Transcriber's Note:

Punctuation and possible typographical errors have been changed.

Archaic, variable and inconsistent spelling have been preserved.

Footnotes appear at the end of the text, after the Index.

The cover image was created by the transcriber and placed in the public domain.

MENTAL DISEASES

A Public Health Problem

BY

JAMES V. MAY, M.D.

Superintendent, Boston State Hospital, Boston, Mass.; Fellow, and Chairman
of the Committee on Statistics, of the American Psychiatric Association;
Fellow of the American Medical Association, etc.

Formerly, Superintendent, Grafton State Hospital, North Grafton, Mass.; Medical
Member, The New York State Hospital Commission, Albany, N. Y.;
and Superintendent, Matteawan State Hospital, Beacon, N. Y.

WITH A PREFACE BY

THOMAS W. SALMON, M.D.

Professor of Psychiatry, Columbia University; Medical Advisor to the
National Committee for Mental Hygiene, New York City

BOSTON

RICHARD G. BADGER

THE GORHAM PRESS

Copyright, 1922, by Richard G. Badger

All Rights Reserved

Made in the United States of America

The Gorham Press, Boston, U. S. A.

PREFACE

Interest in mental disorders is no longer confined to the relatively small number of persons whose duties or family ties bring them into daily contact with the mentally ill. Disorders that so profoundly affect human conduct were certain, sooner or later, to attract the attention of those who are interested in the study of human behavior in its broadest relations or who have special responsibilities with reference to the conduct of individuals and require all the information that they can secure on factors that modify the reactions of men, women or children in the social environments in which they live and die. Uncertain of themselves until they made sure of the sciences upon which their future work was to develop, social workers since the commencement of organized social work in this country demanded of the sciences concerned with the human mind some information that might aid them in dealing with the difficult problems in human adaptation which they found constituted the chief part of social work. Judges and those who are interested in penology have within recent years turned also to the students of abnormal human behavior for light upon problems of crime and delinquency. With mental hygiene becoming firmly established as a practical field of preventive medicine, another group of persons not directly concerned with the care of the mentally ill has become deeply interested in the forms, types and causes of mental illness. It is by such readers, quite as much as physicians, medical students and nurses, that Dr. May's work in bringing together the main facts regarding mental diseases and the people who suffer from them will be appreciated. For those whose interest in the subject is incidental and not part of a life-long study, the information here presented will be of special value. There are, it is true, many technical works on mental diseases in their medical, social and legal relations, but it is doubtful whether elsewhere there can be found in a single volume as much varied information as that which Dr. May has brought together.

There is probably no group of diseases about which there is such widespread popular ignorance or misinformation as those that affect the mind. People who would be ashamed not to have accurate information regarding the more important infectious diseases and more than general knowledge of the means by which they are transmitted speak of "insanity" as if there were a single disorder to which that name could properly be applied, and are without the slightest knowledge of the different forms of mental diseases, the periods of life in which they appear, their main characteristics and the means by which they terminate. Statistics relating even to those persons with mental disorders who are cared for in special institutions are usually quite unfamiliar to persons who have more than an ordinary amount of information regarding the prevalence of other diseases. Such a book as this will go far toward supplying the extraordinary lack of knowledge of conditions that have exceedingly important social and economic relations and from the study of which many lessons can be drawn that are applicable to human affairs far removed from those relating to patients in our hospitals for the insane.

Thomas W. Salmon.

Larchmont, New York,
January 11, 1922.

CONTENTS

PART I. GENERAL CONSIDERATIONS.

CHAPTER

 

PAGE

I.

The Social and Economic Importance of Mental Diseases

15

II.

The Evolution of the Modern Hospital

34

III.

Legislation and Methods of Administration

50

IV.

The State Hospitals—Their Organization and Functions

68

V.

The Hospital Treatment of Mental Diseases

84

VI.

The Development of the Psychopathic Hospital

104

VII.

The Mental Hygiene Movement

121

VIII.

The Etiology of Mental Diseases

138

IX.

Immigration and Mental Diseases

155

X.

Mental Diseases and Criminal Responsibility

169

XI.

The Psychiatry of the War

185

XII.

Endocrinology and Psychiatry

202

XIII.

The Modern Progress of Psychiatry

217

XIV.

The Classification of Mental Diseases

234

PART II. THE PSYCHOSES

I.

The Traumatic Psychoses

253

II.

The Senile Psychoses

266

III.

The Psychoses with Cerebral Arteriosclerosis

280

IV.

General Paralysis

293

V.

The Psychoses with Cerebral Syphilis

308

VI.

The Psychoses with Huntington's Chorea, Brain Tumor and other Brain or Nervous Diseases

323

VII.

The Alcoholic Psychoses

344

VIII.

The Psychoses Due to Drugs and other Exogenous Toxins

363

IX.

The Psychoses with Pellagra

378

X.

The Psychoses with other Somatic Diseases

392

XI.

The Manic-Depressive Psychoses

409

XII.

Involution Melancholia

427

XIII.

Dementia Præcox

440

XIV.

Paranoia and the Paranoid Conditions

461

XV.

The Epileptic Psychoses

475

XVI.

The Psychoneuroses and Neuroses

489

XVII.

The Psychoses with Psychopathic Personality

504

XVIII.

The Psychoses with Mental Deficiency

524  

Index

537

AUTHOR'S PREFACE

In presenting a preliminary consideration of the subject of mental diseases as a public health problem the author is actuated by no other motive than that of stimulating the undertaking, at some future time, of a comprehensive investigation and survey of an important field which has never been systematically and adequately studied in the past. Under existing circumstances the facts necessary for an intelligent discussion of this question are unfortunately not obtainable. We have, as will be shown, practically no information whatever as to the incidence of mental diseases in the community. Hospital statistics are still in such a chaotic state that we are not even in a position to speak authoritatively of that part of the population which is entirely within our supervision and control in institutions. Before any progress can be hoped for we must at least have at our disposal accurate data relative to the patients within the walls of our hospitals. This presupposes a uniform scheme of statistical reports based upon some common viewpoint. Adequate preparations for this undertaking have been made by the American Psychiatric Association and the National Committee for Mental Hygiene. Every hospital for mental diseases in the country has been urged to cooperate in this movement. To show the necessity for more actively prosecuting this research has been one of the principal purposes of this book.

In elaborating somewhat briefly the conception of the various psychoses generally accepted by American psychiatrists, and for that reason included in the classification adopted by the Association, every effort has been made, as far as possible, to show the steps which have led up to present developments. The author has endeavored to confine himself to reflecting the views of others throughout and has used actual quotations from recognized authorities as far as was deemed advisable. In the discussion of the various psychoses frequent references will be noted to the description of the various clinical groups contained in the manual prepared by the Committee on Statistics for the American Psychiatric Association. As is shown in the manual, these definitions and explanatory notes were formulated by Dr. George H. Kirby.

Special reference should be made to the important contributions to the literature of psychiatry of such well-known American writers as Meyer, Hoch, Kirby, White, Barrett, Campbell, Southard, Peterson, Diefendorf, Jelliffe, Paton, Salmon, Russell, Buckley, Rosanoff, Orton, Singer and many others. The work of Kraepelin, Bleuler, Nissl, Alzheimer, Freud, Jung, Stekel, Janet and others abroad has exercised an influence on the psychiatry of the day which must be recognized. We are very largely indebted to Pollock and to Furbush for the available information relating to the incidence of the various psychoses in this country. To the American Psychiatric, for many years the American Medico-Psychological, Association we owe an exhaustive historical review of the institutional care and treatment of mental diseases in the United States and Canada.

Obviously this work was not intended as a textbook, nor was it designed to serve the purpose of one. It is an appeal to those who are already familiar with the fundamental principles of psychiatry. For that reason the interpretation of mental mechanisms given so much space in textbooks has been entirely omitted and no reference is made to the treatment of the individual psychoses. Such reliable statistical data as could be gathered from recent hospital reports and publications have been utilized in full. The following institutions were represented in this study:

1. Massachusetts—fourteen hospitals (1919-1920): Boston State Hospital, Boston; Bridgewater State Hospital, State Farm; Danvers State Hospital, Hathorne; Foxborough State Hospital, Foxborough; Gardner State Colony, Gardner; Grafton State Hospital, North Grafton; McLean Hospital, Waverley; Medfield State Hospital, Harding; Monson State Hospital, Palmer; Northampton State Hospital, Northampton; State Infirmary, Tewksbury (Mental Wards); Taunton State Hospital, Taunton; Westborough State Hospital, Westborough; Worcester State Hospital, Worcester.

2. New York—thirteen hospitals (1912-1919): Binghamton State Hospital, Binghamton; Brooklyn State Hospital, Brooklyn; Buffalo State Hospital, Buffalo; Central Islip State Hospital, Central Islip; Gowanda State Homeopathic Hospital, Collins; Hudson River State Hospital, Poughkeepsie; Kings Park State Hospital, Kings Park, L. I.; Manhattan State Hospital, Ward's Island, New York City; Middletown State Homeopathic Hospital, Middletown; Rochester State Hospital, Rochester; St. Lawrence State Hospital, Ogdensburg; Utica State Hospital, Utica; Willard State Hospital, Ovid.

3. Twenty-one hospitals in fourteen other states:

Arkansas—State Hospital for Nervous Diseases, Little Rock (1917-1918).

Colorado—Colorado State Hospital, Pueblo (1917 and 1918).

Connecticut—Connecticut State Hospital, Middletown (1917 and 1918); Norwich State Hospital, Norwich (1905-1918 inclusive).

Maryland—Springfield State Hospital, Sykesville, 1919; Spring Grove State Hospital, Catonsville, 1918 and 1919.

Michigan—Pontiac State Hospital, Pontiac, 1917 and 1918; State Psychopathic Hospital, Ann Arbor, 1917 and 1918; Traverse City State Hospital, Traverse City, 1917 and 1918.

Montana—Montana State Hospital, Warm Springs, 1917 and 1918.

New Jersey—Essex County Hospital, Overbrook, 1918.

Pennsylvania—State Hospital Southeastern District of Pennsylvania, Norristown, 1919.

South Carolina—South Carolina State Hospital, Columbia, 1918.

Utah—State Mental Hospital, Provo, 1918.

Vermont—Vermont State Hospital, Waterbury, 1917 and 1918.

Virginia—Central State Hospital, Petersburg, 1919; Western State Hospital, Staunton, 1919.

Washington—Eastern State Hospital, Medical Lake, 1917 and 1918; Northern State Hospital, Sedro Woolley, 1917 and 1918.

West Virginia—Spencer State Hospital, 1917 and 1918; Weston State Hospital, Weston, 1917 and 1918.

These institutions may, I think, be looked upon as fairly representative of the hospitals of this country. Based on their official reports an analysis has been made of over seventy thousand consecutive first admissions.

There is no disposition on the part of the writer to overestimate the value of statistical studies. Our conclusions should, however, be based as fully as possible on facts rather than on abstract theories or individual observations alone. The social, economic and clinical aspects of mental diseases must all be given adequate consideration if psychiatry is to fulfill its obligation to the community and assume a dignified rôle in the advancement of modern medicine.

James V. May.

Boston, Mass.,
December 15, 1921.

PART I

GENERAL CONSIDERATIONS

MENTAL DISEASES

CHAPTER I

THE SOCIAL AND ECONOMIC IMPORTANCE OF MENTAL DISEASES

The importance of mental diseases as a factor in the social and economic welfare of the community has not been given adequate consideration, notwithstanding the remarkable progress of modern psychiatry. Nor is this influence, unfortunately, one which can be easily estimated or accurately determined. We have, as a matter of fact, no data at hand to show the prevalence of disease, either physical or mental, with any degree of exactness even under our most elaborately organized forms of government. There is no complete information available which will enable us to determine the frequency of such important conditions as appendicitis, cardiac or renal diseases, peritonitis, septic infections, diseases of the eye, ear, skin or nervous system. It is true that there are, in the majority of states, records of contagious or readily communicable diseases which are probably fairly reliable. Aside from this, the only information at our disposal is confined to mortality statistics.

This suggests a further consideration of the advisability, if not absolute necessity, of more extensive statistical studies of diseases, both mental and physical, if the welfare of the community is to be safeguarded and the future of medical science assured. Every physician should be required by law to make careful reports to the Board of Health of his state showing all medical conditions requiring treatment by him or coming to his professional notice. The value of such information to medical science would much more than compensate for the comparatively small cost of such an undertaking. Nor is this procedure more radical either in theory or practice than was the proposal to report all communicable diseases only a few years since. The data thus made available in the various states should be correlated and published by the Public Health Service.

The mortality statistics of the United States Census Bureau furnish us with a valuable index of the relative frequency of the various disease processes which determine the death rate of the community. They are based on the transcripts of death certificates received from the so-called registration area, which in 1920 had an estimated population of 87,486,713. The total number of deaths reported in 1920 was 1,142,558, a rate of 13.1 per 1,000 of the population. It is true that the epidemic of influenza was still a factor of some importance at that time. The rate for 1916, however, was fourteen, for 1917 fourteen and two-tenths, for 1918 eighteen and one-tenth and for 1919 twelve and nine-tenths per 1,000 of the population. The registration area now includes thirty-four states:—California, Colorado, Connecticut, Delaware, Florida, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Utah, Vermont, Virginia, Washington and Wisconsin. It is interesting, at least, to note the states not included in the registration area:—Alabama, Arkansas, Arizona, Georgia, Idaho, Iowa, Nevada, New Mexico, North Dakota, Oklahoma, South Dakota, Texas, West Virginia and Wyoming. The results obtained from a study of the reports from such an extensive district must be looked upon as thoroughly representative of the country at large. The last complete statistics available are those for 1920. Influenza was still an important factor at that time, it being responsible for a death rate of 71 per 100,000. The influenza rate was 98.8 in 1919, 302.1 in 1918, 17.3 in 1917, 26.5 in 1916, 16 in 1915, 9.1 in 1914 and 10.3 in 1912.

The important causes of death in 1920 were as follows:

 

Rate per 100,000

Percentage

Typhoid fever

7.8

.6

Malaria

3.6

.3

Measles

8.8

.7

Whooping cough

12.5

1.0

Diphtheria and croup

15.3

1.2

Influenza

71.0

5.4

Tuberculosis of the lungs

100.8

7.7

Other forms of tuberculosis

7.8

.6

Cancer and other malignant tumors

83.4

6.4

Simple meningitis

6.0

.5

Cerebral hemorrhage

80.9

6.2

Organic diseases of the heart

141.9

10.9

Pneumonia (all forms)

137.3

10.5

Other diseases of the respiratory system

(tuberculosis and pneumonia excepted)

11.6

.9

Appendicitis and typhlitis

13.4

1.0

Hernia, intestinal obstruction

10.6

.8

Cirrhosis of the liver

7.1

.5

Acute nephritis and Bright's disease

89.4

6.8

Puerperal septicaemia

6.6

.5

Other puerperal accidents of pregnancy and labor

12.5

1.0

Congenital debility and malformation

69.8

5.3

Violent deaths (suicide excepted)

78.5

6.0

Suicide

10.2

.8

Unknown or ill-defined diseases

17.7

1.4

The pneumonia rate (all forms) for 1920 was quite unusual, 137.3 per 100,000, as compared with 123.5 in 1919, 286.6 in 1918, 150.5 in 1917, 137.8 in 1916, 133.1 in 1915, 127.3 in 1914, 132.6 in 1913, 132.4 in 1912, etc.

The following table shows the average rate per 100,000 of some of the more important general diseases during a period of eight years (1912, 1913, 1914, 1915, 1916, 1917, 1918 and 1919):

Typhoid fever

13.86

Measles

9.01

Scarlet fever

4.87

Whooping cough

10.11

Diphtheria and croup

16.30

Tuberculosis (all forms)

144.52

Cancer and other malignant tumors

80.27

Cerebral hemorrhage, apoplexy

78.91

Acute endocarditis and organic diseases of the heart

153.65

Pneumonia (all forms)

152.98

Acute nephritis and Bright's disease

101.63

The death rate from diseases of the nervous system is of particular interest. The average annual rate per 100,000 of the population for the years 1916, 1917, 1918 and 1919 was as follows:

Encephalitis

1.0

Meningitis (total)

8.17

Locomotor ataxia

2.27

Other diseases of the spinal cord (total)

8.57

Cerebral hemorrhage, apoplexy

80.57

Softening of the brain

1.25

Paralysis without specified cause

7.65

General paralysis of the insane

6.77

Other forms of mental alienation

2.17

Epilepsy

4.07

Chorea

.10

Other diseases of the nervous system

3.85

This shows a total death rate for nervous and mental diseases of 126.44 per 100,000. It is a fairly reasonable assumption that of the above, the following, at least, may be classified as having been definitely associated with psychoses:

 

Rate per 100,000

Encephalitis

1.0

Meningitis

8.17

Softening of the brain

1.25

General paralysis of the insane

6.77

Other forms of mental alienation

2.17

We may, therefore, reasonably conclude that there was an average number of at least 19.36 per 100,000 (from 1906 to 1910 this amounted to 32.1) in which the primary cause of death was associated with mental diseases, an exceedingly conservative estimate. This does not take into consideration the deaths due to senility (15.5) or suicide (12.8), conditions which might very logically be included for obvious reasons. It is, of course, well known that the psychoses rarely, if ever, appear in the death certificates as a primary cause of death. As a matter of fact, they are not always shown in the secondary causes. Information on this subject is still less satisfactory from a statistical point of view. During the year 1917 (contributory causes have not been reported since that year) there was a total of 1,066,711 primary causes of death shown in the registration area and only 372,291 contributory causes. Of this number the following may be classified as having been associated with psychoses:

Disease

Primary

Cause

Contributory

Cause

Encephalitis

620

904

Meningitis (total)

6,673

6,815

Softening of the brain

888

722

General paralysis of the insane

5,248

648

Other forms of mental alienation

1,651

3,895

 

———

———

Total

15,080

12,987

The contributory causes definitely showing mental diseases constitute only 3.4 per cent of the whole number, and the death rate for 1917, including both primary and contributory causes suggestive of probable psychoses, was 37.2 per 100,000. This would indicate that the number of deaths from mental diseases shown in the primary causes represents only about fifty-three per cent of all mental cases which are actual factors in determining the death rate of the community. A comparison of these figures with the number of cases dying in hospitals shows that they cannot be looked upon as determining the percentage of the general population showing psychoses. Of the 1,952 persons dying in the institutions for mental diseases in Massachusetts in 1919, approximately nineteen per cent showed the psychoses in the primary causes of death. This percentage would probably be fairly constant throughout the country. It is, of course, a well recognized fact that the death certificate at best is not beyond suspicion and does not furnish information regarding the cause of death which can be accepted without question.

Dr. Richard C. Cabot[1] has made an elaborate study of errors in diagnosis as shown by autopsies. His work shows the following percentage of diagnostic accuracy:

Per cent.

Diabetes mellitus

95

Typhoid fever

92

Aortic regurgitation

84

Lobar pneumonia

74

Cerebral tumor

72.8

Tubercular meningitis

72

Gastric cancer

72

Mitral stenosis

69

Brain hemorrhage

67

Aortic stenosis

61

Phthisis, active

59

Miliary tuberculosis

52

Chronic interstitial nephritis

50

Hepatic cirrhosis

39

Acute endocarditis

39

Bronchopneumonia

33

Acute nephritis

16

It must be admitted that Cabot's findings are discouraging. They are not so bad as they would seem, however, at first thought. Death certificates, unfortunately, do not have the significance which they should have. Physicians are well known to be entirely too careless in their preparation and inclined to look upon them merely as legal formalities which cannot readily be avoided. It is furthermore difficult, as every doctor knows, to point to one immediate primary cause of death in every instance. Very often there is a combination of factors concerned and it is possible at practically every autopsy to find lesions not represented in any way whatever in the death certificate. It is unquestionably true that statistics of any kind must be based on information some of which we know to be inaccurate. This should not be used as an argument for discontinuing, absolutely, our search for knowledge. It is merely a reason why our clinical standards should be improved.

An exceedingly important contribution to our rather limited fund of accurate information regarding the general health of the country was the publication recently issued by the Metropolitan Life Insurance Company[2] on the mortality statistics of wage earners and their families. This covers a period of six years (1911 to 1916) and represents a study of 635,449 deaths. The cases reported came from every state in the union with the following exceptions: Mississippi, North Dakota, South Dakota, Wyoming, Colorado, Texas, Nevada, Arizona and New Mexico. Canada and many other localities outside of the "Registration Area" of the United States Census Bureau were included. The facts presented in this report are unique in that they render available for the first time a careful and detailed consideration of the diseases which may be looked upon as representative of the industrial population of the country. The various occupations shown in the order of their numerical importance were as follows:—Laborers, teamsters, drivers and chauffeurs, machinists, textile mill operatives, clerks, office assistants, etc. It covers a study of ten million policy holders and nearly fifty-four million years of life in the aggregate. The age groups studied range from one year to seventy-five in ratios not very different from those exhibited in the general population. The death rate for all persons exposed was 11.81 per 1,000 as compared with a rate of over thirteen per 1,000 (white) of the general population of the registration area during the same period of time. The death rate per 100,000 from 1911 to 1916 of some of the more important general diseases was as follows:

Typhoid fever

16.8

Diphtheria and croup

24.3

Scarlet fever

8.6

Acute articular rheumatism

6.3

Diabetes

14.4

Cancer and other malignant tumors

70.0

Bronchopneumonia

30.2

Diarrhea and enteritis (over two years old)

13.9

Cirrhosis of the liver

15.0

Puerperal septicemia

8.1

Accidents of all forms

75.1

Ill-defined diseases

10.1

Measles

8.9

Influenza

15.0

Tuberculosis (all forms)

205.1

Tuberculosis (pulmonary)

173.9

Alcoholism

4.7

Diseases of the arteries, including atheroma, aneurysm, etc.

17.0

Pneumonia (lobar and undefined)

77.5

Intestinal obstruction

5.9

Bright's disease

96.8

Suicide

12.2

Homicide

7.0

The death rate for syphilis, locomotor ataxia and general paralysis of the insane, combined, was 14.3 per 100,000. The percentage of deaths due to diseases of the nervous system, many of which must be looked upon as probably having been associated with mental disturbances, is somewhat surprising, as shown by the following table:

Encephalitis

1.0

Meningitis

7.8

Locomotor ataxia

1.5

Acute anterior poliomyelitis

3.5

Other diseases of the spinal cord

4.0

Cerebral hemorrhage (apoplexy)

68.1

Softening of the brain

.9

Paralysis without specified cause

5.2

General paralysis of the insane

4.1

Other forms of mental alienation

1.4

Epilepsy

3.5

Convulsions (non-puerperal)

.2

Chorea

.2

Neuralgia and neuritis

.6

Other diseases of the nervous system

2.5

This shows a total rate of 104.5 per 100,000 due to diseases of the nervous system. If to this we add those dying of senility and the suicides as probably representing psychoses it would bring the total up to 123.2 per 100,000. It must be confessed, however, that such speculations mean comparatively little.

Practically the only other source of information at our disposal relative to the incidence of general diseases in the community is the tabulation of communicable diseases by Boards of Heath. The annual report of the United States Public Health Service for 1919 shows a case rate for diphtheria of 137 per 100,000 of the population based on the reports of thirty-seven states. The case rate for measles in thirty-seven states was 170. Poliomyelitis in thirty states showed a rate of 2.5 and scarlet fever a rate of 110 in thirty-seven states. The smallpox rate was sixty-eight and represented thirty-six states. The typhoid fever rate for thirty-seven states was only forty. The case rate for tuberculosis, all forms, was 346.7 in 1918. It was 274.2 in New York, 271.6 in the District of Columbia and 271.3 in New Jersey. These were the highest reported in the United States during that year. Unfortunately these statistics relate to communicable diseases only. This difficulty is due largely to the fact that comparatively few states have made attempts to keep elaborate records. The reports of Massachusetts are probably as comprehensive as any. The case rate per 100,000 of the population of all reportable diseases during the year 1920 was as follows:

Influenza

938.5

Measles

830.7

Pneumonia, lobar

143.6

German measles

12.5

Pulmonary tuberculosis

173.1

Tuberculosis, other forms

20.7

Diphtheria

194.2

Gonorrhea

186.7

Whooping cough

258.3

Scarlet fever

265.2

Chicken pox

138.4

Mumps

154.1

Syphilis

77.2

Ophthalmia

42.3

Typhoid fever

24.2

Dysentery

1.0

Epidemic cerebrospinal meningitis

4.7

Malaria

1.6

Pellagra

.4

Smallpox

.7

Trachoma

2.2

The case rates for influenza and pneumonia cannot be looked upon as representative, owing to the epidemic of 1919 and 1920. During 1917 the death rate from influenza was 12.9 per 100,000 and from pneumonia 163.8. The death rate from heart diseases (organic diseases of the heart and endocarditis) in Massachusetts in 1920 was 178 per 100,000 of the population, from apoplexy 108.4, cancer and other malignant diseases 116.7, Bright's disease and nephritis 92.4, diarrhea and enteritis 52.9, violence 76.3, automobile accidents and injuries 11.9 and suicides 10.1.

It must be admitted that it is exceedingly difficult to establish a definite basis for a comparison of our statistics relating to mental disorders and those dealing with the frequency of other diseases in the community. As has been shown, our information on the latter subject, such as it is, has to do only with communicable diseases and the reported death rates. In making an analysis of the reports of mental diseases we are limited almost entirely to the institution population. It is true that these statistics are much more reliable than the others, as we are dealing with a stable population entirely under control. The cases, furthermore, are almost invariably subject to a prolonged observation and careful study. The diagnosis in almost every instance is based on elaborate mental examinations and exhaustive personal and family histories. It is, of course, true that there are innumerable cases of mental diseases outside of institutions. There were 18,268 patients at home on visit from the state hospitals alone on January 1, 1920. Those not requiring hospital treatment or custody in an institution can, however, be eliminated for the purpose of comparative studies. The fact that an analysis of death rates alone does not throw any light whatever on the frequence of psychoses for reasons already given will, I think, be conceded. For statistical purposes, at least, it may be assumed that the frequence of mental diseases as shown by a study of the hospital population is fairly representative of conditions existing in the community.

For purposes of comparison we may contrast the admission rate of mental diseases per 100,000 of the population in Massachusetts in 1920 with the case rate of communicable diseases as follows:

Mental diseases

101.7

Chicken pox

138.4

Diphtheria

194.2

German measles

12.5

Gonorrhea

186.7

Measles

830.7

Mumps

154.1

Scarlet fever

265.2

Syphilis

77.2

Tuberculosis, pulmonary

173.1

Tuberculosis, other forms

20.7

Typhoid fever

24.2

Whooping cough

258.3

The total institution population (mental cases) at the end of the year 1920 represented a rate of 395.49 per 100,000 of the population. It should be borne in mind that, with the exception of tuberculosis and syphilis, the communicable diseases reported above represent, as a rule, the total number of cases in the state during the year. Comparative studies should, therefore, be based not on the number of mental cases in the hospitals at any one given time, but on the total number under treatment during the year. This would indicate an incidence of mental diseases of 566.98 per 100,000 of the population.

On January 1, 1916, there were 147 state and federal institutions for the care and treatment of mental diseases in the United States, as shown by the Census Bureau reports. There were at this same time twenty-seven institutions for the feebleminded, nine for epileptics, three for inebriates, forty-five for tuberculosis, twenty-eight for the blind, thirty-three for the deaf, twelve for the blind and deaf and eighty-four for the dependent classes. [3]

The appropriations for the maintenance of these institutions for 1915 amounted to $33,557,058.29. This constituted 7.6 per cent of the appropriations made by those states for all purposes. In Massachusetts it represented 14.8 per cent, in New Hampshire 10.1, in New York 12.7, in Ohio 12, in Indiana 10.7, in Illinois 13.4, and in a number of other states over ten per cent of the appropriations for all purposes. It was equivalent to an average of $431.16 per million of the total assessed valuation of these states. In Massachusetts it was as high as $653.62 and in New York $567.37. This means thirty-three cents per capita for all states, eighty-four cents for Massachusetts and sixty-eight cents for New York.

The actual expenditure for the maintenance of these institutions was $36,312,662.20. For purposes of comparison, attention should be called to the fact that the maintenance of the tuberculosis hospitals of the United States for the same year cost $3,539,454.95, institutions for criminals $21,244,892.00, for the feebleminded $3,341,442.85, for epileptics $1,345,821.57, for the blind $1,066,973.14, for the deaf $1,893,490.09 and for the dependent classes $9,675,932.37.

The value of the property invested in the state and federal hospitals for mental diseases in 1916 was estimated at $187,028,728.00. The valuation of these institutions per 100,000 of the population was $184,795.81. This does not include establishments for mental defectives. The average value per patient was $938.43. In Massachusetts it was $1,097.85 and in New York $1,039.85. In Arkansas it was as high as $2,264.00. The total acreage of land was 109,503.2, an average of 744.9 acres per hospital. There were 33,124 persons employed, an average of 226.9 for each institution. This represented one employee for every six patients.

The census taken by the National Committee for Mental Hygiene [4] in 1920 shows 156 state hospitals for mental diseases, two federal institutions, 125 county or city hospitals and twenty-one institutions of a temporary care type. In the public and private hospitals for mental diseases on January 1, 1920, there were 232,680 patients under treatment. Of these, 200,109 were in public and 9,238 in private hospitals. This represented an increase of 8,723 in two years. It is interesting to note that city and county institutions cared for 21,584 persons.

The first authoritative information relative to the institution care of mental diseases was obtained from the federal census reports of 1880. In that year there were 40,942 patients in the public hospitals. In 1890 there were 74,028; in 1904, 150,151; in 1910, 187,791; in 1917, 232,873 and in 1918, 239,820. The rate per 100,000 of the population increased from 81.6 in 1880 to 229.6 in 1918. From 1910 to 1918 the general population increased 13.6 per cent and the hospital population 27.7 per cent. The rate per 100,000 of the population in institutions in Massachusetts[5] on January 1, 1920, was 373.8, in New York 374.6, in Connecticut 317.8, in Iowa 248.1, in Wisconsin 300.6, in California 297.2, in Pennsylvania 215.2, in Ohio 212.1, in Illinois 229.5 and in Michigan 210.8. The admission rate per 100,000 of the population in 1917 was 151.6 in Massachusetts, 109.2 in Illinois, 124.8 in Montana, 97.3 in New York, 80.9 in Connecticut and 85.7 in California.

The cost of maintenance in the state hospitals increased to $43,926,888.88 in 1917 with an average per capita cost of $207.28. The number of cases cared for in some of the more populous states is of interest. On January 1, 1920, the institution population of New York was 38,903, Pennsylvania 18,764, Ohio 12,217, Illinois 14,884, Massachusetts 14,399 and California 10,184.

Based on the estimated population of Massachusetts on July 1, 1920 (3,869,098), the 1,475 deaths in institutions for mental diseases would represent a death rate of 38.12 per 100,000 of the population. The death rate for other diseases for that year was: diphtheria 15.4, measles 9.0, pulmonary tuberculosis 96.7, typhoid fever 2.5, whooping cough 14.0, scarlet fever 5.5, syphilis 5.8, lobar pneumonia 71.9 and influenza 43.9. The importance to be attached, however, to such comparisons is very uncertain at best. From the standpoint of social and economic importance to the community there is another factor under consideration which should not be overlooked. The duration of other diseases, as a general rule, is comparatively short. A study of over ten thousand deaths in New York state hospitals for mental diseases shows the average hospital residence of these cases to have been over six years. At the rate of admission to public institutions for 1917 (62,898) and the average per capita cost for that year ($207.28) the care of persons admitted annually, during their years of hospital life, would mean an expenditure of over seventy-eight millions of dollars.

If we figured the earning capacity of the 62,000 persons admitted to institutions for mental diseases in the United States as averaging only one thousand dollars per year, it would represent an economic loss to the country of sixty-two millions of dollars annually. Estimated in the same way, the total population of the hospitals would represent the staggering sum of nearly two hundred and forty million dollars. This, of course, does not take into consideration at all the cost of maintenance or the property investment represented by hospitals.

To avoid any possibility of confusion, no reference has been made heretofore to statistical studies of mental deficiency or epilepsy. From a public health point of view, however, and as social and economic problems, they are questions which cannot be disregarded in a consideration of mental diseases. As a matter of fact, they are very closely correlated in many ways. A survey made by the National Committee for Mental Hygiene shows that on January 1, 1920, there were in this country thirty-two state institutions for mental defectives, eleven admitting both feebleminded and epileptics and twenty exclusively for the latter class. [6] In addition to this, one city institution was reported. Of the private hospitals twenty-seven care for the feebleminded only, and six for epileptics, while nineteen admit either of these classes. The total number of mental defectives in institutions on January 1, 1920, was 40,519. At that time 34,836 were in state, 2,732 in other public institutions and 2,951 in private hospitals. In the following states they are cared for in hospitals for mental diseases, no other provisions having been made for their treatment:—Alabama, Arizona, Arkansas, Florida, Louisiana, Mississippi, Nevada, South Carolina, Tennessee, Utah and West Virgina. The states reporting the largest number are New York 5,762, Pennsylvania 4,281, Massachusetts 3,192, Illinois 3,147, Ohio 2,435, Michigan 1,849, Iowa 1,704, New Jersey 1,762, Wisconsin 1,624, Minnesota 1,502, Indiana 1,264 and Missouri 1,047. At the same time there were 14,937 epileptics under treatment, 13,223 in state, 859 in other public institutions and 855 in private hospitals. Colorado, Delaware, Georgia, Nebraska, New Mexico and Washington take care of the epileptics in their hospitals for mental diseases. The intimate relation between mental diseases and epilepsy is shown by the fact that as nearly as can be determined at this time approximately thirty per cent of all of the epileptics in our state institutions have been committed as insane. This, however, nowhere nearly includes all of the cases which actually show mental disorders of one kind or another. The states showing the largest numbers of epileptics are New York with 1,683, Ohio 1,680 and Massachusetts 1,227. No other states report over one thousand, although Michigan and Pennsylvania have over eight hundred and Illinois and Missouri over seven hundred.

Although the incidence of mental as compared with other diseases prevalent in the community cannot be established with absolute accuracy, sufficient evidence has been presented to warrant the statement that from the standpoint of the public health we are dealing with no other problem of equal importance today. The state care of mental defects, epilepsy, tuberculosis and the deaf, dumb and blind is, for various reasons, of much less consequence to the community than the hospital treatment of mental diseases. The defective, delinquent, criminal and dependent classes combined do not equal in number the population housed in our state hospitals for mental diseases. Nor does the number of cases cared for in the general hospitals of the state, county or municipal type compare in any way with the mental cases coming under state or federal supervision. It can, I think, be said without any fear of contradiction that no other disease or group of diseases is of equal importance from a social or economic point of view. Perhaps nothing emphasizes this fact more strongly than the report recently issued from the Surgeon General's office relative to the second examination of the first million recruits drafted in 1917. Twelve per cent of these were rejected on account of nervous or mental diseases. The number disqualified for service finally reached a total of over sixty-seven thousand.

Mental integrity is now looked upon as a military necessity and is insisted upon as one of the important requirements of the soldier. It has been demonstrated conclusively that only men of the most stable mental equilibrium can withstand the stress and strain of modern methods of warfare. Nor are peacetime requirements any less exacting. In commercial competition the law of the survival of the fittest is practically absolute. The feebleminded often inherit wealth, but they rarely acquire it. Vaccination for the prevention of smallpox is compulsory and the isolation of communicable diseases dangerous to the public welfare is rigidly enforced. At the same time we allow many paranoics the freedom of the country and they occasionally assassinate a President. Psychopaths are not infrequently elected to public office and epileptics are not disqualified from driving high-powered and dangerous motor vehicles. The engineers of our fastest trains must not be color blind, but they occasionally are victims of the most fatal of all mental diseases,—general paresis. The navigating officer of a transatlantic liner, responsible for the lives of hundreds of passengers, must pass an examination for a license, but he may be dominated by delusions which escape observation because they are not looked for. Important trials, where human lives were at stake, have been presided over by insane judges. Army officers in command of troops in time of war have been influenced by imaginary voices. Insurance companies issue large policies to individuals suffering from incipient mental diseases which could be detected by even a superficial psychiatric examination.

Serious consideration should be given to the advisability of subjecting to a careful mental examination such persons, at least, as are to be charged with an entire responsibility for the lives of others. It is a question as to whether this procedure is not indicated in the case of other important public trusts where the interest of the community should be safeguarded.

The correlation of psychiatry and psychology as scientific aids to industrial efficiency promises to open up entirely new and important sociological fields of research which have only recently attracted attention. [7] This is a subject of far reaching importance. The extent to which the industrial classes of the country are affected is shown by the following analysis of the occupations represented by 104,013 admissions to New York state hospitals: 1. Professional—(clergy, military and naval officers, physicians, lawyers, architects, artists, authors, civil engineers, surveyors, etc.) 1,926 or 1.8 per cent; 2. Commercial—(bankers, merchants, accountants, clerks, salesmen, shopkeepers, shopmen, stenographers, typewriters, etc.) 7,572 or 7.2 per cent; 3. Agricultural—(farmers, gardeners, etc.) 5,942 or 5.7 per cent; 4. Mechanics—at Outdoor Vocations—(blacksmiths, carpenters, enginefitters, sawyers, painters, etc.) 8,564 or 8.2 per cent; 5. Mechanics at Sedentary Vocations—(bootmakers, bookbinders, compositors, tailors, weavers, bakers, etc.) 7,501 or 7.2 per cent; 6. Domestic Service—(waiters, cooks, servants, etc.) 21,037 or 20.2 per cent; 7. Educational and Higher Domestic Duties—(governesses, teachers, students, housekeepers, nurses, etc.) 21,861 or 21 per cent; 8. Commercial—(shopkeepers, saleswomen, stenographers, typewriters, etc.) 1,140 or 1.09 per cent; 9. Employed at Sedentary Occupations— (tailoresses, seamstresses, bookbinders, factory workers, etc.) 4,310 or 4.1 per cent; 10. Miners, Seamen, etc., 581 or .56 per cent; 11. Prostitutes, 81 or .08 per cent; 12. Laborers, 12,962 or 12.4 per cent; No occupation, 7,820 or 7.5 per cent; Unascertained, 2,715 or 2.6 per cent. [8] This certainly indicates an enormous economic loss to the community.

The intimate relation between mental diseases, alcoholism, ignorance, poverty, prostitution, criminality, mental defects, etc., suggests social and economic problems of far reaching importance, each one meriting separate and special consideration. These problems, while perhaps essentially sociological in origin, have at the same time an important educational bearing, invade the realm of psychology and depend largely, if not entirely, upon psychiatry for a solution.

CHAPTER II

THE EVOLUTION OF THE MODERN HOSPITAL

The medical treatment of mental diseases had its inception, in this country, in the wards of the Philadelphia Hospital, established in 1732 and referred to officially for over a century as an almshouse. It included an infirmary for the "sick and insane," although it apparently had no distinct and separate hospital department for many years. "In 1742," to use the words of Dr. D. Hayes Agnew, "it was fulfilling a varied routine of beneficent functions in affording shelter, support and employment for the poor and indigent, a hospital for the sick, and an asylum for the idiotic, the insane and the orphan. It was dispensing its acts of mercy and blessing when Pennsylvania was yet a province and her inhabitants the loyal subjects of Great Britain." In 1772 it housed as many as three hundred and fifty persons. In 1769 the General Assembly passed an act authorizing the "Managers of the Contributions for the Relief and Employment of the Poor," who had charge of the almshouse, to issue bills of credit for the purpose of relieving their indebtedness. This paper currency was issued in three denominations—one shilling, two shillings and a half crown. The law provided that counterfeiters or persons altering the denomination of these bills should be "sentenced to the pillory, have both his or her ears cut off and nailed to the pillory and be publicly whipped on his or her back with thirty-nine lashes, well laid on, and, moreover, every such offender shall forfeit the sum of one hundred pounds, to be levied on his or her land, tenements, goods and chattels." [9] This certainly must have discouraged counterfeiting. It was not until after the institution was removed to the Hamilton estate in Blockley (now a part of West Philadelphia) in 1834 that it came to be known as the "Philadelphia Hospital and Almshouse," although there was no change made in its organization or functions. In 1902, after one hundred and seventy years of continuous existence, it was finally divided officially for administrative purposes into The Philadelphia Home or Hospital for the Indigent, The Philadelphia General Hospital and The Philadelphia Hospital for the Insane. At that time the hospital was, as it is today, the largest on the American continent. The institution, which has admitted mental cases uninterruptedly since 1732, had over seventeen hundred patients in the department for the insane. In 1917 this number had increased to nearly three thousand.

One of the reasons set forth by sundry petitioners in 1751 for a "small Provincial Hospital" in Philadelphia, which at that time had made provision for the care of indigent cases only, was "THAT with the Numbers of People, the Number of Lunaticks or Persons distempered in Mind and deprived of their rational Faculties, hath greatly increased in this Province. That some of them going at large are a Terror to their Neighbours, who are daily apprehensive of the Violences they may commit; And others are continually wasting their Substance, to the great Injury of themselves and Families, ill disposed Persons wickedly taking Advantage of their unhappy Condition, and drawing them into unreasonable Bargains, etc. That few or none of them are so sensible of their Condition, as to submit voluntarily to the Treatment their respective Cases require, and therefore continue in the same deplorable State during their Lives; whereas it has been found, by the Experience of many Years, that above two Thirds of the Mad People received into Bethlehem Hospital, and there treated properly, have been perfectly cured." [10] This resulted eventually in the opening of the Pennsylvania Hospital in 1752. This institution is a general hospital supported by private funds and has always received mental cases. A separate department for mental diseases was established in West Philadelphia in 1841. Before this was done considerable difficulty was experienced on account of the annoyance of the patients by curious-minded citizens of the neighborhood. This developed into such a nuisance in 1760 that it was suggested "That a suitable Pallisade Fence, either of Iron or Wood, the Iron being preferred, shall be erected in Order to prevent the Disturbance which is given to the Lunatics confined in the Cells by the great Number of People who frequently resort and converse with them." [11] It was also deemed advisable to employ "Two Constables or other proper Persons, to attend at such times as are necessary to prevent this Inconvenience until ye Fence is erected." The public was notified later "that such persons who come out of curiosity to visit the house should pay a sum of money, a Groat at least, for admittance." [12] The Pennsylvania Hospital has played a very important part in the history of the care and treatment of mental diseases in this country. In 1919 it had over three hundred patients.

The first institution designed and used exclusively for mental diseases in this country was the Eastern State Hospital at Williamsburg, Virginia. It was incorporated by the House of Burgesses in 1768 and opened for patients on October 12, 1773. It is interesting to note that the act of incorporation, except in the title, makes no use of the word lunatic, refers frequently to the care and treatment of the patients, authorizes the appointment of physicians and nurses, and specifically designates the institution as a hospital and not an asylum. The original building was one hundred feet long by thirty-two feet two inches wide. During the first year thirty-six patients were admitted. The first pay patient was received in 1774 at a rate of fifteen pounds per annum. An allowance of twenty-five pounds per year was made by the legislature for the maintenance and support of each person admitted. Visiting physicians prescribed for the patients, and the "keepers" for the first few years were not graduates in medicine. The superintendents were, however, physicians after 1841. Known for many years as the "Publick Hospital," the legislature made the mistake of changing this designation to The Eastern Lunatic Asylum in 1841 and it was not until 1894 that it again officially became a hospital. Virginia opened its second institution, The Western State Hospital for the Insane, at Staunton on July 25, 1828. Its third hospital was opened at Weston on September 9, 1859. Virginia is thus entitled to the credit of being the first commonwealth to furnish state care for mental cases and make adequate provision for them.

The next step in the evolution of hospital treatment of mental diseases was taken by Maryland in incorporating a hospital for "The Relief of Indigent Sick Persons and for the Reception and Care of Lunatics" in 1797. The hospital was formally opened in 1798 under the management of the city of Baltimore, which leased the establishment in 1808 to two physicians, who conducted it as a private institution until 1834. It then reverted to the state and was operated as the Maryland Hospital. The institution was removed to Catonsville in 1872 and is now known as the Spring Grove State Hospital, the Johns Hopkins Hospital occupying the site of the original building in Baltimore. Another interesting event in the history of this institution was the founding of what subsequently became the Mount Hope Retreat by the Sisters of Charity, who withdrew from the Maryland Hospital in 1840.

The earliest hospital care of mental diseases in New York was in the wards of the New York Hospital which was opened in 1791. A separate building for mental cases was ready for the reception of patients in 1808. The total number of cases treated up to July 1820 was 1,553. The Bloomingdale Asylum replaced this in 1821, on a piece of property which now belongs in part to Columbia University. Public patients were cared for at the expense of the state until the opening of the New York City Asylum in 1839. Church services were inaugurated in 1819. The hospital buildings furnished accommodations for about three hundred patients. In 1894 the property on Bloomingdale Road was abandoned and the hospital removed to White Plains in Westchester County. It is still known as the Bloomingdale Hospital and is supported entirely by public contributions and the income derived from the care of patients. It has about three hundred and fifty beds.

The activities of the "Religious Society of Friends," which were indirectly responsible probably for the inception of the Pennsylvania Hospital, ultimately led to the establishment of the Friends' Asylum for the Insane at Frankford, Pennsylvania, in 1817. It was under sectarian control until 1834, when its doors were thrown open to all, without regard to religious belief. It claims to be the first institution "erected on this side of the Atlantic in which a chain was never used for the confinement of a patient." [13] The hospital is still in a flourishing condition and has accommodations for over two hundred patients.

Massachusetts at the beginning of the nineteenth century had no hospitals of any kind. In 1764, on the death of Thomas Handcock, it was found that provision had been made in his will for the establishment of a hospital for mental diseases in Boston. An expenditure of six hundred pounds was authorized for the purpose of "erecting and furnishing a convenient House for the reception and more comfortable keeping of such unhappy persons as it shall please God, in His Providence, to deprive of their reason in any part of this Province." [14] The Selectmen of Boston declined this legacy on the grounds that there were not enough mental cases in the vicinity to warrant the existence of such an establishment. This proved to be an error of judgment on their part. In 1811 the Massachusetts General Hospital was incorporated and a fund of over $93,000 was subscribed for building purposes. As it was deemed more urgent, the department for mental diseases in Charlestown was opened first. It was ready for the reception of patients on October 6, 1818, when it admitted a young man supposed to be possessed of a devil. This department became the McLean Asylum in 1826 as the result of a legacy of $25,000 left to the institution by a Boston merchant of that name. The corporation finally received in all an amount approximating $120,000 from the McLean estate. As early as 1822 the first published report of the hospital[15] called attention to the fact that the various amusements offered the patients included "draughts, chess, backgammon, ninepins, swinging, sawing wood, gardening, reading, writing, music, etc." A carriage and pair of horses for the use of patients was purchased in 1828. In 1835 the first pianos and billiard tables were installed and a library of one hundred and twenty volumes placed in the wards. Hot water heating was introduced in 1848. It is interesting to note that in 1827 the visiting committee reported that the rates for the maintenance of patients should not be less than three dollars or more than twelve dollars per week. In 1882 the McLean Hospital established the first training school for nurses connected with any institution for mental diseases in this country. The first class was graduated in 1886. In 1895 the hospital was removed to Waverley, Massachusetts. A chemical laboratory was opened in 1900 and a psychological laboratory in 1904. Hydrotherapy was first used in 1899, and a gymnasium was built in 1904. In 1913 the hospital owned three hundred and seventeen acres of land and had a capacity of two hundred and twenty beds, with a plant valued at nearly two million dollars.

The first provision for the care of mental diseases in Connecticut was a direct result of the activities of the State Medical Society. It was on their petition that the Hartford Retreat was chartered in 1822. Over two thousand persons subscribed to a fund for the opening of the hospital. These subscriptions included "$30 payable in medicine," "One gross New London bilious pills, price $30" and two lottery tickets.[16] About fourteen thousand dollars was subscribed in all, the citizens of Hartford contributing four thousand. The hospital building, designed to accommodate forty patients, was opened on April 1, 1824, and has always been conducted on an unusually high plane. It now averages about one hundred and seventy-five patients.

Mental cases were first provided with hospital care in Kentucky when the Eastern State Hospital was opened in Lexington on May 1, 1824. Governor Adams, who suggested the establishment of this institution, in a message written in 1821 expressed the opinion that it would be of great benefit to the students of Transylvania University, "which would in time repay the obligation by useful discoveries in the treatment of mental maladies."

The State Hospital at Columbia, South Carolina, was opened in December, 1828. A curious fact in connection with its history is that in 1829 the management, having received no patients as yet, advertised for them in the newspapers of South Carolina and adjoining states.

In 1829 the necessity of making further provision for mental diseases in Massachusetts became the subject of a legislative investigation and a committee was appointed "to examine and ascertain the practicability and expediency of erecting or procuring, at the expense of the Commonwealth, an asylum for the safe keeping of lunatics and persons furiously mad." [17] The report of this committee, of which Horace Mann was Chairman, is exceedingly interesting. The following is an illustration:—"To him whose mind is alienated, a prison is a tomb, and within its walls he must suffer as one who awakes to life in the solitude of the grave. Existence and the capacity for pain alone are left him. From every former source of pleasure or contentment he is violently sequestered. Every former habit is abruptly broken off. No medical skill seconds the efforts of nature for his recovery, or breaks the strength of pain when it seizes him with convulsive grasp. No friends relieve each other in solacing the weariness of protracted disease. No assiduous affection guards the avenues of approaching disquietude. He is alike removed from all the occupations of health, and from all the attentions everywhere but within his homeless abode bestowed upon sickness. The solitary cell, the noisome atmosphere, the unmitigated cold and the untempered heat, are of themselves sufficient soon to derange every vital function of the body, and this only aggravates the derangement of his mind. On every side is raised up an insurmountable barrier against his recovery. Cut off from all the charities of life, endued with quickened sensibilities to pain, and perpetually stung by annoyances which, though individually small, rise by constant accumulation to agonies almost beyond the power of mortal sufferance; if his exiled mind in its devious wanderings ever approach the light by which it was once cheered and directed, it sees everything unwelcoming, everything repulsive and hostile, and is driven away into returnless banishment."[18] The investigation conducted by this committee led to the establishment of the Worcester Lunatic Hospital, later the Worcester State Hospital, opened on January 19, 1833. The original building was designed to care for one hundred and twenty patients. After many years of agitation on the part of the public, the hospital was removed to a site overlooking Lake Quinsigamond in the outskirts of Worcester in 1877. It was soon found that it was impracticable to dispense with the use of the old building on Summer Street and it became the Worcester Insane Asylum, later the Worcester State Asylum, and finally the Grafton State Hospital. In 1919 it again became a part of the Worcester State Hospital. The original building is in excellent condition today and promises an indefinite continuation of an unusual career of usefulness. Many men destined to occupy positions of importance in the psychiatric world were trained within its walls.

The death of a prominent politician in 1806 is said to have led indirectly to the establishment of the first hospital for mental diseases in Vermont.[19] His medical advisers treated him for some form of mental alienation by submerging him in water until he became unconscious. It was thought that this "would divert his mind and, by breaking the chain of unhappy associations, thus remove the cause of his disease." As this plan failed he was given opium as "the proper agent for the stupefaction of the life forces." In spite of this vigorous treatment he died. The immediate event which made possible the incorporation of the Vermont Asylum for the Insane in 1835 was a legacy of ten thousand dollars rendered available for this purpose by the will of Mrs. Anna Marsh of Hinsdale. The hospital was opened in Brattleboro in 1836 and became the Brattleboro Retreat after the establishment of the State Hospital at Waterbury. The state care of mental diseases began in Ohio with the establishment of the Columbus State Hospital, which was opened on November 30, 1838. This was the first of a number of institutions now under the supervision of the Ohio Board of Administration.

The study of the development of the state hospital system of care now takes us back to Massachusetts. Notwithstanding the fact that the state already had two institutions for mental cases, McLean and the Worcester Lunatic Hospital, further accommodations were urgently indicated. This was largely on account of the needs of the metropolitan population centering in the city of Boston. To meet this situation the city established a hospital of its own in South Boston in 1839,—the first municipal institution for this exclusive purpose in America. Originally known as the Boston Lunatic Hospital and afterwards as the Boston Insane Hospital, it finally became the Boston State Hospital in December, 1908. Charles Dickens on the occasion of his visit to America was very profoundly impressed by the hospital and made the following references to it in 1842 [20]:—"At South Boston, as it is called, in a situation excellently adapted for the purpose, several charitable institutions are clustered together. One of these is the hospital for the insane; admirably conducted on those enlightened principles of conciliation and kindness which 20 years ago would have been worse than heretical, and which have been acted upon with so much success in our own pauper asylum at Hanwell...." "At every meal, moral influence alone restrains the more violent among them from cutting the throats of the rest; but the effect of that influence is reduced to an absolute certainty, and is found, even as a measure of restraint, to say nothing of it as a means of cure, a hundred times more efficacious than all the straight waistcoats, fetters and handcuffs that ignorance, prejudice and cruelty have manufactured since the creation of the world." ... "In the labor department every patient is as freely trusted with the tools of his trade as if he were a sane man. In the garden and on the farm they work with spades, rakes and hoes. For amusement they walk, run, fish, paint, read, and ride out to take the air in carriages provided for the purpose. They have among themselves a sewing society to make clothes for the poor, which holds meetings, passes resolutions, never comes to fisticuffs or bowie-knives as sane assemblies have been known to do elsewhere; and conducts all its proceedings with the greatest decorum. The irritability which would otherwise be expended on their own flesh, clothes and furniture is dissipated in these pursuits. They are cheerful, tranquil and healthy." ... "It is obvious that one great feature of this system is the inculcation and encouragement, even among such unhappy persons, of a decent self-respect." The institution was removed to the Dorchester district of Boston in 1895, where it now houses in the neighborhood of two thousand patients. The Boston State Hospital was the first institution of its kind in the United States to establish a separate psychopathic department, which was opened in 1912.

Influenced doubtless by the attention given to this subject in other states, Maine opened its first state hospital at Augusta in 1840. There were between two and three hundred mental cases in the state at that time. A second hospital was opened at Bangor in 1889. This humanitarian movement naturally extended to New Hampshire. Governor Dinsmore in 1832 [21] called attention to the condition of the insane, seventy-six of whom were in confinement. Of this number seven were in cells or cages, six in chains and irons and four in jail. Of those not in confinement at the time, some had been handcuffed previously, while others had been in cells or chained. After much unavoidable delay the New Hampshire State Hospital was opened at Concord on October 29, 1842. The next hospital development appeared in Georgia. After an active campaign inaugurated by the physicians of the state and continued for several years, the Georgia State Sanitarium was opened in Milledgeville in December, 1842. It now houses over four thousand patients.

By this time it became evident that further procedures on behalf of the persons requiring treatment for mental diseases in New York were imperative. The Bloomingdale Hospital, although taxed to its utmost capacity, was not able to meet the needs of the situation. In 1830 the population of the state had increased to nearly two million. The report of a legislative committee showed that there were 2,695 insane persons in the state in 1830, with hospital accommodations at Bloomingdale and one other private hospital at Hudson for only two hundred and fifty of these cases. An extensive system of state care was inaugurated by the opening of the Utica State Hospital on January 16, 1843. In addition to numerous other industries and occupations, a printing office was established in the hospital and the publication of the "American Journal of Insanity" was undertaken in 1844. This was the first journal in the world to be devoted exclusively to the subject of mental diseases. "The Opal," edited, published and printed by the patients of the hospital, was started at the same time. In the early days, strong rooms, padded cells and mechanical restraint of all kinds were used extensively. The "Utica Crib" has received a great deal of attention. This consisted of an ordinary ward bed enclosed in wooden slats, making it impossible for the patient to escape. These were eliminated for all time by Dr. G. Alder Blumer in 1887. Attendants were first required to wear uniforms in 1887. During the following year female nurses were assigned for the first time to male wards. Annual field day exercises for the benefit of the patients have been held since 1887. Baseball games, steamboat excursions, Fourth of July celebrations and Christmas entertainments have been in vogue since 1888. With the development of a large department on the "Marcy" site, nine miles from the city, the Utica State Hospital promises to add new accomplishments to an already dignified history.

The early care of mental cases in Rhode Island, as shown by a report to the legislature by Thomas R. Hazard in 1851, was perhaps no worse than that of other states, although the conditions he described so graphically have not been attributed to other New England communities by historians. The following extract from a codicil to the will of Nicholas Brown, who died in 1843, is proof of the fact that this unfortunate state of affairs had not entirely escaped notice [22]:—"And whereas it has long been deeply impressed on my mind that an insane or lunatic hospital or retreat for the insane should be established upon a firm and permanent basis, under an act of the Legislature, where that unhappy portion of our fellow beings who are, by the visitation of Providence, deprived of their reason, may find a safe retreat and be provided with whatever may be most conducive to their comfort and to their restoration to a sound state of mind: Therefore, for the purpose of aiding an object so desirable and in the hope that such an establishment may soon be commenced, I do hereby set apart and give and bequeath the sum of $30,000 towards the erection or endowment of an insane or lunatic hospital or retreat for the insane, or by whatever other name it may be called, to be located in Providence or its vicinity." Supplemental contributions by Cyrus Butler made it possible for the incorporators to found the Butler Hospital in Providence. The first patients were received on December 1, 1847.

More than any other one person, Miss Dorothea L. Dix of Massachusetts was undoubtedly directly responsible for the inauguration of the state care of mental diseases in this country. She is credited with having memorialized twenty-two different state legislatures on this subject. One of her first accomplishments consisted in inducing the New Jersey legislature to make an appropriation for the establishment of the state hospital at Trenton. This institution was opened in 1848, after some of the hardest campaigning that Miss Dix conducted. The last years of her life were spent as an honored guest of the hospital and she died there in 1887 at the advanced age of eighty-five.

Indiana inaugurated a system of state care by the establishment of the Central Hospital for the Insane in 1848. The East Louisiana Hospital at Jackson was opened in the same year. Missouri made its first provision for mental cases by opening a hospital at Fulton in 1852. Notwithstanding the fact that the first hospitals for mental diseases in this country were located in Philadelphia, the Commonwealth of Pennsylvania did not make any provision for a state institution until the State Hospital at Harrisburg was opened in 1851. This was only undertaken after a vigorous campaign on the part of Dorothea Dix had made some legislative action almost imperative. This is probably the only hospital in the country which has found it necessary to demolish all of the original buildings and replace them by others. In 1847 Miss Dix visited Tennessee and started a movement which resulted in the opening of The Central Hospital for the Insane at Nashville, the first institution of the kind in the state. California entered the state hospital field in 1853 with the establishment of an institution at Stockton. The St. Elizabeths Hospital in Washington, D.C., the first federal institution for mental diseases, was opened for patients in 1855. It receives cases from the United States Government Services and from the District of Columbia. Dorothea Dix was largely instrumental in its origin. The St. Elizabeths Hospital was an early invader of the field of scientific research. A pathologist was appointed in 1883. It was one of the first institutions to use hydrotherapy extensively. It now cares for nearly four thousand patients. Mississippi established its first state hospital for mental diseases in 1856, North Carolina in 1856, West Virginia in 1859, Michigan in 1859, Wisconsin in 1860, Texas in 1861, Kansas in 1866, Minnesota in 1866, Connecticut in 1868, Rhode Island in 1870 and Vermont in 1891. The Sheppard and Enoch Pratt Hospital, a well known private institution in Baltimore, was also opened in 1891.

It is hardly worth while at this time to emphasize the fact that the necessity of providing adequate facilities for the care and treatment of mental diseases, a problem which received little consideration of any kind for many years, gradually led to the elaboration of an extensive system of state hospitals. These are to be found now in every part of the country. They have long since passed through the purely custodial stage and have developed into highly specialized modern hospitals of most advanced type. Their function is to provide proper treatment for persons who cannot for financial or other reasons be cared for in the private hospitals which are to be found in almost all localities. These institutions, originating in Virginia in 1773, now represent one of the most important activities conducted by any state government. The extent of the field which they cover is illustrated by the fact that Kansas, Kentucky, Nebraska, North Carolina, Oklahoma, Tennessee, Texas, Washington, West Virginia and Wisconsin each maintain three state hospitals for mental diseases; Iowa, Maryland, Missouri and Virginia each have four institutions of this type, Minnesota five, California, Indiana and Michigan six, Pennsylvania seven, Ohio and Illinois nine, Massachusetts twelve and New York fifteen. In addition to this eight other states have two hospitals each and seventeen find one such institution sufficient for their needs. It is worthy of note that every state without any exception has now recognized the necessity of making provision for the care and treatment of mental diseases.

CHAPTER III

LEGISLATION AND METHODS OF ADMINISTRATION

The administration of the earlier hospitals for mental diseases was placed very wisely in the hands of local boards of directors, managers or trustees. These were made up of persons prominent in the community in which they lived, well known as having a keen interest in humanitarian movements, and fully deserving of the confidence reposed in them by the public. They received no compensation other than the satisfaction of having served in a worthy cause. The state hospital at Williamsburg, Virginia, the first of its kind in America, was controlled by a court of directors which was made up of some of the most prominent Virginians of colonial days. It included Thomas Nelson, Jr., a signer of the Declaration of Independence who served with distinction in the Revolutionary War, Peyton Randolph, the President of the first Continental Congress, and George Wythe, the preceptor in law of both Marshall and Jefferson, as well as a signer of the Declaration of Independence and professor of law at William and Mary College, together with various other distinguished citizens, some perhaps of less prominence, but all men of the highest standing in Virginia. The first "court" consisted of fifteen members. The second state institution, the Maryland Hospital, under the management of the city of Baltimore for some years, was eventually placed under the control of a board of visitors in 1828. Kentucky's first hospital was from the beginning in the charge of a board of ten commissioners. When the second Virginia institution was opened at Staunton, the form of organization adopted at Williamsburg was duplicated and a court of directors appointed. There were, however, thirteen instead of fifteen members. The state hospital at Columbia, South Carolina, was originally, and still is, under a board of regents. The Massachusetts hospitals, dating from the opening of Worcester in 1833, have always had trustees. The Vermont Asylum, later the Brattleboro Retreat, was also managed by a board of trustees, as was the New Hampshire State Hospital at Concord. The Georgia State Sanitarium, opened in the same year, adopted a similar form of control. The Utica State Hospital has been conducted from the first by a board of managers, a term which is generally used by the New York institutions. When the Trenton State Hospital was founded it was placed under a board of ten managers, more or less along the lines followed at Utica. The State Hospital at Raleigh, North Carolina, had a board of directors. For many years the earlier institutions for mental diseases were under no other form of control, the powers of the trustees being absolute. This is still the case in a few states. Usually, however, there is some additional form of supervision.

Boards of trustees, managers, directors, or some other local governing body, exist in the following states but without exclusive control:—Alabama, California, Connecticut, Delaware, Georgia, Idaho, Indiana, Louisiana (administrators), Maine, Maryland, Massachusetts, Mississippi, Missouri, New Jersey, New Mexico, New York, Pennsylvania, South Carolina (regents), Texas and Virginia. [23]

In the following states the hospitals have no local boards of any kind:—Arizona, Arkansas, Colorado, Florida, Illinois, Iowa, Kansas, Kentucky, Michigan, Minnesota, Montana, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, South Dakota, Tennessee, Utah, Vermont, Washington, West Virginia, Wisconsin and Wyoming.[24]

As the state hospitals increased in number and importance, steps were taken to coordinate their activities and for various obvious reasons they were soon grouped together in departments. In the states having a sufficient number of hospitals to warrant such a procedure, separate specialized administrative units were established under lunacy commissions, etc. In less populous communities where there were only a few hospitals there soon developed a tendency to associate them with the charitable, correctional and, in some instances, penal institutions. Seventeen states, as has been shown, now have only one hospital for mental diseases, eight have two and ten only three institutions. This led either to placing the hospitals under boards of charities and corrections or to the organization of new departments known as boards of control. The hospitals for mental diseases are under the supervision of boards of charities and corrections in the following states:—Colorado, Connecticut, Indiana, Louisiana, Maine, Nebraska, North Carolina, South Carolina, South Dakota and Virginia. [24]

Boards of control exist in Arkansas, California, Iowa, Kentucky, Minnesota, North Dakota, Oregon, Vermont, West Virginia and Wisconsin. California has, in addition to this, a board of charities and corrections and a commission in lunacy. Vermont has a director of state institutions. In New Hampshire the board of trustees of the state hospital constitutes a commission in lunacy. A number of states have special departments for the supervision of hospitals for mental diseases and in some instances for the control of all institutions. Delaware has a board of supervisors of state institutions. This is essentially a board of control. This is true of the board of commissioners of state institutions in Florida. Illinois has a department of public welfare, which places the control of the charitable, penal and corrective institutions, as well as the hospitals for mental diseases, largely in the hands of one man, a layman. Michigan and Pennsylvania also have departments of public welfare. Kansas has placed its hospitals under the control of a board of administration of state charitable institutions. Maryland has a lunacy commission and Missouri a board of managers. Montana and Nevada each have a board of commissioners for the insane. New Jersey has a state board of control of institutions and agencies, the direction of the state hospitals being delegated to a commissioner of charities and corrections. New York has the largest department in the country having exclusive state hospital functions. It is under the supervision of a hospital commission. Ohio has a board of administration which manages and governs all of the charitable, corrective and penal institutions of the state. This is, of course, a board of control pure and simple. Oklahoma has a commissioner of charities and corrections who is an elective officer, and has, in addition, a lunacy commission and a board of public affairs. Rhode Island has a penal and charitable commission of nine members. Utah has a board of insanity and Wyoming a board of charities and reform. Massachusetts has a department of mental diseases under the direction of a medical commissioner, with four unpaid associates. In addition to the hospitals for mental diseases the department has under its jurisdiction the institutions for the feebleminded and the epileptics.

The necessity of some form of central supervision or control, of state institutions in general and hospitals for mental diseases in particular, has long been a subject of serious consideration and discussion. The administration of hospitals, prisons, reformatories, etc., by a central board of control may be indicated in states where there are only a few institutions and the creation of highly specialized and expensive departments obviously would not be warranted. The question may very properly be raised as to the necessity of any supervision other than that by local boards of trustees in such communities. A study of methods of supervision made some years ago by the medical director of the National Committee for Mental Hygiene [25] shows that the board of control system leaves much to be desired. He has expressed himself on this subject in no uncertain terms, as is shown by the following:—"Under Boards of Control, politics influence the care of the sick to a degree unknown under different types of supervision and the scientific and humane aspects of the work undertaken are generally subordinated to doubtful administrative advantages. With hardly an exception, these Boards of Control have not endeavored to secure better commitment laws, to lead public sentiment so that higher standards of treatment will be demanded or to deal with the great problems of mental disease in any except their narrowest institutional aspects. There has been striking absence of evidences of any feeling of personal responsibility in these matters; indeed many members of these boards would doubtless unhesitatingly state that their duties do not involve such considerations. What the results would have been if efficient and fearless local boards of managers had been retained when these states created Boards of Control cannot be stated. It is an essential part of the policy which places the care of the insane under this form of administration that there shall be no "division of responsibility" and, seemingly, there is no place in such a scheme for bodies which are as much interested in the personal welfare of the wards of the State as they are in governmental "efficiency" and, which, moreover, are directly accountable to their neighbors—the friends and relatives of patients. It is interesting to compare some of the conditions mentioned with those existing in States in which the care of the insane is entrusted to Boards created for that special purpose. In these States,—California, Maryland, Massachusetts and New York,—it can be said truly that the care of the insane reaches its highest level."

The experience of the past has shown that the injection of politics into the administration of state institutions is almost invariably due to the over-centralization of power in state departments, the local boards of trustees or managers either being abolished or largely deprived of their authority. The greatest menace to the future welfare of the hospitals for mental diseases is, in the opinion of many, the unfortunate result of a popular and more or less legitimate demand for the reorganization of state governments, reducing their administrative activities to a few separate departments, each one under the entire charge of a director responsible only to the Governor. The argument for this procedure is that it does away with innumerable commissions, boards and departments working along independent lines without any reference to the desirability of coordinating the activities of the state as a whole and places the affairs of the commonwealth on an efficient, systematic and economical basis. There is no question as to the theoretical advisability of such methods. The difficulty is, that in putting into practical operation this unquestionably commendable undertaking, the humanitarian aspect of the charitable enterprises conducted by state governments for more than a century, is likely to be lost sight of. It is almost invariably urged that the directors of these various departments should be experienced business men of recognized ability and that in only such a way can the affairs of the state be put on a "businesslike basis." It must be confessed that this argument is one which appeals very strongly to the taxpayer, who naturally has not given the matter very careful thought. There are other important considerations, however, where the question of administering hospitals is involved. As Commissioner Kline [26] has said:—"If it be conceded that the care and treatment of the mentally sick is a highly specialized medical problem, requiring the services of medical experts, and that the institutions function primarily for the welfare of the patient, then the supervision and control of institutions should be in the hands of medical men especially trained for the purpose."

In some instances where the state governments have been reorganized and the proposed consolidation of departments effected, the administration of the state hospitals has come under the direction of a single individual without hospital or institution experience of any kind and without any special knowledge of medicine or psychiatry. There is no escaping the fact that the administration of a hospital is a medical problem. Nor is there any question as to the advisability of some central supervision and financial control of institutions. The hospital departments in our more populous states are, however, so extensive and so important that they cannot be merged with other interests without sacrificing to a considerable extent the welfare of the patients. It should be remembered, moreover, that the administration of hospitals for mental diseases is a specialty and a large one, not specifically related to the problems arising in the management of charitable institutions or prisons. The best results have been obtained where there is a division of responsibility between local boards of trustees or managers and a central body charged with the supervision, and a limited or complete financial control, of institutions for mental diseases only. The head of such a department should unquestionably be a medical man with psychiatric hospital experience. This policy has been responsible for the high standards maintained in the state hospitals of Massachusetts and New York.

It is, unfortunately, true that the care of mental diseases is not exclusively a function of the state or private hospitals. In thirteen states, county or municipal institutions are maintained and in twenty-five, persons suffering from mental diseases may legally be cared for in almshouses or poorhouses.

There is little uniformity in the laws of the various states relative to the hospital care of mental diseases, aside from the fact that almost without any exception they are designed to provide solely for the legal custody of the so-called "insane" and the protection of the public. "Insanity," as a matter of fact, is a purely legal and not a medical term, and may be said to relate to mental diseases only in so far as they come within the jurisdiction of the courts.

Statutory enactments relative to the forms of mental disease which render the individual subject to legal custody and detention in an institution are illustrated by the provisions of the Civil Code of Illinois. This defines an "insane" person as one "who by reason of unsoundness of mind is incapable of managing his own estate, or is dangerous to himself or others, if permitted to go at large, or in such condition of mind or body as to be a fit subject for care and treatment in a hospital or asylum for the insane." In Alabama a person is legally insane "if he has been found by a proper court deficient or defective mentally so that for his own or others' welfare his removal is required for restraint, care, and treatment." As a general rule, provision by law is made 1, for an application for commitment; 2, for a medical certificate of two or more properly qualified physicians showing the person to be insane and a proper subject for care and treatment in an institution, and 3, for the order of the Judge of a Court of Record for commitment to a state hospital. The necessity of some form of legal authorization for detention is a result of the fundamental principle in English procedure that no man, against his will, may be deprived of his liberty without due process of law. This right was recognized and perpetuated by the Magna Charta signed by King John in 1215 and is very definitely referred to in at least two different articles in the Constitution of the United States.

As a rule the application for commitment can be made only by certain persons definitely specified in the law,—parents, near relatives, the guardian or various public officials such as overseers of the poor. In Massachusetts any person may sign such a petition. In Florida a request must be jointly made by five reputable citizens. This would not appear to be a material point in law. Some courts require that a notice of the application be served upon the person whose commitment is requested. In New York a notice must be served at least one day prior to the hearing of the case unless the judge personally certifies that substituted service has been made upon some other person or that personal service was considered inadvisable for some adequate reason noted and has therefore been dispensed with. The Arizona law requires the judge to hold a hearing and have the alleged insane person before him for examination. In California a jury trial may be requested and a commitment made only on a verdict of insanity requiring a vote of at least three-fourths of the jurors. A trial by jury may be asked for in Colorado, Connecticut and many other states and must be granted. Trial by jury is necessary in all cases in Georgia. Provision is usually made for an appeal to some higher court. In many states hearings are mandatory, in others they are optional with the court. In Iowa each county has a board of three commissioners of insanity, one of whom must be a physician. They have full authority under the law to make commitments to institutions. Hearings are required in Kansas but inquests in lunacy may be either by jury or commission at the discretion of the court. In Kentucky inquests in lunacy must be held by the Circuit Court of a county. The hearings are always in the presence of a jury. In Louisiana two physicians must examine the patient in the presence of the court. If the physicians do not agree the judge himself decides the case. In Maine parents and guardians may send insane minors to an institution without a commitment. Other insane persons are subject to examination by the municipal officers of towns. In Mississippi the Chancery Courts have jurisdiction over writs of lunacy and an inquest may be made by jury. Nebraska has three commissioners in insanity in each county, appointed by the judge of the District Court. In the case of persons found insane they issue a warrant authorizing admission to a state hospital. Each county in New Jersey has a commissioner in lunacy, who has jurisdiction over the steps relating to admission to institutions. Commitments are made by the judge of a Court of Record. All orders for commitments in North Carolina must be made by the clerk of a Superior Court. No person who has moved into the state while insane is deemed a resident. North Dakota has a board of three commissioners of insanity in each county, the county judge being a member. The commissioners authorize hospitals to receive persons found to be insane. Appeal may be made to a commission of three persons to be appointed by the county judge. A jury trial is provided for, on demand, in Oklahoma. In cases of appeal the county judge must appoint a commission of three, one of whom is a physician, for the examination of the patient. Examination by a commission of three is required in Pennsylvania before commitment by a justice of a Court of Common Pleas or Quarter Sessions. South Dakota has a board of three commissioners of insanity in each county, the county judge being a member. An insane person may be received in a hospital in Vermont on the certificate of two physicians or by the order of a County or Supreme Court without a physician's certificate. Appeal may be made to the state board of control. In Virginia the committing judge and two physicians constitute a commission for the examination of alleged insane persons. In West Virginia there is a county commission of lunacy composed of the president and clerk of the County Court and the prosecuting attorney. Commitments are ordered by the commission. On the arrival of the patient at a hospital a board composed of the Superintendent and assistant physicians must be convened for the examination of the patient. Application for commitment must be made in Wisconsin by three reputable citizens. The determination of insanity in Wyoming must be made in all instances by a jury of six men.

When an insane person has been committed to an institution it is sometimes the duty of an officer of the court to accompany the patient to the hospital. The order of the court in Massachusetts includes the following:—"Now, Therefore, You, the said Sheriff, Deputies, Constables or Police Officers, and each of you, with necessary assistance, ... are hereby commanded, in the name of the Commonwealth of Massachusetts, forthwith to convey the said —— to the hospital aforesaid, and to deliver h— to the Superintendent thereof, and make due return of a copy of this precept with your doings therein." This practically amounts to a warrant of arrest and makes the removal of the patient to the hospital to all intents and purposes analogous to a criminal proceeding.

Attention should be called to one of the very excellent and humane provisions of the New York Law:—"All county superintendents of the poor, overseers of the poor, health officers and other city, town or county authorities, having duties to perform relating to the poor, are charged with the duty of seeing that all poor and indigent insane persons within their respective municipalities, are timely granted the necessary relief conferred by this chapter. The poor officers or authorities above specified, except in the city of New York and in the county of Albany, shall notify the health officer of the town, city or village of any poor or indigent insane or apparently insane person within such municipality whom they know to be in need of the relief conferred by this chapter. When so notified, or when otherwise informed of such fact, the health officer of the city, town or village, except in the city of New York and the county of Albany, where such insane or apparently insane person may be, shall see that proceedings are taken for the determination of his mental condition and for his commitment to a state hospital. Such health officer may direct the proper poor officer to make an application for such commitment, and, if a qualified medical examiner, may join in making the required certificate of lunacy. When so directed by such health officer it shall be the duty of the said poor officer to make such application for commitment. When notified or informed of any poor or indigent insane or apparently insane person in need of the relief conferred by this chapter such health officer shall provide for the proper care, treatment and nursing of such person, as provided by law and the rules of the commission, pending the determination of his mental condition and his commitment and until the delivery of such insane person to the attendant sent to bring him to the state hospital, as provided in this chapter."

In New York City these responsibilities are delegated to the trustees of Bellevue and Allied Hospitals and in the county of Albany to the Commissioner of Public Charities. In New York City a medical examiner or nurse from the psychopathic wards of Bellevue Hospital, or both, may be sent "to the place where the alleged insane person resides or is to be found." If in the opinion of this examiner medical care is necessary, the patient is taken to the psychopathic ward for observation for a period of not to exceed ten days. When a person has been committed to a state hospital in New York, the Superintendent is required by law to send a trained nurse or attendant to bring the patient to the institution. The desirability of having such cases under the immediate care of nurses who have had psychiatric training would seem to be obvious. There is no reason why persons suffering from mental diseases should be subjected to the same form of supervision that is given to criminals. The New York plan of holding the health officer responsible for providing proper hospital care and treatment for mental cases not coming directly under the legal jurisdiction of other persons or officials is well worthy of serious consideration. There would appear to be no reason why the health officer should not be responsible for mental conditions in somewhat the same way that he is for communicable diseases. Nor is there any public official to whom the supervision of the insane pending commitment can more logically be delegated.

In twenty-nine states voluntary patients may be received by state hospitals. The provisions of the law usually are that the patient must make application on his own initiative, that his mental condition must be such as to understand the purpose of this proceeding and the need of treatment and that he must be released on a demand in writing in from three to seven days of such request. In the twelve following states the temporary care of the insane in jails, usually as an emergency measure, is still authorized:—Arkansas, Colorado, Georgia, Indiana, Iowa, Nebraska, North Dakota, Oklahoma, South Dakota, Virginia, West Virginia and Wisconsin. Arrangements of some kind for the emergency care of cases pending examination and commitment are provided for in Connecticut, Illinois, Maine, Massachusetts, Michigan, Minnesota, New Jersey, New York, North Carolina, Oklahoma, Pennsylvania, South Carolina, Tennessee, Washington and Wisconsin. Massachusetts has the most comprehensive provisions for temporary care and observation. The Superintendent of a state hospital may receive and detain, for not more than five days without a court order, any person whose case is "certified to be one of violent and dangerous insanity or of other emergency" by two qualified medical examiners. Officers authorized to serve a criminal process, or police officers, must, on the request of the applicant or one of the examining physicians, bring such a person to the hospital. The applicant for this form of admission must within five days arrange for the commitment of the person so received, or for his removal from the hospital.

Under the provisions of the Massachusetts Law a person found by two qualified examiners to be in such mental condition that his admission to a hospital for the insane is necessary for his proper care or observation may be committed for a period of thirty-five days "pending the determination of his insanity." The superintendent must discharge such a person within thirty days if not insane or report to the committing judge his opinion that the patient's mental condition is such as to require a further residence in the hospital necessary.

Under the provisions of the so-called "Boston Police Act" (chapter 307 of the Acts of 1910) all persons suffering from delirium, mania, mental confusion, delusions or hallucinations, under arrest or "who come under the care or protection of the police of the city of Boston" shall be taken to the Psychopathic Hospital "in the same manner in which persons afflicted with other diseases are taken to a general hospital." Cases suffering from delirium tremens or drunkenness may be refused by the hospital authorities; otherwise, all such persons are admitted, observed and cared for "until they can be committed or admitted to the hospital or institution appropriate in each particular case" unless the patient recovers or is discharged.

Under the provisions of the Massachusetts Law "No person suffering from insanity, mental derangement, delirium or mental confusion, except delirium tremens and drunkenness, shall, except in case of emergency, be placed or detained in a lockup, police station, city prison, house of detention, jail or other penal institution, or place for the detention of criminals. If, in case of emergency, any such person is so placed or detained, he shall forthwith be examined by a physician and shall be furnished suitable medical care and nursing and shall not be so detained for more than twelve hours." In Boston these cases are sent to the Psychopathic Hospital. In other parts of the state they are cared for by the board of health of the city or town in question until they can be committed to a hospital or cared for by relatives or friends.

The superintendent of a state hospital, under the authority of chapter 123 of the General Laws, "When requested by a physician, by a member of the board of health or a police officer of a city or town, by an agent of the institutions registration department of the city of Boston, or by a member of the district police 'may' receive and care for in such hospital as a patient, for a period not exceeding ten days, any person who needs immediate care and treatment because of mental derangement other than delirium tremens or drunkenness." Such cases are received on application in writing filed at the time of the reception of the patient or within twenty-four hours thereafter and must be discharged or committed within ten days unless they make a request for voluntary care. During 1920 there were 1,929 temporary care cases reported by the various Massachusetts state hospitals, as follows:

Boston State Hospital (Psychopathic Department) 1,049, Danvers 217, Northampton 188, Worcester 159, Taunton 154, Westborough 68, Foxborough 56, Medfield 33, Grafton 2, and Gardner State Colony 3.

Nowhere else in the country has this particular form of legislation been used so extensively. It is something more than a mere authorization for the reception of mental cases in observation or detention wards. Under its provisions, at the request of any reputable practicing physician and without further legal formalities, mental cases may be cared for in a state hospital until their condition can be definitely determined and arrangements made for their proper disposition and treatment. The criticism to which this plan is open is that the period of time, ten days, is not long enough. It should be extended to thirty days at least.

The provision of the Massachusetts Law for the determination of the mental condition of persons under arrest or held under criminal charges is an excellent one and well worthy of consideration. This is covered by chapter 123 of the General Laws:—"If a person under complaint or indictment for any crime, is, at the time appointed for trial or sentence, or at any time prior thereto, found by the Court to be insane or in such mental condition that his commitment to a hospital for the insane is necessary for the proper care or observation of such person pending the determination of his insanity, the Court may commit him to a State hospital for the insane under such limitations as it may order." The Court may in its discretion employ one or more experts to examine such persons. These cases are on recovery returned by the hospital authorities to the custody of the Court. One of the interesting features of the Massachusetts Law is the provision relating to persons indicted for murder or manslaughter but acquitted by a jury by reason of insanity. Such cases are committed to a state hospital for life and can be discharged only by the Governor of the state, with the advice and consent of the Executive Council, when he is satisfied, after an investigation by the Department of Mental Diseases, that such a person may be discharged "without danger to others." Persons charged with a crime "other than murder or manslaughter" and acquitted by a jury by reason of insanity may also be committed by the Court to a state hospital "under such limitations as it deems proper" and such orders may be revoked at any time.

A recent enactment (Chapter 415, Acts of 1921) provides that "Whenever a person is indicted by a grand jury for a capital offense or whenever a person, who is known to have been indicted for any other offense more than once or to have been previously convicted of a felony, is indicted by a grand jury or bound over for trial in the superior court, the clerk of the court in which the indictment is returned, or the clerk of the district court or the trial justice, as the case may be, shall give notice to the department of mental diseases, and the department shall cause such person to be examined with a view to determine his mental condition and the existence of any mental disease or defect which would affect his criminal responsibility. The department shall file a report of its investigation with the clerk of the court in which the trial is to be held, and the report shall be accessible to the court, the district attorney and to the attorney for the accused, and shall be admissible as evidence of the mental condition of the accused."

The whole question of methods of commitment was made the subject of an extended study by the National Committee for Mental Hygiene in 1919. A comprehensive report covering such legislation as was deemed necessary was submitted by a committee consisting of the following:—Dr. George M. Kline, Commissioner, Massachusetts State Department of Mental Diseases; Dr. Charles W. Pilgrim, Chairman of the New York State Hospital Commission; Dr. Owen Copp, Superintendent, Pennsylvania Hospital, Department for Nervous and Mental Diseases: Dr. Frank P. Norbury, of the Board of Public Welfare Commissioners of Illinois; and Dr. Frankwood E. Williams, Associate Medical Director, National Committee for Mental Hygiene. In addition to the ordinary form of commitment by a court of record in a civil proceeding, they recommended legislation in all states authorizing temporary and emergency care, observation pending the determination of insanity, and voluntary admissions. In a general way, the legislation recommended followed the lines of the present laws of Massachusetts and New York.

CHAPTER IV

THE STATE HOSPITALS—THEIR ORGANIZATION AND FUNCTIONS

The efficiency of the hospital is very largely a reflection of its organization, administration and personnel, but the material equipment of the institution and the financial resources available are factors of no less importance. The future of a hospital is often settled for all time by the degree of judgment exercised in determining its location. The founders must be guided to a very great extent by the purposes which they hope to accomplish. In the location of a public institution of any considerable size, however, there are certain considerations which, if overlooked, will eventually lead to serious difficulties. The initial cost of the property is unfortunately a factor which cannot be disregarded. It is usually considered desirable for obvious reasons to choose a site somewhat removed from great centers of population. A sufficient acreage must be obtained to guarantee an adequate amount of land for farming and gardening on a fairly large scale. This not only insures a ready occupation for patients, but will materially reduce the cost of maintenance. A point which should never be lost sight of is the necessity of choosing a location which can be reached easily by railroads, trolley cars and motor trucks. The hospital must be readily accessible to the relatives and friends of patients. It is equally important that it should be convenient for employees; otherwise an adequate force of nurses and attendants can only be maintained with great difficulty. Above all, the hospital should be in the community which it is destined to serve. The patients should not be removed to any great distance from their homes. In numerous instances severe hardships have been inflicted upon all persons concerned owing to the fact that state institutions have been located in districts where they are not needed by the community and where they cannot be easily reached.

Every large public hospital should be in almost immediate contact with a railroad. Otherwise thousands of dollars must be expended annually for the transportation of coal, food and other necessary supplies. The fertility of the soil to be used for agricultural purposes is only second in importance to the necessity of obtaining satisfactory building sites. A practically unlimited supply of pure water is absolutely essential. The possibility of utilizing some existing system of sewerage or providing the institution with one of its own should be given serious consideration. Drainage must be provided for and sanitary surroundings obtained. There should always be opportunity for future expansion of the plant. Practically every state of any importance has at least one institution which has been seriously handicapped throughout its entire existence by an unfortunate neglect of one or more of these important considerations.

In 1917 a special commission was appointed by the Governor of New York for the purpose of preparing an intelligent and comprehensive plan for the future development of the institutions of the state. In a report presented during the following year the commission called attention to a phase of hospital construction the importance of which cannot be too strongly emphasized. [27] "Nearly all of the state hospitals suffer from the fact that as originally planned they were smaller institutions and of a different type from those that are now desired, and the additions which have been made from time to time during the past twenty-five years, in order to meet the immediate demands for increased space, have not always been made with a completed and well rounded institution in mind. The results are badly balanced institutions, lacking in efficiency and ease of administration.... In planning a hospital for the insane the ultimate maximum capacity should be decided upon even if it is not possible to build the entire institution at once. A well co-ordinated plan should then be developed, which would permit the building of various sections as appropriations become available, with the idea of finally having a complete institution, harmonious in arrangement, and so planned as to attain the most desirable classification and the maximum of efficiency and economy in administration." The classification of the population which an average state hospital should provide buildings for is shown by the commission as follows:—Reception building, six per cent; convalescents, four per cent; hospital buildings, two per cent; buildings for the infirm, eight per cent; noisy, disturbed, etc., twenty per cent; epileptics, three per cent; working patients, forty per cent; quiet, clean and appreciative chronic class, fourteen per cent; and tuberculous, three per cent. They also suggest that every hospital should have a small isolation building for the care of contagious diseases. Their recommendation as to the amount of floor space per patient in the various buildings is exceedingly interesting and no less important. "First, That single rooms should have about eighty square feet of floor space. A room seven feet by eleven or eight by ten, while large enough for one bed, a bureau and a chair, is not large enough to permit placing two beds end to end or alongside of each other. If a room measures ten feet by twelve, there is always a temptation to place two beds in it if the hospital becomes crowded, and the advantage of single rooms is wholly lost. The number of single rooms in an institution should be from fifteen per cent to twenty per cent of the population, varying with the character of the cases to be cared for. Second, Dormitories should have above fifty square feet of floor space per patient, and no dormitory should have more than fifty beds nor less than six. This, of course, applies to the wards for the chronic cases. An adequate system of ventilation throughout the hospital is presupposed. Third, The day space allotted should provide forty to fifty square feet per patient. Fourth, The dining room allowance should be from fourteen to sixteen square feet per patient, in order to permit the use of small tables and to provide adequate passages for the expeditious service of food."

In former years much time and space was devoted to a discussion of the respective merits of the congregate type of hospital construction, the so-called "Kirkbride" or block plan (although it was in use long before Kirkbride described it) and the arrangement of buildings in groups. There is no question but what an institution that is all under one roof can be administered much more economically and operated at a lower maintenance cost. Very little, if any, advantage is derived by the patient from the group scheme. In its practical operation in the state hospitals almost the only point of difference, as far as the patient is concerned, is that he must go out of doors as a rule to get to the dining room in the summer as well as in the winter, in good weather and bad. This has been responsible for much discomfort and has resulted in a great increase in the number of escapes. When buildings are arranged in groups they should be connected with a central dining room either by corridors or tunnels. Small cottages, except for special purposes, are out of the question as far as state institutions are concerned, on account of the cost involved. As a matter of fact, in the development of a large hospital all types of construction must be ultimately employed. The reception building should be separate and detached from the other parts of the hospital, as should, of course, the wards for the tuberculous cases, the contagious building, the building for convalescents, the farm cottages, etc. The noisy and violent patients certainly should be in separate buildings far enough away so that they will not disturb others. The hospital wards, for the exclusive care of bed patients, may well be detached. The larger part of the hospital population, consisting of the quiet, orderly, chronic, custodial cases, can be cared for just as well in the large buildings as in groups or cottages.

The reception building, from the standpoint of the patient, is the most important building in the hospital. It should be equipped to care for from five to ten per cent of the hospital population, depending entirely upon the location and special problems of the institution in question and the community which it serves. In any event it should include both large and small dormitories, the larger accommodating from fifteen to thirty patients, and the smaller not more than six or eight, adequate day-room space, numerous single rooms and commodious enclosed verandas. There should, of course, be ample dining room facilities as well as diet rooms to provide for those whose condition makes it necessary or advisable for them to be served in the wards. Special provision should be made for the separate care of the noisy, violent, disturbed, etc., and they should be in a part of the building which can be isolated. The suicidal cases must be given special care and separate supervision. A well equipped hydrotherapeutic department is an essential part of the reception building. Continuous bath and pack rooms are equally necessary. No less important are admission and examination rooms, a pharmacy, laboratories, rooms for the special treatment of eye, ear, nose and throat conditions, recreation rooms, a library, space for occupational therapy, provision for social service and psychological departments, etc. At least two physicians should reside in the building. It is unfortunate that reception buildings as a rule are entirely too small. They should be large enough so that the acute and recoverable cases, as well as those found on observation not to require hospital treatment, can be returned to their homes without any further contact with the hospital or the necessity of a protracted residence with the chronic and purely custodial cases.

The experience of many years has shown quite conclusively that the supervision and general direction of a hospital for mental diseases should be delegated to a medical superintendent with such clinical and administrative assistants as the nature and size of the institution may indicate. The dual system of management frequently suggested by politicians, with a layman as the executive head and a medical director subordinated to his authority, has proved to be a failure in every instance in which it has been tried. The administrative details necessary to the successful operation of a large institution are such as to require the entire time and attention not only of the superintendent but usually of an assistant superintendent. In a large hospital the activities of the medical staff should be under the immediate supervision of a specialist whose training and experience qualify him to direct the clinical and psychiatric work of others. This is a quite sufficient task to require the constant attention and undivided energies of a clinical director who has no other interests or responsibilities. In this way recent graduates with proper qualifications may be interested in entering the psychiatric field. Every state hospital, in addition to fulfilling its entire duty to the patients in its charge, should be a training school for psychiatrists, social workers, psychologists, occupational therapists and psychiatric nurses. The hospital staff, as well as providing for the services of physicians well trained in psychiatry, must include other specialists. A hospital of any size should have a staff of consulting and visiting physicians including several internists and surgeons, a gynecologist, a neurologist, a dermatologist, an ophthalmologist, a laryngologist and an otologist. These consultants should visit the hospital regularly and direct and supervise the work of the resident staff along the lines of their specialty. It is hardly necessary to suggest today that a hospital of any size without a resident dentist is one which is not properly equipped to care for its patients.

Nothing is more important in the modern hospital than the training school for nurses. It is the nursing care of the patients more than any other one thing perhaps that has made the difference between the old time asylum and the psychiatric hospital of the highest type. The state hospital training school of the present day offers its pupils a three years' course of instruction, including a year of practical experience in an affiliated general hospital. Its graduates, moreover, are trained not only in psychiatric and general nursing, as well as the care of neurological cases, but in hydrotherapy, occupational therapy, reeducational, industrial and social work. The nurse of the future who has had no psychiatric training and experience is one whose education is not complete. Every effort should be made to encourage the training schools of general hospitals to send their senior nurses to a hospital for mental diseases for a service of at least three months. The specialized care and treatment of cases suffering from tuberculosis has been neglected in many institutions. It should not be necessary to suggest that such cases have no place in a ward with other patients who have not contracted that disease, and yet in many of our large and important hospitals there are no separate buildings for that purpose. It has been shown by statistical studies that persons suffering from dementia praecox have an unusual and remarkable susceptibility to tuberculosis. Unfortunately, it has never been possible to completely segregate the epileptics in our public hospitals for mental diseases. They constitute a special problem and should receive a different diet as well as an entirely different type of treatment. Their presence in the wards with mental cases is highly detrimental to both. This is equally true of drug cases and mental defectives, and especially the so-called defective delinquents.

There are many reasons why every hospital of any consequence that is engaged in the care of mental diseases should be provided with a well trained and experienced pathologist. Examinations of urine and sputum must be made daily. Widal tests are sometimes necessary for the diagnosis of typhoid fever. Analyses of water and milk should be made at frequent intervals. Bacteriological vaccines should be available at any time. Only laboratory investigations can throw any light on the source of the frequent infections which are found in large institutions. Diphtheria is a disease which must be guarded against constantly. Lumbar punctures, Wassermann tests, the colloidal gold reaction, cell counts, etc., are daily necessities in a large hospital. We lose much information of value to us if autopsies are neglected. A definite program of pathological research work should be carried on in every hospital for mental diseases. It has been suggested frequently that the microscope has no part to play in studying the etiology of the psychoses and that they are purely functional in origin. Many of them are functional. It is nevertheless equally true that we have a definite pathological basis for the traumatic psychoses, the senile conditions, cerebral arteriosclerosis, general paresis, brain syphilis, cerebral growths, mental deficiency and many other brain and nervous diseases. The psychosis most clearly understood from the standpoint of etiology, pathology, symptomatology and diagnosis is general paresis. Our definite knowledge of that condition was obtained entirely from the laboratory. Further information may be secured in the same way. While it is true that we have not had any great amount of success as yet with the treatment of general paresis with salvarsan, the positive knowledge that the disease is of syphilitic origin should encourage us in our efforts to solve the problem of curing it. Histological, pathological, bacteriological, chemical, clinical and psychological researches must be pushed vigorously if psychiatry is to keep pace with the general progress shown by modern medicine in other fields.

In connection with this subject some reference should be made to the general neglect of statistical studies. They should be based on detailed, accurate and exhaustive clinical records, which unfortunately are not now available to the extent that they should be. It is true that in a general way some progress has been made. The studies instituted by the American Psychiatric Association will ultimately tell us quite definitely the frequency of the various psychoses, the recovery and death rates to be expected, etc. We should not be satisfied with that alone. The great wealth of material which we have in our hospitals, together with the excellent clinical and laboratory facilities at our disposal, should enable us to accomplish much more. An analysis of our case records, if properly made, would give us definite information as to the clinical aspects of the mental diseases we are dealing with. These should be made the subject of exhaustive study by the scientific institutes and other research departments conducted by the various state authorities to an extent never yet undertaken or even attempted. If it cannot be done by the states it should be instituted by the federal government.

The fact that the field of influence of our public institutions should extend far beyond the walls of the hospital is one which has received general recognition only within the last few years. Every hospital has a large number of patients still within its legal custody but who have been allowed to return temporarily to their homes or occupations while still under observation pending their final discharge. These are now, to a very limited extent, under the supervision of social workers. The hospitals have unfortunately, owing to a lack of funds, never had a sufficient number of social workers to look after them properly. The hospitals as a rule now maintain out-patient departments where those who have been allowed to go home on visit or resume their occupations are encouraged to come for assistance and advice. The public is gradually learning to take advantage of this opportunity to obtain expert advice on matters relating to mental hygiene and secure professional opinions as to the disposition and treatment of members of the family showing symptoms of incipient mental disorders. This field of influence extends even further. Clinics have been established in various locations outside of the hospitals in the larger cities in several states. In New York they are conducted by state hospital physicians in Binghamton, Brooklyn, Buffalo, Plattsburg, Dunkirk, Jamestown, Olean, Salamanca, Poughkeepsie, Peekskill, Yonkers, Mount Vernon, Mineola, Newburgh, Kingston, Rochester, Middletown, Ogdensburg, Malone, Watertown, Utica, Schenectady, Ovid, Ithaca and New York City. Physicians and social workers are in attendance at all of these places. The last published report of the New York State Hospital Commission (1919) shows that 7,203 visits were made to these clinics during the year. Paroled patients made 5,102 of these, discharged patients 265 and others who had no connection with the hospitals at all, 1,836. In addition to this the hospital social workers made 3,496 visits to paroled patients as well as four hundred and sixty-two visits to other patients for the purpose of preventing mental diseases. Situations were obtained for one hundred and sixty-seven discharged patients. An enormous amount of work was also done in history taking, etc. Numerous clinics have been established in Massachusetts by the Department of Mental Diseases. [28] During the year ending November 30, 1919, a total of 4,333 visits were reported. Of these 3,057 were first visits. The number reported by the various hospitals was as follows:—Worcester State Hospital 1,278, Taunton State Hospital 182, Northampton State Hospital 458, Danvers State Hospital 282, Westborough State Hospital 177, Grafton State Hospital 129, Gardner Colony 65, Monson State Hospital 70, Foxborough State Hospital 27, Massachusetts School for the Feebleminded 541, Boston State Hospital (Psychopathic Department) 2,112. Clinics were maintained in the following localities:—Athol, Boston, Brockton, Danvers, Fitchburg, Foxborough, Gardner, Grafton, Gloucester, Greenfield, Haverhill, Lawrence, Lynn, Malden, Medfield, Monson, New Bedford, Newburyport, Northampton, Pittsfield, Salem, Springfield, Taunton, Waverley, Westborough, Worcester and Wrentham.

This is a gratifying evidence of progress. There are indications of an awakening. The hospital treatment of mental diseases will eventually be conducted on a much higher plane and along lines more nearly comparable to those of the general hospital. A study of legislation relating to mental disease shows that efforts are being made very generally to make their treatment a medical problem rather than a legal question. It has been no easy matter to obtain treatment for mental diseases, assuming a desire on the part of the individual to take advantage of such an opportunity. A review of our legal enactments shows that as a general rule it means a formal application, properly verified, an elaborate examination by two qualified physicians, an order of commitment by the judge of a court of record, a legal notice and an opportunity for a hearing if one is demanded. Pennsylvania as early as 1883 made provision for the immediate admission of such cases as required it, pending the usual court procedure. As has been shown in another chapter, arrangements have been legalized in many states for the emergency reception of mental cases, at least for those persons who are known to be dangerous to themselves or others. Temporary care enactments have been written into the law in various communities, making it possible to keep mental cases under observation for a limited period of time. In a large number of states it is now possible for a person requesting treatment voluntarily to receive it on his own application without any other legal formalities. Perhaps the greatest advance is the custom, not so infrequent now, of sending persons held by courts under a criminal process to a hospital for observation as to their mental condition. The fact should not be lost sight of that it is still possible to find "insane" persons in jails, poorhouses and county institutions in many parts of the country. Worse than this, however, is the custom of delegating their care to police officers. Nevertheless, distinct progress has been made.

As has already been shown, a study of methods of care in this country indicates that every state has passed through several very definite preliminary stages. These may be summarized as follows:—

1.  A period of home care only. During the colonial days mental cases were cared for at home or not at all. There was nothing else that could be done for them at the time.

2.  Confinement with criminals. In cases of unusual violence, dangerous persons were confined in jails, lockups and prisons. If necessary, under certain circumstances the law in some states even authorized the use of chains.

3.  Almshouse care. There has been a time in practically every state when the poorhouse has been looked upon as the proper place for the insane.

4.  Asylum care. As a result of the agitation of Dorothea Dix and others, mental diseases were eventually given custodial care in asylums.

5.  Modern hospital care.

In 1894 Dr. S. Weir Mitchell [29] delivered the annual address at the semi-centennial meeting of the American Medico-Psychological Association in Philadelphia. It was a very painful occasion for many. His remarks may be summed up as a vigorous arraignment of the asylum methods of that day. He severely criticized the public, the state legislatures, boards of management and the hospital superintendents. His principal charge was that they were operating asylums along the lines of the past and were perfectly satisfied with what they had accomplished. He pointed out the necessity of properly qualified physicians, more scientific methods and modern treatment. "We have done with whip and chains and ill usage, and having won this noble battle have we not rested too easily content with having made the condition of the insane more comfortable?" It seems incredible that in the case records of that day he should have found no evidences "of blood counts, temperatures, reflexes, the eye-ground, color fields, all the minute examinations with which we are so unrestingly busy." One institution was unable to furnish Dr. Mitchell with a stethoscope or an ophthalmoscope! One of his criticisms was that few institutions for mental diseases had a training school for nurses or any provisions for hydrotherapy. His last words were almost a prophecy: "Fifty years hence, when we must all have been swept away, another will possibly stand in my place and tell your history, and to him and the bountiful wisdom of time I leave it to be declared whether I was right or wrong." Dr. Mitchell's description of the asylums and their methods was bitterly resented. Who is there today who would not feel that he was fully justified?

The time has come when we must again look to the future and prepare for it. The purely custodial care of mental diseases has led to a dread of asylums on the part of the public. There are unfortunately too many hospitals that are asylums in everything but name. The establishment of psychopathic hospitals and psychiatric clinics and the way in which they have been welcomed by the public is suggestive. The problems of mental diseases, as far as possible, must be approached from a general hospital point of view and the psychiatric hospital of the future must have a modern equipment, an efficient staff and adequate facilities for the employment of the latest methods. Above all, the institutions must be such that they will be looked upon by the community not merely as a place to which the insane may be sent for final disposition, but as hospitals where the development of mental diseases may be prevented and where recoveries may be reasonably expected if the patient is given early treatment. This should be the principal object of the state hospital of the future. "The concept of its beneficent ministration to the mind diseased as any physical part of the human body," as Copp[30] has pointed out, "is just appearing in shadowy outline in public consciousness. The effacement of this barrier to early treatment is slowly but steadily progressing. Its pace will be hastened if every mental hospital continues to become, as speedily as may be, the real hospital in the broadest sense, with emphasis laid upon its treatment function and subordination of its control relation within the reasonable limit of caution. The mental hospital and the general hospital are essentially alike. Mental factors predominate in the former, but are potent influences in the latter. The difference is one of degree only. All the imperative requirements of the one must be met by the other. They are supplementary agencies in curing and alleviating disease and must be, eventually, viewed in the same light and administered in the same spirit on even planes of humaneness and efficiency."

One thing should be made clear at the outset. A comprehensive and progressive program for further development means an expenditure of money. If the state hospitals are to fulfill their obligations to the community which they serve they must have more physicians. Provisions must be made for directors of clinical psychiatry, pathologists, internists, surgeons, dentists, and specialists of various kinds. Experts in hydrotherapy, massage and electrical treatments are necessary, as well as dietitians, industrial instructors, occupational teachers, specialists in reeducational work, psychologists, social workers, etc. Furthermore, they must be provided in sufficient numbers if anything is to be accomplished. As a matter of fact, no very great outlay of funds would be required in making a tremendous increase in efficiency. Although the institutional expenditures have increased enormously of late years, largely as a result of war conditions, increased costs, higher wages, etc., the amount actually invested in this humanitarian movement by the various states is not commensurate in any way with the results which are to be obtained. If we leave out of consideration everything except the saving in dollars and cents to be effected by methods which will in many instances render a protracted hospital residence unnecessary, the outlay involved would be well warranted. It should be brought to the attention of the public that very few states are expending as much as one dollar per day for the maintenance of the individual patient. Modern hospital treatment of the highest type, under these circumstances, is manifestly impossible. The time has come when we should no longer be satisfied with the purely custodial care of mental cases.

CHAPTER V

THE HOSPITAL TREATMENT OF MENTAL DISEASES

The responsibility of the hospital for the future of the patient begins with his arrival at the institution and the ultimate outcome of the case often depends entirely upon the developments of the first few weeks of his residence in the wards. A complete understanding of the patient's mental condition, the prospects of an ultimate recovery and the line of treatment to be followed can only be determined by a thorough and accurate examination on admission. This constitutes the basis for all further procedure. If satisfactory results are to be obtained this task should be delegated to a medical officer who has had an extended psychiatric experience. For purposes of completeness, as well as uniformity, a definite plan should be followed. The form used in writing the initial history and in recording the results of the routine mental and physical examinations at the Boston State Hospital are described in full in the "Medical Staff Manual" which is furnished to all assistant physicians entering the service. This has been found to be of great assistance in the training of new men along proper lines and insures a uniformity of hospital records which is indispensable. In a general way the form of examination employed by Meyer and Kirby [31] for some years has been followed. As this scheme is fairly representative of the method of procedure used by hospitals for mental diseases throughout the country it has been thought worth while to reproduce it in full.

HISTORY

Name of Physician: Date:

Name of Informant, Address, Relation to Patient:

It is often desirable to make a note on the intelligence and apparent reliability of the informant.

Residence and Citizenship of Patient:

Birthplace? Date of birth? Time in Massachusetts? If foreign born, date of arrival in U. S.? Naturalized or alien?

Family History:

It is not sufficient to ask simply the general question: Has any member of the family been insane or nervous? A great many persons will answer in the negative, whereas a detailed inquiry will often bring out a number of instances of nervous or mental troubles.

Specific inquiry must be made concerning the persons of the direct ancestral lines as follows:

(a) Paternal grandparents—nervous or mental disease?

(b) Maternal grandparents—nervous or mental disease?

(c) Father: Age, nervous or mental disease, alcoholism? If dead, age at death and cause of death?

(d) Mother: Age, nervous or mental disease, alcoholism? If dead, age at death and cause of death?

(e) Number of children in family (brothers and sisters of patient). Nervous or mental trouble in any of these besides patient? Psychopathic personality, alcoholism, criminality, etc.?

(f) Collateral branches: mention any known cases of insanity or nervous diseases in uncles, aunts or cousins.

PERSONAL HISTORY OF PATIENT

1. Early Development:

Birthplace and age, unusual incidents attending birth, retardation in talking or walking, infantile convulsions, night terrors, fits of temper, etc.—Severe illness or infectious diseases in infancy or childhood—Sequella? Frights, shocks or injuries?

2. Education, Intellectual and Moral Development:

Educational opportunities, time spent in school, interest in studies, progress, marks, behavior, truancy, etc.?

As an adult, regarded as bright, intelligent or dullminded? Well informed or ignorant? Reading, memory, judgment?

Moral responsibility, reliability, religious interests? Church affiliations?

Criminal traits, tramp life, police record?

3. Sexual Life:

Precocious interests in childhood, masturbation, abnormal practices, assaults or seduction?

Love affairs and disappointments? Age at marriage or reasons for single life. Moderate or excessive sexual desires, irregularities or prostitution.

Miscarriages, number of children, date of birth of youngest? If barren, what explanation; what effect on patient?

Frigidity, loss of power, refusal of partner, infidelity, measures to prevent conception. Treatment of partner, abuse, separation, divorce.

Perversions, abnormal methods of gratification with same or opposite sex.

In women, unusual symptoms at menstrual periods; age at menopause, nervous symptoms accompanying climacterium?

4. Diseases and Injuries:

Any previous nervous affection or symptoms, such as headaches, nervous prostration, chorea, epilepsy, hysterical attacks, etc.?

Mention severe infections diseases and sequella, if any. Inquire concerning tuberculosis, rheumatism, heart disease, nephritis, etc.

Venereal disease, syphilis and gonorrhea, full account, if possible, of how acquired, age, treatment and after affects.

Severe injuries, particularly head traumata, should be described as regards their immediate and subsequent effects.

5. Occupation:

Kinds of work undertaken, ambition, efficiency, wages, etc. Length of time in different positions, reasons for change, etc.

6. Alcoholism and Other Toxic Influences:

Intemperate, moderate or total abstainer? If intemperate, age at which drinking began, apparent cause of same, kind of beverage consumed and approximate amounts. Periodic or steady drinker? Usual reaction to alcohol?

Inquire about attacks of neuritis, delirium, hallucinatory episodes, suspicions, ideas of jealousy.

Other toxic influences: Drug habits, occupational poisons, lead, arsenic, phosphorus, mercury, etc. Illuminating gas poisoning, nicotine intoxication.

7. Mental Make-up or Type of Personality:

Very important because certain of the non-organic psychoses appear to be a further development of mental traits or tendencies early recognized as personal peculiarities or deviations from the normal. In addition to the points already covered under the preceding headings, the following important types should always be borne in mind and appropriate inquiries made:

Manic make-up: Lively, active, sociable, pushing, talkative, cheerful, optimistic; may be domineering, irritable and inclined to cruelty; sometimes not very efficient, may be noted as changeable, lacking in persistence, concentration and application. May show transient blue spells or lowering of spirits.

Depressive make-up: Gloomy, worrisome, blue natures who feel continuously inhibited or restrained and unable to make decisions; easily discouraged.

Cyclothymic make-up: Emotionally unstable, either up or down, have blue spells or are unduly cheerful and care-free.

Shut-in make-up: Shy, retiring, self-conscious, bashful, quiet, secretive, seclusive and unsociable. Lack of interest in opposite sex or definite aversion; often prudish and over-particular. Unusual religious interest frequent. Inclined to day-dreaming, show fondness for the abstract and mystical. Odd habits, hobbies or cranky pursuits are common.

Paranoid make-up: Mistrustful, suspicious, tend to misunderstand; unduly sensitive, feel discriminated against and have feelings of self-importance. (These traits may be related to shut-in tendencies.)

Other types of make-up include the psychasthenic, neurasthenic and hysterical; also the mentally retarded or undeveloped (feebleminded).

8. Previous Attacks of Mental Disorder:

Obtain dates, places where treated, apparent cause, duration of attacks and general character of symptoms.

9. Precipitating Cause of Present Psychosis:

Try to determine what occurrence or situation appeared to bring about the mental breakdown. Emotional strains, excitement, quarrels, worries, griefs, disappointments, sexual episodes, separation, deaths, childbirth, etc., financial loss, overwork, physical disease, etc.

10. Onset and Symptoms of the Psychosis:

Take as far as possible a spontaneous account beginning with date when first symptoms were noticed in the patient. In this connection particular attention should be given to changes in behavior, in mood, in manner of speech, in attitude towards others and towards work.

Appearance of suspicious, unusual interests, peculiar ideas and delusions?

Hallucinations in various fields and reaction to them?

Obtain as much as possible regarding trend of patient's ideas, topics of conversation and content of hallucinations. What did voices say? What was seen in visions?

Forgetfulness, impairment of memory, loss of orientation and clouding of sensorium.

Always inquire regarding suicidal inclinations or attempts, threats of violence, assaults or homicidal tendencies.

Compare informant's statement with those given in the commitment certificate.

What treatment was given at home? Name of physician in attendance?

Date on which patient was taken to hospital.

PHYSICAL EXAMINATION

I. GENERAL TYPE, APPEARANCE AND CONDITION:

1. Weight (with or without clothes).

2. Height and general frame.

3. Malformations (wherever possible state the origin); asymmetries of skull, face, body, spine, thorax; form of palate (low, high, asymmetrical, saddle or V-shaped, longitudinal torus).

Ears (adherent lobules, prominent anthelix, satyr-points, large, angle, asymmetry, length, etc.).

Abnormalities of hands, feet, sexual organs.

4. Color of the skin.

Color and quantity of the hair.

Color of the eyes.

General complexion.

5. General nutrition (panniculus and muscles).

6. Condition of the skin and mucous membranes; anemia, jaundice, dropsy, pallor, flushing and cyanosis; eruptions (describe in detail). Trophic disorders.

7. Scars, bruises and moles (size, location, color and origin).

8. Evidence of syphilis: scars, including those of the penis, back of tongue (patches devoid of villi and fissures) and palate; tibial crests; glands of elbow, groins and neck.

9. Signs of gout and rheumatism, goitre or nodes of the thyroid, etc.

10. Temperature, general, and various parts of the body (both sides if indicated as in hemiplegia).

II. NERVOUS SYSTEM:

1. General and subjective sensations and facial expression:

General feeling of well-being or exhaustion, general complaints, weakness, etc.

Vertigo: (constant, occasional, or occurring when the patient walks, or in the dark).

Headache: Whole head or limited space; frontal, vertical, occipital, unilateral, bilateral, deep or superficial; constant or periodic, aggravated at night or by some special cause, as with heat, with or without tenderness of head or spine to touch or pressure. Backache (general or localized).

Ovarian, infra-mammary, lumbar and vertex pains (in hysteria).

Neuralgic pains: (fifth nerve, intercostal nerves, sciatic nerve, with pain points, etc.) and muscular pains.

General or wandering pains: Pains in bones (legs) afternoon or night. Girdle pains. Precordial pains (with or without anxiety).

Zones of hyperesthesia: See below.

2. Eyes:

Expression: lids: obliquity, mongol type, lagophthalmus, protrusion of eyeballs (with or without the Graefe symptom), ptosis; spasm of palpebral muscles.

Movement of eyes, nystagmus, strabismus (divergent or convergent); position and extent of movement of the eyes; double vision (in what direction does the second object move and incline?).

Weakness of the internal rectus (in close focussing).

Conjunctiva, lachrymal canal. Scars of cornea. Arcus senilis. Reflectory iridoplegia.

Size and form of pupils. Residuals or formation of adhesion of iris. Contraction of iris on exposure to strong light; on accommodation (for near vision) and after shutting the eye.

Imperfect sight (reading print), improved or not by glasses, dimness of sight, limitation of field of vision, scotoma, hemianopsia, loss of color sense; anomalies of refraction. Condition of apparatus (cornea, lens, vitreous body). Ophthalmoscopy where indicated (for choked disc, optic atrophy, lesions of the fundus). Field of vision where indicated and possible (reversal of color fields in hysteria; scotomata).

3. Ears:

Discharge, otoscopy. Defect of hearing on one or both sides (use watch and tuning fork).

Conduction through skull. Tinnitus aurium (auscultation for actual sound, over the head).

4. Taste:

Test separately the anterior two-thirds of tongue and the posterior third with weak solution of sugar, quinine, acid, salt.

5. Smell:

Test each nostril with oil of cloves, bergamot, peppermint, wintergreen and lemon. Note the actual answers.

Parosmia. Put down the actual extent of discrimination and recognition, with explanation of defect (mental, local, or nervous).

6. Cutaneous Sensibility:

1. Tactile sensibility (use the finger-tip, feather, or pin). Compare both sides of face, arms, hands, fingers, breasts, inner and outer aspects of thighs and legs. (Never omit the ulnar side and the area outside and above the knee). Sole and dorsum of feet.

2. Localization of touch (time and space) and tickle.

3. Sensibility to pain (cautious pricks with a pin, localization in time and space), with or without the attention of the patient.

4. Sensations of heat and cold (cold water and warm water in a glass tube).

(a) Sense of position: See below.

(b) Stereognostic sense.

5. Subjective sensations (formication, feeling of needles and pins, numbness).

6. Tenderness of nerve trunks and muscles on pressure and percussion. The distribution to be noted on the drawings of the body surface.

7. Biernacki's sign (analgesia of the ulnar nerve); anesthesia of eyeball; of testicles.

7. Vasomotor and Trophic Conditions:

Salivation, seborrhea.

Cyanosis or pallor; scaliness or loss of hair; change of nails.

Blushing, dermatographia. General or localized perspiration. Temperature of paralyzed or anesthetic parts.

8. Motor Functions:

Mobility of facial muscles (laugh) (wrinkle the forehead and the nose; move the ears; show the teeth and shut the eyes); tongue; palate.

Muscles of the neck, trunk and extremities; gait.

Functions of the successive segments: In case of paresis or paralysis define the limits of the condition and indicate the results of the following tests: For loss of power: for the coordination of movement (writing, buttoning coat); for muscular sense (discriminating difference in weight; with eyes shut tell the position of the limbs and show with one side the position of the other). Balancing power: (walking along a straight line, stand upright with heels and toes together and eyes closed).

Never forget the test of equality of grip, flexor and extensor strength of elbow, knees and toes. For test of weakness of one lower extremity have both lower extremities raised and hold to fatigue limit. The weaker limb will sink a certain number of seconds before the other.

9. Reflexes:

1. Deep reflexes.

Masseteric: elbow, wrist, knee-jerk with or without Jendrassic, with clonus, or contralateral adductor reflex, knee-cap reflex; ankle clonus and Achilles tendon reflex.

2. Superficial reflexes:

Plantar (with full description as to the Babinski reflex), gluteal, cremasteric, abdominal, epigastric, scapular, corneal, palmar, sneezing.

10. Condition of the Paralyzed Muscles:

Firm and of good tone, or flaccid or deficient in tone. Rigid and contracted. Note attitude of limb and the limitation of the motion, active and passive. Atrophy, hypertrophy, electric reaction of nerve and muscle (galvanic and faradic irritability when required).

11. Fibrillary Twitching:

Its distribution.

12. Tremor:

Of what parts; rhythm, intensity, rapidity. Condition at rest during sleep; when first observed. Condition during motion, how influenced by will.

13. Organic Reflexes and Their Control:

Bladder; delay of micturition. Dribbling from empty bladder, from distended bladder. Peculiar sensations on micturition.

Sexual reflexes: Frequent involuntary contraction and evacuation.

Defecation: Is the patient conscious of evacuation?

14. Convulsions:

Distribution: Extending over head, trunk, extremities, one side, one member.

Character: Which parts first and most attacked, and how do the waves of the tonic and clonic spasm spread; what movements predominate?

Average duration, frequency, occurring night or day, or early in the morning.

Breathing; pupils; vasomotor condition; froth and bites.

Sphincters: Consciousness totally or partially lost.

Aura.

Equivalents: with or without what automatic movements.

Physical and nervous symptoms before and after attack.

Hysterical attacks.

III. THORACIC ORGANS:

Respiratory organs: Is there any difficulty of breathing, permanent or in attacks? Sleep with mouth open? Any pain on deep inspiration? Any cough or expectoration (where from). Nose and larynx. Shape of chest. Frequency of respiration. Respiratory movements. (Compare both sides in deep inspiration and expiration).

Lungs: Percussion. Auscultation. Expansion.

In case of dullness or other abnormalities: Fremitus.

Contents of pleura.

Circulatory organs: Is there any palpitation? In attacks? Due to what? Subjective sensation of arhythmia? Heart: The impulse seen and felt in what area? Relative dullness (right, upper and lateral borders). Sounds and bruits (localized). Pay special attention to muffling of the first sound, to duplication; to change of murmurs in inspiration and by position. Rhythm and accentuation.

Radial pulse: Rate, quality, on lying and sitting and standing. Special attention to variability through position or motion or exertion. If desirable, sphygmogram.

Condition of radial, brachial and temporal arteries.

Arcus senilis.

Sclerosis of veins. Varicosities.

Blood pressure.

IV. DIGESTIVE AND ABDOMINAL ORGANS:

Appetite, thirst, anorexia, nausea: Relative to quantity and quality of food. Vomiting (time and form), eructations and brashes; pain (locality, irradiation and time).

Mouth and teeth. Fetor. Fauces and pharynx. Stomach (position, etc.). Digestion. Movement of bowels. Any subjective feeling of obstacle? Form of stools. Flatulence and distensions. Hemorrhoids and fistulas.

Liver and spleen.

If indicated, examination of stomach contents.

V. URINARY APPARATUS:

Micturition: Urine, amount in 24 hours, specific gravity, color, reaction, odor, albumen, sugar and indican, etc.

Macroscopic and microscopic examinations of sediment, clouds and threads; casts, epithelia, erythrocytes, leukocytes, bacteria, threads, crystals, amorphous substances.

VI. GENITAL ORGANS:

Scars of genital organs. Menstruation: regular; profuse; scanty; accompanying symptoms.

Discharges at intervals; constant; profuse; color.

Internal examination.

In men: Frequency and character of the sexual functions. Frequency of emissions, their occasional exciting causes and correlated symptoms.

Diagnostic summary and indications for further observation and treatment.

MENTAL EXAMINATION

I. ATTITUDE AND MANNER:

General appearance of the patient, adaptation to surroundings, patient's general attitude and behavior, attention and cooperation. Note any peculiarities of conduct or demeanor (peculiarity of dress, mannerisms, grimacing, affectations, etc.). Note the manner, gestures, form of intonation, rapidity or slowness of speech, or special peculiarities. Facial and general expression (sadness, anxiety, fear, restlessness, excitement, etc.). Psychomotor retardation or excitement (violence, destructiveness), care of person (whether cleanly or untidy, etc.).

II. STREAM OF MENTAL ACTIVITY:

1. Flow of thought: Give sample of spontaneous expression or productivity, if possible. If not, give reaction to questioning. Show any disturbance of train of thought (retardation, confusion, incoherence, poverty of ideas, volubility, flight of ideas, distractibility, rhyming, desultoriness, circumstantiality, perseveration, fabrication, coinage of words, verbigeration, echolalia).

2. Abnormalities in the motor reactions: Negativism, catalepsy, echopraxia, stereotypy, automatism, mutism, etc. Show loss of initiative, lack of spontaneity or slowness in action, etc.

III. EMOTIONAL TONE:

Moods and affects. Show the presence of cheerfulness, laughter, mischievousness, excitement, exaltation, depression, anxiety, fear, perplexity, tendency to be startled, irritability, constraint, confusion, indifference or apathy. Show sensitiveness, seclusiveness, suspicion, emotional instability or suggestibility.

IV. MENTAL CONTENT:

1. Hallucinations; hearing, vision, taste, smell, sensation, etc.

2. Delusions; persecution, suspicion, infidelity, poisoning, electricity, hypnotism, mind-reading, self-accusation, grandeur, etc. Show whether permanent or transitory, systematized or unsystematized.

3. Illusions.

4. Obsessions, phobias, etc.

5. Nature of sleep, dreams, etc.

V. ORIENTATION:

Time, place and person.

VI. MEMORY AND MENTAL GRASP:

1. Recent past.

2. Remote past.

3. Retention of school knowledge.

4. Fund of general information.

5. Data of personal identification.

6. Counting and calculation.

7. Reading and writing.

VII. INSIGHT AND JUDGMENT:

The judgment concerning the situation, insight concerning physical and mental health and efficiency, financial status, plans in case of discharge? In discussion of abstract and complicated topics? To what extent is he sensitive to his own errors and to comments?

VIII. SUMMARY: Physical and mental.

IX. DIFFERENTIAL AND PROVISIONAL DIAGNOSIS.

The question as to what benefit is to be derived by the patient from a residence in a hospital for mental diseases is one which is often raised by relatives and friends. They are quite inclined to feel that if no medicines are being prescribed nothing is being done for the patient and that he could be cared for just as well at home. In considering this question it should be borne in mind that the persons under treatment in a hospital for mental diseases are there, either because they appreciate the need of hospital care themselves, or because, as a result of mental disorders, they are incapable of directing their own affairs, or are, in the eyes of the law, dangerous to themselves or others. Their property and other legal interests must be protected during their period of incompetence. Such persons are liable, if not adequately safeguarded, to enter into improper contracts or make legal conveyances that mean financial ruin to themselves as well as others. Unfortunate sexual irregularities frequently occur. Conduct disorders of various kinds are to be expected and a tendency towards criminal acts is common to several of the psychoses. It is a well-known fact that every mentally unbalanced individual is potentially dangerous, no matter how harmless he may appear. The suicide rate of the country as shown in one hundred of the largest cities has not fallen below fourteen per hundred thousand of the sane population at any time during the last twenty years. The homicide rate in thirty-one of our large cities has not dropped below eight per hundred thousand of the population since 1909. Many of these crimes were undoubtedly committed by persons who should not have been at large and who were not responsible for their acts. The most important benefit derived by the patient in the hospital is the constant personal supervision given him by experts throughout the twenty-four hours of the day, whether he is asleep or awake. He gets the benefit of regular hours of rest and exercise, a properly regulated diet adapted to his needs, a sufficient amount of fresh air, and amusement and entertainments suited to his mental condition. He receives competent medical, dental and nursing care and is provided with opportunities for occupying himself in many different ways. Reading matter is always available for those who care for it. Even religious services are held for his benefit.

The tendency of late years is to dispense with the use of drugs as far as possible and resort to other methods of accomplishing the same results. One of the most important therapeutic procedures in common use in the modern hospital for mental diseases is hydrotherapy. This should be used intelligently if any results are expected. Sending the patient to the hydriatic department where identically the same treatment is applied to all cases whether of excitement, depression, exhaustion, etc., by an attendant who has no knowledge of either medicine, psychiatry or nursing may be referred to as the application of water to the exterior, but it is not hydrotherapy. Hydriatic treatments should be prescribed by a physician who has a thorough familiarity with that particular therapeutic procedure and every patient should receive the form adapted to his individual needs. The treatment should be given by an expert hydrotherapist. The equipment should provide for hot air, electric light, vapor and saline baths, Sitz baths, circular, rain, fan, jet and Scotch douches, dry, hot and cold packs, etc. Much can be accomplished by tonic, stimulating and eliminative therapy. Sedative treatments are much used in hospitals for mental diseases. The hot air bath[32] is given at from 134 to 170 degrees Fahrenheit for from four to ten minutes, preceded by a foot bath at from 104 to 110 degrees. The patient enters the electric light and vapor bath at the room temperature, the baths being continued from four to eight minutes usually. The needle spray is given at a temperature ranging from 96 to 102 degrees, with a pressure of from twenty to thirty pounds, and continued from one to two minutes. The fan douche starts at 90 degrees, is reduced gradually with a pressure of from twenty to twenty-five pounds and is continued for from fifteen to twenty seconds. The jet douche is first used at 90 degrees and gradually reduced, with a pressure of from fifteen to twenty-five pounds, for from ten to twenty seconds. The Scotch douche is used at a temperature of 80 degrees alternating with 110, with from fifteen to thirty pounds pressure. It should be used with extreme care. The same is true of vapor douches. The saline bath contains five pounds of ordinary salt to sixty gallons of water at a temperature of 94 degrees and is continued from ten to thirty minutes. The dry pack is usually continued from twenty to forty-five minutes, although it may be used longer with safety. In the use of the hot blanket pack the inner blanket is wrung out of water at from 140 to 160 degrees and must be applied with great care. Depending on the condition of the patient, etc., the cold wet pack is given with sheets wrung out of water at a temperature ranging from 50 to 60 degrees, although lower temperature may be used. "Neutral" wet sheet packs are often used at a temperature of from 100 to 116 degrees for approximately three-quarters of an hour, as preparatory treatments. These measures should never be attempted by anyone who has not had an extended practical experience. Much can be accomplished by hydrotherapy in the alcoholic and toxic conditions, infective and exhaustive psychoses, manic excitements, involutional melancholia, hysterical and neurasthenic conditions, as well as in occasional cases of dementia praecox. Occupational therapy has been used to great advantage in connection with the hydrotherapeutic treatments.

In the reception service and in the buildings for the noisy and violent cases ample facilities should be at hand for the continuous bath treatments. Pack rooms are also desirable. There is no means at our disposal equal in any way to the efficacy of the continuous bath in controlling excitements. The patient is usually kept in the tub from five to eight hours at a temperature varying from 92 to 97 degrees and averaging 96 degrees. In some hospitals they are kept in the tubs for periods of from two to three weeks. The continuous bath is of no value unless it means what the name implies—the continuous submersion of the body in water. In dealing with very excited cases this necessitates the use of a tub cover and a hammock, although sheet coverings are often used satisfactorily. Not much is to be gained by the tub bath if the patient is to be allowed to get out and in as he pleases and only come into partial contact with the water. The continuous bath is not without drawbacks. There is danger of chilling, scalding and drowning either by accident or with suicidal intent, etc. Too much care cannot be exercised in the supervision of the bath rooms. Every tub room in the Boston State Hospital has the following rules conspicuously displayed:—

THE CONTINUOUS BATH ROOM

1. The nurse on duty in the bath room will be held personally responsible for the safety of the patients and must be thoroughly familiar with these rules. The nurse must never leave the room unless relieved by some other nurse. Eternal vigilance is necessary to prevent the chilling, scalding or drowning of the patient.

2. Patients are to be given continuous baths only on the written order of a physician.

3. Patients going to or from the bath room must wear a nightdress or bathrobe and slippers when not fully clothed.

4. Tubs not in good condition or not properly equipped must not be used.

5. Only patients under treatment are allowed in the room.

6. Toilet each patient just before the bath. Patients may be removed from the tub for toilet purposes when necessary.

7. In preparing for the bath, warm the tubs with hot water and then regulate the temperature so that a small amount of water at 96 degrees will be flowing continually.

8. Adjust the hammock to the tub and place the patient in the bath resting on the hammock. Adjust the cover to the tub, with patient's head through the neck opening unless sheets or other covers are used.

9. The temperature of the water must be taken in each tub at least every half hour. Feel the water in each tub frequently. If it seems too warm or too cold, take the temperature at once. If you find it varying from 96 degrees adjust to that temperature by adding a small amount of hot or cold water. If the temperature cannot be kept between 95 and 97 degrees, let the water out of the tub and remove the patient immediately. The physician in charge and the chief engineer should be notified at once. The bath tub key must be fastened to a special cord worn by the nurse on duty. It must be delivered to the nurse in charge of the ward when the bathroom is closed.

10. If the patient is very noisy, restless or flushed, fasten an ice poultice to the tub cover so that as the patient lies in the water the back of the head or neck will rest upon it. Replace with a fresh one before the ice is entirely melted.

Intensely excited patients may have cold compresses to the neck, changed often, for periods of 20 minutes.

Sponge all faces with cold water once an hour.

11. Patients are to be permitted to drink as much cool water (not iced) as they desire, and must be offered a drink at least once an hour.

12. The nurse must record the following: 1. The water temperature and the patient's pulse rate (temporal or facial) every half hour. 2. The amount of sleep in the bath. 3. Bowel movements. 4. Nourishment. 5. Medicine administered. 6. Hours of each patient in the tub. 7. The name of each nurse and the exact time of going on or off duty.

13. In case the patient shows symptoms of fainting or convulsions, makes any attempt at drowning, shows suicidal tendencies or becomes too violent to remain in the tub with safety, let the water out and remove the patient at once.

14. In the event of any serious accident or injury or sudden illness the patient should be removed from the tub at once and the physician notified.

15. Patients are not to be allowed to feed themselves but must always be fed by the nurse. The inlets to the bath may be closed for twenty minutes while patients are being fed.

16. During the day the warming closet must always contain one sheet and one towel for each patient in preparation for drying. It must also contain washable rugs for patients coming out of the tubs to step upon; also two blankets for emergencies.

At least one hour before the patients are to be removed from the baths the garments they are to wear after the bath must be placed in the closet.

17. The temperature of the room should be kept as nearly as possible at 76 degrees Fahrenheit. If the temperature of the room cannot be kept above 68 degrees discontinue the bathing.

When the care and treatment of mental diseases was first undertaken in our state institutions it was soon found necessary to take advantage in every way of such material assistance as could be offered by the more intelligent class of ablebodied patients in carrying on the routine work of the hospital. There were never employees enough to dispense with their services. In this way it came about that they were employed in the farms and gardens, assisted with the kitchen and housework, shared the tasks of the nurses and attendants in the wards and were busily engaged in almost every department of the hospital activities. It became apparent that occupation, undertaken originally for purely economical purposes, constituted one of the most important therapeutic agents at the disposal of the institution. The next step was the development of industries. Patients were taught by instructors to make clothing, underwear, stockings, shoes, brooms, mats, brushes, mattresses, furniture and many other useful products needed by the hospital. The end products were in every instance utilitarian. These accomplishments led to a still further development—purely occupational in character. Women were encouraged to take up such activities as rug making of all varieties, basketry, weaving, crocheting, embroidery, and needlework of every description. Men usually make towelling on looms, weave rugs, renovate mattresses, do repairing of all sorts and manufacture small articles which interest the masculine mind. Brass work, clay modelling and making jewelry of various kinds have been extensively employed.

All of these forms of employment mean, of course, that the patient must leave the ward and go to some place designed for the purpose. The others, however, have not been overlooked and occupational therapists, who devote their entire time to stimulating the interest of the patients who cannot leave the wards, on account of their mental or physical condition, in some absorbing and diverting occupation, are an important part of the personnel of every institution. No other form of treatment employed in hospitals for mental diseases has been so productive of results. It is interesting to note that the medical officers of all of the forces engaged in the recent war found that occupational therapy was of great value in cases of shell shock and war neuroses.

The highest development perhaps of occupational therapy has been in its application to strictly reeducational work in dementia praecox. This consists in a graduated and systematized reeducation of interests in apparently deteriorated individuals. The success of these efforts depends largely on the fact that very simple lines are followed at first. The patients are interested in marching to music, simple drills, calisthenics, games, basketball and purely physical exercises. Some can be induced to sort out raffia and ultimately take part in basket making. Others cut out pictures or put puzzles together. The women sometimes are willing to do plain sewing or make paper flowers. They progress by easy stages to more advanced and elaborate undertakings leading eventually to occupational work in the wards or possibly in the industrial rooms. Some of the apparently most hopeless cases have, as a result of these reeducational efforts, been able to return to their homes greatly improved. The mental improvement goes hand in hand with a resumption of their interests in their former work or some new occupational venture which may have proved attractive.

Every effort should be made to avoid the possibility of long hours of idleness in the wards. When not actively employed in occupational work, ward games, reading, etc., the patients should be taken out of doors for fresh air and exercise. This, of course, suggests the necessity and importance of attractive surroundings. Nothing can be more depressive or detrimental to the welfare of the patient than a prisonlike appearance either inside of the buildings or on the grounds. The successful operation of a hospital is dependent in no small measure on the amount of attention devoted to the preparation of food. There must be a general dietary for the active ablebodied class, one for the working patients, an entirely different one for the tuberculous and epileptic cases and a special diet for the strictly hospital wards. In an institution of any size this requires the constant supervision of several dietitians.

The advances of recent years in our knowledge as to the etiology and nature of general paresis have led to the introduction of highly specialized therapeutic methods in the treatment of that disease and of cerebro-spinal syphilis. This is an important feature of the work of our hospitals at the present time. The interest recently shown in the study of the endocrine system has already brought about a new line of therapy which is destined to receive much attention in the future.

Even the amusements necessary for the individual are given special attention in the treatment of mental diseases. This refers not only to methods of recreation and diversion in the wards day by day but includes moving picture shows, dances and various other special entertainments. Not the least important consideration is the patient's bodily health. This is often a determining factor in bringing about a restoration of mental integrity. It very often happens that there are diseases of the eye, ear, nose, throat, skin, nervous system, etc., which may require attention. Dental, surgical, gynecological and other special treatments sometimes prevent ordinarily acute and recoverable psychoses from terminating unfavorably.

In a word, the modern hospital treatment of mental diseases may be said to consist of a direct personal supervision of the mental and physical hygiene of the patient, supplemented by such specialized therapeutic procedures as may be indicated in the individual case.

CHAPTER VI

THE DEVELOPMENT OF THE PSYCHOPATHIC HOSPITAL

As has already been shown, the modern hospital treatment of mental diseases in this country is a development which represents the progress of nearly two centuries. Satisfactory as this has been in many respects, it nevertheless leaves much to be desired. All indications point to much greater accomplishments in the future. We are emerging from an era of custodial care and entering one of prevention, scientific investigation, and highly specialized treatment along entirely different lines. The interest of the public has been aroused in a subject which has heretofore been one to be avoided by common consent. Mental hygiene societies are no longer viewed with suspicion and curiosity. We are approaching a time when mental diseases can be dealt with, as other conditions are, without prejudice or unjust discrimination. Psychiatric wards promise to become integral parts of a completed medical organization. Psychopathic hospitals will soon be found in all of our great centers of population. The outlook for specialized institutes for purely research purposes, unfortunately, is not so encouraging at this time.

At last there is some evidence of progress in the teaching of psychiatry in medical schools, hospitals and clinics, although only a beginning has been made as yet. More noteworthy advances have been made in other countries. The appointment of Heinroth as a professor of psychiatry at Leipsic in 1811 promised developments which did not materialize to any great extent for many years. According to Sibbald,[33] psychiatric wards or clinics were established at Würzburg in 1833, Jena in 1848, Vienna in 1853, Berlin in 1865 and at Göttingen in 1866. Scholz made provision for observation wards in a general hospital in Bremen in 1875. Fürstner opened a psychiatric clinic at Heidelberg in 1878. Hitzig accomplished the same thing at Halle in 1891 and Siemerling at Kiel in 1901. The inception of the modern psychiatric clinic has generally been attributed to Griesinger.[34] In his preface to volume one of the "Archiv für Psychiatrie und Nervenkrankheiten" in 1868 he advocated the establishment of small hospitals in cities for the intensive treatment of acute and recoverable mental cases. He recommended a large staff of physicians and accommodation for from sixty to eighty patients, according to the needs of the community, but not to exceed one hundred and fifty under any circumstances. "In close connection with the organization of such institutions there is a crying need and a new, most important interest—the question of psychiatrical instruction. This is absolutely indispensable." This he proposed to accomplish by establishing a highly specialized clinic to be maintained largely by the teaching staff of a university. Griesinger's ideas were eventually carried out in full by Ziehen in Berlin, Sommer in Giessen and Bleuler in Zurich. Perhaps nothing has had more to do with the development of psychopathic hospitals in the United States than the well-known clinic established by Kraepelin at Munich in 1905. It occupies a three-story building accommodating one hundred patients and cares for between fifteen hundred and two thousand cases annually. Hydrotherapeutic and electrical treatments are used extensively.

A certain number of beds are reserved for research purposes. Psychological studies receive a great deal of attention. The out-patient department is a prominent feature. The teaching of psychiatry is one of the important purposes of the clinic. Kraepelin's methods have been followed rather closely here. The remarks made by Pliny Earle[35] in 1867 were almost prophetic in character. "Carbon agglomerated is charcoal, carbon crystallized is diamond. What charcoal is to the diamond, such, I believe, is the psychopathic hospital of the present compared with the psychopathic hospital of the future.... When the defects which I have mentioned shall have been thoroughly remedied by a comprehensive curriculum, a complete organization, a perfect systematization, an efficient administration, the charcoal now just ready to begin the process of crystallization will have become the diamond and the world will possess the psychopathic hospital of the future."

Psychiatric research was inaugurated in this country by the establishment of the Pathological Institute of the New York State Hospitals in New York City in 1896. Its original field of investigation was limited to the laboratory. The name was changed to "Psychiatric Institute" on the appointment of Dr. Adolf Meyer as director in 1902 and the establishment was removed to Wards Island, where it was provided with clinical facilities by the Manhattan State Hospital. It thus became the precursor of the psychiatric clinic movement in America. The observation wards for the examination and commitment of mental cases, at the Philadelphia Hospital (1890) and at Bellevue in New York City were probably the first of the kind in this country. In 1902 the first psychopathic wards connected with a general hospital were opened by the Albany Hospital. Pavilion F, as it was designated, admitted 3,132 patients during its first twelve and one-half years. These included persons awaiting examination and commitment, voluntary patients and cases of delirium, stupor, etc., transferred from other wards of the hospital. Of 1,038 cases admitted during a period of six years, only 17.6 per cent were committed to state hospitals. In a total of 1,855 cases, twenty-five per cent were found to be suffering from some form of alcoholism and twenty-six per cent from chronic mental conditions, while thirty-five per cent were cases of the acute and recoverable class. About fourteen per cent were psychoses associated with renal conditions, neurasthenia, hysteria, tuberculosis or traumatism.

The Psychopathic Hospital at the University of Michigan, the first of its kind on this continent, was established at Ann Arbor in 1906 as a direct result of the activities of Dr. William J. Herdman. The objects and purposes of the hospital were shown by the provision of the legislature for the appointment of "an experienced investigator in clinical psychiatry, who shall be placed in charge of the psychopathic ward, whose duty it shall be to conduct the clinical and pathological investigations therein; to direct the treatment of such patients as are inmates of the psychopathic ward; to guide and direct the work of clinical and pathological research in the several asylums of the state, and to instruct the students of the State University in diseases of the mind." It was thus an integral part of the hospital of the University of Michigan but fully coordinated with the state institutions. A subsequent act of the legislature changed its status to that of a "State hospital, specially equipped and administered for the care, observation and treatment of insanity and for persons who are afflicted mentally but are not insane." It also provided that a clinical pathological laboratory should be maintained for the benefit of the state hospitals. During a period of eleven years it admitted an average of 168.82 patients per year. Twenty-four per cent of these were voluntary cases. The psychoses represented were: manic-depressive insanity, twenty-four per cent; dementia praecox, seventeen per cent; paranoid conditions, two per cent; hysteria, seven per cent; psychopathic personality, two per cent; alcoholic psychoses, four per cent; morphine intoxication, one per cent; imbecility, two per cent; general paralysis, eight per cent; cerebral syphilis, one per cent; epilepsy, two per cent; senile psychoses, one per cent; cerebral arteriosclerosis, three per cent; unclassified conditions, five per cent; and not insane, two per cent. Seventy-four per cent of all the cases admitted were discharged after a residence of three months or less and eighty-two per cent after a residence of four months or less. Fourteen and eight-tenths per cent of all cases were discharged as recovered and 32.7 per cent as improved. Owing to the fact that it has only sixty-two beds at its disposal, the number of admissions is necessarily limited and cases are carefully selected.

The Psychopathic Hospital in Boston, the first institution of the kind established in this country as a department of a state hospital (The Psychopathic Department of the Boston State Hospital), was opened for the reception of patients in 1912. The purposes of the institution were very clearly shown by the Twelfth Annual Report of the Massachusetts State Board of Insanity (1910):—"The psychopathic hospital should receive all classes of mental patients for first care, examination and observation, and provide short, intensive treatment of incipient, acute and curable insanity. Its capacity should be small, not exceeding such requirement. An adequate staff of physicians, investigators and trained workers in every department should provide as high a standard of efficiency as that of the best general and special hospitals, or that in any field of medical science. Ample facilities should be available for the treatment of mental and nervous conditions, the clinical study of patients on the wards, and scientific investigation in well-equipped laboratories, with a view to prevention and cure of mental disease and addition to the knowledge of insanity and associated problems. Clinical instruction should be given to medical students, the future family physicians, who would thus be taught to recognize and treat mental disease in its earliest stages, when curative measures avail most. Such a hospital, therefore, should be accessible to medical schools, other hospitals, clinics and laboratories. It should be a center of education and training of physicians, nurses, investigators, and special workers in this and allied fields of work. Its out-patient department should afford free consultation to the poor, and such advice and medical treatment as would, with the aid of district nursing, promote the home care of mental patients. Its social workers should facilitate early discharge and after care of patients, and investigate their previous history, habits, home and working conditions and environment, heredity and other causes of insanity, and endeavor to apply corrective and preventive measures."

The building has a capacity of one hundred and ten beds. The institution may be said to differ from other psychopathic hospitals in being an establishment essentially of the temporary care type, not designed primarily either for the reception or for the care and custody of obviously committable cases, but rather for the observation and treatment of incipient mental disorders as well as psychopathic conditions not properly coming within the scope of the state hospitals. It has been as a rule the policy of the court to commit directly to other institutions for the insane all cases showing clearly the necessity of an extended hospital residence. The fact that only forty per cent of the temporary care cases have been committed shows that a preliminary period of observation before these cases are definitely disposed of is unquestionably warranted. The legal status of cases admitted may be described as follows:—1. Temporary care (not to exceed ten days); 2. Boston Police cases (Persons suffering from delirium, mania, mental confusion, delusions or hallucinations, or who come under the care or protection of the police); 3. Observation cases (for a period of thirty-five days, pending commitment); 4. Cases pending examination and hearing; 5. Emergency commitments (not more than five days); 6. Voluntary admissions; 7. Cases held under complaint or indictment.

An analysis of the work done by the Psychopathic Department from 1912 to 1920 shows a total of 14,922 admissions to the wards,—an average of 1,865 per year. Of these, 59.77 per cent were temporary care (10 day) cases, 18.56 per cent "Boston Police" cases, 1.38 per cent observation cases (thirty-five days), .50 per cent emergency cases, .61 per cent committed "pending examination and hearing," 1.02 per cent under complaint or indictment and 16.96 per cent were voluntary cases. The entire temporary care group, including all of the above classes except the voluntary and criminal cases, constituted 81.34 per cent of the admissions. It is interesting to note that the principal psychoses represented by the cases coming into the hands of the Boston Police are dementia praecox, alcoholic psychoses and mental deficiency. The number of emergency cases is very small, as is the number committed by courts for observation. The number of voluntary admissions, an average of 316 per year, constituting 16.96 per cent of the total, is very significant as showing the response to be expected from the public to an opportunity for hospital treatment without the formality of any legal procedure. Of the 14,922 cases admitted between 1912 and 1920, 38.45 per cent were subsequently committed as insane and 3,797, or 25.44 per cent, were returned to the community as not requiring further hospital care or treatment.

It has been shown that the special field covered by the Boston Psychopathic Hospital consists of temporary care cases. The principal psychoses represented by 12,252 admissions of that class were as follows: alcoholic psychoses, 9.25 per cent; dementia praecox, 25.0 per cent; senile psychoses, 3.16 per cent; general paresis, 6.06 per cent; manic-depressive psychoses, 10.14 per cent; arteriosclerosis, 3.23 per cent; epilepsy, 1.85 per cent; and without psychoses, 20.63 per cent.

This latter class (without psychosis) is looked upon by some as constituting the most important field of a psychopathic hospital. It is exceedingly interesting to note the conditions which bring such individuals to the institution. An analysis of 1,430 cases shows the principal mental types represented to be as follows:—mental deficiency, thirty-four per cent; psychopathic personality, 15.17 per cent; hysteria, neurasthenia and other psychoneuroses, 11.2 per cent; epilepsy, 8.04 per cent; alcoholism, 6.08 per cent; conduct disorders, 4.2 per cent; syphilis, 2.03 per cent; organic brain diseases, 1.68 per cent; neurosyphilis, 1.26 per cent; drug addictions, 1.4 per cent; somatic conditions, 1.19 per cent, etc.

No less interesting and instructive is a study of the voluntary cases. An analysis of 1,807 admissions of this type shows the following distribution of psychoses: alcoholic psychoses, 5.64 per cent; dementia praecox, 18.43 per cent; manic-depressive, 6.81 per cent; involution melancholia, .99 per cent; senile psychoses, 1.11 per cent; general paresis, 7.9 per cent; epilepsy, 1.05 per cent; psychoneuroses, 3.59 per cent; and without psychosis, 34.64 per cent.

The work of the out-patient service includes in a general way the study of cases referred to that department from the wards of the hospital or by its social service staff; cases referred by courts, schools, social agencies, and other institutions, as well as those sent by practicing physicians and individuals coming on their own initiative. The response on the part of the public to the facilities offered by the out-patient department is shown by the fact that 9,273 new cases were reported during a seven-year period, an average of 1,324.7 per year. Fifty-seven and six hundredths per cent of these cases were adults, 17.8 per cent were classified as adolescents, 24.25 per cent as children and .89 per cent as infants. The source of origin of these cases is exceedingly interesting. Four and eighty-seven hundredths per cent were referred to the out-patient service by courts; 4.65 per cent, by schools; 11.77 per cent, by hospitals; 9.77 per cent, by physicians; and 3.55 per cent, by individuals. Fifteen and five tenths per cent came from the wards of the Psychopathic Hospital; 9.96 per cent, from the social service department and 13.3 per cent came on their own initiative. The question as to why these cases are sent to an institution of the psychopathic hospital type can now be answered. Fourteen and fifty-two hundredths per cent were examined solely for the purpose of determining the existence of probable mental diseases and 21.88 per cent on account of suspected mental defects. Four and fifty-two hundredths per cent were sex offenders. In 8.64 per cent the only question at issue was the possibility of a psychoneurosis and in 7.97 per cent the purpose of the examination was to ascertain whether or not syphilis was present. The diagnoses show the nature of the cases encountered in an out-patient mental clinic. Four and eighteen hundredths per cent were cases of dementia praecox; 1.7 per cent of alcoholism; 2.26 per cent of alcoholic psychoses; 2.39 per cent of epilepsy; 15.72 per cent of mental deficiency; 9.0 per cent of psychoneuroses; 2.14 per cent of manic-depressive insanity; 2.09 per cent of psychopathic personality; 1.21 per cent of general paresis; and 2.94 per cent were unclassified. Two and thirty-two hundredths per cent were diagnosed as suffering from syphilis in some form and 6.27 per cent were either delinquent, defective, subnormal, retarded or distinctly feebleminded. In 3.76 per cent no disease was found, either mental or physical. The great bulk of these cases were diagnosed either as mental deficiency, psychopathic personality or epilepsy. The ultimate disposition of 2,741 cases, covering a period of two years, serves as an index of the practical operation of such a department. In 42.03 per cent of these cases no care or observation other than that of the out-patient department was required. In 1.69 per cent of the cases commitment was recommended to hospitals for mental diseases, in 7.15 per cent, to schools for the feebleminded and in .11 per cent, to penal institutions. General or psychopathic hospital care was recommended in 11.31 per cent. In 2.74 per cent of the cases a report was made to courts; in 1.61 per cent, to schools; in 18.75 per cent, to social agencies; and in 1.13 per cent, to physicians.

The functions of the social service department in a general way may be summarized as follows:—1. The after care and supervision of patients at home; 2. Advice to families of patients in regard to their cases; 3. Advice given other members of the family; 4. Financial relief; 5. Reference to other social agencies or institutions; 6. Information obtained for case histories; 7. Inquiries relative to home conditions when discharge of a patient is under consideration, etc. The routine operation of the department is well illustrated by the annual report of the Boston State Hospital for 1920. The number under social service supervision during the year was 428. Of these, 278 were new cases. Thirty-two and thirty-seven hundredths per cent were referred by the out-patient physicians; 59.71 per cent by the ward service; 7.19 per cent by other social agencies; and .73 per cent were brought by relatives or friends. The principal reasons for their reference to the social service workers were shown as follows:—For medical history, 50.36 per cent; assistance in securing employment, 9.35 per cent; financial aid, 3.6 per cent; supervision, 7.2 per cent; advice, 19.42 per cent; convalescent care, 2.87 per cent; home care, 2.87 per cent, etc. An analysis of the cases under supervision shows the principal psychoses represented to be as follows:—Arteriosclerosis, 1.8 per cent; general paresis, 4.68 per cent; alcoholic psychoses, 1.8 per cent; manic-depressive psychoses, 4.68 per cent; dementia praecox, 16.55 per cent; paranoid conditions, 4.31 per cent; psychoneuroses, 9.35 per cent; undiagnosed psychoses, 6.84 per cent; and without psychoses, 44.24 per cent. This latter group was made up mostly of psychopathic personalities (28.45 per cent) and mental deficiency (26.29 per cent). The purely social problems presenting themselves in connection with these cases were reported as follows:—Mental disease, 75.54 per cent; physical disease, 2.16 per cent; poverty, 2.88 per cent; criminality, 3.24 per cent; juvenile delinquency, 2.52 per cent; sex offenses, 2.16 per cent; alcoholism, 2.16 per cent; family dissension, 6.12 per cent; ignorance, 2.52 per cent; and bad environment, .36 per cent. In addition to this, 299 discharged soldiers and 543 out-patient cases were reported as being under the supervision of the department, as well as 532 special cases studied in connection with the investigation of syphilis.

The Psychopathic Hospital in Boston started on a new chapter in its history on December 1, 1920, at which time it was formally separated from the Boston State Hospital and became a separate institution under the direction of Dr. C. Macfie Campbell.

The Phipps Psychiatric Clinic at the Johns Hopkins Hospital in Baltimore was established in 1913. An integral part of a large general hospital and intimately associated with a medical school, it conforms rather closely to the plan of the German psychiatric clinics. A study of its activities shows that during a period of five years (ending January 31, 1918) the admission rate averaged 403.8 per year. Fourteen and three-tenths per cent of the cases were diagnosed as dementia praecox or schizophrenic reaction and 13.7 per cent conform apparently to the classification of manic-depressive psychoses. Ten and five-tenths per cent were diagnosed as neuroses or psychoneuroses; 6.1 per cent as general paresis; fifteen per cent as agitated depressions; 2.3 per cent as alcoholic psychoses; and 6.1 per cent as constitutional inferiority or constitutional psychopathic states. Seven and nine-tenths per cent were cases of anxiety neuroses, agitated depressions or anxiety psychoses; 2.3 per cent were paranoic states or reactions; 3.5 per cent were cases of alcoholism, and 3.7 per cent of drug habits. The dispensary service of the Phipps Clinic has reported an average of 565 cases per year, representing a total of 2,260.5 visits annually.

The work of Drs. Meyer, Hoch and Kirby at the Psychiatric Institute, of Dr. Barrett at the Psychopathic Hospital at the University of Michigan, of Dr. Southard at the Psychopathic Department of the Boston State Hospital, and that of Drs. Meyer and Campbell at the Phipps Psychiatric Clinic in Baltimore has brought the subject of psychopathic hospitals very prominently before the public. Various other establishments of a similar nature have been planned and some are in process of construction, or already in operation. The State Psychopathic Institute at Chicago and the Psychopathic Hospital of the University of Iowa should be mentioned in this connection. Psychopathic hospitals have been planned for New York City and one is to be built by the State of California. The legislature of Colorado has already made an appropriation of $350,000 for the establishment of an institution of this type in the city of Denver.

The work already done in this field shows quite conclusively that general hospital methods are not inconsistent with the developments of modern psychiatric progress. The large percentage of voluntary cases received and the number of persons consulting the physicians in the out-patient departments shows an unexpected demand on the part of the public for institutions of a new type. As Dr. Adolf Meyer[36] has pointed out, "Our organized system for the care of mental disorder is in many respects forbidding. It throws together all kinds of diseases, and shocks in that way the already sensitive patient who fears the worst for himself or herself. It comes at once with an outspoken declaration of insanity in the very commitment to a hospital, an expression which carries a humiliation to the patient and adds insult to injury. It often means carrying the patient off to a remote asylum which is too widely supposed to have the inscription, 'Leave hope behind all ye that enter here.' Helpfulness rather than coercion must take the place of all this." What the psychiatric clinic may be expected to accomplish in remedying this difficulty was summarized by Dr. Meyer[37] in the following words:—"It is eminently necessary to get model institutions in which medical students and physicians can learn how to deal with the many problems of the disorders of the organ of behaviour from their inceptions into all their ramifications. The clinic must do the work for at least one limited district, with its out-patient and social service and consultation department, and with its hospital wards. Everything must be done to make help in mental disorders more acceptable and convincingly helpful. More patients must learn to look to it for help and the organization must be so as to give the patient and the physician and the public at large a conception very different from that to-day associated with insanity. It is not so much the issue of more help to the curable, but the issue of more work near where the troubles begin, and work against that which breeds trouble. For this we must learn to put the chief weight on hospitals and organizations for natural districts for intensive work rather than upon the mere economy of large hospitals far away from where the troubles develop."

Southard has raised the question as to the correct designation of institutions of the psychopathic hospital type:—"A word is again necessary as to the meaning of the term 'psychopathic hospital.' For various reasons the term has become so attractive in propaganda that a comparatively large number of institutions of whatever scope have been founded or recommended to receive the term 'psychopathic hospital,' 'institute,' 'department' or 'ward.' Thus there is developing a tendency in state hospitals to denominate the receiving ward 'psychopathic.' There can be no advantage in this designation other than that of calling old ideas by new names. The idea of the receiving ward for committed cases destined to receive the ordinary probate court group of cases is not altered or improved in any manner by the designation 'psychopathic.' The best opinion seems to be that a psychopathic hospital or institute shall be an institution in which all types of mental cases, from the probate court group on the one hand up to the most dubious and difficult cases of mental disorder on the other, may be examined; but if an institution is primarily or chiefly concerned with patients of the medicolegal, committable or custodial group, to serve merely as a vestibule through which committed cases pass, such an institution has by no means the broad scope which the very general term 'psychopathic' implies. The institution is not a modified or sublimated form of receiving ward for a great district hospital."

There is, of course, no reason why the reception service of an ordinary state hospital should be spoken of as constituting a psychopathic ward. This accomplishes nothing more, perhaps, than to raise some question as to what the functions of the rest of the institution may be. The designation psychopathic hospital has been rather loosely used and is, as Southard has definitely shown, of American origin. It has been applied somewhat indiscriminately from time to time to practically every form of activity related to the care and treatment of mental diseases outside of the generally recognized state hospital field. These may be summarized as follows:—

1. Detention wards, pavilions, etc. Intended for no purpose other than the custody of the "insane" pending commitment.

2. Psychiatric wards of general hospitals—such as Pavilion F in Albany. There would appear to be no reason for the use of the word psychopathic in such cases, the term psychiatric being much more clearly applicable.

3. Institutes designed primarily for research only or for research and instruction, with or without clinical facilities.

4. Psychopathic hospitals. Independent units or integral parts of a general hospital—with or without facilities for research and instruction. Designed exclusively for mental cases, without regard to legal status, whether committed or voluntary, their detailed examination and careful observation with intensive treatment in the wards for limited periods when indicated, or their supervision and direction in out-patient departments, serving also in some instances as receiving and distributing centers supplying other institutions.

Owing to their limited size, the necessity of treating large numbers in a short space of time, and the fact that institutional care is already amply provided for in the existing state hospitals, the obvious field of the psychopathic hospital is primarily the acute and recoverable psychoses and the milder forms of mental disorder which may or may not require a residence in the wards. Only a thorough examination and a brief period of observation can determine whether or not that is needed. The question at issue is largely that of determining the necessity of a more or less indefinite committed status. These problems arise particularly in dealing with the so-called psychogenic disorders and the psychopathic states—hysteria, neurasthenia, psychasthenia, the psychoneuroses in general and the episodes which characterize the psychopathic personalities. Traumatic psychoses often come into consideration, as well as cases of cerebrospinal syphilis, toxic conditions, drug addictions, the psychoses of infection and exhaustion, and above all, of course, manic-depressive insanity and incipient forms of dementia praecox. Many of these cases require only a brief hospital treatment and are able in a short time to return to home surroundings and resume their former occupations. Often a contact with the chronic and custodial classes is not only without advantage but actually detrimental. The psychopathic hospitals thus exercise a sort of clearing house function and return to the community many patients who otherwise would be subjected to the stigma, if there is one, of a legal commitment. While questions relating to the public health cannot be analyzed in terms of dollars and cents, the saving to the state which is made by substituting a short period of supervision and treatment, for a protracted residence in an institution of the custodial class amounts to millions. In view of the difficulties encountered in obtaining adequate appropriations for the proper maintenance of the enormous population now housed in our state hospitals, this is a factor which cannot be disregarded.

CHAPTER VII

THE MENTAL HYGIENE MOVEMENT

As the result of an intimate personal knowledge of the subject, acquired during an extended hospital residence as a patient in both public and private institutions, Clifford W. Beers, having recovered his health, resumed his place in the world profoundly impressed with the feeling that the question of mental diseases as a public health problem was one which demanded immediate consideration. In no position financially to institute a campaign for the purpose of interesting the public in the importance of topics which had not been made the subject of general discussion in the past, he was confronted with the necessity of securing the cooperation and support of persons who had the means to launch such an undertaking. With this object in view he wrote his book—"A Mind That Found Itself,"[38] now in its fourth edition and destined, to use the words of the "American Journal of Insanity,"[39] "to become one of the classics of psychological literature." There is some question as to the accuracy with which Mr. Beers analyzed the experiences through which he had passed. Although there is no reason for questioning his mental condition when the book was written, his conclusions were apparently formulated when he had not as yet had sufficient time in which to readjust himself and recover his perspective. Some of his viewpoints certainly reflect a morbid coloring of which he was probably unconscious, although at the time he recognized in himself "symptoms hardly distinguishable from those which had obtained eight months earlier when it had been deemed expedient temporarily to restrict my freedom." His work was referred to as an "autopathography" by Farrar,[40] who made a detailed study of the various psychological trends manifested. These are more or less immaterial. The interesting feature of his book is the elaborate description of a common but exceedingly important psychosis written by a well educated observer with a collegiate training. Its greatest value, however, lies in the fact that he brings home to us so graphically the overwhelming importance of the personal element so often overlooked by those who are accustomed to dealing with mental cases in large numbers. "It carries the reader away from the technical dissertations, and brings him face to face with the feelings and reactions of a distorted mind, showing him the patient as a human being with a sentient soul and not as a case."[41]

That the plan which Mr. Beers had formulated for an organized mental hygiene movement had a practical application was recognized at once by Dr. Adolf Meyer,[42] who expressed the following views on the subject as early as 1907:—"It will be a difficult task to find the not very common level-headed and well-informed persons in various parts of the country capable of organizing the public conscience of the people. Neglected by physicians and dreaded by the fiscal authorities, the facts are not available today, except in fragments, mixed up with innumerable extraneous considerations; the hospitals are closed corporations, the press injudicious in inquiry and reform, and those capable of judgment unable to get the facts. The crying needs persist in the meantime. Instead of a land fund (the 12,225,000 acres bill and ideal of Dorothea Dix) we must have a permanent survey of the facts and efficient handling of what is not prevented. The experience with what remains as inevitable experiments of nature, as well as with people who should know better, must be put into practical form for communication and teaching, and brought home where it will tell; in opportunities of work and education for physicians, and cooperation between our educational forces and those who labor for physical hygiene and prophylaxis. Most of us are already under too definite obligations to meet the call for devoted work for the maintenance of an organization as well as can Mr. Beers. In my judgment, he deserves the assistance which will make it possible for others to join in the work which will be one of the greatest achievements of this country and of this century,—less sensational than the breaking of chains but more far-reaching and also more exacting in labor. A Society for Mental Hygiene with a capable and devoted and judicious agent of organization will put an end to the work of makeshift and short-sighted opportunism, and initiate work of prevention and of helping the existing hospitals to attain what they should attain, and further of adding those links which are needed to put an end to conditions almost unfit for publication. What officialism will never do alone must be helped along by an organized body of persons who have set their hearts on serious devotion to the cause. If Mr. Beers gets the means to pursue his aim he will secure the body which will guarantee proper judgment in a cause which has been a mere foster-child in the field of charitable donations merely because it seemed too difficult. Here is a man who is not afraid of the task. May he get the help to enable him to surround himself with the best wisdom of our nation!"

Encouraged by this and many other such expressions of opinion, Mr. Beers proceeded to the organization of the first state mental hygiene society, that of Connecticut, which began its activities in 1908. The National Committee for Mental Hygiene was formally organized on February 19, 1909. The first few years were devoted to raising funds and making comprehensive preparations for further activities which did not start until 1912. In the meanwhile the cooperation of many prominent philanthropists, educators, physicians, etc., was assured. The importance of this movement is illustrated by the prominence of the persons who were willing to associate themselves with an undertaking of this nature. The membership of the committee has included, in addition to many others, Professor William James, Dr. Lewellys F. Barker, Dr. Rupert Blue, Dr. George Blumer, Dr. G. Alder Blumer, Professor Russell H. Chittenden, Ex-President Charles W. Eliot, President W. H. P. Faunce, President John H. Finley, Professor Irving Fisher, Dr. Charles H. Frazier, Cardinal Gibbons, President Arthur T. Hadley, Chancellor David Starr Jordan, President Cyrus Northrop, Dr. Stewart Paton, Dr. Frederick Peterson, Professor Gifford Pinchot, President Jacob G. Sherman, Rev. Anson Phelps Stokes, Mrs. William K. Vanderbilt, Professor Henry VanDyke, Dr. William H. Welch and Ex-President Benjamin Ide Wheeler. Important financial contributions were made by Professor William James, Mr. Jacob A. Riis, Mr. Henry Phipps, Mrs. Elizabeth M. Anderson, Mrs. William K. Vanderbilt, Mrs. E. H. Harriman, Mrs. Willard Straight, the Rockefeller Foundation, etc. With the appointment of Dr. Thomas W. Salmon as Medical Director in 1912 the committee commenced active operations with its future success assured in every way.

The objects and purposes of the National Committee have been very adequately summarized in the following language used in one of its publications:—"The National Committee for Mental Hygiene and its affiliated state societies and committees are organized to work for the conservation of mental health; to help prevent nervous and mental disorders and mental defect; to help raise the standards of care and treatment for those suffering from any of these disorders or mental defect; to secure and disseminate reliable information on these subjects and also on mental factors involved in problems related to industry, education, delinquency, dependency, and the like; to aid ex-service men disabled in the war; to cooperate with the federal, state, and local agencies and with officials and with public and private agencies whose work is in any way related to that of a society or committee for mental hygiene. Though methods vary, these organizations seek to accomplish their purposes by means of education, encouraging psychiatric social service, conducting surveys, promoting legislation, and through cooperation with the many agencies whose work touches at one point or another the field of mental hygiene. When one considers the large groups of people who may be benefited by organized work in mental hygiene, the importance of the movement at once becomes apparent. Such work is not only for the mentally disordered and those suffering from mental defect, but for all those who, through mental causes, are unable so to adjust themselves to their environment as to live happy and efficient lives." The first few years of the committee's existence have demonstrated conclusively that it is the most powerful factor in promoting the welfare and interests of the insane in this country since the time of Dorothea Dix. The elaborate surveys which it has made of conditions existing in various states have resulted in beneficial legislation which had been needed for years. Surveys have been completed in California, Tennessee, Louisiana, Pennsylvania, Texas, Connecticut, Georgia, Wisconsin and South Carolina, and others are under way. It has brought about an interest in mental diseases and mental defects such as has never been manifested before in this country. Its activities during the early part of the war were responsible largely, if not entirely, for the attention given by the Army and Navy to matters relating to psychiatry. The National Committee has taken a very active part in encouraging the establishment of psychiatric clinics in connection with the state hospitals. It has been largely responsible for the psychological and psychiatric examination of defectives in penal institutions and reformatories now generally recognized as being of vital importance. Its activities have emphasized the importance of a preliminary mental examination of obviously defective individuals brought before the courts. One of its accomplishments has been the publication of a very successful quarterly magazine, "Mental Hygiene," which was undertaken in 1917 and has long since passed the experimental stage. A summary of its activities would not be complete without a reference to the valuable work which the committee has done in standardizing the reports made of institutions and compiling accurate statistics relating to mental diseases and defects which will be of inestimable value to all who are interested in the progress of psychiatry in this country.

State mental hygiene societies now exist in Alabama, California, Connecticut, the District of Columbia, Georgia, Illinois, Indiana, Iowa, Kansas, Louisiana, Maryland, Massachusetts, Maine, Mississippi, Missouri, North Carolina, Oregon, Pennsylvania, Rhode Island, Tennessee and Virginia. The committee on mental hygiene in New York is a department of the State Charities Aid Association, which has been actively interested in matters relating to the care and treatment of the insane for many years. The chief purposes of the state organizations have been officially described as follows:—[43] "To work for the conservation of mental health; for the prevention of mental diseases and mental deficiency and for improvement in the care and treatment of those suffering from nervous or mental diseases or mental deficiency." The interest of the public is stimulated by pamphlets, reports and publications of various kinds, mental hygiene exhibits of an educational nature, public lectures, mental hygiene conferences, etc. The local societies have as a definite object, moreover, the encouragement of[44] "(a) Out-patient departments for mental cases in connection with hospitals for mental diseases and general hospitals, and independent of either of these agencies, such, for instance, as dispensaries and mental hygiene clinics, (b) Systematic psychiatric as well as psychological examination of school children, (e) Provision for incipient and emergency cases in psychopathic wards of general hospitals, (d) Psychopathic hospitals in which cases of mental disorder may be treated in their earliest and most curable stages and where practical work in prevention and social service may be done, (e) Increased institutional provision for the feebleminded and epileptic." One of their most important objects is the enactment of laws in the various states which will take care of the insane pending commitment out of the hands of the poor authorities and delegate it to health officers or physicians. As Dr. William L. Russell[45] has pointed out, the mere provision of institutional care for the mental diseases of a community is not the only thing to be considered, "Unless the vital issues occasioned by mental disorders in the homes, the schools, the industries, and in social relations are intelligently grasped and dealt with by means of the state system, state institutions are liable to be looked upon as a resource which is only to be appealed to when complete separation of the patient from his usual environment has become imperative. They will still be regarded as asylums. In such case, their development is likely to be in the direction of great custodial centers, and economic and so-called business consideration in their management are likely to prevail over those dictated by science and humanity. This has happened in more than one state in which state care has been adopted under conditions of great promise. A system of state care must, to be effective, not only be adopted, but it must be planned and developed with reference to the known needs of the sufferers from mental disorder."

The Canadian National Committee for Mental Hygiene, the second national organization of this type, was established at Ottawa on April 26, 1918, largely as a result of the activities of Dr. Clarence M. Hincks of Toronto University. Arrangements were at once effected for an active participation in war work, a comprehensive study of immigration, elaborate statistical institutional studies, the establishment of a library, special investigation of delinquency and a series of lectures to be given in various parts of the Dominion. This organization has been an exceedingly active one from the beginning. The first number of the "Canadian Journal of Mental Hygiene" appeared early in 1919. A survey was made of Manitoba and its needs during the first year. The University of Toronto announced an extension course beginning April, 1919, for the special training of social workers desiring to enter the mental hygiene field. Instruction was given in psychiatry, social and economic problems, neurology, mental tests, case work, social institutions, occupational therapy, child welfare, home economics and recreation. In 1919 a mental hygiene survey was made of British Columbia. Alberta, New Brunswick and Nova Scotia have already requested similar surveys with the intention of improving the methods of caring for mental diseases and defects in those provinces. Psychiatric clinics have been established in connection with the Toronto University and the Royal Victoria Hospital in Quebec. New institutions have been planned in British Columbia and a psychopathic hospital is to be built in Toronto. In 1920 a mental hygiene committee was instituted in France[46] by the Minister of Hygiene, Assistance and Social Providence. The committee is made up of about forty members, psychiatrists, pathologists, physiologists, managers and magistrates. Dr. Dron, Senator and Mayor of Tourcoing, was elected chairman. The committee is to make a study of all questions relating to mental hygiene and psychiatry. It will consider particularly methods of coordinating the activities of various organizations already at work, the creation of new interests and spreading broadcast information on mental hygiene topics. A representative of this society has already made a visit to this country to study methods employed here. The mental hygiene movement has even reached South Africa. "Mental Hygiene"[47] has called attention to the fact that the Cape Province Society for Mental Hygiene has actively interested itself in the provisions discussed by the government for the care, education and training of the feebleminded. Two institutions are to be opened for this purpose. The Cape Province Society has already instituted a campaign for the purpose of organizing other local societies as well as a national council.

When Mr. Beers wrote his well-known book he evidently had in mind more particularly the amelioration of material conditions existing in institutions. He was looking forward to provision for the more humane and scientific care of mental diseases. This is unquestionably a consideration of vital importance and these objects have not been neglected in the practical operation of the mental hygiene organizations. Mental hygiene in its broadest sense, however, has come to mean much more than that. The foundation of the present-day conception of mental hygiene may be said to have been laid by Adolf Meyer in 1906, when he described the fundamental principles which he believed to be concerned in the development of dementia praecox. He saw in this disease a disorder of the personality due to a deterioration of mental habits, in other words, to faulty mental hygiene. While his views as to the etiology of dementia praecox have not been generally accepted, they suggested an entirely new avenue of approach to the problem of mental diseases in general. Hoch's "shut in" personality and Bleuler's "autismus" were more or less comparable hypotheses which do warrant to a certain extent the tenability of such theories as were advanced by Meyer. The same may be said of some of the mental mechanisms advocated by Freud and others of the more purely psychological school of psychiatrists. This viewpoint is reflected somewhat by White[48] in his conception of childhood as the golden period for mental hygiene. "The outstanding fact that present-day psychiatry emphasizes is that mental illness is a type of reaction of the individual to his problems of adjustment which is conditioned by two factors—the nature of those problems and the character equipment with which they are met.... Mental illnesses, defects of adjustment at the psychological level, are therefore dependent upon defects in the personality make-up, and as this personality make-up is what it is as a result of its development from infancy onward, it follows that the foundation of those defects which later issue in mental illness are to be found in the past history of that development." He protests very properly against accepting the theory that the characteristics of the personality are entirely the products of germ-plasm determiners moulded in strict accordance with the laws of heredity and therefore immutable.

Copp[49] has called attention to the fact that the dominant figure in mental hygiene activities must eventually be the family physician, who has an opportunity to see the beginnings of mental disorders when they first manifest themselves. He must, therefore, be qualified to intelligently understand such conditions and be prepared to suggest a remedy. His is inevitably the first point of contact. Mental hygienists have found a fertile and almost untouched field in our public school system. As Professor Burnham[50] suggests, "It is a grave reflection upon the schools that so many of their graduates have to be reeducated in the sanitarium or the hospital." The hygiene movement in the school population, as suggested by Professor Gesell,[51] means something more than psychological examinations and mental tests, important as they are. It means a study of the individual. He would have a new type of school nurse or social worker, one interested particularly in "the child with the night terrors, the nail biter, the over-tearful child, the over-silent child, the stammering child, the extremely indifferent child, the pervert, the infantile child, the unstable choreic, and a whole host of suffering, frustrated and unhealthily constituted growing minds, that we are barely aware of in a quantitative sense, because we do not have the agencies to bring them to our attention as problems of public hygiene and prophylaxis." They require highly specialized supervision and training if they are not to become future residents of our hospitals for mental diseases or possibly of institutions of a reformatory type. If such reforms as these are to be brought about in our public school system it is hardly necessary to suggest that the teacher herself must have very clear conceptions as to the significance and importance of mental training in youth.

If these matters are important in the public schools they must be even more serious factors in higher education. Campbell[52] has raised the question as to how far the universities "fulfill their responsibilities with regard to the mental hygiene of the community? It is doubtful whether they have attained a clear recognition of the fact that a man's mind may be richly supplied with a great variety of special information, that he may have attained a high intellectual level, and yet the man's life may be rendered inefficient because it rests upon insecure foundations. An education may enable a man to solve abstruse intellectual problems, and yet leave him so hopelessly unable to cope with a bereavement, an unsuccessful love affair, difficult marriage relations, or even simple instructive impulses that he may lose control of the direction of his life and for a period be dominated by factors which have been almost entirely repressed in his conscious life; the disorder may be so marked as to be included under the wide term "insanity." To rear a superb intellectual structure on such a foundation is surely not an ideal education; it is like building a house on the sand, or, to speak more hygienically, it is like building a superb mansion without paying any attention to the plumbing." Deplorable as it may seem that such important elements in the education of the individual have been overlooked, it is not nearly so surprising as the fact that no instruction of any consequence is given in psychiatry in the great majority of our medical schools. This is a matter which is well worthy of attention and is fortunately beginning to receive some consideration. A rather systematic campaign has been instituted by the mental hygiene organizations to bring about some instruction in these topics in our schools and universities,—a campaign which promises to be productive of results sooner or later.

An interesting phase of the mental hygiene movement is the relation which it has been shown to hold to the field of industry. It must be admitted that this is an intensely practical question. We even have a Journal of Industrial Hygiene, which has been published successfully now for some time. The mere taking of intelligence tests for industrial purposes is only an incident. The important thing, as shown by Cobb,[53] is the prevention of mental disorder by bringing about a proper relation of the worker to his environment and the elimination of causes of discontent. Beyond this there is, of course, the early treatment of individuals before the opportunity of bringing about a proper adjustment has been lost for all time. Cobb[54] suggests that, above all, the physician must "forget orthodox psychiatry (as the economist seems to be forgetting cut-and-dried political economy) and interest himself in a dynamic, individual psychology which recognizes the essentials of human nature and at last begins to analyze for us the elements of which human nature really consists, looking on each case as a human experiment in reaction to environment."

There would appear to be no limit to the possibilities of the mental hygiene movement. Perhaps no more comprehensive summary of its objects and purposes can be given at this time than that contained in a definition recently formulated by Southard:[55] "To stem the tide of syphilis, to wage war on alcohol, to counsel against marriage of defectives, to generalize the insane hospitals, to specialize the general hospitals, to weed defects out of general school classes, to open out the shut-in personality, to ventilate sex questions, to perturb and at the same time reassure the interested public—these are infinitives that belong perhaps in a rational movement for mental hygiene. They are things the past has taught us more or less clearly to do and in that sense the movement for mental hygiene is surely not much more than the elaboration of the obvious."

It may be suggested that these are functions which properly belong to the medical profession exclusively. A little reflection will, however, be sufficient to show that this is not the case. Efforts have been made for years to prevent the spread of venereal disease. Attempts were made to accomplish this by legislative enactment. That these methods of control have been ineffectual is now well known to everyone. Continental governments have for a long while been trying to regulate prostitution by police supervision and frequent medical inspections. The percentage of venereal disease has, however, not been appreciably reduced by this plan and it has been repeatedly condemned by vice commissions as a result of official investigations. It may be stated now, I think, without fear of contradiction that this is a matter which must be regulated by educating the public and which can be handled in no other way. It is a well known fact that no law can be enforced unless it meets with public approval. The will of the majority rules. When the effects of venereal disease are generally recognized there will no longer be a necessity for much legislation on the subject. This is a question of far-reaching importance. When it is recalled that twelve per cent of the cases admitted to our hospitals for mental diseases are suffering from general paresis or cerebral syphilis, the necessity of a more general understanding of these conditions is readily apparent. The percentage is much higher in the densely populated metropolitan districts.

Legislative restrictions in the past were never very successful in limiting the use of alcoholic beverages. It is true that the Eighteenth Amendment to the Constitution of the United States and the Volstead Act have had a very material effect on the number of cases of alcoholism admitted to our institutions. The influences which resulted in alcoholism, however, will find an outlet in some other direction unless they are modified in some way. This again is largely a matter of education. There never was a time in the history of the country when a knowledge of the effect of drugs of various kinds on the nervous system was as important as it is today.

The history of the movement to prevent the marriage of mental defectives is more or less familiar to all. The sentiment of the community is apparently not such at this time as to encourage the regulation of the marriage of the mentally or physically unfit by legislative restrictions. Attempts to do so have been almost a flat failure. Various states have passed laws providing for the sterilization of defective delinquents. These laws, generally speaking, have accomplished nothing because public sentiment was not behind them. All of these matters have been brought to the attention of the public by prominent speakers on numerous occasions. Frequent articles have been printed in medical journals, well-known periodicals, and even in the daily papers. Attention has been called to the mental clinics established here and there and repeated reference has been made to the fact that physicians at our state hospitals may be consulted at any time on questions pertaining to mental diseases or mental defects.

Something has been accomplished along these lines. It is unfortunate that, as a rule, people look with more or less suspicion upon institutions which are even now generally referred to as asylums. There are many who still believe that every hospital for mental diseases has its padded cells and underground dungeons. There is a rather widespread idea that the most common causes of insanity are cigarette smoking, religion and self abuse. Even in our most progressive communities it has been difficult, if not impossible, to entirely prevent the temporary detention, at least, of mental cases in jails and police stations. Very few general hospitals have psychopathic wards or any realization as to the necessity of establishing them. It is not to be denied that in many states the care of the mentally ill in our public institutions is far from being what it should be in this enlightened day. These are conditions that cannot be remedied by the medical profession without the active assistance of leaders of public sentiment. The fact that the importance of these questions is recognized by prominent educators, business men, lawyers, and other persons active in the affairs of the community, and well known to the public, will accomplish more than articles in the medical journals by physicians. This constitutes the great field of the mental hygiene organizations. They will mould public sentiment as nothing else ever has, in matters which relate to the mental health of the country. They will influence legislation where it is needed in a way that no medical society can hope to do. Above all, they can in time bring the public face to face with the fact that mental diseases should be discussed, generally understood and prevented, instead of being merely concealed and misrepresented. Possibly it would not be looking too far into the future to express the hope that an organization composed largely of laymen may be able eventually to accomplish something that the medical profession has never been able to do,—induce those who frame our laws to provide medical treatment for defective delinquents instead of merely locking them up for the protection of society. It would seem, moreover, that the time has come when the public should insist that the mental condition of persons accused of crime be made a medical rather than a legal question exclusively.

CHAPTER VIII

THE ETIOLOGY OF MENTAL DISEASES

In reviewing the history of medicine there is nothing more discouraging than the references found in literature to the views entertained from time to time relative to the cause of mental diseases. To a certain extent this may be looked upon as an index of the progress of civilization. It must be admitted that it is at the same time, nevertheless, a reflection upon the medical profession which has never shown the interest in psychiatry that the importance of the subject warrants. It has been suggested that mental diseases did not play a prominent part in ancient history, owing to the fact that the law of the survival of the fittest automatically eliminated the insane and defective. As Tuke[56] says, "They perished in the course of nature, or were stamped out of existence; many of the perverse and morally insane were stoned to death; war destroyed a large number of feeble persons; while the Romans deliberately, and in the interests of the race, threw down from the Tarpeian Rock the children who were unfit to live." The papyri of the fifteenth century before Christ show clearly that the doctrine of demoniacal possession was generally entertained at that time.

One of the earliest attempts to explain the origin of mental diseases perhaps was that of Plato. "There are two kinds of madness, one arising from human diseases, the other from an inspired deviation from established custom." Hippocrates[56] had some very clearly defined views on this subject: "As long as the brain is at rest a man enjoys his reason; but the depravement of the brain arises from phlegm and bile, either of which you may recognise in this manner: Those who are mad from phlegm are quiet, and do not cry out or make a noise, but those from bile are vociferous, malignant, and will not be quiet, but are always doing something improper. If the madness be constant, these are the causes thereof; but if terrors and fears assail, they are connected with derangement of the brain, and derangement is owing to its being heated. And it is heated by bile when it is determined to the brain along the blood-vessels running from the trunk, and fear is present until it return again to the veins and trunk, when it ceases. He is grieved and troubled when the brain is unreasonably cooled and contracted beyond its wont. It suffers this from phlegm, and from the same affection the patient becomes oblivious." An interesting theory which he evolved was that the appearance of varicose veins or hemorrhoids tended to relieve the patient's mental suffering. Celsus subscribed to the black bile doctrine. Galen's teaching was that fatuity was due to moisture, while dryness produced sagacity. In cases where the whole body contained melancholy blood he recommended venesection. Thick and black wine was to be avoided, "as from it the melancholy humour is made."[57] This he described as a condition of the blood "thickened, and more like black bile, which exhaling to the brain, causes melancholy symptoms to affect the mind." The Roman custom of appealing to the household gods, sons of the Goddess of Madness, was quite significant. Horace, in speaking of Orestes, says: "Was he not driven into frenzy by those wicked Furies, before he pierced his mother's throat with the reeking point of his sword? Nay, from the time that Orestes passed for being unsound of mind he did nothing in any way to be condemned; he never dared wound with his sword either his friend Pylades or his sister Electra; he merely abused both, calling one a Fury, the other some other name suggested by his active or bright bile." In the story of Argive, Horace says that "his relations cured him with much labour and care, by expelling the disease and the bile by doses of pure hellebore."

Little progress was made, if any, by the time of the Christian era. In fact, as Clouston[58] says, "The mental pathology of the New Testament and of the early ages of Christianity was founded on the idea that the disease was a possession of the devil, and the feeling towards this afflicted class of human beings was naturally that of repulsion and hatred, their treatment following on those lines. Neglect, the whip, chains, confinement in stone cells, starvation, unsuitable medical treatment, speedy death were the natural results."

Passing to the seventeenth century we find that Sennert, a professor in Wittenberg, believed that maniacs evacuated stones, iron, living animals, etc., things not produced in the natural body and therefore caused by demons. He also believed firmly in witchcraft. Thomas Willis (1682) is said by some to have been one of the first to suggest a relation between insanity and pathological changes in the brain. Prochaska in 1784 went so far as to say, "We think, with Haller, that no light can be thrown upon it in any other way than by a careful dissection of the brains of fatuous persons, apoplectics, and such as have other disorders of the understanding." It would appear to have been the belief of Pinel that the primary seat of disease in mental conditions was in the stomach and intestinal tract. Spreading from these centers it caused a derangement of the mind when the brain became involved. The influence of the moon, as well as the stars, was spoken of by Hippocrates and admitted by Galen. To these ideas we owe the word lunacy which appeared in the laws of England in 1320 and may be found there today.

The influence of the moon on the mind was taken quite seriously. Rush seems to have been somewhat in doubt on this subject and suggested the probability of there being a kind of sixth sense involved—a perception of the state of the air, and of light and darkness, as Pritchard expressed it, to which we are insensible in health. It was thought that the full moon, by rarefying the air, increased the amount of light, thus affecting the mind. Dr. Rush noted that during an eclipse of the sun in 1806 "there was a sudden and total silence in all the cells of the hospital." He expressed the opinion in his "Medical Inquiries and Observations" in 1812 that there are few cases in which the insane feel the influence of the moon and that the excitement resulting in such cases is to be attributed to the resulting increase of light. It is interesting to note that von Feuchtersleben, an eminent German writer, in 1845 was unwilling to go on record as stating positively that the moon was not a factor in the causation of insanity. Esquirol, in his "Maladies Mentales," in 1838, branded this belief as a superstition, but admitted that there were certain facts which could not be overlooked. "It is true that the insane are more agitated at the full moon as they are also at the dawn of day; but is it not the bright light of the moon that excites them, as that of the day every morning? Nevertheless, an opinion which has existed for ages—which has spread over all lands, and which is consecrated by popular language—demands the most careful attention of observers." Dr. Allen of the York Lunatic Asylum was very firmly of the opinion that the moon had a decided influence on the time of death in mental diseases. This question was given very serious consideration by various writers as late as 1856.

In the meanwhile efforts were being made to ascertain the cause of mental disease by means of pathological researches. Morgagni,[59] one of the earlier investigators, came to the conclusion that the more common lesions were in the pineal gland, although he found some induration of the brain and various other well-defined changes. Arnold (1782) thought that insanity was due to an increased density of the cerebral substance, particularly, according to Tuke, "of those parts of the brain by means of which the soul is connected with the body." Pinel finally concluded that pathology had practically nothing to do with the problem and Esquirol in 1838 wrote very discouragingly on the subject. Early contributions of considerable importance were made, however, by Foville, Bayle, Greding, Calmeil, Guislain, Parchappe and others. These were confined almost entirely to a study of gross or macroscopic lesions of the brain. Griesinger in 1845 reviewed the pathological changes in the nervous system quite thoroughly as far as they were known at that time. It must be admitted that the greater part of our knowledge of the pathology of mental diseases was acquired at a much later date.

A very definite indication of the progress, or lack of progress, made in determining the etiology of the psychoses is the list of causes agreed upon at the International Congress of Alienists[60] in 1867:—1. Physical causes: Artificial deformities of cranium; convulsions of infancy and dentition; cerebral congestion (primary, not that which arises in the course of certain forms of insanity); organic affections of the brain; senility; pellagra; anemia; constitutional syphilis; intermittent fever; typhoid fever; acute rheumatism; gout and chronic rheumatism; organic affections of the heart; pulmonary phthisis; intestinal worms; other acute diseases; other chronic diseases; suppression of the hemorrhoidal flux; menstrual disorders; metastasis; alcoholic drinks; abuse of tobacco; other vegetable poisons; mineral poisons (lead, mercury, coffee, etc.); insolation; intense heat; intense cold; blows and falls upon the head; other traumatic causes. 2. Moral causes: Appertain to religion; education; love (love thwarted, jealousy); family affections; fluctuations of fortune; domestic troubles; pride; disappointed ambition; fright; irritation; anger; wounded modesty; political events; nostalgia; ennui; misanthropy; sudden joy; simple imprisonment; solitary confinement.

In 1897 the New York State Commission in Lunacy in its eighth annual report published an analysis of the assigned causes of insanity given in 39,369 cases admitted from 1888 to 1896. Of these 11,999 were reported as unascertained. In the remaining 27,370 cases the important "assigned causes" in the order of their frequency were as follows: Moral causes (including domestic trouble, loss of friends, business anxieties, pecuniary difficulties, grief, fright, disappointed affections, disappointed ambition, political excitement, religious excitement, etc.) 6,608, intemperance in drink 4,763, hereditary predisposition 2,095, old age 1,723, general ill health 1,681, epilepsy 1,605, ill health following overwork 1,092, masturbation 1,063, puerperal (including childbirth and abortion) 773, traumatic 608, climacteric 502, la grippe 442, sunstroke 402, physical diseases 375, syphilis 368, cerebral diseases 312, intemperance in drink and narcotics 277, congenital defects 223, shock from injury 167, fever 147, uterine and ovarian disease 132, pregnancy 109, privation and overwork 110, etc. These are given in detail not that they throw any light on the question of etiology but that they are quite significant as to the ideas prevalent on this subject only a few years ago. In justice to the Commission in Lunacy attention should be called to the fact that this tabulation does not purport to give actual causes but those officially "assigned" by the examining authorities or others interested. Clouston[61] in 1911, in making a statistical study of 11,346 cases admitted to the Royal Edinburgh Mental Hospital in the course of thirty-five years, enumerated a long list of causes shown in the hospital reports. It is interesting to note that they include nursing, disordered menstruation, self abuse, sexual excess, surgical operations, bronchitis, prostatic disease, lupus, commencing menstruation, transference of morbid action from other organs to the brain, excessive tobacco smoking, chloroform inhalation, excessive number of children, religious excitement, marriage, changes of residence, sedentary habits, political excitement, bad temper, the Queen's Jubilee, etc. As he says, "No other disease has anything like this list of 107 causes. A black and terrible roll it is. Poor humanity has much to contend with to keep sound in mind." Analyzing these statistical findings, Clouston concludes that "bad heredity, congenital defects, and previous attacks are the great predisposing causes, and that alcohol, the crises of life, epilepsy, the various forms of brain poisons and the gross brain and nervous diseases constitute the mass of exciting causes. Together they account for over seventy per cent of the defects and diseases of the mind that come under my observation."

A reference to the statistical reports of the past as published by the hospitals of this and other countries will show nothing radically different until within the last few years. It will readily be observed that fundamentals were almost entirely lost sight of and nonessentials overemphasized. Masturbation, for instance, is often a symptom of dementia praecox and other forms of mental disease, but is not now looked upon as an important etiological factor. The immediate cause, so-called, is usually a mere incident, often not without some significance, but bearing little if any definite relation to the fundamental underlying condition responsible for a mental breakdown. The studies of Meyer, Hoch, Kraepelin, Freud, Jung, Bleuler and many others have shown that in manic-depressive insanity, dementia praecox and various other psychoses we are dealing with very definite constitutional conditions, morbid temperaments, personality defects, etc., which are responsible for the maladjustments leading to the development of psychoses. Financial reverses, domestic difficulties, the death of near relatives, the ordinary hardships and disappointments of life, even ill health, do not as a rule mean the development of a psychosis in the normal, properly balanced individual. In the constitutionally predisposed, the love affair, the loss of a position, the upsetting factor, whatever it may be, is merely the "straw that breaks the camel's back" and is nothing more than an accident of fate, a pure coincidence. Any other comparatively trifling occurrence out of the ordinary, any difficult situation which the makeup of the individual could not adequately meet and react to, would have accomplished the same result. There are, however, of course, certain psychic traumas to which these inadequate personalities are particularly susceptible.

Experience has shown that without any doubt there are conditions for which defective heredity is largely responsible. It is often difficult to determine the actual rôle which this plays in a given case. Efforts have been made to reduce the study of these factors to a definite scientific basis. In 1865 Gregor Mendel,[62] Abbot of Brünn, published an account of a series of experiments made by him with the common pea (pisum sativum) which was destined to revolutionize our views on the subject of heredity. On crossing a tall with a dwarf plant, tall hybrids resulted with no intermediate forms. This inheritance is said to be due to the presence of a definite "determiner" in the germ plasm. All of his hybrids being of the tall variety, he designated that character as the "dominant," the dwarf being spoken of as the "recessive." On the fertilization of these hybrids he obtained another generation, which averages three tall plants to one dwarf. Further investigation showed that the dwarfs always bred true, as did about one out of three of the tall varieties, the remaining two behaving as did the original hybrids and giving three talls to one dwarf. He therefore observed that he was dealing with three varieties of inheritance, the dwarfs which bred true, the talls which bred true and the talls with a fixed proportion of talls and dwarfs. The phenomenon as noted by Mendel is not, however, universal in its application. Curiously enough no attention was given to Mendel's experiments until eighteen years after his death, when his work was rediscovered by de Vries, Correns and Tschermak in 1900.

Davenport[63] has shown that there are six possible matings of germ cells as illustrated by the pigment of the eye:—1. Both parents, pigmented iris (brown eyes) and duplex—all offspring with pigmented iris and duplex; 2. Both parents brown-eyed, one duplex, one simplex—all children brown-eyed, but half simplex; 3. One parent brown-eyed and duplex, the other blue-eyed—all children brown-eyed and simplex; 4. Both parents brown-eyed and simplex—one-fourth of the children brown-eyed and duplex, one-half brown-eyed and simplex, and one-fourth blue-eyed; 5. One parent brown-eyed and simplex, and the other blue-eyed—one-half the children brown-eyed and simplex, the other half blue-eyed; 6. Both parents blue-eyed—all children blue-eyed. It should be explained that a duplex origin means the inheritance of a character from both parents and simplex from only one. The principles of the Mendelian laws of heredity have been applied to a study of the color of the eyes and skin, the color and form of the hair, the stature, body weight and many other family traits such as musical knowledge, ability along artistic and literary lines, mechanical skill, etc. They have also been applied to the study of various diseases, such as Huntington's chorea, hereditary ataxia, deaf-mutism, feeblemindedness, epilepsy and insanity, etc.

Rosanoff[64] and Orr have suggested the following hypothesis relative to the transmission of the neuropathic constitution as based on the Mendelian theory:—1. Both parents being neuropathic, all children will be neuropathic; 2. One parent being normal but with the neuropathic taint from one grandparent, and the other parent being neuropathic, half the children will be normal but capable of transmitting the neuropathic constitution to their progeny, and half will themselves be neuropathic; 3. One parent being normal and of pure normal ancestry, and the other parent being neuropathic, all the children will be normal but capable of transmitting the neuropathic makeup to their progeny; 4. Both parents being normal, but each with the neuropathic taint from one grandparent, one-fourth of the children will be normal and not capable of transmitting the neuropathic makeup to their progeny, one-half will be normal but capable of transmitting the neuropathic makeup, and the remaining one-fourth will be neuropathic; 5. Both parents being normal, one of pure normal ancestry and the other with the neuropathic taint from one grandparent, all the children will be normal; half of them will be capable and half not capable of transmitting the neuropathic makeup to their progeny; 6. Both parents being normal and of pure normal ancestry, all the children will be normal and not capable of transmitting the neuropathic makeup to their progeny.

Just how much importance is to be attached to these theories is a difficult matter to determine. A study of a considerable number of families by Rosanoff[65] would appear to be very suggestive, although his conclusions must be looked upon as fairly conservative:—"On the whole, taking into consideration the limited amount of material as well as the various sources of possible error, the correspondence between the actual findings and theoretical expectation, as shown in the table, must be regarded as strikingly close." On the other hand, as White[66] says, "In dealing with the subject of heredity, however, it must not be forgotten that our ideas are of necessity largely founded upon hypotheses, as biological science has not yet unfolded a sufficient number of facts to make it possible to tell just how much, in any individual case, must be attributed to the inherent qualities of the "germ plasm" and just how much to the influences of environment. The view which is pretty generally admitted among biologists at present is that there is little warrant for the belief in the Lamarckian hypothesis of the inheritance of acquired characters."

The New York statistical tables on heredity were discontinued in 1907, at which time a total of 104,013 cases had been reported. In 31,290 of these no information was available, leaving a total of 72,622, excluding the not insane. A history of insanity was shown in the paternal branch of the family in 8.6 per cent of the ascertained cases, in the maternal branch in 10.1 per cent, in both paternal and maternal in 1.7 per cent, and in collateral branches in eleven per cent,—a total of 31.4 per cent in which some form of heredity was reported. These statistics relate only to insanity in the family history. There were so many sources of inaccuracy that it was not thought worth while to continue these studies after 1907. Comparisons between the heredity of mental cases and that of normal individuals have been rather surprising. Koller, for instance, as quoted by Kraepelin,[67] in a comparison of 370 healthy with a similar number of insane individuals found a history of psychopathic defects in the immediate families of fifty-nine per cent of the former and 76.8 per cent of the latter. Diem[68] in 1905 made an analysis of the family history of 1193 healthy individuals. This was compared with 1850 mental cases. Neuropathic heredity of some kind was found in 78.2 per cent of the mental cases and 66.9 per cent of the healthy individuals. There was, however, a history of mental diseases in the families of 38.3 per cent of the insane patients as compared with 7.1 per cent of the normal individuals. Somewhat different results were noted in a study of the parents. There was a paternal or maternal history of insanity in 18.1 per cent of the families of the mental cases as compared with 2.2 per cent in the cases of the normal individuals. In the direct parentage, Koller found mental diseases in 57.3 per cent of the families of the insane as compared with 28 per cent in the case of normal individuals. Kraepelin states that the influence of the father is greater in heredity than is that of the mother. The father, furthermore, usually transmits to the son while the mother influences the daughter more.

Heredity varies with the psychoses, having its greatest influence in the transmission of manic-depressive attacks, epileptic and hysterical conditions, nervousness, compulsive and impulsive insanity, sexual perversions and morbid personalities (Kraepelin). As the result of a study of two thousand cases, Pilcz[69] (1907) found that in alcoholism heredity was most likely to manifest itself in the form of alcoholism, epilepsy and imbecility or manic-depressive psychoses. In the progenitors of epileptics he found epilepsy and migraine. Apoplectics showed a family history of paralysis, arteriosclerosis, senile dementia or melancholia. Senile dementia preceded paralysis, arteriosclerosis, feeblemindedness and dementia praecox. Tabes and paralysis apparently frequently precede paralysis and dementia praecox. The various forms of alcoholic psychoses furthermore show a tendency to repeat themselves in the offspring of alcoholics. Similar heredity is said to be the general rule in manic-depressive psychoses, epilepsy and alcoholism, and to a less extent in arteriosclerosis. Heredity, in so far as it is related to mental diseases, may be said to be largely a question of the transmission of a neuropathic or psychopathic constitution or predisposition. Various psychoses are now held to be the direct result of constitutional causes or hereditary influences. This is probably true of manic-depressive insanity, Huntington's chorea, involution melancholia, dementia praecox, paranoia and paranoid conditions, epileptic psychoses, the psychoneuroses and neuroses, psychopathic personality and mental deficiency. It is true that some of these conditions develop as the immediate results of certain predisposing factors and that in frequent instances no evidences of heredity can be found. It is also true that various authorities maintain that a predisposition to the development of certain psychoses may be acquired. If, however, we assume that the above mentioned psychoses are constitutional in their nature and due primarily to heredity, it may be definitely stated that, based on recent statistical studies, hereditary influences account for from fifty-five to sixty per cent of the mental cases admitted to our institutions. It may be pointed out, as an objection to this suggestion, that although manic-depressive psychoses often develop in an emotionally unstable or cyclothymic personality and dementia praecox is associated with certain peculiarities of makeup, not all of these cases show clear evidences of constitutional origins. This is unquestionably true. It is equally true, on the other hand, that heredity is also probably very often a factor in the production of the senile and arteriosclerotic conditions, various nervous diseases, alcoholism and drug habits.

When we leave the subject of heredity we are on much more certain ground. There is no question whatever as to the rôle played by traumatism, senility, arteriosclerosis, syphilis, brain and nervous diseases, alcoholism, exogenous toxins, epilepsy, pellagra and somatic diseases in the causation of mental disorders. In an analysis of 4,079 cases examined at the Munich Clinic, Kraepelin[70] found the following factors involved:—1. Physical diseases, infections and gross brain lesions, 1.3 per cent; 2. Syphilis and metasyphilis, 10.3 per cent (general paresis 9.4 per cent); 3. Toxins—alcohol, morphine, cocaine, etc., 22.8 per cent (alcoholic psychoses 22.4 per cent); 4. Traumatic neuroses and prison psychoses, 2.5 per cent; 5. The presenile and senile psychoses, arteriosclerosis, etc., 5.6 per cent; 6. Dementia praecox, epilepsy, idiocy and imbecility, 27.2 per cent; 7. Psychopathic and hysterical states, and manic-depressive insanity, 30.3 per cent. Conditions existing in our hospitals and clinics are somewhat different. As the result of a study of over seventy thousand first admissions to forty-eight hospitals in sixteen different states we are now in a position to speak quite definitely as to the frequency of the conditions above referred to as etiological factors. Traumatic psychoses quite uniformly represent a little less than one-half of one per cent of the admissions to our institutions. The senile psychoses constitute approximately ten per cent and arteriosclerosis five per cent of the total. General paresis averages about twelve per cent in the New York hospitals and from seven to ten per cent in the other states. Cerebral syphilis amounts to a little less than one per cent of the cases. It should be said that in the large cities the rate for syphilis is, in some instances at least, twice as high as that given. Brain tumor, with all other brain and nervous diseases, only constitutes about one and one-half per cent of our admissions. Alcoholism, which has been responsible for as high as ten per cent of all admissions, from time to time, has been decreasing gradually during the last five years and in New York in 1920 constituted less than two per cent. Epileptic psychoses in our state hospitals amount to from one to two and one-half per cent of the total. As a general rule pellagra is not a factor of any consequence, amounting to less than one-half of one per cent of the admissions. In a few of the southern hospitals large numbers of pellagra are encountered. The psychoses accompanying somatic diseases are represented by from three to four per cent of the whole number. In addition to this, there is still a considerable number of cases reported from the hospitals as being caused by psychic trauma of various kinds. These represent the acute psychoses usually resulting from mental and emotional upsets but with nothing which definitely points to constitutional disorders or hereditary influences.

If we speak of predisposing causes, some reference should be made to the influence of the physiological landmarks which are of so much significance in the life of the individual in more ways than one—puberty, adolescence, the climacterium and the senium. A no less noteworthy factor in the female sex is the puerperium. These periods of life are of tremendous importance in the development of the psychoses. It is customary to speak of age, sex, race, civil condition, degree of education, climate, civilization, etc., as factors in the production of mental diseases. Not much is to be said on these questions, nor are they closely related to the subject. On January 1, 1920, there were 232,680 patients in the hospitals for mental diseases in the United States. Fifty-two per cent of these were men and forty-eight per cent women. This represents about the difference that has been shown for many years. The reduction in alcoholic psychoses may affect this ultimately. The striking exceptions to this ratio are Massachusetts and New York, where the number of women has slightly exceeded the men for a number of years. The admission rate for men is, however, slightly higher than that for women in both of those states. Less than one-half of one per cent of the patients admitted to the New York hospitals are under fifteen years of age. In that state approximately five per cent have been between fifteen and nineteen years old. In Massachusetts the percentage of persons admitted who were under twenty years of age has averaged 8.5 quite consistently for some time. The admission rate, for twenty to twenty-five, twenty-five to thirty, thirty to thirty-five and thirty-five to forty years of age in Massachusetts and New York has averaged from ten to eleven per cent for each of those periods for several years. From the age of forty to fifty the admission rate is about 8.5 per cent, and from fifty to sixty between five and six per cent. Nine per cent of the admissions in Massachusetts and eight per cent in New York are seventy years of age or over. The statistics on race, birthplace and the psychoses of the various races are shown in detail in the chapter on Immigration. The admission rate in New York is almost exactly the same for the married and the unmarried, the former constituting about thirty-nine per cent and the latter forty. In Massachusetts the single first admissions amount to about forty-three per cent and the married approximately forty per cent. Throughout the country generally the unmarried slightly predominate. The percentage of widowed in Massachusetts and New York varies from thirteen to fourteen per cent. The divorced constitute only about one per cent of all admissions. As to education, it may be said that about nine per cent of all first admissions are illiterate, from fifteen to twenty per cent can read and write only, about sixty per cent have had a high school and two per cent a college education. A study of economic conditions shows that from fifteen to seventeen per cent are dependent, from sixty to seventy per cent are rated as marginal, and from eleven to thirteen per cent as being in comfortable circumstances. In Massachusetts and New York about eighty-five per cent of the admissions come from a city environment and from twelve to fifteen per cent from rural communities. It is interesting to note that in 1919 eighteen per cent of the admissions in Massachusetts and New York were reported as being intemperate in their habits, with over fifty per cent abstinent.

In conclusion, it may be said that the important etiological factors in the production of mental disease are heredity, senility, syphilis, arteriosclerosis, somatic diseases, mental deficiency, epilepsy, diseases of the brain and nervous system, alcoholism, drugs, traumatism and mental stress and shocks of various kinds. It is hardly necessary to add that our information on this subject is far from complete.