ALCOHOL'S RELATION TO MENTAL HYGIENE

[Excerpts from an address by Dr. Frankwood E. Williams, Executive Secretary of the Massachusetts Society for Mental Hygiene, before the American Public Health Association, Cincinnati, O., October 24, 1916.]

Not so many years ago an insane person was supposed to be possessed of a devil. A still less number of years ago insanity was considered a moral rather than a physical or psychological disease, and the insane person was supposed to have sinned so seriously that God had turned against him and had taken from him his reason. Until comparatively recent times the field of mental disease has been so enwrapped in an atmosphere of mystery and the supernatural that it has been considered a field for the metaphysician and the moralist rather than for the physician.

No intelligent person believes to-day, however, that an insane person is possessed of a devil, and no one believes to-day that an insane person has in some unusual way transgressed spiritual laws. But there are intelligent people who still believe that disappointment in love, failure in business, masturbation, so-called overstudy and the like are important causes of mental disease. "Mortified pride,” "agitation on the approach of matrimony," "metaphysical hairsplitting," "predisposition excited by novel reading," "the complete gratification of every wish of the heart," "changes from ordinary to vegetable and abstemious diet," are some of the assigned causes which are to be found in hospital reports of comparatively recent times. In a quite recent Ohio report I found Christian Science assigned as a cause of mental disease.

Because of the lack of understanding of the nature of the disease, because of the apparent mystery attached to it, and because of the manifold manifestations of the disease and its apparently manifold causes, mental disease has not been considered a fruitful

field for public hygiene. Were the factors formerly assigned as the causes of mental disease the true causes, there would be little room for mental hygiene, for people would continue to make love, to enter into business and to read novels, regardless of the possible danger of mental disease.

But the modern methods of study and research have been applied to mental disease within the last 20 years, just as they have been applied in other fields of medicine, and the results have been illuminating. The problem, considered as a whole, is confusing. But, like most large problems, it is found to be divisible into its several constituent parts, and these parts, considered separately, are in many instances found manageable. . . .

When we come to discuss the part that alcohol plays in the production of mental disease, we must speak with the greatest caution. There is already current a great deal of misunderstanding and misinformation on the subject. It is of the utmost importance that we distinguish between alcohol as a primary and fundamental factor in the production of mental disease and alcohol as a contributing or social factor in the production of mental disease. If we confuse the two, we shall be wholly misled in the results we may hope to obtain by proper prophylactic measures. Fifty years ago, before the causes of mental disease were really known, the superintendents of the insane hospitals in the country were united in their belief that alcohol was the chief cause of insanity, and the reports of those years devote pages to the discussion of the havoc wrought in mental life by alcohol. But, as so often happens, a more careful study of the problem has shown that the early reports are inaccurate, due to a frequent getting of the cart before the horse. The excessive drinking of alcohol, which leads to the production of what are known as the alcoholic psychoses, is frequently but a symptom of a previously existing and underlying nervous and mental condition. A comparatively mild, but important, type of mental disease exists in many of these individuals long before they become alcoholic, and and their becoming alcoholic is, in fact, dependent largely upon this previous mental condition.

The feeble-minded individual who, because of his feeble-mindedness, has less resisting power to social temptations, and who con

sumes alcohol to the point of developing alcoholic hallucinosis, figures in the statistics of our hospitals as a case of mental disease due to alcohol. Obviously, however, mental disease of a serious kind existed in the individual before he came to the attention of the hospital, and had there been no alcohol for him to consume, he would still have been a case of mental disease in the community, making for inefficiency, creating intricate social problems and multiplying his own kind. This is one type of individual who is coming to our hospitals with alcoholic mental disease, in whom alcohol is not the fundamental factor. Others are those suffering from mild attacks of maniac depressive insanity, certain types of dementia praecox and the psychoneuroses.

I wish to emphasize this point. If we assume that 20 per cent— and many enthusiasts have placed the figure at 80 per cent of insanity is due to alcohol, and work upon that basis, we are going to find that with alcohol abolished, should the time come, we shall be disappointed in the comparatively small diminution that will take place in the amount of mental disease in the community. It is obvious, therefore, that the figures which are published to-day by the majority of our state hospitals as to the per cent of alcoholic psychoses in their institutions are not reliable as evidences of the amount of insanity produced by alcohol. That figure would be difficult to obtain, and I do not believe that any exact figure exists to-day. On the other hand, the figures which are issued annually by the state hospitals are of very great importance in showing the amount of mental disease that it is necessary to care for in our state hospitals at public expense because of alcohol. Had there been no alcohol in the community, the feeble-minded or neurotic individual who previously had been doing sufficiently well to maintain his place in the community would not have developed alcoholic hallucinosis, and would not have been brought to the state hospital, to be cared for at state expense. This is true of a large proportion of the alcoholic cases brought to the hospitals. Alcohol has not been the fundamental cause of their mental disease, but, granting their mild form of mental disease, alcohol has superimposed a serious condition which has made necessary their care in a hospital. I insist that this is a distinction with a real difference. It is of the utmost im

portance that, in our search for the causes of mental disease, we do not confuse cause with effect.

The part that alcohol plays in the fundamental production of insanity we do not know. On the other hand, in the consideration of the more immediately practicable problem-the amount of mental disease it is necessary to care for at public expense because of alcohol, we do know, and the figures are important.

The hospital reports of Massachusetts from 1910 to 1914 give the following as the per cents of patients admitted suffering from alcoholic psychoses:

In other words, Massachusetts, during this period, was forced to expend large sums of money to care for persons suffering from mental disease within its borders, and during these years from 17 to 22 per cent of the patients cared for were brought to the hospitals because of alcohol.

In New York, where a greater effort has been made to sift out alcohol as a fundamental cause rather than as a contributing cause, the per cent runs about 12. Where alcohol as a contributing factor is taken into consideration the per cents are somewhat larger than those in Massachusetts, running from 25 to 30 per cent.

It is difficult to ascertain, from Ohio reports, just what elements have been taken into consideration in reporting alcoholic cases, but the reports give a per cent of from 15 to 20. Hospitals in general agree at about the figure of 20 per cent. In other words, 20 per cent of the patients under public care in our hospitals for the insane are there because of alcohol. In considering the social and economic side of the problem of mental disease, these figures are important and are reliable. In considering the strictly medical and biologic side of the problem, these figures are not reliable, but for our immediate purposes this is not important.

A PRETTY KETTLE OF FISH

(An editorial in the Louisville Courier-Journal, December 12, 1916)

I

SATAN MASQUERADES AS A CHRISTIAN

Soon or late-there are those who think the sooner the betterthe people of Kentucky will be brought face to face with a proposed Amendment to their Constitution abolishing the manufacture, sale and use of distilled and malt liquors within the State. This is called Prohibition. But it were more descriptively and accurately entitled a plan to destroy property, increase taxes and promote hypocrisy.

Elsewhere similar schemes of meditated reform have had this effect. Seventy-five years of drastic Prohibition have not expelled intoxicants from the State of Maine. In those States of the West and South to which it has been applied the result has been to drive the distemper inward, not to cure it. But in none of them have the actual interests at stake been nearly so great as they are in Kentucky. Here they mount to millions-many millions—and embrace thousands, tens of thousands, of citizens, who own property honestly acquired and pursue avocations from time immemorial recognized by law, menaced with sudden and complete extinguishment, the pretext being that men, and for the matter of that women, will drink, that sometimes they get drunk and that drunkenness is the root of all evil.

We live in a world of sin, disease and death; whence, we know not; why, we know not; whither, we know not; but it is a fair conjecture for some all-wise purpose.

Less than two thousand years ago there arrived on earth a Spirit claiming to come from Heaven and to bear a message from God. The Spirit seemed an exhalation of the dawn of a new and perfect