D LIQUOR LEGISLATION AND INSANITY. BY EDWARD HUNTINGTON WILLIAMS, M.D. URING the past year the statement has appeared repeatedly in print that prohibition is directly responsible for the decrease of insanity in Kansas. Certain publications have asserted, indeed, that Kansas is the only State in which insanity is actually decreasing. If either of these statements be true the fact is of great significance. For in the United States as a whole insanity seems to be steadily increasing. It is a well-known fact that such thickly populated States as Massachusetts and New York have a higher percentage of insanity per capita than the group of rural States extending northward from Oklahoma to the Canadian line. But obviously this fact does not prove that Western legislation is superior. We are justified in assuming, for example, simply because the "wet" State of New York has more insane persons per capita than Kansas, that prohibition is responsible for this difference. Yet this comparison has been used repeatedly as an argument in favor of prohibitive liquor legislation. Any comparison to be convincing must be made between States closely similar in every particular. Kansas and Nebraska present such similarity in a more striking degree than almost any other two States in the Union. They are closely similar in size and shape and in the geographical distribution of the population, each State having a relatively thickly settled eastern half, while the western half is sparsely settled. They have practically the same percentage of native whites, negroes, foreign-born whites, ratio of males to females, percentage of illiterates, percentage of urban population, and percentage of increase in rural population. Neither State has any large city, and their gain in general population during the census period was practically the same, Kansas gaining 15 per cent., while Nebraska gained 11. Obviously, then, they are strikingly similar in every important particular except in methods of controlling liquor traffic. Let us see what a comparison between their insane populations will show. According to the statistics issued recently by the Census Bureau the number of cases of insanity committed per 100,000 population in Kansas decreased from 62.2 in 1904 to 52.4 in 1910. Meanwhile in Nebraska there was a decrease from 62.1 (practically the same as Kansas) in 1904, to 34.5 per 100,000 in 1910. Moreover, there were fewer cases of insanity present in the Nebraska institutions than in those of Kansas at the close of the period, Nebraska having only 143.9, while Kansas had 165.6 for each 100,000 population. It is evident, therefore, that Kansas is not the only State in which insanity is decreasing. It is not even the State in which there has been the greatest decrease, this last honor going to its neighbor, Nebraska. From all of which it is evident that Kansas's insanity record furnishes no basis for claiming superiority of the prohibitive form of liquor legislation. However, in the case of such a complex problem as the relation of liquor legislation to insanity, we should hesitate to accept as conclusive evidence any single set of statistics lacking definite corroboration along other lines. Fortunately in this instance we have such evidence in the index given by the alcoholic psychoses. It is understood, of course, that the excessive use of alcohol may affect the mentality without producing alcoholic insanity, and that indirectly it may be a factor in producing certain forms of insanity without the usual manifestations of alcoholism. But the forms of insanity included in the well-defined group known as the alcoholic psychoses are the direct result of the use of alcohol. It is apparent, therefore, that the number of cases of alcoholic insanity committed to the institutions of similar communities will give a fairly accurate index to the relative amount of alcohol consumed. If prohibition is really effective, as claimed, such States as Kansas and North Dakota should have no alcoholic insanity, or, at worst, should make a far better showing than the license States, Nebraska and South Dakota. What the records really show is as follows. In the North Dakota Hospital for the insane a little less than 4 per cent. of the patients admitted in 1910 had alcoholic insanity. In South Dakota the percentage of this form of insanity was just over one per cent. in 1912. In the Nebraska hospitals the average percentage of alcoholic psychoses admitted last year was a little over 4 per cent. Meanwhile the Kansas hospitals admitted 5 per cent. of this form of insanity during the same period.* *This is the figure given by an officer of the Kansas State Hospital service after a careful study of the subject. The printed reports give this percentage as slightly lower, but the officer's estimate is probably correct. In several other instances I have been greatly aided by personal reports made by staff members, and these reports are particularly valuable, since in several institutions the printed classification of patients is wholly inadequate. Thus Kansas heads the list in high percentage of alcoholic insanity, with South Dakota trailing so far behind as to make the prohibition State seem like a veritable den of tipplers by comparison. But perhaps the most significant thing shown by a study of the records is the fact that Kansas had an actual increase in the alcoholic psychoses during the last three years at the very time when prohibition was "being more rigidly enforced than ever before.' There is another index to the relative consumption of spirituous liquors which may very properly be considered. This is the percentage of cases of paresis to the total insane population. We know, of course, that syphilis, not alcohol, is probably the direct cause of the disease. But this does not alter the long-known fact that alcoholism and venereal diseases are usually concomitant conditions. Indeed, there are eminent psychiatrists who maintain that alcohol is at least indirectly productive of paresis, judging from the prevalence of paresis in communities addicted to alcoholic excesses. We should expect, therefore, that in communities where there is a high rate of alcoholic insanity there will be a high percentage of paresis, and vice versa. It is not an absolute index in either case, of course, but an examination of the records of a large number of institutions show that this evidence is at least strongly confirmatory. We should expect to find, for example, in the Manhattan State Hospital, which draws its patients from New York City and has a high percentage of alcoholic psychoses, a far higher percentage of paresis than in the rural State of Iowa. And we do actually find that during the last five years there has been an average percentage of about .12 of paresis to .09 of alcoholic psychoses in the Manhattan hospital, as against .06 of paresis to about .05 of alcoholic insanity in Iowa during that period. It is significant, therefore, to find that North Dakota in 1910 had about 2 per cent. cases of paresis to about 4 per cent. alcoholic psychoses; South Dakota, paresis about 2 per cent. to alcoholic psychoses one per cent. in 1912; Nebraska, paresis a little over 6 per cent. to alcoholic psychoses something over 4 per cent., and in the Topeka hospital, which I am assured by its officers is representative of the State, the paresis 8 per cent. to alcoholic psychoses 5 per cent. Here again, then, Kansas leads her group of States in high percentage completely overshadows them in paretic population. Moreover, just as in the case of alcoholic psychoses, the records show a steady increase of paresis in Kansas during the same period in which there has been a fairly uniform decline of this disease in each of the other States except Nebraska. Yet even in Nebraska the percentage of paresis to the total insane population is far less than in Kansas. It is evident, therefore, on the basis of government statistics showing the decrease of insanity in the different States, and the records of the various State hospitals as to the relative number of cases of alcoholic insanity and paresis, that there is no justification for the claim that Kansas's "prohibitive" form of legislation lessens the amount of insanity. On the contrary, the facts seem to substantiate the claims of the license advocates that in prohibition States the relative consumption of spirituous liquors is increased, and the amount of malt beverages diminished. For whiskey, not beer, is the cause of most alcoholic psychoses. It has been suggested that the relatively small number of insane in this group of Western States "may be simply an evidence of how poorly these unfortunates are cared for." But such a suggestion is entirely unwarranted. The Western hospitals for the insane, individually and collectively, make as good a showing in every particular as any group of similar institutions in the East. The work done in the State Hospital for the Insane at Topeka, for example, and the hospital itself, compares favorably with any of the New York institutions. The superintendent, Dr. T. C. Biddle, a veteran in psychiatry, is a man of progressive ideas and unusual executive ability. In addition, he has the rare faculty of "putting the right man in the right place," as illustrated by the work done by the members of his staff. The hospital itself affords opportunity for the most advanced methods of studying and treating insanity. The new Psychopathic Hospital, completed last year, is one of the best in the country. It is the result of Dr. Biddle's long and careful personal studies of similar institutions, East and West, and represents a combination of all their good qualities. Its equipment is complete, and the methods of observing and recording cases are thorough and systematic. The laws governing the commitment and care of the insane in Kansas, while unfortunate in some respects, are good as a whole and growing progressively better, thanks to the efforts of such men as Dr. Biddle and Mr. Harry C. Bowman of the Board of Control. Mr. Bowman has recently prepared a bill providing for the examination and treatment of voluntary patients at the State hospitals that might well be copied by our Eastern States. The effect of this bill will be to bring the members of the hospital staffs in contact with cases of incipient insanity at the time when preventive measures may be effective, and before the disease has reached a stage necessitating commitment. This will be a noteworthy step in practical mental hygiene. I mention these things as illustrating how keenly alive Kansas is to the importance of properly caring for the insane. And Kansas is no more so than Nebraska, or the Dakotas. So that the suggestion that the low insanity rate is due to ignorance or indifference may be discarded. The real explanation seems to be that the people and their surrounding conditions are different from those in the East-a higher type of people on the average, with much better surroundings. Most of them are native Americans, and, as compared with the East, live in comfortable circumstances. Great wealth and distressing poverty are unusual conditions there, and the average general intelligence is much higher than in most Eastern States. This last fact is shown conspicuously in the character of the inmates of Western insane hospitals, who present a striking contrast to the inmates of the New York or Massachusetts hospitals. The degraded, disgusting types that are the product of city slums are wanting; and the class of ignorant foreigners that congests our metropolitan hospitals is practically unknown. So we are justified in believing that Kansas and her sister States should thank general conditions, rather than any special form of liquor legislation, for their relatively small insane population. (New York Medical Record, November, 1913) |