide hearing among European scientists. Of especial interest are his views of the extent of inebriety among the populations of England and Wales. But of greater significance, because more fundamental, are the conclusions he has arrived at in regard to the nature of the malady we know as inebriety. The standpoint Dr. Branthwaite takes on both these matters does not accord with popular notions, but has the merit of being scientifically correct. Its more general acceptance would help us to straighter thinking and saner action in dealing with questions arising out of the liquor problem.

The following extracts from Dr. Branthwaite's official report for the year 1912 (published by the British government in 1914) restates his conclusions concerning the extent and nature of inebriety:

"Viewed from an alcohol-drinking standpoint, all members of the community may be divided into those who take alcohol and those who do not. Alcohol-takers may again be subdivided into: (1) Moderate drinkers-persons who are always strictly moderate in their indulgence;

(2) Occasional drunkards—persons who drink more freely than is consistent with strict moderation, and are occasionally drunken; and

(3) Inebriates-persons who are habitually under the influence of drink, or, with intervals of abstinence, are subject to outbursts of uncontrollable drunkenness of more or less defined duration.

"Moderate drinkers.-So far as members of the first section are concerned, there is little to be said; the harm they do to themselves is problematical, and the harm they do to others still more so. The large majority take alcohol because it is customary, as an

aid to social intercourse, to give relish to food, or for the bodily sense of well-being it engenders when swallowed in small quantities. This bodily sense of well-being is the only pharmaco-dynamic effect they desire to experience, and any sensation of more advanced alcoholization is repugnant to them. There is no credit due to such persons for being sober, because they have no desire to be otherwise, and it is no trouble for them to keep sober, because they are not called upon to exercise control over desires that do not exist.

"The occasional drunkard.-So far also as this type of man is concerned, merely passing attention will suffice; then we may similarly dismiss him from further notice. The essential difference between the occasional drunkard and the inebriate is the fact that the former retains the power to remain sober if he cares to exercise it. Deficient perhaps to some extent in moral sense, power of control over impulses, and power of judgment, he still remains on the right side of the line, and may therefore be eliminated from consideration for present purposes. He is a person who requires education into sobriety by moral means; if these fail and he becomes a nuisance to the community, causes disorder or commits crime when under the influence of drink, he needs coercion more penal than reformatory to bring him to his senses. We may safely leave him to the temperance worker, or the magistrate. It is possible, of course, that degenerative change consequent upon many bank-holiday sprees, convivial meetings, or banquets, may eventually turn him into an inebriate; but until such change occurs he remains outside the class in which we are specially interested.

"The inebriate. So far, however, as the inebriate (habitual drunkard, chronic alcoholic, or dipsomaniac) is concerned, the matter is entirely different. Although there may be difficulties at arriving at a legal definition of the species, the medical point of view is clear enough. An inebriate is a man who may or may not desire to live soberly, but in any case cannot, unless and until some change takes place in his physical and mental state. The more we see of habitual drunkards, the more we are convinced that the real condition to be studied, the trouble we have to fight, and the source of all the mischief, is a psycho-neurotic peculiarity of some sort; an inherent defect in mechanism, generally congenital, sometimes (more or less) acquired. Alcohol, far from being the chief cause. of inebriety, is merely the medium that brings into prominence cer

tain defects that might have remained hidden but for its exposing or developing influence.

"The inebriate, then, is the subject of a peculiarity, the distinctive characteristic of which is inability to take alcohol in moderation, despite the most strenuous effort of which he is capable. It is often possible for him to abstain from alcohol altogether; but rarely (if ever) possible for him to take it without becoming drunken. He is the victim of a psycho-neurotic fault that implies a defective power of resistance to the action of alcohol or drugs, in exactly the same sense as tubercular tendency implies impaired resistance to the specific infection of that disease. The peculiarity or fault is an extremely potent one, calling for recognition as the true inebriate state of which drunkenness, disorder, and erratic behavior generally are merely outward and visible signs.

"Although it is clear that a marked correlation exists between the recognized forms of mental defect or disease, on the one hand, and habitual drunkenness on the other, the association is not definite enough to justify the commonly heard statement that all inebriates are more or less insane or mentally defective. When inebriates of all social grades are classed together it will be found that the majority are neither the one nor the other; indeed, many typical inebriates are extremely capable individuals during sober intervals. Notwithstanding this, even the most mentally sound amongst them are not normal persons; the evidences of peculiarity are too definite to be ignored, although its character is difficult to define, and its location obscure.

"If this be so, it follows that the inebriate is not primarily vicious or criminal, but primarily abnormal, and only secondarily anti-social. Most of the offences he commits are of passive nature, due rather to impaired reason that to wilful intention, or to imperfect control-the result of a drunkenness he is partially, or perhaps wholly, unable to avoid.

"It is held that a drunken person should be accorded full measure of responsibility for the perpetration of offences against the law, in that his condition results from a wilful act-the taking of liquor. Of the occasional drunkard this is probably true; but not of the inebriate. The latter is impelled to his first glass by irresistible desire, and his constitutional peculiarity does the rest. The desire is abnormal, and so is the constitutional condition that renders him incapable of being satisfied with one glass, as would be the case with