# The Increase of Insanity, 1907/Lecture 3

LECTURE III
The next generally accepted cause of insanity is alcoholic intemperance. That this is a potent cause, not only of actual insanity, but of nervous weakness and instability in the individual and in his offspring, must be admitted. And there is a generally accepted belief that the character of the alcohol taken to a certain extent affects the results, so that those who consumed the more potent alcoholic liquids suffer most nervously. It was till quite recently looked upon as an established fact that with higher wages and the increased consumption of alcohol, especially in its stronger forms, there was a definite increase in the pauper insane. This may have been true, but, as I shall point out later, the increase of insanity at the present time certainly bears no actual relationship to the consumption of alcohol. There is no doubt whatever that the people in England at present are far more temperate than they were. The returns as to the consumption of all forms of alcohol show marked reduction, and this probably is more marked in the lower middle and lower classes than among the higher classes. One would therefore have expected, if there is a direct relationship between ​the consumption of alcohol and mental unsoundness, that there would have been a reduction rather than an increase of insanity at present. But, as I have said, this is not the fact. It is always dangerous to come rapidly to conclusions on comparatively slight statistics or general information. But I am bound to say that the very large number of total abstainers whom I see in consulting practice has made me wonder whether the complete and total change from moderate indulgence in alcohol to total abstinence had been altogether for the good, the mental good, I may say, of the race. It is well, however, to remember that a certain proportion of total abstainers are the descendants of alcoholic parents, who, having seen the disastrous results of excess in a parent, have determined at once to refrain altogether. Such individuals have already a weakened nervous system by inheritance, and, therefore, that they should become abnormally sensitive and tend to melancholy is not surprising. There are others who are total abstainers not having strength of will to be moderate. Such people are predisposed to break down mentally if unusual strain is thrown upon them. It is interesting to note that in Ireland, where certainly a considerable amount of alcohol is consumed, the medical superintendents of many ol the asylums report that, next to heredity, they look upon alcoholic excess as the chief cause of insanity; a second cause is given by a large number of the superintendents — excess ol ​tea drinking. I am hardly prepared to accept this as a cause, yet it is right that I should mention it. There is no doubt that excess of alcoholic stimulants leads to direct alteration in the nutrition of the brain and nervous system, and also that, with the induced recurring alteration, there will be permanent nutritional changes which become visible in the whole nervous system. And these changes give rise to corresponding mental symptoms. The peripheral neuritis which is frequent in cases of chronic alcoholism, not seldom gives rise to cutaneous hallucinations; and gastro-intestinal disorder produced from the same cause may give rise to delusions. Thus, as a result of peripheral neuritis, chiefly affecting the limbs, it is a common experience to meet with patients — and I think I might say more commonly women — who complain that they are annoyed, electrified, or interfered with by some systematic persecution. In the second group one not infrequently meets with alcoholics suffering from some stomach or bowel affection who accuse persons of tampering with their food. It will thus be seen how readily delusions and hallucinations of the senses may be the direct outcome of chronic alcoholism. Continued excess leads to premature degeneration of the brain. Thus on one hand we have symptoms allied to delirium similar to those produced by general toxic influences, while on the other we have symptoms of premature senility. And the whole group of symptoms, which have been described more ​54
LUMLEIAN LECTURES
recently under the name of Korsakow’s syndrome, depend almost invariably on toxic influences and are most marked in alcoholic cases, and in senility with mental decay ; Metchnikoff has suggested that toxins may be associated with symptoms of senile decay. The great similarity which there is between the mental symptoms occurring with senility and those depending upon chronic toxic in- fection is certainly noteworthy. We have alcohol as pro- ducing a definite set of symptoms, and we recognise that any mental disorder which may be produced temporarily may, if the toxic influence is continued, become established as a morbid habit, associated with organic change. I have also pointed out that chronic alcoholism leads to some- thing more than mere toxic changes, to permanent decay of the Avhole nervous system.
The next, and a most important, question, especially in relationship to the increase of insanity, is the fact that alcoholic parents tend to have degenerate children. The children of chronic alcoholics often have most of the characteristics of the children of the highly neurotic or the degenera tingly insane ; idiocy, imbecility, and moral insanity being most marked in the children of the chronic alcoholic. Dr. F. W. Mott recently published some very important observations in relationship to alcoholism and nervous disorder. Similar observations were recorded by Mr. W. Bevan Lewis. And I would sum up their results as follows. Dr. Mott considered that one-fourth of the ​out-patients whom he saw at Charing Cross Hospital had alcohol as an efficient or coefficient in causing the bodily disease for which he was consulted. He believed that the grocer’s licence tended to drinking among women, which produced many of the polyneuritic neuroses. Dr. Mott, however, goes so far as to say that he is of opinion that there is no proof that insanity itself would diminish to anything like the extent that is believed by many enthusiasts if alcohol were altogether abolished, and I have already said the same. Next follows the startling statement that the people who were in general hospitals and who consulted him in the out-patient room as a result of alcoholic excess, generally had visceral disease of some kind : that they had kidney disease, or liver disease, or some polyneuritis. On the other hand, at the asylum he found that those patients who were admitted suffering from the insanity of alcoholic excess, rarely, if ever, had the pathological signs generally asso- ciated with alcoholic excess. So that the post-mortem examinations of the insane from alcohol rarely provided cirrhotic liver or contracted kidneys. Various interpretations may be given to this. One is that some people are predisposed to be affected by alcohol along their digestive tracts, whereas others are more affected along the nerve lines. Others have thought that when one system was affected, whatever the cause might be, the other would be free, and that, in fact, the old belief was true, that if ​a man had a bodily disease he would not have a mental one, or if he had a mental one he would not have a bodily one. The interpretation which I believe Dr. Mott prefers is this: that the people who become insane as a result of alcohol require quite a small amount of alcohol to upset their balance in comparison with others: that, in fact, they may be compared to those persons who, having had some severe head injury, ever afterwards are predisposed to be easily affected by alcohol. The fact, however, is an important one, and although one has not time to consider the question of alcoholism as written about by Dr. A. Reid, yet one has to recognise that there is such a thing as the survival of some alcoholics.
Having referred to the effect of alcohol in the production of insanity it is necessary to refer to the effects of alcohol when added to other causal conditions. I have very little evidence indeed to support the contention that general paralysis of the insane depends to any extent upon alcoholic excess alone. My own experience leads me to believe that from seventy to eighty per cent. of the cases of general paralysis which I see have suffered from syphilis. But in nearly all these cases the patients had led exciting, trying lives, that they were people who had indulged freely in alcohol and, as a rule, were large meat eaters. So that alcohol, when added to syphilis and to other abnormal or exciting conditions, may be considered as one of the causes of general paralysis of the insane. ​I add some notes now from the Commissioners in Lunacy in Ireland in relationship to alcohol as a cause of insanity, as the difference of opinions among the medical officers is interesting, showing that there is no definite evidence of any real increase of insanity in Ireland depending on alcoholic excess.
ALCOHOLIC EXCESS.
General . — The proportion attributed to alcohol underwent some fluctuations during the decade, but in 1903 it was only 0’8 per cent, higher than in 1894.
Perhaps, as regards its effects on the future prosperity and health of the population the most important of these causes is intemperance in the use of alcohol.
As already stated, these statistics show that alcohol was found to have been the principal cause of the outbreak of mental disease in 15 per cent, of the cases admitted to asylums during the decade under review. This does not differ materially from the proportion in earlier years.
Page 2. — Alcohol is, no doubt, a frequent cause of mental break- down. It is difficult to differentiate as to whether it is more frequently a cause or that excessive indulgence is a result of mental weakness or instability. (Lawless.)
Page 4. — Alcohol is an increasing factor in the causation of insanity, both by its acute and chronic toxic effect. (Mills.)
Page 13.— Alcohol is often suggested as being a fruitful cause, but my experience would not justify such a conclusion with regard to it. Undoubtedly the drink sold at fairs and markets is of the worst kind, and must have an injurious effect on those who indulge in it ; still, it may be fairly claimed for the female population ​of the district, and especially those residing in the country villages, that only very rarely indeed do they ever taste intoxicants. So rarely that I would be inclined to eliminate this as a cause of the insanity among them. (Hatchell.)
Page 22. — In close on 9 per cent, of the cases admitted there was the strongest possible evidence that alcohol was the main cause of the evil. (Nolan.)
Page 39. — I am of opinion that the next greatest cause of insanity is drink, and by this I mean not only persons become insane by drinking to excess, but also that many of the children of confirmed drunkards who are saturated with alcohol become weak-minded or insane. (West.)
Page 45. — Ether drinking still exists in this district (Londonderry), but to a much less degree of late. (Hetherington.)
Page 54. — The most frequent causes will be seen to be hereditary predisposition and alcoholic excesses. (Oakshott.)
Many years since, when the first of recent epidemics of influenza appeared, certain medical journals pointed out what seemed to be the immunity from this disease of the insane in asylums ; but it was soon made manifest that the attendants and nurses who went into the outer world contracted the disease, and when once it was started in an asylum it spread as rapidly as it did else- where. I pointed out, on the other hand, that it was a very powerful starting point for neuroses, and it is now pretty generally accepted that it predisposes to such neuroses and may be either a predisposing or exciting cause. I believe that it has been a real and efficient ​cause for inducing any increase which now exists, and I believe from my personal experience that it is and has been more powerful than all the other causes put together. I fear that I shall not have time to do more than point out the effect which influenza has had generally on the production of nervous disorders of various kinds. In the first place it is a constant cause of most obstinate insomnia; and as food and digestion are to the body, so is sleep to the whole nervous system.
It causes painful neuralgias and often disturbs digestion and nutrition.
But from these general statements I pass to the more concrete and definite ones. Influenza, like other fevers, may set up any form of psychopathy. Morbid mental symptoms may come on at any period of the influenza; it may start any form of insanity. Thus, the febrile stage may be followed by acute delirious mania of the worst possible type, or it may give rise to sleeplessness with melancholia, either of an active or passive land. It may lead directly to dementia either of a permanent or transient type. There is, however, no specific form of insanity which can be called influenzal. I believe influenza produces effects on the nervous system comparable with those depending on strong neurotic heredity or alcoholic or senile degeneration. Therefore, after several attacks of influenza it is not uncommon for fully organised delusional insanity, with grandiose ideas or ideas of persecution, to ​appear. In patients with strong neurotic heredity the first attack of insanity often follows influenza. In patients who have had previous attacks of insanity influenza may start a fresh attack, which may or may not follow the course of previous attacks. The mental disorder need have no relation to the severity of the attack of influenza. Though not a cause of general paralysis of the insane, yet it may be the exciting cause, so that a person who has other causes of nervous degeneration, such as syphilis and alcohol, after an attack of influenza may rapidly develop all the symptoms of general paralysis of the insane. In a few instances I have seen an attack of influenza modify an attack of insanity, and even relieve it. It is noteworthy that suicides increase markedly after an epidemic of influenza.
While fully recognising that the time at my disposal will only allow me the opportunity of bringing before you the most potent causes of mental instability and those which I think may, to a certain extent, be looked upon as causes of any increase of insanity which is found to exist, I feel that I cannot omit the question of sexual morality. I do not believe the present time is much better, or much worse, than the past, but there are certain considerations which I believe to be important, and to which I now refer. Marriages are, in England at all events, less frequent than they were, and with men certainly it is common for the marriages to take place ​at a later age, so that many more men remain celibate up to forty years than formerly. This, of course, cannot be taken as a single and isolated fact. It is associated with the greater strain and tension required to make a position in life, and it is also associated with the growth of ideas of luxury which are present now both with men and women. But a still more serious fact is that after these marriages there are fewer children and also that mothers much less frequently suckle their offspring than they did. They look upon pregnancy and lactation as interfering with their busy social life, therefore they avoid these contingencies as much as possible. I believe sexual continence is possible and admirable, but it is constantly nowadays replaced by onanism, and though I do not attribute any serious increase of insanity to this head yet the dread of its results, which are so commonly enforced upon the public by quacks, has a very serious influence in producing a number of youthful hypochondriacs and a considerable number of suicides. Very few days pass but that I am consulted about the effects of onanism in the production of insanity. I do not believe that it produces more insanity than it did formerly, except that there are more celibates who indulge in the habit to a longer period and greater extent than if they married early. I am also frequently consulted about women whose whole mental character has become changed as a result of restriction of child-bearing and nursing. ​On some, probably the majority of women in England and France nowadays, the feeling that in thus acting they are opposing Nature’s laws does not weigh very heavily. But still, there are many women who feel degraded, and even sinful, in thus acting ; and I know that many leaders among obstetric physicians recognise the neurotic woman who is produced by conjugal frauds. Though I should not say that this class adds very materially to the sum of the increase of insanity, yet I must speak very definitely as to my belief that it contributes a certain amount.
And now to proceed to the definite conclusion of the whole matter. I have already said that, in my opinion, there is an increase of insanity, that this has been steady in all classes of society, and that the reports of the Commissioners of England, Scotland, and Ireland all support this statement. So far as the lower orders are concerned the statistics are clear, but as regards the upper classes in the different countries there seems to be a decrease. To this I shall refer later. There has also been a slight temporary decrease in Scotland and England, but this really does not, I think, interfere with the pretty steady tide of increase. In England there is this year a decrease among registered or certified patients of unsound mind. But, as I have said, this is, I think, of very little value. For, especially in reference to the richer classes, whatever may be said as to the feeling ​among the poor in relationship to asylums and certification, I believe there never was a time when the word “ asylum ” and the term “ lunatic ” were more dreaded among the well-to-do than at present. Among the causes for this increased dread doubtless is the growth by education of the feeling of the danger of inheriting mental disorder. If I have been able in any way to show that this dread is too dominant, good may result. The feeling undoubtedly exists that insanity is one of the most transmissible of all diseases, and this has weighed, and still weighs, heavily on the lay mind. They will ignore other forms of disorder, even though they may be somewhat serious, but they will not admit the existence of insanity in the family unless it is absolutely forced upon them. Anything that can be treated in a home of rest by Weir-Mitchell treatment, or by change of residence and travel, appears as nothing to their minds, but as soon as a patient has been certified they believe an indelible blot rests on the family, a blot which will have a serious influence upon the future, certainly of marriageable daughters. When I tell you that there are several thousand medical men in England who are willing to receive so-called mild mental cases into their homes, it surely shows how widespread this home treatment of nervous and mental diseases is. Therefore, when the Commissioners report a decrease in the certified insane in England, it, of course, has to be discounted very ​seriously by the fact that the dread of asylums and the fear of certification act so strongly that many patients who had better be certified are sent into private care. The various bodies of Commissioners have felt it their duty to consider especially the question of this increase of insanity, and so far as possible to reassure the public that they, at all events, have no great fear of any serious increase.
And now I must proceed to details; and although I cannot expect to make the dry bones of statistics live, yet I will make such use of them as is necessary. In January, 1906, there were 121,976 certified patients in England, this being an increase of 2,150 on the year 1905. This rate of increase is less than that of the average increase for the previous five years, which was an average yearly increase of 2,807, the average increase for the ten previous years being 2,554. The chief decrease was in the numbers of private patients in licensed houses. It is important, as I shall have to repeat later when considering the apparent increase of the poor in asylums, to recognise that many more patients are now sent to asylums who formerly were retained in workhouses. Thus, nearly 50 years ago only 56.2 per cent. of the pauper lunatics were in asylums. This is a very important fact to remember, for recently in England, Scotland, and Ireland pauper persons of unsound mind of all degrees have been swept into the class of certified lunatics, and this class in future will not be so ​efficient in adding to the numbers of the certified insane. The greatest increase is noticed in England in the metropolitan area and in the home counties. The lodestone of the capital attracts the weak even more than it does the strong, the failing in mind and morals become aggregated in the larger centres in increasing numbers. If we compare the returns of the certified insane in 1859 with those of 1906 the numbers are startling if not appalling. In the former year in England and Wales there were 36,762. Now there are 121,976, that is an increase of 231 per cent., while the population increased during that period only 7 5 - 4 per cent. The ratio of certified patients to the general population in 1906 is 1 to 283, that is, 3531 to every 10,000 inhabitants, whereas in 1859 it was only 18’64 per 10,000. In passing, I may refer to the recovery rate, which I regret to say does not in any way encourage one to think that the present humane methods of treatment have greatly increased the numbers cured. In an article “ Statistics of Insanity,” by Sir Charles Hood, from 1846 to 1855, he refers to the percentage of cures being quite as high as at the present time. He gives the aggregate of the hundred years ending Dec. 31st, 1855: admitted into Bethlem Hospital, 19,373 patients ; cured, 8,341, a percentage of 43-5. From 1846 to 1855, 2,726 were admitted, and during that period the high percentage of recoveries was 5419. It is well, of course, to remember that the patients admitted into Bethlem Hospital were ​and are of a special type, no chronic, or incurable or epileptic cases being received. But even taking that into consideration, the rate of cure of the last return is higher than it was over 100 years ago, it is certainly no higher than it was 50 years ago. This all points, I think, to the fact that only a certain number of insane are curable under any conditions whatever, and that the idea of any universal system of treatment greatly increasing the recovery rate is altogether misleading. The Scotch Commissioners this year give an account of the increase since 1858, in which year there were 5,824 certified patients, whereas on Jan. 1st, 1906, there were 17,450, showing an increase in nearly half a century of 11,606. This increase is confined to the general public asylums, there being a decrease of 624 in the residents in private asylums. A very large increase of patients in private dwellings is noted, and this is a point of special interest in Scotland, where the system of boarding-out is carried on largely and successfully, and certainly more than is possible in England. In Scotland during the last three years there has been a decrease of insane persons in proportion to the population, and this is the first time such a thing has occurred since 1858. During the whole period the lunatics have increased 200 per cent., while the population has increased only 56 per cent. Among the causes of total increase of admissions are a large number of senile cases from infirmaries, but this must not be taken to connote a ​general deterioration of the race. In Scotland, as else- where, the struggle for existence renders it more difficult for the poor and healthy to maintain the feeble or insane in their own houses, the residence of such people inter- fering with the wage-earning capacity of the family, so' that it is altogether easier for them to contribute something towards the maintenance of a patient in an asylum than to keep him at home. And with the steady development of treatment of weak-minded and feeble people in cottage homes the demand has created a supply that proves, at all events in the north, to be quite satisfactory. It is noteworthy that — whether there is an increase in other forms of mental disorder or not being doubtful — there is in Scotland as well as in England a marked increase in the number of general paralytics. Not a quarter of a century ago the numbers were quite small ; now they are large and increasing. And what is more astonishing is that the increase is more marked and more recognised in Edinburgh than in Glasgow, though, as a rule, one finds more general paralytics in big manufacturing cities than in smaller residential capitals. Another anomalous point among the general paralytics of Scotland is that the increase has been more marked among women than among men. The increase of general paralytics, then, is one of the distinct causes of increase of insane individuals. The Irish Commissioners this year have made a special report on the alleged increase of insanity. I ​have already had occasion to quote from this and it will be necessary now to refer to it more in detail. The contribution has the advantage of giving the individual opinions of the superintendents of the various asylums, and also the conclusions arrived at by the Commissioners themselves. I may briefly, before referring to the detailed reports of the Commissioners, give their conclusions, which were : That the apparent increase is due chiefly to accumulation, and that the increase is more apparent than real ; that patients live longer, being retained longer in many cases (in many cases all their lives) in asylums. In reference to this I might quote Dr. William Farr, who thus expressed the same idea : “ There may be ten times
as many lunatics in civilised as in barbarous countries, and not because the tendency of insanity is greater but because the lunatics live ten times as long as they did.” The increase depends, too, on the withdrawal of a large number of quiet, harmless, senile, or weak-minded persons from their homes. This is shown by the fact that the general census returns showed the number of such persons to be very greatly reduced. Doubtless the drawing of the healthy and able-bodied to the cities and to the colonies has also tended to the removal of the more feeble to the asylums, as there were fewer people personally able to look after them. The unusual increase pointed to some special causes, and the Commissioners have given their report under five headings. These are considered as ​heredity, including consanguineous marriages, malnutrition and bad diet, the inordinate use of stimulants, and mental strain due to agricultural depression. These returns provide very interesting matter for further consideration. One effect of emigration has been that the healthier and younger go abroad and the less fit and the older remain behind ; and, what is certain, quite a considerable number of those who break down in America are repatriated as insane, so that the healthy remain there, whereas many of the feeble are returned to swell the list of lunatics in Ireland. This is made clear by the fact that in the 30 years between 1871 and 1901 there was no increase in the proportion of insane in reference to population between the ages of 20 and 55. There was, however, a very large increase in the ratio of insane to population in the old-age period. In Ireland the amount of insanity in proportion to the population is greater in the most remote rural districts, whilst in the busiest towns the ratio of the insane to the sane population is lowest. This is due, of course, to the exodus of the healthy from the country places. Even the first admissions to asylums are misleading, as these represent failures to cure after residence at home ; so that a very large proportion of people who come under the head of “first admissions” after all have been insane for long periods before they are sent to an asylum. It has often been said that the only way we can judge of the relative increase of the insane in ​a country is by reckoning the number of first admissions ; and the Commissioners in Lunacy have, of recent years, taken special pains to show the proportion of first admissions to other admissions, and I add to this paper certain tables from the Commissioners’ Report. It is an interesting point, and one not easy to explain, that the Irish in America produce a much larger proportion of insane patients than any of the other emigrants. I remember being very much struck when in America with the very large numbers of physical, social, and mental failures represented in the asylums and infirmaries near New York which the Irish provided. This has, of course, been explained by the instability of the Celtic temperament, but that hardly seems sufficient. Doubtless there are other contributing causes; among others, the home-loving instinct of the Irish is very characteristic, and also their tendency to wander. And a tendency to wander is pretty frequently recognised as an early symptom of mental disorder. It might be interesting to note that similar conditions exist in America.
Before proceeding to my general summary and conclusions I feel that I cannot do better than quote from Dr. Mott on the general pathology of insanity:—
A pathology which only considers the morbid macroscopic and microscopic anatomy is useless; there must be a correlation of the clinical and psychological symptoms with the morbid physical, chemical, and structural changes of the organs and tissues of the