CHAPTER XIV

INSANITY, EPILEPSY, TUBERCULOSIS AND GENIUS

(1) INSANITY

Is it Increasing?

In the two preceding chapters we have been considering the treatment from the eugenic point of view of those who have been picked out by certain legal processes because they possessed certain harmful qualities. Criminals and mental defectives have thus been dealt with, and the insane constitute the only remaining important group of individuals selected by the law on account of their defects. In dealing with legal insanity one would like to begin by quoting some well-chosen definition of this malady; but this is impossible because none has ever been formulated, as far as I know. The difficulty lies in the fact that every gradation exists between the sane and the legally insane; and all that can be said is that up till now an arbitrary line has been drawn so as to permit the confinement of those who are likely to be a serious danger to the public or to themselves because of the abnormal workings of their minds. Whether any of the persons allowed to remain at liberty are likely to be a source of danger to posterity by transmitting certain harmful propensities to their descendants is a consideration which has been thus far almost entirely ignored by our legislators. As to the questions which thus arise that is as to the need for eugenic reforms in connexion with insanity-no doubt the problems involved are both difficult and technical, and as I am no expert, they will here be but briefly treated. The amount of space allotted to insanity in this volume must not be taken as an indication of the importance of the subject.

In England and Wales the number of those certified in 1922 as being insane was over 123,000; this being about three per thousand of the total population. Statistics indicate that insanity has been increasing in recent years; but such figures cannot be accepted as proving that any increase in this type of mental defect has really taken place. The amount of accommodation for the insane, though still insufficient, has been increasing; and the pressure has ever been such that many have been discharged as 'cured' in order to make room for worse cases rather than because such a proceeding seemed advisable. The number of certified insane has, therefore, in large measure been dependent on the accommodation available, and it has increased with every additional asylum built. It is possible that it is mainly on account of the relative amount of accommodation in the United States that a lower rate of incidence of legal insanity obtains in that country, the figure being only 1.8 per thousand. Then, again, the greater care now taken of lunatics has caused an increase in the span of their lives greater than that which has taken place amongst the population as a whole, and those who have thus been kept alive now help to swell the ranks of the certified insane, thus giving rise to a comparative increase in their numbers. Lastly, as the line drawn is purely arbitrary, a change in the views of the authorities in regard to the degree of mental defect held by them to justify segregation might show itself in an increase in the numbers certified. We have, therefore, no proof that insanity is really increasing, though any indication that it is not increasing is even more certainly not to be found.2

Few sayings have been invented which have more often been used with harmful results than that which tells us that it is the last straw which breaks the camel's back; for it is often made an excuse for neglecting every remedy but one. Every straw which the camel carries plays a part in helping to bring about the final catastrophe, and to avoid it all straws must be considered. But here it is

1 Applied Eugenics, Popenoe and Johnson, p. 177.

2 Sir F. W. Mott, Problems in Eugenics, 1912, Vol. I, p. 406.

PROBLEMS OF CAUSATION

229

more important to note that in this saying attention seems to be concentrated on the weight of the load, hardly any thought being given to the strength of the back of the particular camel in question; which would only be excusable if all camels were equally strong-just as in reference to all human questions it would only be right to pay exclusive attention to possible improvements in human surroundings if all men were born alike. If either heredity or environment is ignored, when considering the problems here dealt with, many pitfalls will be found in our path; from which escape is difficult for those who have been thus entrapped. For example, in regard to the transmission of the propensity to mental instability from one generation to another, estimates have been made by various observers of the "proportion of insanity due to heredity," the recorded percentages varying from 15 to 90 per cent. If these investigators had spent a little more time in considering exactly what it was that they desired to know, these results would probably have been either less discrepant or recorded differently. Those who regard a certain percentage of cases of insanity as being due to heredity presumably regard the remainder as being due to environment; for are not these the only factors which have to be taken into account? If a case of insanity is said to be entirely due to heredity, that seems to imply that it was in no way due to environment; and if a case of insanity was not at all due to environment, it must be held that the individual in question would have gone mad whatever had been his surroundings. But an assertion that this was the case could not be made with complete confidence with regard to many of the insane, and it would at the best be mere unscientific guesswork. And if "due to heredity "does not mean the same as entirely due to heredity," what does it mean? Then, again, if a case of insanity is said to be due to environment, does that mean that all men would have gone mad under like conditions? If not, and if under the conditions in question some persons would have become insane and

66

1 A good epitome of this subject is given in Holmes's Trend of the Race, p. 44. Constable, 1921.

others would not, this could only have been due to differences in their inborn 'qualities; in which case their heredity was obviously one of the deciding factors. But if, on the other hand, in order to make the case truly one 66 due to environment" it must be assumed that no man would have remained sane in like circumstances, then very few such cases could with certainty be said to exist. In studying the causes of insanity both factors must always be taken into account, and the only logical course to adopt is to entirely discard all such phrases as due to heredity" and "due to environment."

66

There are certainly two questions which can be logically asked, even if the answers obtainable are very imperfect, and to these questions our main attention should be devoted. In the first place, we can seek to ascertain how much insanity would be eliminated from the present generation by any possible changes of environment; and as no change can take place in the natural endowment of those already born, the factor of heredity is here in a sense eliminated. This is the inquiry which the physician is always making; and rightly so, for it points to the only possible methods of benefiting his existing patients. In the second place, we may endeavour to find out whether the insane have as a fact, in the past, produced more than an average proportion of insane or defective offspring; though if the results of any such inquiry are to be utilized without qualification in connexion with problems of heredity, it must be assumed that changes in surroundings were not simultaneously producing any material changes in the incidence of insanity. Both questions are logical; and if the physician is right in turning to the first, that is as to what is immediately possible in the way of cure or prevention, the eugenist is equally right in turning to the second, that is to the study of the facts concerning the heredity of insanity. Insanity may be accompanied by brain disease, defects of the endocrinal glands, septic poisoning, or other physical defects; and a knowledge of this association may give a clue to curative or preventive treatment, a clue which should be pursued to the utmost. This is the physician's province; whilst the eugenist should

endeavour to ascertain the extent to which the propensity to insanity is received as a natural endowment or legacy from preceding generations. If it should be proved that a relatively high percentage of insane offspring are now being produced in certain stocks, this fact would be enough to justify the eugenist in declaring that a diminution in the fertility of these stocks would be beneficial to posterity. It is true that if any further improvement in either medical treatment or social conditions would have the effect of making such children of insane parents as would under existing conditions become insane, in fact live lives free from both insanity and other associated defects, then as regards those who were thus saved from such inflictions, all that is desired would have been accomplished. But any such curative or preventive process would show its results in a decrease in the statistics of insanity; whereas the facts before us indicate that mental illness is more likely now to be increasing than decreasing. We must conclude either that slow progress is now being made in the art of healing or that other forces are at work which counterbalance or more than counterbalance such progress as is being made. Surely we ought, therefore, not to neglect any other means of attempting to rid the world of this terrible scourge. If it can be proved that a certain type of parent is producing an exceptionally high proportion of insane offspring, and if past experience can be taken as a true guide, then any reduction in the size of the families of such parents would diminish the incidence of insanity in the future; and we have seen nothing to make us doubt that here past experience is the best guide for future policy.

In so far as insanity is hereditary, it must be assumed that these diseases of the mind have such a counterpart in human structure as would cause the tendency for their appearance to be passed from generation to generation by means of the germ plasm. It is true that the "how of the mind's connection with its bodily place seems still utterly enigma." But biological science does continually serve to emphasize the nexus between the mental and the bodily processes; and until the riddle of the universe