Popular Science Monthly/Volume 76/June 1910/Two Preventable Causes of Insanity
| TWO PREVENTABLE CAUSES OF INSANITY |
By Dr. THOMAS W. SALMON
PASSED ASSISTANT SURGEON, U. S. PUBLIC HEALTH AND MARINE HOSPITAL SERVICE
A FEW successful skirmishes in the interminable conflict with disease happened to take place recently on American soil. We saw the weapons of defense which scientific research had forged for us valiantly wielded by some of our countrymen and a new interest in preventive medicine, which has spread far beyond the ranks of the medical profession, was the result. Such discoveries as the detection of the part played by the mosquito in the transmission of yellow fever and by the rat flea in the spread of bubonic plague were interesting enough to gain a place in the news of the day but it was the fact that the first demonstrations of their surpassing practical value were given by medical officers of the American Army and Marine Hospital Service in our own land that gave rise to the present widespread confidence in the achievements possible in the domain of public health. It is natural, perhaps, that this newly awakened interest in the prevention of disease should center in the infectious diseases, in which the relation between cause and effect is often so obvious and the means of prevention are so logical. The school children of New Orleans easily grasped the simple facts in the case against the yellow-fever mosquito and they became efficient recruits in the memorable campaign of 1905. Much of the success in the present general movement against tuberculosis, the most formidable of all our unseen foes, is due to the fact that nearly all we know of its transmission can be reduced to half a dozen maxims, each of which can be expressed in as many words. It would be unfortunate, however, if popular interest in the battles for the public health should not extend to those diseases in which the relation between cause and effect is one step farther removed.
It is essential that the front presented to the common enemy should be as wide as our present knowledge justifies. There need be no fear of disaster from advancing in extended order, for an attack upon one position of the adversary will not infrequently disclose an unsuspected weakness in another. Since May, 1907, every effort has been made by the combined federal and city forces to rid San Francisco of bubonic plague. With victory assured, the results of what has been done are being counted up and it is found that measures undertaken for the extermination of plague have brought about a sanitary regeneration of the city and that the mortality from all diseases has been reduced to an unprecedented figure. We know that efforts for the public welfare often produce results where they were least expected, and so, the different fields of preventive medicine, special as some of them seem to be, are really inseparably related. Contrary to general belief, the prevention of insanity is not a matter which depends upon such special factors that it does not concern us all. It is, instead, only a phase of the general warfare against preventable disease; it has points of contact with many familiar problems of sanitation and, as will be shown, it bears a fundamental relation to two social questions which are occupying a very large place in the public attention at the present time.
The prevention of insanity is a matter well worthy of some consideration, for it is doubtful if any other human infliction can produce keener distress. A better conception of the nature of disorders of the mind and a kindlier attitude toward the insane have done a great deal to improve the lot of the sufferers themselves, but nothing can do much to lessen the unhappiness which insanity brings to others. It is difficult to tell exactly how prevalent insanity is. A few years ago some writers, who failed to take account of factors which greatly modified their statistics, startled the public in England by showing that the total number of the insane was increasing at a much more rapid rate than the general population, and one of the more gloomy of these writers did not hesitate to predict that insanity would ultimately engulf the race. It was, of course, absurd to ignore the effect, in increasing the aggregate number of insane persons under treatment, of an increasing readiness to seek institution treatment on account of the enormous advances in standards of care, of the earlier recognition of mental diseases and of the effect of building more hospitals, thus affording ready access for cases not often committed to distant institutions. At the close of 1908, there were 30,456 patients in the public and private institutions for the insane in New York state; about one in 280 of the general population of the state. This is approximately the ratio which exists in neighboring states and, it happens, exactly the same as the ratio in England. This number is not, fortunately, a satisfactory index of the prevalence of mental diseases, for the reason given and because the duration of some mental diseases is so great, in patients who do not recover, that the aggregate number under treatment at any given time represents, in large measure, the accumulation of unrecoverable cases admitted in former years. A patient died recently at the Utica State Hospital who had been admitted in 1843; she had been counted in 65 annual enumerations. The number of patients admitted for the first time to any hospital for the insane during a specified period is a much more trustworthy guide. Last year 5,301 patients were admitted for the first time to any hospital for the insane in New York state; one in 1,600 of the whole population or one in 1,000 if only those above the age of sixteen are considered. Here, then, is our problem in the prevention of insanity. Was it possible, by means at our command to have saved any of these unfortunates from becoming insane last year? Must an equal number, the population of a large town, be admitted next year, another 5,000 in 1912 and so on in the years to come? Are there facts at hand which point to practical measures of prevention or are the causes of mental disease so little understood or so deeply rooted that this sad toll of 5,000 new cases in a single state must be paid each year without hope of reducing it in the future?
Those who are responsible for the care of the insane in the various states are deeply impressed with the necessity of being able to give definite answers to these questions. In preventive medicine accurate knowledge must precede action and so statistics are being carefully gathered and analyzed in order that reliable information may not be wanting in this field of the prevention of disease. The New York State Lunacy Commission, which is charged with the care of nearly one fifth of all the insane in the United States, has recently adopted a greatly improved method of obtaining statistical data regarding new patients and already sufficient material is available to permit the accurate statement of some conditions which could be presented previously only in a general and rather unconvincing way. So, in this discussion of two preventable causes of insanity, it is worth while to examine the records of the 5,301 "first admissions" in New York state for the year which ended September 30, 1908.
At the very outset of any consideration of insanity, it is necessary to make it plain that we have to do not with one disease, manifesting itself in different ways, but with a number of diseases, differing very greatly from each other in many important respects. What is true of the causes or of the clinical characteristics of one mental disease may be entirely untrue of another. Various mental diseases, or "insanities" as it would be quite permissible to call them, are grouped together because of some similarity, and all these groups make up insanity as that term is generally used.
The mental diseases of one such group have the common characteristic of depending upon a preceding infectious disease. Permanent or transitory mental impairment may follow typhoid fever, influenza and some other acute, infectious diseases and it is obvious that these mental disorders are preventable in just the measure in which the diseases upon which they depend are preventable. The number of these cases is not large, and yet, when the cost of the needless prevalence of typhoid fever is estimated, these more remote effects should be considered. There is, however, one mental disease depending upon a preceding infectious disease which overshadows all others in importance. This is general paralysis or "general paresis," "paresis" or "paralytic dementia" as it is variously known. Almost invariably fatal within a few years after its onset, often a danger to the reputation or to the happiness of whole families in its earlier stages and distressing in its final phases, this disease occupies a place of its own in the interest of physicians and of others who chance to become familiar with it. Six hundred and sixty-four patients, or 12 per cent, of all the 5,301 new cases admitted to the New York state hospitals last year, had general paralysis. Some comparisons with the prevalence of other more familiar diseases may make the significance of this number clearer. Last year there were 1,368 deaths from typhoid fever in New York. Half as many persons died of general paralysis. Cancer of the breast is a relatively common and a much-dreaded disease, yet there were more deaths from general paralysis than from cancer of the breast. Angina pectoris is another frequent cause of death, but more people die of general paralysis. More people died in 1908 in New York from general paralysis than died from smallpox in the whole registration area of the United States in that year and the three preceding it.
The fact about general paralysis which is of the greatest importance is that it depends upon previous infection with syphilis. To just what extent it is not possible to say, but, whatever other causes may combine to produce general paralysis, testimony is increasing that syphilis is essential. In other words, if these 664 men and women had not had syphilis, very few of them would have had general paralysis.
Whatever is to be accomplished in the prevention of disease by the medical profession and an enlightened public will be brought about by concerted action. Without authoritative information and skilled leadership, popular movements in this field will be unlikely to succeed and may even result in harm, and, without popular support, the efforts of doctors will end in academic discussion and in plans incapable of execution. In this alliance frankness is essential; there must be no secrets or half-hidden truths between allies in the battles which are to be fought together for the public health. So the prevalent belief that syphilis is a menace only in an underworld of criminals, prostitutes and the utterly depraved must be abandoned, and the truth realized that it is a peril from which no class of society is exempt and to which the thoughtless, the innocent and the immoral are equally exposed. Three fourths of the 664 cases of general paralysis were married and 69 per cent, of them were in comfortable or affluent circumstances. The most unfortunate feature of general paralysis is that it occurs most often in the third and fourth decades of life; frequently in those who have long since abandoned the immoral or heedless mode of life which led to their infection and have become responsible for the support of families and of economic value to their communities. It not infrequently means that an innocent mother must be taken from her home, and even from the cradle of her baby, to pay, in mental darkness, a dreadful penalty for her faith in the man who became her husband.
Turning again to the cases we have selected to examine for preventable causes, we find that there were a very large number of patients in whom alcoholic intemperance was the cause of their mental disease. There is no subject which needs to be discussed with so much conservatism or with such scrupulous regard for accuracy as the effects of alcohol. So much in the relation of alcohol to social and bodily ills is the subject of bitter controversy, and so much damage may be done a worthy cause by careless or ambiguous statements that it seems desirable to define very precisely what we mean when we speak of alcohol as a cause of mental disease. Alcohol has been assigned as the cause, directly or indirectly, of more than one half the admissions to hospitals for the insane by Kraepelin of Munich, a very great leader in psychiatry and perhaps the foremost worker in Europe in the cause of temperance. In order to remain upon unassailable ground in this important matter, we will consider separately those cases in which alcohol is directly responsible and those in which it was a controlling and probably the only cause. So the facts relating to the "alcoholic insanities," those in which to name the disease is to give the cause, will be presented first. In our series of 5,301 first admissions there were 638 such cases, or about 12 per cent, of all.
There were together, then, 664 cases of general paralysis (depending upon syphilis) and 638 cases of the alcoholic psychoses (all due to intemperance) or more than one fourth of all first admissions due to these two preventable causes. Before considering any measures of prevention, it is desirable to examine a little in detail these 1,302 cases because there are some matters of sex and environment which are particularly significant. It is seen in the smaller chart that, as would have been supposed, both these causes affected men to a much greater extent than women. A factor which bears directly upon preventive measures is shown in the larger chart, which indicates the residence, as "rural" and "urban," of patients admitted with general paralysis and of those with alcoholic psychoses. It is seen that in the case of male admissions environment did not have a very marked influence upon the prevalence of the alcoholic psychoses, but that the percentage of cases of general paralysis in men was nearly three times as great in the admissions from cities as in those from the country. For women, this chart shows that the percentage of cases of general paralysis from cities was twice that from rural communities, but that the percentage of admissions with alcoholic psychoses was seven times as great for 
cities as from rural communities. This is eloquent testimony to the influence exerted by the back room and the "ladies' entrance" of the city saloon. The most striking fact shown by these charts, however, is that 42 per cent, of all the male admissions from cities were for general paralysis and the alcoholic psychoses. Where are "the nervous tension of the cities" and "the mad rush of modern life," of which we speak so glibly, compared with syphilis and drunkenness as the real dangers of city life? But for the undue prevalence of insanity due to these two causes, the ratio of the insane to the population would actually be greater in the quiet countryside than in the cities, in spite of their congestion of population, their unequal share of immigrants (an important factor in the prevalence of insanity) and their increased economic stress.
All through the etiology of other types of mental diseases than those which we have considered, appears the trail of syphilis and intemperance; sometimes unmistakable and sometimes faint but recognizable. A considerable percentage of the 5,301 first admissions were for mental diseases arising upon a basis of congenital mental defect or epilepsy. Some of these psychoses are temporary attacks in epileptics and in imbeciles and some are really terminal stages of such conditions. The tremendous effect of alcohol in the parents as a cause of mental deficiency has been pointed out by many competent observers and there are many very interesting studies which could be mentioned if space permitted. Alcoholism in parents has nearly as great an influence in the causation of epilepsy as of mental defect in descendants. Dr. E. E. Doran found that the parents of 257 of 1,300 epileptic children admitted to the Craig Colony had been confirmed alcoholics. A group forming about one tenth of all admissions to state hospitals is made up of patients with psychoses dependent upon gross disease of the brain. In these mental diseases there is destruction of cells of the brain, resulting from arterial changes, the effects of hemorrhages, the pressure of new growths and similar causes. In a very large proportion of such cases it was syphilis or alcohol which first attacked the integrity of the blood vessels or in other ways laid the train which was destined to lead finally to insanity.
So, if we care to go beyond the field of what is demonstrable by absolutely trustworthy statistics and can be shown by tables and charts, we find that alcohol and syphilis are factors in the production of mental diseases which have no equal. If we prefer to confine our attention to general paralysis and the alcoholic psychoses, we find that these diseases, due directly to syphilis and alcohol, are responsible for nearly one fourth of the sad procession of new patients entering the hospitals of a single state at the rate of more than a hundred a week.
The lesson of these statistics is full of hope and encouragement. A large proportion of all cases of insanity are found to be due to causes within our own control. We have come across the trail again of two formidable enemies, but they are old foes and we know their strongholds; we have been gathering evidences of their depredations in other directions and there are already movements on foot against them. "We have gained the tremendous advantage of being able to talk about both of them in public and before any hearers. Instead of vague tales of the ravages of these enemies of the race, in one direction or another, we have come to statistics, tabulations, investigations with reference to specific effects and to the widest publicity. This is why it is justifiable to speak of syphilis and alcohol as two preventable causes of insanity.