Transcriber's Note:
Punctuation and possible typographical errors have been changed.
Archaic and variable spelling have been preserved.
Footnotes appear at the end of the text, after the Index.
Cover image 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
[Illustration]
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 _Percentage_
100,000_
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 _Contributory
Cause_ 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.
CHAPTER IX
IMMIGRATION AND MENTAL DISEASES
A history of the development of our western civilization is very
largely a study of the process of assimilation of the various racial
elements representing a new population. While it must be conceded
that we are indebted to European countries for much that has been
contributory to the welfare and success of American institutions, it
is equally true that the tremendous increase in mental diseases and
defects here is to be attributed in no small degree to immigration.
This constitutes a problem of social and economic importance which is
worthy of serious consideration. Perhaps no better evidence of this
fact can be offered than a study of such statistics as are available
relating to the thirty-three millions of people coming to the United
States from other countries during the last century. This would seem
to be particularly indicated at this time, in view of the fact that
the conclusion of the war has brought about the necessity of a new
adjustment of our relations with other countries.
Immigration to the United States has varied greatly from time to time.
It is a well known fact that the founders of our government were
practically all of English, Dutch, German or Scotch-Irish extraction.
Unfortunately no information of any consequence is available regarding
the aliens entering the country prior to 1820, when their study
was first undertaken by the federal authorities. As far as can be
determined, during the ensuing ten years about 128,000 were admitted
at the various ports of entry. The history of immigration since that
time has been determined very largely by existing conditions in other
countries. The famines and political disturbances in Ireland between
1840 and 1850 were the occasion of a large influx, concededly of a
highly desirable type. The nature of the tide of incoming immigrants
was changed by the revolutionary troubles in Germany during the decade
following 1848. There was a decrease for a time during the civil war.
This was soon followed by a considerable increase which continued
quite consistently until the outbreak of the world war. There would at
this time seem to be every reason for thinking that an unprecedented
invasion can be expected during the next twenty-five years as a result
of conditions prevailing abroad unless some restrictions are imposed.
In 1850 and 1860 the number of Irish people in the United States
exceeded the German born. The 1890 census showed a predominance of the
latter race and they have exceeded the Irish element in the population
for some time. Nearly a million Germans were admitted between 1880 and
1885. Since 1890, however, the number of Irish and Germans entering
have both decreased markedly. After the Spanish-American war a great
increase in immigration was noted and the rate of admission per year
reached a million in 1905, but the source of supply had entirely
changed.
Salmon[71] has shown that in spite of the fact that in 1882 only 12.9
per cent of all incoming aliens admitted were from those countries,
eighty-one per cent of all immigration from Europe in 1907 came from
Austria-Hungary, Bulgaria, Greece, Italy, Montenegro, Poland, Portugal,
Roumania, Russia, Servia, Syria and Turkey. In 1882, 87.1 per cent of
those admitted came from England, Germany, Holland, Norway, Sweden,
Switzerland and Belgium. The races represented by the new tide of
immigration, according to Salmon, were Slavic, thirty per cent,
Italian, twenty-six per cent, and Hebrew, fifteen per cent, the
remainder being made up of various other miscellaneous elements. This
change is shown by the fact that the immigration from Austria-Hungary,
which amounted to only 711,926 from 1820 to 1896, increased to
2,303,323 during the first decade of the present century. Five hundred
and thirty-four thousand three hundred and thirty-six were admitted
from Russia between 1820 and 1896 and 1,756,027 between 1900 and 1911.
The Italian immigration, which amounted to 676,826 between 1820 and
1896, increased to 2,228,759 between 1901 and 1911 (Salmon[72]). The
numerical status of immigration by decades is shown in the following
table:
From 1831 to 1840 528,721
1841 to 1850 1,604,805
1851 to 1860 2,648,912
1861 to 1870 2,369,878
1871 to 1880 2,812,191
1881 to 1890 5,246,613
1891 to 1900 3,687,564
1901 to 1910 8,795,386
1911 to 1920 6,747,381
A study made by the United States Immigration Commission some years ago
showed that of 68,942 foreign born males employed in various mining
and manufacturing industries, and who had been in the United States
for five years or more, only 33.3 per cent had obtained naturalization
papers. Of 246,673 of this same class representing non-English speaking
races, only 53.2 per cent had learned the language of this country to
any extent. A report made by the Commissioner General of Immigration
showed that of 719,906 immigrants over fourteen years of age and
admitted from 1899 to 1909, 26.6 per cent could neither read nor write
and 29.8 per cent had no occupation. The following table shows the
percentage of foreign born in the population of the United States from
time to time as stated in official reports:—
1850 9.7 per cent
1860 13.3 " "
1870 14.4 " "
1880 13.3 " "
1890 14.7 " "
1900 13.6 " "
1910 14.7 " "
1920 12.96 " " (white only)
The foreign born population naturally varies more or less in different
parts of the country. In New York state it was twenty-six per cent in
1870, 23.8 in 1880, 26.2 in 1890, 26.1 in 1900, 29.9 in 1910, and 26.8
per cent in 1920. In Massachusetts it was 30.6 per cent in 1895, 30.2
in 1900, 30.3 in 1905, 31.5 in 1910, 31.2 in 1915, and 28 per cent in
1920.
We have little authentic information relative to the institution
population prior to 1903. The United States Census Bureau in its
report of 1904 on the insane in hospitals shows that in 1903 there
were 140,312 patients, of which number 47,078, or 34.3 per cent, were
of foreign birth. The percentage of foreign born in state hospitals in
various parts of the country at that time were as follows:—
New York 46.9 per cent
Massachusetts 42.0 " "
New Jersey 39.5 " "
Pennsylvania 30.9 " "
District of Columbia 36.7 " "
Connecticut 35.4 " "
Michigan 43.5 " "
Illinois 41.6 " "
Wisconsin 50.9 " "
Minnesota 63.5 " "
North Dakota 68.4 " "
South Dakota 49.9 " "
Montana 57.8 " "
Nevada 63.1 " "
In 1912 an investigation was made of the foreign born in the New York
state hospitals. As a result of the census taken, it was found that
of 31,624 patients, 13,728, or 43.4 per cent, were foreign born. Of
this number 4,487 had been naturalized and 9,241, or 29.2 per cent
of the total hospital population were aliens. At the Manhattan State
Hospital in New York City, out of a total of 4,570 patients 2,526 were
foreign born and only 708 had been naturalized. The Central Islip State
Hospital at the same time had 4,438 patients. Of this number 2,803
were foreign born and only 891 were naturalized citizens. Thus, at the
Manhattan State Hospital 39.8 per cent and at the Central Islip State
Hospital 43.1 per cent of the patients were aliens. It was shown that
the average hospital residence of the insane in the state was 9.85
years. Based on the maintenance expenditures for 1912 it was estimated
that the cost to New York for caring for its 9,241 aliens in the state
hospitals was $2,579,902.78 per year, and for their entire hospital
residence, over twenty-five million dollars.[73] Of the first admissions
to the New York hospitals for the eight years beginning October 1,
1904, and ending September 30, 1910, 46.2 per cent were foreign born.
The citizenship of the first admissions for this same period is shown
by the following table:—
_Year_ _Aliens_
1905 28.4 per cent
1906 31.4 " "
1907 32.6 " "
1908 33.9 " "
1909 33.4 " "
1910 33.0 " "
1911 32.9 " "
1912 29.3 " "
It was also shown that 14.7 per cent of the aliens admitted in 1905
had been in the United States less than three years, in 1906, 18.7, in
1907, 21.8, in 1908, 20.1, in 1909, 18.1, in 1910, 15.5, in 1911, 14.9
and in 1912, 18.1 per cent. The birthplace and citizenship of first
admissions to the New York state hospitals since 1912 is shown in the
following table:—
_Year_ _Foreign born_ _Aliens_
1913 47.0 per cent 22.5 per cent
1914 46.7 " " 25.2 " "
1915 47.0 " " 26.4 " "
1916 48.5 " " 27.8 " "
1917 47.8 " " 27.1 " "
1918 46.4 " " 27.5 " "
1919 46.8 " " 26.4 " "
1920 45.3 " " 24.8 " "
The percentage of the foreign born as shown by the first admissions to
the Massachusetts state hospitals during the last eleven years was as
follows:—
1910 44.88 per cent
1911 44.65 " "
1912 44.40 " "
1913 45.30 " "
1914 45.75 " "
1915 45.59 " "
1916 43.87 " "
1917 43.40 " "
1918 43.07 " "
1919 43.38 " "
1920 42.18 " "
The percentage of aliens as shown by the first admissions to
Massachusetts hospitals was 26.40 per cent in 1918, 27.54 in 1919 and
22.73 per cent in 1920.
Studies of the population of the New York state hospitals show that the
aliens have for a period of several years constituted nearly thirty per
cent of the entire number. The influence which immigration may have
had in determining the relative frequency of various psychoses in our
institutions is an exceedingly interesting question. In speaking of the
susceptibility of certain races to special types of disease, Salmon[74]
says, "This is particularly true of mental diseases, for if racial
characteristics profoundly affect political, social and religious
ideals we must look for a similar influence upon the individual makeup
which so largely determines trends in mental disease. All those who are
familiar with mental diseases among the Japanese in California testify
to the remarkable tendency to suicide in that race, not only in
depressed conditions but in conditions in which suicidal tendencies, in
other races, are not frequent. This is in accordance with the general
attitude of the Japanese toward self-destruction. The strong tendency
to delusional trends of a persecutory nature in West Indian negroes,
the frequency with which we find hidden sexual complexes among the
Hebrews and the remarkable prevalence of mutism among Poles, even
in psychoses in which mutism is not a common symptom, are familiar
examples of the influence of racial traits upon mental diseases."
As the result of a special study of this subject Salmon has reached
the following conclusions: "1. The psychoses more prevalent among
Hebrews than in the native stock are manic depressive psychosis,
dementia praecox, the psychoneuroses, and psychoses associated with
constitutional inferiority. 2. The absence of alcoholic psychoses
among Hebrews is the most striking clinical fact in connection with
immigration. In 1909 there were but 3 patients with alcoholic psychoses
in 448 Hebrews admitted to all the New York state hospitals. 3. The
very high prevalence of general paresis among Italians bears a direct
relation to the high prevalence of venereal diseases among Italians in
New York.... 4. Italians show a freedom from alcoholic psychoses second
only to Hebrews. 5. Italians exceed the native born in the prevalence
of epileptic psychoses, infective exhaustive psychoses and dementia
praecox.... 7. From the data available, alcoholic psychoses are found
to be more prevalent among Slavs than among any other races of the new
immigration, but not as prevalent as among the native-born. 8. General
paresis is nearly twice as prevalent among Slavs as in the native-born,
but not so prevalent as among the Italians. Dementia praecox is more
prevalent among the Slavs than among the native-born."
The racial representation as shown by statistics of first admissions
is fairly constant in New York state, at least, as is shown by the
following table of percentages:—
_Race_ _1916_ _1917_ _1918_ _1919_ _1920_
African 3.1 3.3 3.9 3.7 3.8
English 7.6 5.7 5.1 4.9 5.1
German 14.3 13.5 12.5 11.7 11.7
Hebrew 12.2 11.6 12.2 11.7 10.5
Irish 19.8 19.5 17.3 16.7 16.5
Italian 6.3 6.9 7.1 8.1 8.5
Magyar .8 .9 1.0 .7 .8
Scandinavian 1.9 2.2 2.2 2.1 2.0
Slavonic 5.7 5.8 5.7 5.4 6.0
Mixed 12.4 16.0 23.6 23.3 24.1
Others 5.7 5.6 4.4 4.9 6.2
Unascertained 10.2 9.0 5.0 6.9 4.8
The 1916 report of the Commission on Mental Diseases shows the
following analysis of the nativity of the 34,300 first admissions to
the Massachusetts state hospitals covering a period of thirteen years
(1904-1916):—
_Birthplace_ _Number_
United States 18,757
Africa 7
Armenia 68
Austria 319
Azores 187
Canada 3,315
England 1,359
Finland 250
Germany 486
Greece 129
Ireland 5,033
Italy 719
Nova Scotia 136
Poland 190
Russia 1,139
Scotland 381
Sweden 539
Turkey 100
It should be borne in mind that these statistics represent birthplace
and not race. An analysis of the above figures shows that 54.68 per
cent were born in the United States and 44.42 per cent in other
countries. Of the other countries represented, 3.96 per cent were born
in England, 3.32 per cent in Russia, 9.63 in Canada and 14.67 per cent
in Ireland.
A comparison of the more important psychoses represented by the various
races, as reported by the New York State Hospital Commission in 1918,
is shown in the following table[75]:—
Per Cent of Total First Admissions of Each Race
African German Hebrew Irish Italian Slavonic Mixed
Psychoses
Senile 5.2 11.6 5.8 13.2 6.2 1.6 10.2
General paralysis 21.3 17.3 13.3 9.9 19.1 6.7 13.1
Alcoholic 5.2 4.5 0.2 10.6 2.3 10.3 4.5
Manic-depressive 12.4 12.2 24.0 9.8 22.0 14.0 12.4
Dementia praecox 29.6 25.5 35.2 26.7 26.6 47.3 24.0
Some variation is shown by a similar analysis of the New York
admissions for the year 1919, as is illustrated by the following
table[76]:—
Per Cent of Total First Admissions of Each Race
African German Hebrew Irish Italian Slavonic Mixed
Psychoses
Senile 8.0 12.7 6.9 14.9 4.9 1.6 11.5
General paralysis 15.7 15.1 11.5 12.0 16.2 9.2 12.3
Alcoholic 4.0 4.0 0.4 7.9 2.4 7.0 3.0
Manic-depressive 10.4 13.7 21.6 11.1 20.6 17.6 13.1
Dementia praecox 31.3 24.2 32.0 25.5 29.7 42.3 23.8
For purposes of comparison an analysis of the psychoses shown by
various races in the admissions of the Massachusetts state hospitals
for a period of three years is added (1917-1918-1919):—
Senile Arterio- General Alco- Manic- Dementia
Race No. Psychoses sclerosis Paresis holic Depressive Praecox
African 211 5.68% 4.73% 6.16% 7.10% 4.26% 27.96%
English 3281 10.75 9.87 7.46 5.76 9.99 18.65
French 647 6.64 6.95 12.05 8.19 6.80 24.88
German 283 6.00 7.77 10.60 9.92 12.01 21.20
Hebrew 353 .56 2.26 5.66 1.41 10.19 37.11
Irish 2994 9.01 7.11 7.11 16.13 7.11 23.31
Italian 522 3.44 2.66 7.66 5.34 10.34 35.44
Mixed 1244 8.76 12.62 7.70 8.11 7.55 24.35
Slavonic 635 6.77 7.08 12.28 8.35 6.93 25.20
This shows some very interesting results. It will be noted that the
Hebrews and Italians have the highest rate for dementia praecox, the
percentage shown by these races being much higher than any of the
others. The Germans, Italians and Hebrews, in the order mentioned,
have the highest rates for manic-depressive psychoses. The frequency
of alcoholic psychoses as shown by the Irish is nearly double that of
any of the others. The Slavonic race has the highest rate for general
paresis, followed in close succession by the French and Germans. The
highest rate for senile and arteriosclerotic psychoses combined is
shown by the races of mixed origin, the next highest by the English,
closely followed by the Irish. The most common psychosis in every
instance is dementia praecox. In the admissions to the institutions for
the criminal insane in New York the highest percentages are represented
by the Irish, Italian and Hebrew races, as shown in another chapter.
During a period of six years (1912 to 1918) a study of first admissions
to the New York state hospitals shows an incidence of dementia praecox
in the native-born of 75.2 per hundred thousand of the population and
in the foreign born of 161.4. The importance of this is shown by the
fact that over fifty per cent of the entire hospital population is made
up of cases of dementia praecox.
The necessity of some supervision of immigration for the purpose of
preventing the entrance of undesirable aliens has long been recognized.
As early as 1824 the state of New York tried by legislation to prevent
the admission of the insane and mental defectives. This effort was
a failure, probably owing to the fact that the proposed enactments
would have compelled the companies responsible for the entrance of
undesirable aliens to remove them if they became a public charge. The
introduction of discordant racial elements from abroad at one time
disturbed the equilibrium of the entire country. The agitation for the
restriction of immigration before the civil war led to the formation
of a political organization known as the "Native American" or "Know
Nothing" party, as it was usually called. It at one time had forty
representatives in Congress and nominated a candidate for President
in 1856. These disturbed conditions led to the consideration of this
subject by Congress as early as 1838 and the Judiciary Committee
recommended legislation prohibiting the entrance of idiots, lunatics
and those suffering from incurable diseases or convicted of crime.
The action of several foreign countries in pardoning murderers with
the provision that they should emigrate to the United States led to
a resolution of protest by Congress in 1860 and shortly thereafter
a statute intended to encourage immigration was repealed. An
investigation made by the United States Immigration Commission brought
to light the fact that the great influx of foreigners was largely
caused by the agents of the steamboat companies abroad and that they
had "five or six thousand ticket agents in Galicia alone."[77]
The activities of those opposed to the indiscriminate entrance of
objectionable aliens led to the federal enactment of August 3, 1882.
The Secretary of the Treasury was charged with the duty of prohibiting
the landing of lunatics, idiots and persons liable to become a
public charge. The provisions for the execution of this law were not
satisfactory and it was amended by an act of 1891. This made it a
misdemeanor to bring in any of the above proscribed classes and imposed
a fine of over one thousand dollars upon anyone guilty of so doing.
Section 11 provided that aliens entering in violation of this law could
be returned at any time within one year thereafter at the expense of
the person or persons, vessel, transportation company or corporation
responsible for their entry, and further, that those becoming public
charges within one year from causes existing prior to landing should
be considered as having entered in violation of law. The provisions
of this statute were unchanged until the act of March 3, 1903. This
excluded persons insane within five years previous to landing, those
having had two or more previous attacks at any time, paupers and all
others liable to become a public charge. Section 17 delegated to
the officers of the United States Public Health Service the duty of
determining the condition of all immigrants. Section 20 provided that
aliens coming to the United States in violation of law, or who were
found to be public charges from causes existing prior to landing, could
be deported at any time within two years. Section 21 authorized the
Secretary of Commerce and Labor to deport any alien within three years
of entering in violation of the act.
An important step in the legislative restriction of immigration was
the amendment of Feb. 20, 1907. This made mandatory the exclusion
of idiots, imbeciles, the feebleminded, epileptics, insane, all who
had been insane within five years and persons having had two or more
attacks of insanity at any time, or who were likely to become a public
charge, as well as individuals not comprehended in the foregoing
excluded classes but found to be suffering from mental or physical
defects of such a nature as to affect their ability to earn a living.
Section 20 provided that an alien entering in violation of law or
becoming a public charge from causes existing prior to landing should,
upon the warrant of the Secretary of Commerce and Labor, be taken into
custody and deported to the country from whence he came at any time
within three years after the date of his entry into the United States.
The cost of this removal was to be a charge upon the owners of the
vessel or transportation line immediately responsible. When the mental
or physical condition of the alien was such as to require personal
care or attention, the Secretary of Commerce and Labor was authorized
to employ a suitable person for that purpose. This was a great step
in advance. There were, however, some very great difficulties to be
overcome. The force placed at the disposal of the Public Health Service
for the inspection and examination of incoming immigrants was entirely
inadequate and one or two men were sometimes responsible for the
examination of several thousands aliens in a day. This was, of course,
impossible. The burden of proof in showing that the mental condition
was due to causes existing prior to landing, furthermore, devolved upon
the persons requesting deportation. It was impossible in many instances
to submit actual proof even where there could be no reasonable doubt as
to the facts. This led to great difficulties and much dissatisfaction.
Another serious objection to the provisions of this law was the
requirement that only such persons could be deported as were likely to
become a public charge. In many instances such persons were supported
by private funds until they were no longer deportable, after which they
became a burden upon the state in which they resided.
These conditions were much improved by the action of the Sixty-fourth
Congress in 1917. This definitely excluded "all idiots, imbeciles,
feebleminded persons, epileptics, insane persons; persons who have
had one or more attacks of insanity at any time previously; persons
of constitutional psychopathic inferiority," etc., or "persons not
comprehended within any of the foregoing excluded classes who are found
to be and are certified by the examining surgeons as being mentally
or physically defective" or persons likely to become a public charge.
Section 9 provided that it shall be unlawful for any person, "including
any transportation company," to bring either from a foreign country
or any insular possession of the United States any alien afflicted
with idiocy, insanity, imbecility, feeblemindedness, epilepsy,
constitutional psychopathic inferiority, etc., and subjected to a
fine any person or persons so doing. The Secretary of Labor was also
authorized to detail inspectors and matrons to duty on vessels carrying
immigrants, who shall "report to the immigration authorities in charge
at the port of landing any information of value in determining the
admissibility of such passengers that may have become known to them
during the voyage." It also provided that a mental examination of
all arriving aliens should be made by medical officers of the United
States Public Health Service who shall certify all mental defects or
diseases observed. "Medical officers of the United States Public Health
Service who have had special training in the diagnosis of insanity and
mental defects shall be detailed for duty or employed at all ports
of entry designated by the Secretary of Labor." Section 19 provided,
that any alien "who within five years after entry becomes a public
charge from causes not affirmatively shown to have arisen subsequent to
landing" shall, upon warrant of the Secretary of Labor, be taken into
custody and deported. The act also made provision for the first time
for a literacy test which has been a subject of discussion for years.
These amendments are of far-reaching importance and will eventually
undoubtedly afford the hospitals considerable relief. The fact still
remains, however, that the individual states are expending millions of
dollars annually for the care and maintenance of an alien population
which should have been excluded by the federal government. Under these
circumstances it would seem nothing more than fair that the states
should be reimbursed for the cost of carrying a burden for which they
are in no way responsible.
CHAPTER X
MENTAL DISEASES AND CRIMINAL RESPONSIBILITY
The question of responsibility for criminal acts, once a legal
problem pure and simple, is now recognized as involving sociological,
psychological and psychiatric considerations of far-reaching
importance. This viewpoint, none too thoroughly established even
now, represents the progress of several centuries, and still lacks
adequate recognition in law. The eloquent protest against the legal
conception of mental diseases written by Isaac Ray[78] in 1838 sounds
like a quotation from a recent medical journal. "In all civilized
communities, ancient or modern, insanity has been regarded as exempting
from the punishment of crime, and vitiating the civil acts of those who
are affected with it. The only difficulty, or diversity of opinion,
consists in determining who are really insane, in the meaning of the
law, which has been content with merely laying down some general
principles, and leaving their application to the discretion of the
judicial authorities.... It is to be feared, that the principles, laid
down on this subject by legal authorities, have received too much of
that reverence which is naturally felt for the opinions and practices
of our ancestors; and that innovations have been too much regarded,
rather as the offspring of new-fangled theories, than of the steady
development of medical science. In their zeal to uphold the wisdom of
the past, from the fancied desecrations of reformers and theorists,
the ministers of the law seem to have forgotten, that, in respect to
this subject, the real dignity and respectability of their profession
is better upheld, by yielding to the improvements of the times, and
thankfully receiving the truth from whatever quarter it may come, than
by turning away with blind obstinacy from everything that conflicts
with long established maxims and decisions."
A brief reference to the history of the development of the present
legal conceptions of criminal responsibility will justify the comments
made by Ray. The terms idiocy, lunacy and non compos mentis were all
used by Coke in his "Institutes of the Laws of England" written, as
nearly as can be determined, in 1625. A differentiation between the
significance of the word idiot and non compos mentis appeared as
early as 1325 in the English statute "De Praerogativa Regis," which
delegated various responsibilities to the crown that are recognized
to this day. Sir Matthew Hale, about 1670, described a partial and a
total insanity, the former not being accepted as relieving the accused
of responsibility for the commitment of a crime. It is an interesting
fact that we still hear the question of partial insanity seriously
discussed. In 1723 Justice Tracy in a murder trial ruled that "a
prisoner in order to be acquitted on the ground of insanity must be
a man that is totally deprived of his understanding and memory, and
doth not know what he is doing no more than an infant, than a brute
or a wild beast." As a result of this ruling a man was found guilty
of attempting to murder a neighbor who sent devils and imps into his
house at night for the purpose of disturbing his sleep. Fortunately
the sentence was commuted to life imprisonment. In 1812 the Attorney
General of England[79] ruled that "a man may be deranged in his
mind—his intellect may be insufficient for enabling him to conduct
the common affairs of life, such as disposing of his property, or
judging of the claims which his respective relations have upon him; and
if he be so, the administration of the country will take his affairs
into their management, and appoint to him trustees; but, at the same
time, such a man is not discharged from his responsibility for criminal
acts."
The legal procedure of the present day is based very largely on the
decisions made at the time of the McNaughton trial in 1843. In this
case the Chief Justice, as quoted by Lord Lyndhurst, addressed the
following words to the jury: "The point which at last will be submitted
to you will be whether or not on the whole of the evidence you have
heard you are satisfied that at the time the act was committed, for
the commission of which the prisoner stands charged, he had not that
competent use of his understanding as not to know what he was doing
with respect to the act itself—a wicked and wrong thing—whether he
knew it was a wicked and a wrong thing he had done, or that he was not
sensible at the time he committed this act that it was contrary to the
laws of God and man." This case led to a very serious consideration
of the subject in the House of Lords. As the result of an official
request for an opinion, the majority of the judges of the court, all
concurring but one, expressed the view that "to establish a defense on
the ground of insanity, it must be clearly proved that at the time of
the committing of the act the accused party was labouring under such a
defect of reason, from disease of the mind, as not to know the nature
and quality of the act he was doing; or if he did know it (sic) that he
did not know he was doing what was wrong."[80]
The importance and significance of these decisions, which one might
very readily assume to be obsolete and too ancient to be worthy of
consideration, will be made clear by a quotation from the penal code in
effect in New York today. "Sec. 1120 (Penal Law). Incompetency of idiot
or lunatic. An act done by a person who is an idiot, imbecile, lunatic
or insane is not a crime. A person cannot be tried, sentenced to any
punishment or punished for a crime while he is in a state of idiocy,
imbecility, lunacy or insanity so as to be incapable of understanding
the proceeding or making his defense. A person is not excused from
criminal liability as an idiot, imbecile, lunatic or insane person
except upon proof that, at the time of committing the alleged insane
act, he was laboring under such a defect of reason as 1, not to know
the nature and quality of the act he was doing; or 2, not to know that
the act was wrong." It will, I think, be conceded that we have, at
least, not lost ground in any way since 1843.
No less interesting is the legal definition of insanity in
Massachusetts: "The words 'insane person' and 'lunatic' shall include
every idiot, non compos, lunatic and insane and distracted person."
(Chapter 4, Sec. 7, General Laws of Massachusetts.) In New York the
terms lunatic and lunacy include every kind of unsoundness of mind
except idiocy. (Chapter 22, Sec. 28, Consolidated Laws.) This would
presumably include psychopathic personality and imbecility.
Numerous court decisions have had a material bearing on the subject of
responsibility. It has been held in New York that partial or incipient
insanity is not a sufficient defense if there is still an ability to
form a correct perception of the legal quality of the act and to know
that it was wrong. (People vs. Taylor, 138 N. Y. 398, 407 (1893)).
A weak or disordered mind is not excused from the consequences of
crime. (People vs. Burgess, 153 N. Y. 561, 569 (1897)), etc. Generally
speaking, the legal methods of determining criminal responsibility
do not vary to any material extent with the different states. It is
obvious that the responsibility for crime as defined by the courts is
far from harmonizing with the conception of competency entertained by
the medical profession. To the psychiatrist, if the criminal act is the
result of the mental condition it constitutes a symptom of the disease
process. It is readily apparent from even a very brief reference to
the statutes that a person concededly suffering from paranoia, general
paresis, dementia praecox or any other well-defined psychosis is still
criminally liable for his insane acts within certain limitations. From
a medical point of view the existence of a psychosis, if associated
with a consequent judgment defect, emotional instability, disturbance
of volition, intellectual deterioration, delusional and particularly
persecutory control, hallucinatory trends, ideas of reference, etc.,
is of itself quite sufficient to explain criminal acts in the insane.
This, however, as has been shown, is not the legal point of view.
The accused is fully responsible unless it can be shown that he is
suffering from such a defect of reason as not to appreciate the quality
or nature of his act or that the act is wrong. There is no other legal
standard. It is a well-known fact that many persons adjudged insane by
the courts and committed to our institutions are fully competent to
discriminate between right and wrong from an ethical point of view,
although legally held to be incompetent and unsafe to be at large.
These divergent viewpoints presumably are due to the fact that the law
moves only with a degree of dignity which theoretically guarantees
absolute security in avoiding any possible sources of error. It
nevertheless is responsible for many miscarriages of justice.
Efforts to remedy this state of affairs have been made repeatedly
by the medical profession. The American Psychiatric Association
has devoted a great deal of time and attention to this subject,
unfortunately without any very concrete results. The last
official action taken was the unanimous approval of the following
resolutions:—[81]
"Resolved: 1. That the proved rarity of wrong acquittals on the ground
of insanity is the strongest evidence that the abuse of the insanity
plea in criminal cases has been unwarrantably exaggerated.
"2. That the insanity plea is not by any means raised as often as it
should be, to prevent the frequent miscarriage of justice arising from
the conviction and imprisonment of insane persons whose true mental
condition has not been recognized.
"3. That the abuses which have crept into the method of presenting
medical expert testimony have been largely the result of established
legal tests and procedures, although their correction does not require
radical change in the laws.
"4. That inaccessibility of the evidence on both sides of the case is
the chief cause of defective medical testimony.
"5. That whenever possible the medical witness should not testify
unless he has had an opportunity to make both a mental and a physical
examination of the person in whose behalf the plea of insanity is
raised.
"6. That we consider the hypothetical question as ordinarily presented
to be unscientific, misleading and dangerous to medical repute and
that the evidence on both sides should always be included in its
presentation to medical witnesses.
"7. That in all criminal cases absolutely equal rights should be
accorded the medical witnesses for both the prosecution and the defence
for the examination of the person alleged to be insane.
"8. That in our judgment the judiciary should by legal enactment be
allowed more latitude in enlightening the jury and enabling it to
comprehend the nature and meaning of the medical testimony laid before
it.
"9. That we recommend as advisable the adoption wherever possible of
the so-called Leed's method of preliminary consultation by medical
witnesses on both sides of the case as to its status.
"10. That we advocate a freer use of appointments of commissions by the
court.
"11. That a period of hospital observation of all persons committing
crimes in whose defence the plea of insanity has been raised is by
far the best method yet devised for securing impartial and accurate
opinions, silencing popular clamor, avoiding prolonged and sensational
trials and saving expense to the State; also that we advocate the
enactment in every State of laws similar to those of Maine, New
Hampshire, Vermont and Massachusetts, providing that such persons may
be committed by the court to a State hospital for the insane there to
remain for such time as the court may direct pending the determination
of their insanity.
"12. That it is the sense of the Association that it is subversive of
the dignity of the medical profession for any of its members to occupy
the position of medical advisory counsel in open court and at the same
time to act as expert witness in a medico-legal case.
"13. That we regard the acceptance by a physician of a fee that
is contingent upon the result of a medico-legal case as not in
accordance with medical ethics and derogatory to the good repute of the
profession, and advocate the regulation of the practice by legislation.
"14. That we are in favor of any legislation that will secure a
definite standard of qualification for medical men giving expert
testimony."
An equal amount of consideration has been given to this important
question from time to time by the American Institute of Criminal Law
and Criminology. At a recent meeting of that organization the following
recommendations were submitted by a committee:
"1. That in all cases of felony or misdemeanor punishable by a prison
sentence the question of responsibility be not submitted to the jury,
which will thus be called upon to determine only that the offense was
committed by the defendant.
"2. That the disposition and treatment (including punishment) of all
such misdemeanants and felons, i.e., the sentence imposed, be based
upon a study of the individual offender by properly qualified and
impartial experts cooperating with the courts.
"3. That provisions be made permitting the transfer of such
misdemeanants and felons at any time after conviction from one
institution to another affording a different kind of treatment upon the
presentation of evidence of the needs for such action satisfactory to
the court which passed sentence.
"4. That no maximum term be set to any sentence.
"5. That no parole or probation be granted without suitable psychiatric
examination.
"6. That in considering applications for pardons and commutation
careful attention be given to reports of qualified experts showing
the applicant's mental age and mental stability and that in drafting
statutes determining or defining juvenile delinquency, mental age
and mental stability, within reasonable limits, be regarded as of
importance with the calendar age of the delinquent.
"In view of the foregoing and as an initial step towards the ends
stated, the committee submits the following resolution and urges its
immediate adoption:
"Resolved, That the several states be urged to make provision for
the psychiatric examination, under conditions permitting prolonged
observation when necessary, of all persons convicted of a felony,
misdemeanor or other offense by properly qualified experts appointed
to assist the court in reaching a decision as to the proper disposition
and treatment of the offender."
The courts, the medical profession and the public have shown
indications of a decided dissatisfaction with existing methods of
determining criminal responsibility. This will certainly continue
as long as the sole test of competency is the power of the accused
to discriminate between a knowledge of right and wrong at the time
when the act is committed. The conditions which lead to crime have
been made the subject of scientific study by many. One of the early
investigators in this field was Morel, who saw in the criminal a
personification "of the various degenerations of the species." Much has
been said of "moral insanity," a condition referred to by Abercromby
as one "in which all the upright sentiments are eliminated while the
intelligence presents no disorders." Lombroso advanced the theory
that criminality is a form of atavism—a reversion of man to the
primitive and savage type represented by his early ancestors. This
theory was based on a careful study of the anatomical, physiological
and psychological characteristics of primitive man. His classification
included the occasional, the emotional, the born criminal, the moral
insane, and the masked epileptic. Marro offered an anatomical basis
for the degenerative theory in the form of nutritional defects in the
central nervous system. Ferri distinguished between criminal lunatics
and emotional criminals and held crime to be "a phenomenon of complex
origin and the result of biological, physical and social conditions."
"Habitual criminals," he says, "are the victims of a clear, evident
and common mental alienation which causes the criminal activity,"
while the occasional offenders are to be explained by "the impulse
of opportunities more than the innate tendency that determines the
crime." The emotional criminal, according to Ferri, is a sane and
moral individual overcome by momentary emotional paroxysms referred
to as a "psychologic storm." Garofalo, on the other hand, looked upon
crime as "an offense against the fundamental altruistic sentiments
of pity and probity." From his point of view a criminal act was an
indication of the loss of a proper sense of appreciation of the
life or property of another—a moral anomaly. The Italian school of
criminology was responsible also for the theory that criminal acts are
only the expression of epileptic symptoms. Sociological workers have
attributed crime to influences which overcome the natural resistance
of the individual, a variation from which is merely an inability of
the person to conform to the laws of environment. Max Nordau sees
in human failings only an abnormality which he describes as "human
parasitism." Others look upon crime as the natural product of a modern
social and economic system. Colajanni ascribes alcoholism, vagrancy
and prostitution to poverty, but crime, he says, is "due to necessity
and to the degree and kind of education received." In the light of our
present knowledge the conclusion would appear to be warranted that
crime is the result of constitutional defects in the form of hereditary
tendencies and arrested mental development, educational defects, a
deterioration of habits as shown by alcoholism, etc., accidental
influences such as environment and poverty, pathological conditions,
including epilepsy and insanity, and precipitating factors in the form
of emotional disturbances.
Criminality, alcoholism, poverty, prostitution and mental deficiency
are closely correlated. A special committee appointed by the New York
State Prison Commission has made an exceedingly interesting report[82]
on the relation existing between mental disease and crime. Their
investigation shows that 21.8 per cent of 608 cases at Sing Sing,
thirty-five per cent of 459 men at Auburn, twenty-two per cent of three
hundred men at the Massachusetts State Prison, twenty-eight per cent of
forty-nine women at Joliet, twenty-five per cent of seventy-six women
at Auburn, twenty-three per cent of one hundred cases at the Indiana
State Prison and thirty per cent of 150 examined at San Quentin were
found to be mentally defective. An average of 27.5 per cent has been
found in the prison population as a whole. Thirty-one and four-tenths
per cent of the inmates of reformatories, training schools, workhouses
and penitentiaries were found to be feebleminded. From twenty-seven
to twenty-nine per cent of the inmates of penal and correctional
institutions of the country were said to be defective. About thirty
per cent of the population of the penal institutions for women in New
York were found to be feebleminded. A study of 502 selected cases at
the Psychopathic Laboratory of the Police Department of New York City
in 1917 showed that fifty-eight per cent were suffering from either
nervous or mental abnormalities. Of one thousand offenders examined
by the medical service of the Boston Municipal Court twenty-three per
cent were feebleminded, 10.4 per cent, psychopathic, 3.17 per cent,
epileptic and nine per cent, mentally diseased and deteriorated;
45.6 per cent in all showed abnormal mental conditions. It has been
shown that one of the most important causes of recidivism is mental
deficiency. The importance of this observation may be illustrated by
the fact that of 133,047 persons admitted to the penal and correctional
institutions of New York state sixty per cent had served previous
terms. Of 25,820 persons received at institutions in Massachusetts
during one year, 57.4 per cent were recidivits. Justice Roads is
responsible for the statement that of 180,000 convictions in England in
one year more than ten thousand represented persons convicted upwards
of twenty times previously.
The mental condition of the cases committed to the Matteawan State
Hospital is of great importance in a consideration of the relation
of crime to the psychoses. Of 2,595 cases admitted between 1875
and 1907 heredity or congenital defects were shown as etiological
factors in eight per cent of the total number. Of 793 admissions
in which more definite and reliable information was available,
hereditary factors were noted in either the paternal or maternal
branches of the family or both in thirty-five per cent of the cases.
In addition to this, heredity was found in collateral branches in
sixteen per cent. Heredity of some kind was thus shown in 51.3 per
cent of the whole number studied. Of 3,247 admissions, 46.9 per
cent were noted as being intemperate in their habits. An analysis
of 576 unconvicted cases in 1912[83] showed that 41.4 per cent were
diagnosed as dementia praecox, 21.1 per cent as alcoholic psychoses,
6.9 per cent as paranoid conditions, 4.1 per cent as epileptic
psychoses, 7.1 per cent as imbecility with excitements, 2.9 per cent
as manic-depressive psychoses, 2.4 per cent as general paresis,
3.1 per cent as undifferentiated depressions, 6.7 per cent as
constitutional inferiority and 2.2 per cent as not insane. An analysis
of 925 cases committed as insane and charged with criminal offenses
attributable to their mental condition shows the more common crimes
as follows:—assault (all forms), 26.2 per cent, burglary, 7.8, grand
larceny, 8.2, petit larceny, 1, manslaughter, 1.4, murder, 18.9,
homicide (total), 22.4, rape, 3.2, and vagrancy, 4.2 per cent.
Nolan[84] has made an analysis of 646 first admissions to Matteawan
during a period of six years (1912 to 1918). Forty-eight per cent of
these were found to have been born in foreign countries. A striking
observation was the large proportion of male cases born in Italy (10.8
per cent) and the female cases born in Ireland (11.7 per cent). Of
the various races represented it was noted that the African, which
was only responsible for 3.9 per cent of the admissions to civil
hospitals, constituted 7.4 per cent of the Matteawan admissions. The
races having the largest representation were the Irish (18.7 per cent),
the Italian (12.4 per cent) and the Hebrew (10.8 per cent). The mixed
races constituted 11.3 per cent of the admissions as compared with
twenty-three per cent of the cases reported from civil institutions.
Among the male cases 11.4 per cent were charged with disorderly conduct
and 26.47 per cent with vagrancy. Of the women, eighteen per cent were
charged with disorderly conduct, 16.4 with public intoxication and 39.8
per cent with vagrancy and prostitution. These three groups represent
74.2 per cent of all of the female cases admitted. Of the 646 criminal
acts causing commitment, 34.1 per cent were classified from a legal
point of view as felonies and 65.9 per cent as misdemeanors. Only 5.3
per cent were charged with murder, manslaughter, etc. Of the various
psychoses represented by these cases 26.9 per cent were diagnosed as
dementia praecox, seventeen per cent as alcoholic psychoses, 14.7
per cent as constitutional psychopathic inferiority, 7.3 as mental
deficiency, 8.3 as manic-depressive psychoses, 11.3 as general paresis,
3.6 as senile psychoses, 2.0 as paranoia or paranoid conditions, 2.2
as epileptic psychoses, and 1.4 per cent as not insane. The alcoholic,
constitutionally inferior and mentally defective group constituted
thirty-eight per cent of the total. Of the 165 cases diagnosed as
dementia praecox it is interesting to note that eleven were charged
with homicide, ten with assault in the first degree, fifteen with
burglary, thirteen with petit larceny, fourteen with disorderly
conduct, and sixty-six with vagrancy or prostitution. Of the
seventy-four cases of general paresis thirteen were charged with petit
larceny, eleven with disorderly conduct, and twenty-nine with vagrancy
or prostitution. The homicides and assaults were committed principally
by the alcoholic, dementia praecox, constitutionally inferior and the
defective cases. The burglaries and larcenies were committed largely by
patients diagnosed as suffering from general paresis, dementia praecox
and constitutional psychopathic inferiority.
The type of cases received at an institution exclusively for insane
convicts is naturally quite different, as shown by the admissions to
the Dannemora State Hospital in New York. Of 185 admissions covering a
period of three years the principal psychoses represented were dementia
praecox, forty-one per cent, constitutional psychopathic inferiority,
nineteen per cent, manic-depressive psychoses, eight, mental
deficiency, nine, alcoholic psychoses, five, paranoid conditions, four
per cent, etc.
Experience has shown that the defective criminal classes are not
suitable cases for either penal institutions or hospitals for the
insane. They are unable to adapt themselves to prison discipline
or hospital routine and prefer to associate only with persons of
their own kind who are given to foolish boasting of their crimes as
their least harmful diversion. They are entirely unappreciative of
any efforts made on their behalf to improve their condition or fit
them in any way for the requirements of society. They are strongly
inclined to unprovoked cruelty to others. Often they manifest an
apparent interest in religious services, thinking it may lead to
some preferment, but not for any moral reason. They are notoriously
untruthful, unreliable and exhibit a low cunning which often deceives
those not familiar with handling individuals of that type. Curiously
enough they are exceedingly critical of others and quick to notice
their shortcomings. Sexual perversions and immoral conduct are only
too common. Prostitution, as has already been shown, is one of the
most common failings of the female delinquent. An interesting but
superficial knowledge of legal matters is noted very frequently and
paraded with a remarkable degree of egotism which is difficult to
understand. It is comparatively an infrequent occurrence for a prisoner
to admit that he is guilty of the crime of which he has already been
convicted by a court. Only a few years since, a prisoner at Sing
Sing wrote the Governor of New York suggesting that his release was
indicated as a moral procedure for the good of the institution, as
he was convinced from information obtained from others that he was
the only guilty man in the establishment. The habitual criminal takes
little, if any, interest in his own relatives or family except when
he is in confinement, and feels no home ties. There is a curious lack
of appreciation for the gravity of his own offense and he always
complains of a "frame up" and asserts that he has not had a square
deal. Homicides even are always explained in an attempt to show that
they were justifiable or unavoidable. The most vicious of assaults
are often committed on their fellow prisoners without any provocation
of consequence. Experience shows that as a rule they are incapable of
any sustained effort and accomplish little or nothing when left to
themselves. Tendencies to crime show not only a marked suggestibility
but a degree of impulsiveness and a lack of self control which is
highly significant.
Another type of institution for this special group of cases is strongly
indicated. They should be held under an indeterminate sentence and in
some instances committed for life. As a result of hereditary defects,
arrested mental development, ignorance and vicious tendencies this
class furnishes the prisons with our most dangerous criminals. They
should receive separate care, with an opportunity for a special
education adapted to their individual needs. The defective classes
have for centuries been held criminally responsible and have filled our
prisons with incorrigibles and recidivists. Modern civilization should
place at our disposal some means for remedying this situation other
than mere punishment for the possession of an intellectual endowment
for which these individuals are in no way responsible. The ends of
justice can be served and the protection of the public assured at the
same time by a form of medical treatment for the defective delinquent
which will look forward to his ultimate restoration to society rather
than a form of punishment which accomplishes nothing.
CHAPTER XI
THE PSYCHIATRY OF THE WAR
The psychiatry of the late war is of unusual interest from various
points of view. Never before have mental diseases or defects been
looked upon as military problems worthy of any special attention either
in times of war or peace. It is true that the United States government
has maintained a hospital for the treatment of such conditions at
Washington for many years, and medical officers from the army and navy
have been sent to that institution for instruction, from time to time.
No adequate provision has been made, however, in previous wars for
the special care or observation of the psychoses or neuroses, nor has
any great consideration been given to a determination of the mental
status of recruits. It is, of course, equally true that modern military
methods have brought about different conditions and given rise to new
problems. In 1917 and 1918 definite psychiatric organizations were
established by the United States army for the first time. The services
of specialists in mental diseases were utilized extensively and they
were ultimately assigned to practically all of the large hospitals.
Division consultants were soon found necessary and the active
cooperation of practically every psychiatrist available in the country
was required before the armistice was declared.
This was directly due to the fact that for the first time in history
one of the most important problems, with which the military authorities
had to deal, was the question of mental diseases and defects. For
purposes of comparison and the intelligent consideration of this
important subject, the incidence of mental diseases in the army in
the past is of considerable interest. The rate in enlisted men, as
shown by the Surgeon General's reports, varied from 1.08 per thousand
in 1898 to 1.73 in 1911, and was 2.72 in 1900, the only year in which
it went above two. In 1912, 1913, 1914 and 1915, when defective mental
development, constitutional psychopathic states, hypochondriasis and
nostalgia were included in the reports the rates per thousand were
respectively 3.45, 3.44, 4.18 and 3.82. The frequency of psychoses was
higher in the men serving in the Philippines—2.07 in 1898, 2.79 in
1900, 1.45 in 1905 and 2.01 in 1911.
The ratio of mental diseases in the American and English armies has
been higher for many years than in the French, Italian, Russian and
German forces. Universal military service is supposed to have been the
factor producing this difference, the larger establishments naturally
more nearly representing the normal insanity rate of the country.
From May 1, 1861, to June 30, 1866, in other words, during the civil
war period, there were 198,849 discharges for disability from the
United States army.[85] Of this number 819 men were discharged on
account of insanity, 3,872 for epilepsy and 2,838 for various forms
of "paralysis." Based on the mean annual strength of the army, this
represented a rate of .34 per thousand for insanity, 1.6 for epilepsy
and 1.17 for paralysis. Based on the total number of discharges alone,
it represented a rate of 6.0 per thousand for insanity, 20.8 for
paralysis, and 28.3 for epilepsy or a rate for the three combined of
55.1 per thousand. These statistics are for white soldiers only. The
rate for colored troops, based on the total discharges, was seven per
thousand for insanity, 14.3 for paralysis and thirty-six for epilepsy.
No information whatever is available as to what the term paralysis
includes in these reports. The rate per thousand in the United States
army, as has been shown, increased from approximately one in 1898 to
three in 1901, during the Spanish war, Philippine insurrection, etc.,
and dropped back to one again in 1903. Weygandt,[86] who made a study
of war neuroses and psychoses in 1904, gives the insanity rate per
thousand of the German army during the Franco-Prussian war as .54, the
American troops during the Spanish war as 2.7, the British army during
the Boer war as 2.6, the Russian army during the Japanese war as 2.0,
and the Bulgarian troops during the Balkan campaign .33. The German
expeditionary corps engaged in Southwestern Africa reported 4.95 per
thousand and a rate of 8.28 including epilepsy and hysteria.
The first attempt ever made to provide special care for mental diseases
in the field was during the Russo-Japanese war. A hospital set aside
for this purpose by the Russian army at Harbin treated between fifteen
hundred and two thousand men in 1905 and 1906. It has, however, never
been claimed that all of the mental cases reached that place. Of 1,310
admissions the following conditions were represented[87]:—epileptic
psychoses, 22.5 per cent; alcoholic forms, 19.5 per cent; dementia
praecox, ten per cent; confused states, nine per cent; hysterical
psychoses, 7.7 per cent; general paresis, 5.6 per cent; toxic
conditions, 4.8 per cent; manic-depressive psychoses, four per cent;
degenerative types, 3.5 per cent; traumatic psychoses, 3.2 per cent;
and organic brain diseases, 2.9 per cent. It is interesting to note
that Steida, who analyzed the statistics of the Russo-Japanese war in
1906, reached the conclusion that a psychic trauma alone was not a
sufficient cause for the development of a neurosis. He attached an
equal importance to prolonged physical exertion, deprivation, loss of
sleep, hunger and thirst, etc. The most common disturbances following
battles were found to be hysterical excitements and confused states.
As soon as the examination of men for military service was undertaken
in this country in 1917 it became apparent that one of the most
frequent causes of rejection was either mental disease or deficiency.
The second report of the Provost Marshal General to the Secretary of
War in 1919[88] showed that of all rejections during the first year of
mobilization, twenty-two per cent were due to physical defects which
would interfere with duty (defects in bones, and joints, flat foot,
hernia, etc.), fifteen per cent were on account of imperfections of the
sense organs, thirteen per cent were for defects in the cardiovascular
system and about twelve per cent were due to nervous or mental
diseases. The inspection at camps following the physical examination
of the first million men mobilized resulted in a rejection of nine
per cent on account of nervous or mental diseases. Of all causes
for rejections from the army up to February 1, 1919, according to
Bailey,[89] mental and nervous diseases ranked fourth numerically. The
"neuropsychiatric" causes were:—psychoses, eleven per cent; neuroses,
fifteen per cent; epilepsy, nine per cent; organic nervous diseases or
injuries, eighteen per cent; mental defects, thirty-two per cent, and
constitutional psychopathic states, nine per cent; a total of 67,417
cases.
In the organization of our military forces in 1917, when this country
entered the war, every effort was made to take advantage of the
experience of others. Of the men returned to Canada from European
battlefields on account of disability, the nervous and mental cases
contributed ten per cent of the total at that time, as was shown by
Farrar.[90] These were distributed as follows:—neurotic reactions,
fifty-eight per cent; mental disease and defect, sixteen per cent; head
injuries, fourteen per cent; epilepsy and epileptoid conditions, eight
per cent; and organic diseases of the central nervous system, four per
cent. The first group mentioned consisted of neuroses in general and
included the so-called cases of "shell shock," which brings us to one
of the most interesting problems of the war. Dean A. Worcester, in a
recent letter to the editor of _Science_, has raised the question as
to whether this is a new disease. He calls attention to the following
reference by Herodotus to the Battle of Marathon which occurred in the
year 490 B.C.:—"The following prodigy occurred there: An Athenian,
Epizelius, son of Capliagoras, while fighting in the medley, and
behaving valiantly, was deprived of sight, though wounded in no part of
his body, nor struck from a distance; and he continued to be blind from
that time for the remainder of his life. I have heard that he used to
give the following account of his loss. He thought that a large, heavy
armed man stood before him, whose beard shaded the whole of his shield;
that this specter passed by him, and killed the man that stood by his
side. Such is the account I have been informed Epizelius used to give."
The nature and cause of shell shock has been the subject of much
controversy. In 1875 Ericksen called attention to the effect of intense
emotional shock on the nervous system. This he explained as "dependent
on molecular changes in the cord itself." Oppenheim's monograph in 1899
was responsible for the general use of the term "traumatic neurosis."
His conception of these conditions was not accepted by Charcot, who
at the time insisted that they belonged to the domain of hysteria,
and were due solely to psychic traumas. Oppenheim's[91] observation
of cases during the first year of the war confirmed his previous
views. He expressed the opinion in 1915 that "in absolutely healthy
and mentally normal individuals, without any trace of hereditary
taint, war trauma may cause psychoses or neuroses. The causal injury
may be of an objective, psychic or mixed nature. Violent detonations
illustrate the mixed type. Their effect upon the nerve of hearing
is certainly physical, but the psychic effect—terror—is also an
important element in the resulting condition. The enormous air
pressure exerted by the close passage of these missiles is another
influential factor. An element that tends to complicate etiology is
the frequent long duration of the exciting causes (prolonged and
continuous artillery fire, a series of injuries received at brief
intervals, exhaustion from various causes, lack of sleep, insufficient
nourishment, extreme heat or cold, etc.)." He admits that the symptoms
indicate a combination of neurasthenic and hysterical complexes which
may be explained on a psychogenic basis, but maintains that the war
has demonstrated them to be of a different nature. An external shock
causes "a functional disturbance of the delicate mechanism of the
psychic centers shown in 1, faulty distribution of motor impulses, 2,
hypo-innervation, 3, hyper-innervation, causing tremors, tonic and
clonic spasms, etc., instead of single muscle actions." He admits that
a hysterical temperament may be an important factor. Max Nonne[92] in
1915 called attention to the fact that conditions combining symptoms
of hysteria, neurasthenia and hypochondriasis plus vasomotor changes
may occur without any history of injury and should not be called
traumatic neuroses for that reason. He felt that the sudden recoveries
occurring so frequently strongly discredited any theories suggesting
an anatomical basis. He expressed the opinion that the most common
cause was the explosion of hand grenades and that the main factor
involved was an emotional disturbance. Binswanger[93] was of the
opinion that mechanical injuries to the nervous system were responsible
for the clinical pictures in war hysterias. He found that in a few
cases only was there a history of predisposition, and maintained
that in pre-war conditions hysteria was the result of a combination
of psychic traumas with physical disturbances. Exciting causes were
"over-exertion, irregular and insufficient nutrition, loss of sleep
and high mental tension." He concludes that "The theory of a psychic
mechanism as the origin of these motor and sensory symptoms is not
demonstrable." "War neurology has demonstrated that emotional shock, in
conjunction with other injuries, may cause a symptom complex identical
in all its details with the well known clinical picture of hysteria."
Wolfsohn,[94] from a study of one hundred psychoneuroses and one
hundred cases of physical injury received on the firing line, reached
the conclusion that war neuroses are very rarely associated with
external wounds. The vast majority of cases studied had a neuropathic
or psychopathic taint, as shown in the family history in fourteen
per cent of the total. A previous neuropathic constitution in the
patient was found in seventy-two per cent. "A gradual psychic shock
from long-continued fear, together with the sudden change from quiet,
peaceful environment to the extraordinary stress and strain of trench
fighting, is the chief predisposing cause of war psychoneurosis in
soldiers with neuropathic predisposition.... Wounded soldiers do not
suffer from war neuroses except in rare instances."
When the United States entered the war, Major, afterwards Colonel,
Thomas W. Salmon[95] of the United States army made an exhaustive
study of "The Care and Treatment of Mental Diseases and War Neuroses
("Shell Shock") in the British Army." At that time one-seventh of
all discharges for disability from the British forces were due to
mental and nervous disorders. As a matter of fact, they accounted for
one-third of all discharges for actual diseases (eliminating wounds).
England with the advantage of three years of experience had presumably
completed her organization to its highest efficiency. One and one-tenth
per cent of the cases in the military hospitals were suffering from
mental diseases. The percentage represented by the expeditionary forces
was 1.3. About six thousand "shell shock" cases were being admitted
annually to the English hospitals. Col. Salmon estimated the admission
rate at two per thousand in the troops at home and four per thousand
in the expeditionary forces. The civilian rate during the same period
was about one to one thousand of the population. The confusion which
existed early in the war was shown by the fact that ten per cent
of the cases sent to the Red Cross Military Hospital at Maghull as
war neuroses turned out to be insane and twenty per cent of those
admitted as mental cases at the Royal Victoria Hospital at Netley were
subsequently found to be suffering from neuroses. The first conclusion
reached by Col. Salmon was that "contrary to popular belief and to some
medical reports published early in the war, no new clinical types of
mental disease have been seen in soldiers. There are no war psychoses."
He found that of the cases being admitted to the hospitals for mental
diseases about eighteen per cent were mental defectives, two per cent
syphilitic psychoses, twenty per cent manic-depressive insanity,
fourteen per cent dementia praecox, and seven per cent epilepsy.
Statistics at that time were not available on purely psychopathic
conditions, owing to the classification used.
In discussing the etiology of shell shock Col. Salmon divides those
conditions into four groups—1. Cases in which death is caused by
exploding shells or mines without external signs of injury; 2. Those
in which severe neurological symptoms follow burial or concussion by
explosions, with characteristic syndromes suggesting the operation
of mechanical factors; 3. Cases in which there may or may not be
damage to the central nervous system, but showing neuroses similar
to those of civil life—"In this group of cases, in which there is
possibility but no proof of damage to the central nervous system, the
symptoms present which might be attributable to such damage are quite
overshadowed by those characteristic of the neuroses;" and 4. Cases in
which even the slightest damage to the central nervous system from the
direct effect of explosions is exceedingly improbable. He also found
that hundreds of men who have not been exposed to battle conditions
at all develop symptoms almost identical with those described as
"shell shock," many occurring in the non-expeditionary forces. The
psychogenic factors involved are very well summarized by Col. Salmon
in the following words:—"The psychological basis of the war neuroses
(like that of the neuroses in civil life) is an elaboration, with
endless variations, of one central theme: escape from an intolerable
situation in real life to one made tolerable by the neurosis. The
conditions which may make intolerable the situation in which a soldier
finds himself hardly need stating. Not only fear, which exists at some
time in nearly all soldiers and in many is constantly present, but
horror, revulsion against the ghastly duties which must be sometimes
performed, intense longing for home, particularly in married men,
emotional situations resulting from the interplay of personal conflicts
and military conditions, all play their part in making an escape of
some sort mandatory. Death provides a means which cannot be sought
consciously. Flight or desertion is rendered impossible by ideals of
duty, patriotism and honor, by the reactions acquired by training or
imposed by discipline and by herd reactions. Malingering is a military
crime and is not at the disposal of those governed by higher ethical
conceptions. Nevertheless, the conflict between a simple and direct
expression in flight of the instinct of self-preservation and such
factors demands some sort of compromise. Wounds solve the problem most
happily for many men and the mild exhilaration so often seen among
the wounded has a sound psychological basis. Others with a sufficient
adaptability find a means of adjustment. The neurosis provides a means
of escape so convenient that the real source of wonder is not that it
should play such an important part in military life but that so many
men should find a satisfactory adjustment without its intervention. The
constitutionally neurotic, having most readily at their disposal the
mechanism of functional nervous diseases, employ it most frequently.
They constitute, therefore, a large proportion of all cases but
a very striking fact in the present war is the number of men of
apparently normal make-up who develop war neuroses in the face of the
unprecedentedly terrible conditions to which they are exposed."
The symptomatology has been briefly summarized by Col. Salmon in a way
which cannot be improved upon:—"Most of them can be summed up in the
statement that the soldier loses a function that either is necessary
to continued military service or prevents his successful adaptation to
war. The symptoms are found in widely separated fields. Disturbances of
psychic functions include delirium, confusion, amnesia, hallucinations,
terrifying battle dreams, anxiety states. The disturbances of
involuntary functions include functional heart disorders, low blood
pressure, vomiting and diarrhea, enuresis, retention or polyuria,
dyspnoea, sweating. Disturbances of voluntary muscular functions
include paralyses, tics, tremors, gait disturbances, contractures and
convulsive movements. Special senses may be affected producing pains
and anesthesias, mutism, deafness, hyperacusis, blindness and disorders
of speech. It is highly significant that, in this unprecedented
prevalence of functional nervous diseases among soldiers, no symptoms
unfamiliar to those who see the neuroses in civil life present
themselves."
An analysis of the 170,000 cases discharged for disability in England
showed that twenty per cent were due to war neuroses. In his second
Lettsomian lecture Mott[96] called attention to the interesting
similarity between shell shock following concussion and burial, and
the symptoms resulting from an acute carbon monoxide poisoning. This
was, of course, a very possible complication in trench warfare.
The headache, ringing in the ears, blurred and indistinct vision,
hallucinations of sight, or actual blindness, giddiness, yawning,
weariness, vomiting, cold sensations, palpitation, sense of oppression
on the chest, etc., so common in gas poisoning are often followed,
when consciousness is regained, by confusion and loss of memory, with
retrograde amnesia. Tremors and loss of speech are also frequently
noted. Mott reached the conclusion that shell shock, in some cases
at least, was due to gas poisoning. In his third Lettsomian lecture
he discusses the symptomatology of shell shock. In some instances
there was a partial loss of consciousness, characterized by dazed
states somewhat similar to those of epilepsy. Under speech defects he
includes mutism, aphonia, stammering, stuttering and verbal repetition.
Headache in the occipital region was found to be a very common symptom.
Vasomotor conditions were palpitation, breathlessness, pericardial
pain, rapid weak pulse, low blood pressure, cold extremities, low
temperature, etc. Anesthesia and hyperesthesia or loss of pain
sense also occurred, and deafness was often observed. Smoky vision,
photophobia and functional blindness were frequent eye symptoms.
Tremors, tics, choreiform movements, functional paralysis and gait
disturbances are also mentioned by Mott. In the Chadwick lecture he
later called attention to the presence of insomnia and terrifying
dreams in practically all cases of true shell shock.
In 1917 Mott[97] reported the examination of the brains from two
cases of pure shell shock. They showed a congestion of the meninges,
scattered subpial hemorrhages, and congested vessels in the internal
capsule, pons and medulla. In one case there was an extravasation of
blood into the substance of the lower surface of the orbital lobe. He
spoke also of a general chromatolysis in the ganglion cells. Eder[98]
in 1917 advanced the theory that the symptoms of neuroses are the
result of mental conflicts and that the mechanisms involved are those
attributed by Freud to hysteria. As a result of an analysis of one
hundred cases he reached the conclusion that mechanical shock, gas
poisoning and other physical traumas were not factors in the production
of these conditions. His cases occurred in persons free from hereditary
or personal psychoneurotic predisposition. Chavigny in a discussion
of the mental diseases in the French army asserted that psychoses and
neuroses were practically unknown until trench warfare began and the
use of heavy artillery became common. From this moment psychiatric
units became necessities. Ballet and de Fursac[99] were very firmly
of the opinion that shell shock was due to purely emotional reactions
in predisposed individuals. "If disturbances from explosion and
from emotional shock, existing with or without traumatism, produce
identical results, it is evident that they have a common factor and
this common factor can be only the emotion itself. Disturbance from
explosion without external injury presupposes an emotional state, and
it is from this state that it derives its causal efficacy; whatever
the etiological complex found as the cause of a condition of shock,
whether the explosion of a shell, bomb or mine, the sight of the dead,
burial in a trench, wound from an explosion or a missile, there is only
one factor of importance, the emotional factor, which is essentially
responsible for all the neuropsychic disorders that together make up
the shock syndrome."
In 1915 Birnbaum summarized seventy-two articles written on war
psychoneuroses in the German army up to the middle of March of that
year. On analyzing this study Hoch reached the conclusion that the rate
of psychoses was only about two in ten thousand, which would appear to
be entirely too low. Birnbaum compared the statistics of various
observers showing the frequency of psychoses during the first year of
the war as follows:—"Psychopathic constitution, hysteria, traumatic
neuroses, etc., Bonhöffer, fifty-four per cent; Meyer, 37.5 per
cent; and Hahn forty-three per cent. Alcoholism, acute and chronic,
Bonhöffer, ten per cent; Meyer, 21.5 per cent; and Hahn, twenty-one
per cent. Dementia praecox, Bonhöffer, seven per cent; Meyer, 7.5 per
cent; and Hahn, thirteen per cent. Epilepsy, Bonhöffer, fourteen per
cent; Meyer, 11.5 per cent; and Hahn, eight per cent. Manic-depressive
insanity, Bonhöffer, three per cent; Meyer, four per cent; and Hahn,
two per cent. General paralysis, Bonhöffer, six per cent; Meyer, 3.5
per cent; and Hahn, three per cent." In discussing these findings Hoch
says:—"It is clear from this table that psychopathic constitutions,
various psychogenic reactions, hysterical and anxiety states, also
exhaustive conditions—all of which are included in the first
group—are strikingly frequent; whereas the more serious constitutional
disorders, such as manic-depressive insanity, dementia praecox and
epilepsy are much rarer." Both Birnbaum and Bonhöffer expressed
surprise at the infrequency of manic-depressive conditions. Wollenberg
found that the individuals who broke down during mobilization, and who
had the least resistance, developed manic-depressive insanity, paranoid
schizophrenias, episodic psychopathic excitements and occasional
clouded states. The cases appearing at the front, on the other hand,
were largely hysterias, anxiety states and exhaustive conditions.
Birnbaum described psychoses similar to those reported by Awtokratow
in the Russo-Japanese war and characterized by great weariness with
a tendency to weeping, disturbed sleep and hallucinations related
directly to unpleasant war experiences to which the patients had been
subjected. He attributed these to exhaustion. Lust[100] quotes Mörchen
as finding only five cases of war neuroses in forty thousand prisoners
at Darmstadt and found very few cases in an additional twenty thousand
which he investigated himself.
Westphal in 1915 expressed the opinion that there were neither war
psychoses nor neuroses and that these conditions did not differ in any
way from those described in times of peace. MacCurdy,[101] who made
an elaborate study of war neuroses in 1917, described them as being
either anxiety conditions or simple conversion hysterias. He looked
upon fatigue as being a very important factor in the development of
a neurosis, with either a physical accident or a mental shock as the
precipitating cause. He defines war neuroses as "Those functional
nervous conditions arising in soldiers which are immediately determined
by modern warfare and have a symptomatology whose content is directly
related to war." MacCurdy found that concussion could be considered as
a possible factor in less than one-fourth of the cases he observed.
He refers to minute cerebral and retinal hemorrhages with blood in
the cerebrospinal fluid as an evidence that concussion is a cause in
some cases. Curschmann, Meyers, Buzzard, Farrar and various others
have noticed that the gross hysterical manifestations were extremely
rare in officers. After an extended discussion of the etiology of
the war neuroses, Farrar in 1918 expressed as one of his conclusions
the opinion that "The drift of opinion is unmistakable towards the
psychogenic basis of war neuroses of all types, including shell shock.
Even in the initial unconsciousness or twilight state of some duration
there is evidence that the psychogenic element may have as great if
not a greater rôle than the item of mechanical shock, although this is
also important."
Hartung[102] in 1918 reported a study of 780 cases of war neuroses
treated by him at Thal. About ninety-eight per cent were cured by
psychic and mechanical treatments. One hundred and sixty-two cases
showed hysterical paralysis, the lower limbs being affected twice as
often as the upper. Tremors of the head or upper limbs were present
in twenty-eight per cent, hysterical convulsions in eight per cent,
speech disturbances in five per cent, hearing disorders in one per
cent, cardiac and respiratory symptoms in 1.5 per cent, neuroses of the
digestive system in 1.5 per cent, and bladder disturbances in 1.5 per
cent of the cases. Neurasthenia "in the strictest sense of the word"
was present in twenty per cent. Hurst[103] and others have spoken of
endocrine disturbances in war neuroses. He includes hyperadrenalism and
hyperthyroidism due to an over-stimulation of the sympathetic nervous
system, resulting from such emotions as anger and fear. Rapid pulse,
enlargement of the heart, and high blood pressure were common symptoms.
The patients in some cases showed conditions strongly suggesting
Graves' disease. In addition to the circulatory disturbances there was
paroxysmal sweating, the eyes were slightly prominent, sometimes with
von Graefe's sign, and pilomotor reflexes were present.
An important contribution to the discussion as to the etiology of war
neuroses was the statement made by Major General Ireland[104] to the
Senate Committee on Military Affairs, that of the twenty-five hundred
cases of shell shock awaiting transportation to the United States,
twenty-one hundred recovered within a day or two after the armistice
was declared. He gave the incidence of mental and nervous diseases
in the forces in camps in this country as 2.5 per thousand and ten
per thousand overseas. Another interesting phase of shell shock was
the surprising results which various German observers obtained by the
so-called "Kaufmann" treatment, the sudden application of a strong
faradic current. One of the most significant contributions to the
psychiatric history of the war as far as this country is concerned
is the statement made by Col. Salmon[105] that in the latter part
of December, 1920, of the beneficiaries of the War Risk Insurance
thirty-two per cent were suffering from general diseases; forty-one
per cent from tuberculosis; and twenty-seven per cent from various
neuropsychiatric disorders. "The vague idea that all these men are
suffering from "shell shock" or other mysterious maladies developed
under the stress of modern warfare was replaced by the realization
that more than two-thirds of all neuropsychiatric patients have one or
another type of insanity." Of these cases sixty-six per cent had well
developed psychoses; nineteen per cent psychoneuroses; five per cent
epilepsy; two per cent mental deficiency; and eight per cent organic
nervous diseases or injuries. On December 16, 1920, there were five
thousand five hundred cases receiving hospital treatment.
CHAPTER XII
ENDOCRINOLOGY AND PSYCHIATRY
The important influence exercised by the glandular structures on the
human organism has long been recognized. Perhaps the earliest evidence
of this is the study of alterations due to the removal of the sexual
glands. Eunuchoidism was described by Larrey as early as 1812 in
his well-known account of the Egyptian campaign. In 1845 Bouchardat
advanced the theory that pancreatic lesions were responsible for the
development of diabetic disorders. Thomas Addison in 1855 showed the
existence of a very definite disease process caused by pathological
conditions in the adrenals. Mongolianism was recognized as a distinct
entity by Langdon-Down in 1866. Gigantism was studied very thoroughly
by von Langer in 1872. The existence of the parathyroids was unknown
until they were described by Sandström in 1880. Weiss in 1881 showed
that the extirpation of the thyroid sometimes caused tetany. After
myxedema had been studied clinically by Charcot and others the fact
that it was clearly related to disturbances of the functions of
the thyroid gland was demonstrated by Kocher and Reverdin in 1882.
Adipositas Dolorosa was described by Dercum as a form of dysthyroidia
in the same year. Acromegaly was originally defined by Pierre Marie
in 1886 and its relation to the hypophysis was pointed out by him.
In 1886 Möbius called attention to the part played by the ductless
glands in Basedow's disease, Grawitz in 1888 showed the significance
of thymic hyperplasia and Paltauf in the following year described the
"lymphato-chlorotic constitution." The pancreatic origin of diabetes
was elaborately outlined by von Mering and Minkowski in 1889. The
influence exerted by glandular secretions on general metabolism was
demonstrated by Brown-Sequard in the same year. Lemoine and Launois
in 1891 reported the existence of sclerosis of the blood and lymph
vessels in the pancreas and Laguerse in 1893 found that the Islands of
Langerhans were often involved in diabetes. Thyroigenic obesity was
reported by von Hertoghe in 1896. The isolation and chemical definition
of adrenalin by Takamine in 1901 was a decided step in advance.
Fröhlich in 1901 suggested that obesity, infantilism of the genitalia
and myxedematous alterations of the skin pointed to tumors of the
hypophysis. In the same year Neumann thoroughly reviewed the subject
of growths in the epiphysis, submitting a study of twenty-two cases.
The various types of dwarfism were first described by von Hansemann in
1902. Thyroplasia and myxedema were exhaustively studied by Pineles
in 1910 and 1912. The literature on the subject of the ductless or
so-called endocrine glands has grown enormously during the last two or
three decades and is shown in full by Falta and Meyers.[106]
The endocrine syndromes as now understood have been briefly summarized
by Blumgarten[107] in a very graphic form as follows:—
THYROID STIGMATA
_Symptoms of So-called Hyperactivity_
Exophthalmus.
Wide palpebral slits.
Tachycardia.
Nervousness.
Tremors.
Stelwag's sign.
Scanty and frequent menstruation.
Emaciation.
Periodic loss of flesh and strength.
Mild hyperthermia.
Increased basal metabolism.
Lymphocytosis.
Von Graefe's sign.
Anginoid attacks.
Hyperidrosis.
Deformities of the nails.
Dryness of the mouth.
Excessive salivation.
Vomiting attacks.
Diarrhea.
Irregular breathing.
Eosinophilia.
Increased coagulation time.
Increased emotional irritability.
Ideas of reference and persecution.
Manic symptoms.
Bluish-white teeth.
High hair line.
Hourglass contraction of the stomach.
_Symptoms of So-called Hyposecretion_
Precocious graying of the hair.
Drowsiness.
Anorexia.
Small stature.
Puffiness of the face.
Sallow complexion.
Scanty hair.
Deepset eyeballs.
Dull and listless cornea.
Hard, brittle nails.
Scanty eyebrows.
Cold, bluish, moist hands.
Tending to chilblains.
Irregularly developed teeth which decay easily.
Defective development.
Dry, thick, scaly skin.
Acrocyanosis.
Localized transitory edema.
Urticaria.
_Parathyroid Stigmata_
Intermittent cramps.
Twitching of the hands.
Tetany with associated symptoms.
_Pituitary Stigmata_
Greatly thickened nose.
Prominence of superciliary ridges.
Tendency to increased tuftings of terminal phalanges.
Coarse, heavy, overhanging eyebrows.
Protruding thick lips.
Prominent hypertrophied lower jaw.
Increased sugar tolerance.
Increased interdental spaces.
Enlarged sella tursica.
Hypertrophied nails.
Hypertrophied, thickened skin.
Short, square hands.
High carbohydrate tolerance.
Amenorrhea.
Visceroptosis.
_So-called Deficiency Symptoms_
Adiposity.
Fat pads around the malleoli.
Increased development of the mammary glands.
Deposit of fat around the buttocks and the neck.
Alabasterlike skin.
Irregular menstruation.
Subnormal temperature.
Wide intercostal angle.
Fatigability.
Infantile uterus.
Slow pulse.
Sluggish mentality.
Mononucleosis.
Eosinophilia.
Leucocytosis.
Short stature.
Childlike voice.
Bitemporal headache.
Supraorbital headache.
Sterility.
_Adrenal Stigmata_
Aggressive type of individual.
Increased growth of hair on body.
Masculine type of female and vice versa.
Prominent canine teeth.
_So-called Deficiency Symptoms_
Asthenia.
Low blood pressure.
Muscular pains.
Fatigability.
Pigmentation.
Sergent's white line.
_Thymus Stigmata_
Very long stature.
High palatal arch.
Infantile epiglottis.
Lymphocytosis.
General glandular enlargement.
Abnormally long thorax.
Visceroptosis.
Eosinophilia.
_Gonadal Stigmata_
Hermaphroditism.
Pale, anemic skin.
Flushes in the female.
Scanty growth of lanugolike hair.
Sparse eyebrows.
Dull, lethargic mentality.
Characteristic pyramidal pubic hair in males and flat in females.
_Symptoms of So-called Gonadal Hyperactivity_
Precocious sexual activity.
Jolly, gay disposition.
Marked fecundity.
Menorrhagia or metrorhagia.
_Symptoms of So-called Hyposecretion_
Infantilism.
Small, atrophic testes.
Late menstruation.
Menorrhagia.
Dysmenorrhea.
Infantile uterus.
Nervous constipation.
Deficient lateral incisors.
Sterility.
Absent lateral incisors.
_Pineal Stigmata_
(occur only in children)
Precocious sexual and mental development.
It will be noted that he associates manic symptoms, increased
emotional irritability, ideas of reference and persecution with
thyroid hyperactivity and speaks of a sluggish mentality in pituitary
deficiency and gonadal stigmata. Blumgarten's summary of these
conditions is very interesting: "The study of the various stigmata
shows that many of these are present regularly in certain types of
individuals. Consequently we may group individuals from an endocrine
viewpoint into various types according to the prominent endocrine
stigmata which they show. For example, the nervous, thin individual
with tachycardia, rather prominent eyeballs, fine, delicate hair,
suffering occasionally from gastric symptoms, suggests the thyroid
type, as does also the clean-cut, alert individual, and the young woman
suffering with amenorrhea and a tendency to obesity and lethargic
mentality. On the other hand, the aggressive, energetic individual,
with the history of an ancestry subject to vascular disease, with
high blood pressure, with abundant, unusual distribution of hair and
a tendency to pigmentation, suggests the adrenal type. And so does
the tired, asthenic individual with low blood pressure and Sergent's
white line, who may have had influenza or diphtheria and even may be
suffering from tuberculosis. On the other hand, however, the heavily
built individual with broad, large frame, wide intercostal angle, broad
nose, prominent supra-orbital ridges, prominent lips, large, square
fingers, suggests the pituitary type. These individuals are very fond
of meats, are heavy eaters, and are constantly subject to diseases of a
gouty nature, may have a history of syphilis, are often musical and, as
a rule, are usually successful in their particular community."
According to Kaplan[108] "such states as lack of courage, melancholy,
suicidal tendencies, dementia praecox, precocious adolescence, and
immature senility, sadism and masochism; all of these are possible
manifestations in a gonadotrop individual." Garretson[109] is of the
opinion that the "large group of patients generally misunderstood and
frequently classed in civil life as neurasthenics, psychasthenics,
hysterics, cyclothymics, and hypochondriacs, is now capable of an
intelligent analysis and rational therapy, if one will concede that
these are the victims of an endocrinic asthenia."
As an evidence of the influence of the endocrine glands on psychical
functions, Falta[110] refers to "the alteration in character that is
almost always associated with the development of Basedow's disease;
to the psychical irritability, the inclination to irascibility, the
manic-euphoristic attitude of patients with Basedow's disease; to the
apathy and lack of interest of the myxedematous; to the characteristic
quiet mental attitude in hypophysial dystrophy, and the feeling of
mental want of strength in those suffering with Addison's disease;
to the depressive attitude of the tetany patient, and finally to the
profound influence that the ripening of the sexual glands at the time
of puberty or the loss of function of the sexual glands in castrates
exercises on the psyche." Going into this subject more in detail Falta
gives the following mental symptoms as associated with Basedow's
disease: abnormal irritability, "immotivated" gaiety, hasty speech,
rapid flow of thoughts, a suggestion of flight of ideas, changeable
moods and terrifying dreams. He also finds an alteration in the
personality as shown by suspiciousness, capriciousness, irritability
and either euphoric or depressed tendencies. Möbius compares this with
a condition of mild intoxication associated with maniacal periods
alternating with depression. Occasional attacks of delirium with
confusion and hallucinations terminating in coma have been described.
Sattler, who has analyzed 150 of these cases as reported in current
literature, classifies over seventy as cases of manic-depressive
insanity. Boinet, Parhan and others have shown that depression with
suicidal inclinations may follow the ingestion of large amounts
of thyroidin. Conditions of excitement have also been reported in
thyroidism, and, according to Falta, are not uncommon. Brunet has
expressed the opinion that in such cases Basedow's disease acts only as
a precipitating factor in an individual predisposed to a psychosis.
The English Myxedema Commission found the apathy characteristic of that
disease present in all but three of 109 cases. This condition develops
early and may manifest itself in the form of a mild mental dulness.
Intellectual activities are often markedly diminished and there is a
slow, monotonous form of speech. Deterioration may be well developed
and memory seriously impaired. The commission in its investigations
found illusions in eighteen cases, hallucinations in sixteen and
psychoses in sixteen. These took the form usually of a depression
with occasional excitements. The symptoms, in some cases at least,
disappeared after thyroid treatment was instituted.
The psychic changes in cretinism have been made the subject of
considerable study. The usual mental state is, of course, one of
feeblemindedness. Perception has been shown to be disturbed, memory is
impaired and there is a marked emotional deterioration and instability.
In the parathyroid form of tetany von Frankl-Hochwart found depressions
and confused states with hallucinations. Depressions were reported by
him in fourteen of thirty-seven cases examined. Excitements were also
noted in some instances. Falta refers to "a characteristic apathy, a
want of initiative, and a slowing of speech" in acromegaly. In rare
cases he has also noted mental exaltation. Oppenheim (1914) has called
attention to cases of acromegaly presenting the picture of general
paresis but due to an alteration of glandular functions and not
syphilitic in origin.
Falta includes the following in his description of the symptomatology
of Addison's disease: "Almost always the disease manifests itself
in ready fatigability, disinclination for work, and apathy; to
these symptoms are sometimes added headaches, poor sleep, sometimes
obstinate insomnia, psychical ill humor and depression, often too,
abnormal irritability; further, diminution in memory, noises in
the ears, vertigo and commonly fainting attacks, singultus, and
rheumatoid pains in the back and in the extremities, sometimes, also
epileptiform convulsions. Extremely stormy manifestations on the part
of the nervous system may, especially in the later stages, make their
appearance—violent delirium, acute confusion, convulsions, deep
stupor, and coma."
Raeder[111] has made an analysis of glandular involvements found in
the study of one hundred cases of feeblemindedness at autopsy. He
classifies these as 1, extreme changes—in which three or four glands
were involved and where there were marked anomalies of growth,
underdevelopment, disproportion of the body parts, etc.; 2, marked
changes—in which at least two glands were involved and where there
were distinct changes in growth and anomalous development; 3, moderate
changes—in which one or two glands were involved; and 4, cases where
no glandular involvement was found. He noted extreme changes in ten per
cent of the series, marked changes in eleven per cent, moderate changes
in fifty-three per cent and none at all in twenty-six per cent. Sixty
per cent of these individuals showed deviation from the normal in size,
fifty-one per cent were undersized and nine per cent were above the
average height, while thirty-eight per cent were normal. The pituitary
was found to be involved in forty per cent of the one hundred cases,
the thyroid in nineteen per cent, the suprarenal in twenty-seven per
cent, the sex glands in thirty-eight per cent, the thymus in twelve
per cent and other glands in six per cent. He frequently found several
involved: "Pituitary with gonads in nine cases, was the most common
dual adenosis, though there were combinations of sex and thyroid in
four instances, sex and suprarenal in four cases, and in three cases
the thyroids, pituitary and gonads were affected in triple involvement.
Furthermore, there were six cases in which the gonads were combined
with three other glands; two included the gonads, thyroid, pituitary
and suprarenal; two, gonads, thyroid, pituitary and thymus." Further
investigation only can accurately determine the exact relation which
exists between disturbance of these glands and the presence of mental
deficiency.
Attention was called some time since to the fact that the injection
of adrenalin leads to an increase in blood pressure. This has been
discussed by Falta, Newburgh, Nobel and others. Neubürger[112] made a
study of thirty-nine cases, seven of which were normal, the others
including alcoholism, neurasthenia, manic-depressive, etc., but not
dementia praecox. A fairly well marked rise of blood pressure followed
adrenalin injection very quickly, reaching its maximum in from six
to twelve minutes. He found the reaction diminished or absent in
eighty per cent of the sixty-three cases of dementia praecox which he
examined, but does not advance the claim that this can be utilized
for diagnostic purposes. Walter and Krumbach[113] found an increased
pressure in sixty per cent of normal control cases and obtained similar
reactions in dementia praecox. Schmidt, on the other hand, confirmed
the findings of Neubürger. Emerson[114] found status lymphaticus in over
twenty-nine per cent of his cases of dementia praecox and Davis[115]
found the same condition in twenty-four per cent of war neuroses in
a series of over one hundred cases. These findings, however, lack
confirmation by other observers. Straus[116] includes as mental
symptoms in thyroidal disbalance: sluggish mental reactions alternating
with sparkling wit, irritability, general moodiness and depression,
difficulty in thought with inability to concentrate, forgetfulness,
fatigability and somnolence.
Turro[117] has shown that all of the physical evidences of
fright—pallor, dilatation of the pupils, rapid pulse, cutis anserinus,
perspiration, etc., can be produced experimentally by the injection of
epinephrin in certain cases. Knauer and Billigheimer[118] have called
attention to the striking similarity between the functional changes
to be found in disturbances of the vegetative (sympathetic) nervous
system and certain manifestations associated with fear neuroses. They
attribute these disturbances to congenital inferiority, toxic sources,
emotional shock or fatigue.
A uniform defective development of the physical and mental personality
of the individual has been designated by Lasègue as infantilismus.
As described by Di Gaspero and de Sanctis the mental status of these
cases belongs to the domain of feeblemindedness and in some instances
to imbecility. According to Kraepelin[119] the attention is easily
attracted and as easily distracted. These individuals are inquisitive
and flighty. Apprehension is defective. What they hear and see can only
be related in a fragmentary and unreliable manner. They often learn
readily and forget as quickly. Pende described the mental development
as only one-third of the normal. Memory gaps are supplied by
exaggeration and fabrication, as influenced by emotion or suggestion.
Di Gaspero found falsification of memory in twenty per cent of
his cases. Imagination is very active with a tendency to dreamlike
unrealities, wonderful tales of adventure, etc. Mental processes are
inadequate, vague and uncertain. The real and the unreal are not
clearly differentiated. Explanations and descriptions are inaccurate
and indefinite. Standards of value, size or time are vague. The store
of ideas is impoverished and associations are poor. Calculations
are slow and faulty. These persons are illogical, impractical and
credulous. They are swayed by prejudices, catchwords and hasty
judgment. Their range of thought is narrow and their viewpoint of life
childish. The emotional and volitional content is immature. They are
cheerful but lack earnestness, and are often ambitious and boastful. At
other times they are likely to be despondent, timid, anxious, fearful
and lacking in self-confidence. The mood is exceedingly variable. They
are not industrious, cannot apply themselves constantly to any line of
work, and tire easily. Their conduct is very uncertain and unreliable.
Some have criminal tendencies. Occasionally hysterical symptoms appear.
Evidences of an absence of physical development manifest themselves
in all varieties of immaturity. These defects, according to Falta,
are shown especially in the genitalia and the lymphatic apparatus,
with a delay in the closure of the epiphysis and the retention of a
childish physique generally. The skeletal framework shows a failure of
development, the lower length of the body exceeds the upper slightly,
if at all, the head is relatively large, the bones slender and the
pelvis infantile in type. The sexual organs and the "vita sexualis"
are those of a child. The blood shows a large lymphocyte count and a
definite status lymphaticus is sometimes found to be present. The hairy
development of the pubis and axillary surface is slight. The internal
organs are normal. True infantilism, according to Falta, is not due to
a glandular disturbance. He also maintains that the mind, while that of
a child, is normal otherwise and shows no defects. Juvenile myxedema,
hypophysial dystrophy and eunuchoidism, Falta would not include with
the infantilismus group. Infantilism has been ascribed to syphilis,
tuberculosis, alcoholism, etc., of the parents. Brissaud in 1907
advanced the theory that it was a hypothyroid symptom. His views have
been supported by various other writers, although not shared by either
Falta or Kraepelin. The latter has also described mental conditions
more or less suggesting feeblemindedness and associated with lesions of
the hypophysis, the pineal gland, the adrenals, the sexual glands and
the thymus.
Lesions in the anterior lobe of the pituitary result in gigantism or
acromegaly, with a childish mentality most marked in the emotional
sphere. These persons are usually indifferent, good-natured and
boastful, and at the same time clumsy and inactive. A diminished
activity of the glandular portion of the hypophysis means dwarfism.
Lesions of the posterior or "nervous" lobe may cause "dystrophia
adiposo genitalis," the "adipositas dolorosa" of Dercum. The mental
status in this condition Kraepelin compares to that described in
acromegaly—apathy and indifference, with occasional restless or
excited types. The intellectual capacity may be normal, mediocre or
somewhat deficient.
The pineal gland is spoken of as having a very definite relation to
sexual development. Extirpation is said to lead to rapid development
of the body, the accumulation of fat and early sexual development,—a
condition described by Pellizzi as "makro-genitosomia praecoce."
Schüller in fifty-one cases with pineal involvements found ten
occurring during the first decade of life. Death usually takes
place within a few months or years. Similar conditions result from
hyperactivity of the adrenal cortex,—rapid development of the body,
and particularly of the sexual organs, obesity and overgrowth of the
hair and beard. Wiesel described as a "suprarenal genital symptom
complex" cases of pseudo-hermaphrodism in women.
Lesions of the adrenal, as studies of Addison's disease show, have,
according to Kraepelin,[120] the following symptoms: weakness of memory,
apathy, dulness, inactivity and inhibition of growth. He also calls
attention to the fact that in anencephaly, hemicephaly and microcephaly
defective development of the adrenals is very common. "Eunuchoidismus"
and "viriginität" with mental symptoms due to defective development of
the sex glands are also described. The physical manifestations include
defective secondary sexual characteristics, in men in the growth of
the beard and change of the voice, and in women in the development
of the mammary glands, the fat deposits and the curve of the hips.
There is a failure of sexual development and absence of menses, as
well as defective physical growth. Eunuchoidismus may manifest itself
in a giantism somewhat suggesting that resulting from lesions of the
pituitary or in a dwarflike physical development. The former variety
is characterized by an unusual height with long arms and legs. The
forehead is receding, with a low hair line. The external genitals are
very small and there is little pubic or axillary hair. Ossification is
delayed. In the second form (dwarfs) the body, arms and legs are short
and thick. The head is large and the neck short. The genitals are small
and the penis is short and button-shaped. Hair formation is slight. The
mental condition in either case is characterized by an intellectual
defect with timidity, emotional instability, helplessness and weakness
of will, sometimes with an active imagination. Kraepelin also describes
endocrine conditions resulting from thymic lesions—thymic idiocy,
status thymolymphaticus—and mentions the pancreatic infantilismus
referred to by Brownell, Basedow's disease, acromegaly, pluriglandular
insufficiency and other conditions already mentioned. Kraepelin has
encountered only seven "dysadenoid" forms in a study of 244 cases.
Bourneville has reported 104 cases of persistent thymus.
One of the most interesting contributions to the literature of
endocrinology is Mott's[121] suggestion that dementia praecox is due
to a combination of degenerative changes in the cortical neurones and
the generative organs. As a result of the study of twenty-two cases of
dementia praecox he found that more marked pathological changes were
found in the testes than were observed in cases of manic-depressive
insanity, alcoholic psychoses, epilepsy or paranoia. The characteristic
findings consisted in regressive changes in the seminal tubules and
abnormal staining reactions in the spermatozoa. He found more evidences
of virility in a senile individual of eighty than in any of his cases
of dementia praecox. His theory as to the pathogenesis of the disease
is based on the fact that the changes in the neurones are of the same
character—a degeneration of the nuclear elements. These findings have
not at this time been confirmed by other observers.
Timme[122] has described a psychic makeup due to subinvolution of the
thymus. "The mental picture presented by these subinvoluted thymic
states is also of great importance, for analogous to their structural
lack of differentiation is their psychic makeup. They remain child-like
in their character, so that they are self-centered; simple in their
mental processes and imitative; looking for protection and care, and
more or less unfitted for the active struggles of life. They are
obstinate and negativistic; if, however, an efficient compensation
takes place, then, although the mental development may have been
delayed, it nevertheless seems finally to reach complete maturity; and
these individuals are among the brightest and most intelligent of their
community." In cases of precocious involution of the thymus he finds
the mental condition to be of chief interest. "They are precocious,
with much initiative, are easily aroused to anger and are resentful.
They have cruel instincts and show little inhibition. Although they
seem far advanced for their years while still young, yet they never
seem thoroughly to mature, and become blocked in early adolescence.
They seem to retain their impulsive, unreasoning characteristics, brook
no restraint and remain constantly a prey to their easily aroused
anger." Of thyroid insufficiency he says: "Mentally, the patient is
dull, sluggish and with little initiative. He moves slowly and thinks
slowly, is extremely forgetful and his lethargy is occasionally
disturbed by outbursts of anger due probably to his maladjustment
to the more quickly moving world about him." In his summary of the
hyperthyroid makeup, Timme says: "Both mind and body are everlastingly
busy. And not only with present problems, but anticipatory of
tomorrow's as well. The patient shows no rest or relaxation. His mind,
filled with echoes of the day's troubles, prevents his falling to sleep
until long after he retires, and he is again awake and immediately on
the "qui vive" as soon as daylight comes." Statistics on endocrine
conditions are unfortunately not available as yet.
CHAPTER XIII
THE MODERN PROGRESS OF PSYCHIATRY
The remarkable accomplishments of medical science during the last
few decades may be looked upon as a fairly accurate index of modern
progress in general. Nor have these advances been confined to any
limited field. Standards of education have changed with almost
startling rapidity. The most extended course of instruction open
to medical students fifty or sixty years ago covered a period of
two years. Qualifications for entrance consisted in little more
than a demonstration of the candidate's ability to pay the required
matriculation fee. The three year course, only recently established
and generally recognized, was lengthened to four years during the
latter part of the nineteenth century. The number of medical colleges
has been materially reduced and the size of the graduating classes has
decreased fifty per cent or more during the last twenty-five years
as a result of the higher standards. Several of our medical schools
admit college graduates only and two years of college work is now a
minimum entrance requirement in institutions of the highest type.
Very few men feel properly equipped for taking up the practice of
medicine today until they have had an experience of at least a year in
a general hospital. The profession is tending more and more towards
specialization and the old-fashioned general practitioner is now at a
considerable disadvantage. Ophthalmology has become almost an exact
science. Gynecologists, obstetricians, pediatrists, orthopedists,
laryngologists, neurologists and internists are looked upon as almost
indispensable in a community of any size. All of these specialists are
more or less dependent on the cooperation of a pathologist, who can do
nothing without a well equipped laboratory at his disposal. Surgery has
long been regarded as a specialty which required an extended training
as well as years of experience.
The progress of modern medical science has been almost bewildering. It
has been a comparatively short time since the principles of antisepsis
and asepsis were established by Lister. The plasmodium of malaria was
described in 1880. It was not until 1882 that the tubercle bacillus was
discovered by Koch. Diphtheria was rendered an almost harmless disease
by the discovery of a specific antitoxin. The uncertainties relating
to the diagnosis of typhoid fever were entirely removed when the Widal
reaction came into general use. The Roentgen ray has revolutionized
surgery. The diagnostic and therapeutic use of tuberculin has been of
inestimable value to internal medicine. Schaudinn's discovery of the
treponema pallidum in 1905 cleared up one of the greatest scientific
mysteries of modern times. The introduction of salvarsan has added
a new and important chapter to our history of therapeutics. The
Wassermann reaction represents probably the most important diagnostic
discovery of the century. The recent studies of the so-called ductless
glands have opened up new and important fields of research which
promise to be far-reaching in their results. Social service, unknown
only a few years ago, is now an indispensable adjunct of the modern
hospital organization. Training schools for nurses have become highly
specialized educational institutions.
What is to be said of the progress made in our knowledge of mental
diseases? Certainly much has been accomplished during the last
century. The earliest American contributor to this branch of medicine
was Benjamin Rush (1745-1813), professor in the Medical Department
of the University of Pennsylvania, member of the Continental
Congress, a signer of the Declaration of Independence and one time
physician-in-chief to the American armies. His "Medical Inquiries and
Observations into Diseases of the Mind," which appeared in 1812 was the
first publication of the kind in this country. It is interesting to
note that he condemned the misuse of mechanical restraint, advocated
hydrotherapy and recommended the appointment of instructors to
direct the employment and amusement of patients. Incidentally he was
the chairman of a committee appointed by the College of Physicians
of Philadelphia to memorialize Congress and the legislature of
Pennsylvania on the evils of alcoholism. Reference should also be made
to the fact that he opposed capital punishment, advocated the abolition
of slavery and objected to the study of the classics as a required
part of the college curriculum. He even favored woman suffrage. In
addition to his other activities this remarkable man was treasurer at
one time of the United States Mint, vice-president of the American
Bible Society, one of the founders of Dickinson College and associated
for many years with Franklin in the work of the American Philosophical
Society. Certainly he was many years in advance of his time. When
his work on "Diseases of the Mind" appeared, the word psychiatry was
unknown in this country. The term lunatic, which first appeared in
the English statutes in 1320, during the reign of Edward the Second,
was still in quite general use. The only state hospital for mental
diseases was the one at Williamsburg, Virginia. Such institutions were
universally known as asylums for many years.
Insanity was generally discussed in the terminology of Pinel and
Esquirol as including mania, melancholia, dementia and idiocy. Those
not thoroughly familiar with the psychiatry of the past may not
understand the sense in which the word dementia was employed. It was
defined by Esquirol in the following terms: "There exists, therefore,
a form of mental alienation which is very distinct—in which the
disorder of the ideas, affections and determinations is characterized
by feebleness and by the abolition, more or less marked, of all the
sensitive, intellectual, and voluntary faculties. This is dementia." It
was looked upon usually as a terminal state following excitements or
depressions and in some rare instances as being primary in origin.
There have been many important developments in psychiatry since the
days of Benjamin Rush. The mania, melancholia and dementia of the
eighteenth century have apparently gone for all time. The events of
the last hundred years include more particularly the delimitation and
complete differentiation of general paresis, the rise and fall of the
paranoia concept, the description of the traumatic psychoses, the
establishment of the alcoholic insanities as clinical entities, a study
of the mental diseases due to endogenous and exogenous toxins, the
recognition of the neuroses and psychoneuroses in their modern sense,
the addition of the psychopathic personalities to our classification
and the definition of manic-depressive insanity, dementia praecox and
involutional melancholia. The mental states due to somatic conditions
have been exhaustively studied and the psychoses associated with
epilepsy and pellagra have been fully investigated. Psychology and
psychiatry have been definitely correlated and pathological research
placed upon a firm foundation. The psychiatric phraseology of today
would have been practically meaningless to the students of Pinel.
Curiously enough the word psychiatry, which goes back to nearly 1800 in
the literature of Germany and Italy has only been used for a few years
in this country and England. The word psychosis is of even more recent
origin.
This modern era may be said to have been ushered in by the preliminary
studies made of general paresis by Haslam in 1798. These were
followed by the researches of Bayle, Delaye and finally Calmeil,
which definitely established the integrity of that disease as a
clinical entity. Even then its specific origin was only a matter of
conjecture. When Esmarch and Jessen suggested that general paresis
was a syphilitic disease in 1857, their views were rejected by men as
prominent as Charcot and Déjerine. Although paranoia is a term which
has appeared in the literature of medicine for centuries, it has only
had the significance now attached to it since the latter part of the
nineteenth century. Its description was foreshadowed perhaps by the
monomania of Esquirol and Pritchard and the partial insanity of Rush
and others. Heinroth, Griesinger, Magnan, Lasègue, Régis, Falret,
Mendel, Krafft-Ebing, Herz, Snell, Werner, Schüle, Ziehen, Kraepelin
and many other well-known psychiatrists have played a part in the
evolution of paranoia which only definitely displaced the wahnsinn,
verrüchtheit, and various other designations of the earlier writers,
in the neighborhood of 1890. Paranoia is a term which has only been
infrequently used since the general acceptance of Kraepelin's paranoid
forms of dementia praecox. Its territory has been still further invaded
by paraphrenia, the fate of which, however, is somewhat uncertain as
yet. The forerunners of the psychopathic personalities were the moral
insanity of Pritchard, the insanity of degeneracy of Morel, Magnan,
Régis, Lombroso, etc., and the "demifous et demiresponsables" of
Grasset, Trélat and others. The introduction of the "constitutional
inferiority" idea into the psychiatry of this country was directly
attributable to Adolf Meyer following the work of Koch in Germany.
After the elaborate study of alcoholism made by Magnus Huss in 1852 the
psychoses due to that condition were described by Bonhöffer, Magnan,
Korsakow, Kraepelin and various other writers. The psychoneuroses
represent the developments of Brachet, who wrote on hysteria in 1847,
Briquet, Oppenheim, Lasègue, Möbius, Charcot, Janet, Babinski, Beard,
Kraepelin and many others. To Meyer again we are indebted for the
first exhaustive study and classification of the traumatic psychoses.
The description of amentia by Meynert in 1881 was of considerable
significance. The first comprehensive study of mental disorders
associated with the use of cocaine was made by Erlenmeyer in 1886. The
same writer was responsible for the first elaborate investigation of
morphinism in the year following. Circular insanity was described by
Falret in 1851 and again as "folie à double forme" by Baillarger in
1854. Hecker was responsible for an event of great importance in the
history of psychiatry when he published his description of hebephrenia
in 1871. Kahlbaum in his "Katatonia" made a contribution which was
destined to influence the future of medicine in 1874.
In the meanwhile what is to be said as to the progress of pathological
research? The earliest contribution to psychiatry from that point of
view was made by Morgagni in 1761, his opinions being based on the
autopsy reports in some thirteen cases. Greding in 1790 published the
results of autopsies in a series of thirty-seven cases. The findings
at that time included variations in the thickness of the skull,
adhesions and thickenings of the dura, changes in the consistency of
the cerebrum and cerebellum, effusions into the ventricles and various
gross defects. The early writers attached a great deal of importance
to the pineal gland changes. These pathological conditions were so
generally reported, that Portal in the eighteenth century went so far
as to say that "Morbid alteration in the brain or spinal marrow has
been so constantly observed, that I should greatly prefer to doubt the
sufficiency of my senses, if I should not at any time discover any
morbid change in the brain, than to believe that mental disease could
exist without any physical disorder in this viscus, or in one or other
of its appurtenances." Pinel spoke very discouragingly, however, of the
results and Esquirol finally reached the conclusion that nothing really
important had been accomplished after all. In his Charenton reports
(1835) he expressed himself on this subject as follows:—"However
important may have been the researches of anatomists made during our
days into diseases which affect the mind, we may venture to repeat
that pathological anatomy is yet silent as to the seat of madness,
and that it has not yet demonstrated what is the precise alteration
in the encephalon which gives rise to this disease. What shall we,
then, think of the rash pretensions of those who assume that they can
fix upon the diseased portion of the brain, judging merely from the
character of the disease?" In 1836 Guislain summarized the various
lesions found in insanity at autopsy under nine headings—congestion of
the brain or meninges or both, serous congestion of the same, cerebral
softening, adhesions of the membranes to each other or to the brain,
cerebral induration, cerebral hypertrophy, and abnormalities of the
brain or skull. The appointment of a pathologist at the Utica State
Hospital in 1868 as a result of the remarkable interest taken in this
subject by Dr. John P. Gray must be looked upon as one of the important
events in the history of American psychiatry. The later developments of
the nineteenth century included studies of general paresis, cerebral
syphilis, arteriosclerosis, senility, epilepsy, mental deficiency,
pellagra and various other somatic conditions. It may fairly be said,
at least, that pathology has kept fully abreast of the progress made by
clinical psychiatry during the nineteenth century.
Notwithstanding all of these advances, the generally recognized mental
diseases, as late as 1895, included the following types:—mania,
melancholia, dementia, imbecility, idiocy, general paresis, chronic
delusional insanity or paranoia and senile insanity. This was in
substance the psychiatry of Savage, Maudsley, Clouston, Blandfield,
Régis, Chapin, Kellogg, Spitzka, Kirchoff, Berkley and many other
well-known writers of a comparatively recent date. A new era in the
history of mental medicine was ushered in by Kraepelin when the sixth
edition of his "Psychiatrie" appeared in 1899. This established
manic-depressive insanity and dementia praecox as clinical entities.
Kraepelin called attention to the fact that excitements and depressions
frequently recur in the same individual, often with frequent attacks
but with no marked tendency towards mental enfeeblement. This class of
cases he grouped together as manic-depressive psychoses and pointed
out certain characteristics common to the excitements and depressions
included. He showed that certain other forms of depression marked
by anxiety, fear, restlessness, self-accusation, marked suicidal
tendencies, etc., were common to the involutional period of life.
To this anxious depression the name involution melancholia has been
applied, although Kraepelin is now somewhat in doubt as to its
differentiation from the manic-depressive group. To certain other
cases characterized by emotional dulness, apathy, hallucinations with
phantastic delusions, and in some types, mannerisms, negativism,
stereotypy, verbigeration, etc., tending sooner or later towards
deterioration, he attached the name dementia praecox. This included the
hebephrenia of Hecker and the katatonia of Kahlbaum.
Wernicke in 1906 advanced the hypothesis that psychical symptoms may
be attributed to disturbances of various association mechanisms. These
interruptions were to be found in various parts of the psychical
reflex arcs. This included the psychosensory tracts or receptive
mechanisms, the intrapsychical tracts or elaboration mechanisms and the
psychomotor mechanisms. Manic-depressive psychoses were looked upon as
representing a disorder of the intrapsychic mechanism, while dementia
praecox was considered to be an illustration of a disturbance of the
psychomotor mechanisms. This was an exceedingly interesting but purely
theoretical scheme for putting psychiatry on a definite anatomical and
pathological basis.
The progress made by Kraepelin, Stransky, Wernicke, Bleuler, Ziehen
and other modern psychiaters led to renewed interest in pathological
research. This was to a considerable extent due to the suggestion
of Kraepelin that dementia praecox was autotoxic and endogenous in
origin. The neurons were exhaustively studied by Alzheimer and changes
in metabolism thoroughly investigated by Folin and many others. To
the researches of Nissl and Alzheimer in 1904 we are largely indebted
for an accurate knowledge of general paresis. Studies of the cortex
in dementia praecox by Alzheimer and many others have been extremely
interesting if not conclusive. The introduction of lumbar puncture
by Quincke and the studies of the cerebrospinal fluid made by Widal,
Plaut, Nonne, Mott and others were of great aid in diagnostic
procedure. These have been supplemented by the Wassermann reaction, the
colloidal gold test, etc. The isolation of the treponema pallidum in
the cortex settled the question of the identity of general paresis and
cerebral syphilis for all time.
Another line of research responsible in no small measure for the
remarkable progress of psychiatry during the last few decades was
that instituted by Freud, Jung and others in their studies of
psychological mechanisms. It is a rather remarkable fact that it is
only in comparatively recent years that a study of the psychological
processes of the normal mind has been looked upon as essential to an
understanding of the mental reactions involved in the development of a
psychoneurosis or psychosis. This is really the basis of Freud's work.
Psychiatry may be said to be practically the only branch of medical
science in which a study of pathological processes has not been based
largely upon physiological and anatomical foundations. Our textbooks
for many years have insisted that "insanity" was a disease of the
brain but have not given much consideration to a correlation of the
physiology with the pathology of that organ. The application of
psychological methods to psychiatric research was largely a result
of the studies of hysteria by Janet. This was supplemented by the
important contribution of Breuer and Freud in 1895 calling attention
to their theories in regard to the production of the psychoneuroses
by psychic traumas, usually of a sexual nature. Freud's views
were outlined more fully in his "Selected Papers on Hysteria,"
"Three Contributions to the Sexual Theory," and his studies of the
"Psychopathology of Everyday Life," etc. The psychological processes of
dementia praecox and paranoia were subjected to elaborate studies by
Freud, Jung and various other authors.
The relation existing between psychology and psychiatry has been placed
on a very practical basis by the studies of shell shock and other
hysterical conditions so important during the recent war. Probably
nothing will contribute more towards a recognition of the importance
of psychiatry than the discovery made early in the war that mental
diseases and defects were responsible for more disabilities than were
attributable to almost any other single cause. Certainly the inactivity
of many years has been followed by an awakening which has placed modern
psychiatry on a dignified plane and its progress will now compare
favorably with the accomplishments of any other branch of medicine.
The statement is, I think, justified, that psychiatry has been
established on a thoroughly scientific basis as the result of the work
of comparatively few years. We have, however, reached a stage where
careful analyses should be made of the clinical data upon which future
progress entirely depends.
A brief consideration of existing conditions should be sufficient to
show this conclusively. Psychiatric literature is, and for many years
has been, characterized largely by an unfortunate absence of accurate
scientific information which would warrant the conclusions reached in
many instances by the authors of our textbooks. We have been subjected
to an avalanche of theories and a remarkable paucity of facts. In the
discussion of abstract propositions where concrete evidence is not
obtainable this is of course unavoidable. There has, however, been a
very noticeable oversight of many facts which the wealth of clinical
material in our hospitals has placed at our disposal. Our literature
has been filled with too many unsubstantiated statements. There is
no reason why many of the views entertained by various authorities
should be matters of personal opinion or based entirely on individual
observation. The fact that there are over two hundred thousand cases
of mental disease in the state hospitals of this country, with an
admission rate of sixty thousand annually, is sufficient evidence to
justify the statement that there is no lack of material for accurate
studies.
A brief reference to some of the discrepancies shown in a consideration
of the various psychoses will serve to illustrate the need of more
accurate information on many of these subjects. In discussing the
predisposing causes of mental diseases, for instance, White[123] made
the following statement, which is perfectly correct: "An inherited
predisposition to mental disorder is found in from 30 to 90 per cent
of cases according to different authorities, while the average for all
conditions has been estimated at from 60 to 70 per cent." Information
on this subject is certainly far from being complete or satisfactory.
The Thirty-first annual report of the State Hospital Commission shows
that of 4,492 first admissions to the New York hospitals during the
year ending June 30, 1919, 2,003, or 44.6 per cent, were reported as
having a family history of insanity, nervous diseases, alcoholism or
other neuropathic taint. As far as could be determined 55.4 per cent
showed no evidence of heredity in their family history. The necessity
of further information on this important subject would appear to be
obvious. The question as to the relation between syphilis and general
paresis may be said to have been definitely settled for all time. The
origin of this disease has, however, been the subject of controversy
since 1857. Paton[124] in a review of this discussion in 1905 states
that Gudden found a history of syphilis in 35.7 per cent of his cases,
Hirsch, in fifty-six per cent, Jolly, in sixty-nine, Mendel, in
seventy-five, and Alzheimer, in ninety per cent. In the light of our
present knowledge this difference of opinion and experience is quite
interesting and illuminating.
The most extravagant and misleading statements made about etiological
factors, perhaps, are those which relate to the alcoholic psychoses.
This was due largely to the statements of enthusiastic propagandists
who were advocating prohibitory legislation. The facts of the matter
are that when the use of liquor was unrestricted, the admission rate of
alcoholic psychoses, as shown by the New York state hospital reports,
had averaged ten per cent for a number of years (1908 to 1913).
Frequent contributions have been made from time to time to the
literature of psychiatry on the subject of dementia praecox. Voluminous
articles have been written on its pathology, psychological mechanisms,
etiology, etc. Many of the theories advanced are not in harmony with
what little definite information we possess. Many of the theses on
this subject have been based on the study of a surprisingly small
number of cases. The statement has been made[125] that attacks either
of a syncopal or epileptic nature are among the most important
physical symptoms of dementia praecox, and "occur in about eighteen
per cent of the cases." In his eighth edition Kraepelin speaks of
convulsive attacks of various sorts in sixteen per cent of all cases
of dementia praecox, and says that they also occur in a few cases of
manic-depressive insanity. These findings are certainly not consistent
with those of other observers. In a review of eight hundred cases, five
hundred of dementia praecox, one hundred and eighty of manic-depressive
insanity and sixty in each of the "allied to" groups, Simon[126] found
convulsions in less than one per cent of the total number of cases in
which epilepsy or organic conditions could be definitely excluded. In
a study of 367 cases of dementia praecox Ullman[127] found convulsive
manifestations in 2.7 per cent of the total. He also reported seizures
in 1.4 per cent of 340 cases of manic-depressive insanity. Kraepelin
formerly held that recovery was to be expected in about eight per cent
of the cases of hebephrenic dementia praecox and thirteen per cent of
the cases of katatonia (seventh edition). Notwithstanding this, he says
in his eighth edition in one place:[128] "Further investigations of a
series of observations carried on extensively and carefully for decades
must show how far the view, which is gaining in probability for myself,
is correct, that permanent and complete recoveries of dementia praecox,
though they may perhaps occur, still in any event belong to the
rarities." As Kraepelin himself suggests, the widely varying views on
this subject are due to different conceptions as to what constitutes
dementia praecox and what is to be considered a cure. Certainly we
are in need of further information. On June 30, 1918, there were
37,352 patients in the state hospitals of New York.[129] Twenty-one
thousand nine hundred and two cases were diagnosed as dementia
praecox. Fifty-four of these were discharged as recovered during the
year. This represents 3.2 per cent of the 1,687 cases discharged as
recovered, 2.8 per cent of the 1,883 cases of dementia praecox admitted
during that period (first admissions) and .2 per cent of the 21,902
cases of dementia praecox in the hospitals. The reports of the State
Psychopathic Hospital at the University of Michigan show 1.19 per cent
of recoveries in the cases of dementia praecox discharged during a
period of eleven years. Reference is made to these discrepancies not
in any spirit of criticism but for the purpose of pointing out the
necessity of utilizing such facts as may be available.
There is nothing new about this suggestion. It was strenuously
advocated by Louis, the founder of one of the greatest French schools
of medicine many years ago. This was referred to by his pupil and
admirer, Oliver Wendell Holmes, in his farewell address to the Harvard
Medical School in 1882 in the following words: "The 'numerical
system,' of which Louis was the greatest advocate, if not the absolute
originator, was an attempt to substitute series of carefully recorded
facts, rigidly counted and closely compared, for those never-ending
records of vague, unverifiable conclusions with which the classics of
the healing art were overloaded. The history of practical medicine had
been like the story of Danaides. 'Experience' had been, from time
immemorial, pouring its flowing treasures into buckets full of holes."
A determined effort has been made by the American Psychiatric
Association to correlate the activities of the various state hospitals
for mental diseases and utilize the great wealth of clinical material
within the walls of these institutions for such studies as may promote
the advancement of psychiatry. With this end in view a committee was
appointed at the annual meeting at Niagara Falls in 1913 to formulate
a plan for the compilation of statistical data relating to mental
diseases. The conclusions reached by this committee are illustrated
by the following quotation from their report in 1917: "That the
statistical data annually compiled by the various institutions for
the insane throughout the country should be uniform in plan and scope
is no longer open to question. The lack of such uniformity makes it
absolutely impossible at the present time to collect comparative
statistics concerning mental diseases in different states and
countries, and extremely difficult to secure comparative data relative
to movement of patients, administration and cost of maintenance and
additions. The importance and need of some system whereby uniformity in
reports would be secured have been repeatedly emphasized by officers
and members of this Association, by statisticians of the United
States Census Bureau, by editors of psychiatric journals, and by
administrative officials in various states. We should know accurately
the forms of mental disease occurring in all parts of the country; we
should know the movement of patients in every hospital for the insane;
we should know the cost of maintenance of patients and the amounts
spent for additions and improvements in every state hospital; we should
be able to compile annually complete data concerning these and other
matters, and compute rates and draw comparisons therefrom. Such data
would serve as the basis for constructive work in raising the standard
of care of the insane, as a guide for preventive effort, and as an aid
to the progress of psychiatry."
A permanent committee on statistics has been maintained by the
Association since 1913. The following statistical tables were
officially adopted some years ago and are now in general use: 1.
General information; 2. Financial statement; 3. Movement of patients;
4. Nativity and parentage of first admissions; 5. Citizenship of
first admissions; 6. Psychoses of first admissions, types as well as
principal psychoses to be designated; 7. Race of first admissions
classified with reference to principal psychoses; 8. Age of first
admissions classified with reference to principal psychoses; 9.
Degree of education of first admissions classified with reference to
principal psychoses; 10. Environment of first admissions classified
with reference to principal psychoses; 11. Economic condition of first
admissions classified with reference to principal psychoses; 12. Use
of alcohol by first admissions classified with reference to principal
psychoses; 13. Marital condition of first admissions classified with
reference to principal psychoses; 14. Psychoses of readmissions, types
as well as principal psychoses to be designated; 15. Discharges of
patients classified with reference to principal psychoses and condition
on discharge; 16. Causes of death of patients classified with reference
to principal psychoses; 17. Age of patients at time of death classified
with reference to principal psychoses; 18. Duration of hospital life
of patients dying in hospital, classified with reference to principal
psychoses.
An elaborate statistical manual fully explaining the use of these
tables has been furnished to the psychiatric hospitals of the country
by the Association. Since this work has been undertaken the full
cooperation of the institutions of the following states has been
assured: Alabama, Arizona, Arkansas, California, Colorado, Connecticut,
Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas,
Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan,
Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New
Hampshire, New Jersey, New Mexico, New York, North Carolina, North
Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South
Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia,
Washington, West Virginia, Wisconsin and Wyoming, and the District of
Columbia. Practically every state hospital in the United States is
now officially represented in this important movement. The success of
this undertaking has been largely due to the active cooperation of the
National Committee for Mental Hygiene through its Bureau of Statistics.
It should receive the enthusiastic support of all who are interested in
the future progress of modern psychiatry.
CHAPTER XIV
THE CLASSIFICATION OF MENTAL DISEASES
When the American Psychiatric Association first approached the problem
of formulating a definite scheme for the collection of statistical
data relating to mental diseases it was immediately confronted with
the necessity of adopting an official classification of psychoses
purely for purposes of uniformity. This undertaking, which suggested
no difficulties at the outset, led to all kinds of unexpected
complications and embarrassments. Classifications of "insanity" are
almost as old as the terms mania and melancholia and have been given a
grossly exaggerated importance by the space which for so many years has
been devoted to a consideration of this subject in textbooks. This, if
nothing else, appears to have been demonstrated quite clearly by the
discussions of the last few years.
A review of the literature of psychiatry shows that attempts to
classify the psychoses date back almost to the beginning of medical
history. Hippocrates is said to have recognized three forms of mental
disorders—mania, melancholia and dementia, although there is some
question as to his having used those terms in accordance with their
present significance. Celsus[130] also described three forms of
insanity. The first, which was accompanied by febrile symptoms, he
termed phrenitis. The second was characterized by sadness and caused by
black bile. The third was accompanied in some cases by false images,
while in others the whole mind or judgment was impaired. The Roman law
divided the dementes or mad into two classes, the excited or violent
(furiosi) and those deficient in intellect (menti capti). Aretaeus[131]
discussed mania, melancholia and dementia, apparently regarding them
as all manifestations of some one disease process. Melancholia, he
said, "does not affect all the faculties of the mind; the patients are
sad and dismayed; they are without fever." He described it as only
an initial stage of mania. Caelius Aurelianus[132] did not regard
melancholia as a form of insanity, "from which disease it differs in
that the stomach chiefly suffers, while in Madness it is the head."
Galen in his writings referred to amentia or dementia, imbecility,
mania and melancholia.
In the sixteenth century Felix Plater[133] devised the following
classification: 1. Mentis imbecillitas: Hebetudo, tarditus, oblivio,
imprudentia. 2. Mentis consternatio: Somnus immodicus, carus,
lethargus, apoplexia, epilepsia, convulsio, catalepsis, ecstasis.
3. Mentis alienatio: Stultitas, temulentia, amor, melancholia,
hypochondriacus morbus, mania, hydrophobia, phrenitis, saltus viti.
4. Mentis defatigatio: Vigiles, insomnia. Linnaeus[134] in 1763 called
his fifth class of diseases Mentales, divided into three orders:
Ideales, Imaginarii and Pathetici. Sauvages in the same year included
Hallucinationes, Morositates and Deliria under the heading of Vesaniae
in his "Nosologia Methodica." Vogel[134] in 1764 divided Paranoiae
into mania, melancholia, and amentia. Cullen in 1772 included insanity
or the Vesaniae in the neuroses, divided into four groups—Amentia,
Melancholia, Mania and Oneirodinia. He described eight varieties of
melancholia and three of mania. Oneirodinia included somnambulism and
nightmare. According to Jelliffe, Plocquet described six varieties of
delirium in his treatise on paranoia in 1772. Pinel in 1791 limited
himself to four classes of insanity—mania, melancholia, dementia
and idiotism. He looked upon melancholia as a delirium exclusively
directed upon one object or series of objects and accompanied by
sadness. Idiotism was an advanced form of dementia. Esquirol in 1838
modified Pinel's scheme somewhat and described Lypemania, Monomania,
Mania, Dementia and Imbecility or Idiocy. The active discussion of
classifications of various kinds led Pritchard[135] to make the
following interesting comment in 1822: "I cannot conceive anything
more preposterously absurd than the attempt to classify diseases with
all the divisions and technology of a botanical or zoological system,
and to force what is essentially disorder and confusion to assume the
appearance of that order and symmetry which nature displays in the
arrangement of the organized world. An aetiological classification
is the only mode of terminology and arrangement that can be of any
practical advantage, and that is all that we have to consult."
He nevertheless published a classification of his own which was
essentially psychological in principle, although containing nothing new.
The German school of this time was exceedingly prolific in the
production of classifications, as will be shown by the following
interesting and elaborate scheme of Flemming's[136] published in 1844:—
FAMILY-AMENTIA—MENTAL DISEASES
_First Group_—Infirmitas (Feeblemindedness).
Varieties:
A. According to etiology:
1. Inf. primaria, or congenita (Idiocy)
2. Inf. secundaria, or acquisita (Imbecility)
a. Inf. e. morbo (Brain injuries, encephalitis, epilepsy, etc.)
b. Inf. senilis
B. According to degree:
1. Inf. adstricta, or partial feeblemindedness (Weakness of a single
mental faculty)
a. Dysmnesia (weakness of memory)
b. Inf. adstr. surdo-mutorum (feeblemindedness of the deaf and
dumb)
c. Inf. adstr. coecorum (feeblemindedness of the blind)
2. Inf. sparsa—General (absolute or relative weakness of general
mental faculties)
_Second Group_—Vesania.
_First Order_:—Dysthymodes or Dysthymia.
Varieties:
A. According to types:
1. Dys. transitoria or subita (acute)
2. Dys. continua (chronic)
3. Dys. remittens (remittent)
B. According to degree:
1. Dys. adstricta (limited or partial)
a. Dys. atra (melancholia or lypemania)
1. Homesickness.
2. Ferocitas et morositas ebriosorum (Alcoholic excitement
and ill humor)
b. Dys. candida (cheerful dysthymia or melancholia hilaris)
c. Dys. mutabilis (changeable or alternating)
2. Dys. sparsa (apathica)—General dysthymia (melancholia attonita).
_Second Order_:—Vesania anoëtos or Anoësia—Deliria of various forms.
Varieties:
A. According to types:
1. Anoësia transitoria or subita (acute)
Species:
a. A. e febre—fever delirium
b. A. e potu—alcoholism
c. A. ex affectu—affective
d. A. semisomnis—confusion of drunken sleep
e. A. Somnambula—somnambulism
2. Anoësia continua—chronic
3. Anoësia remittens—remittent.
B. According to degree:
1. Anoësia adstricta—partial or limited
a. A. ad sensationes—hallucinatory delirium
b. A. ad cogitationes—delusional delirium
2. Anoësia sparsa—general
a. Delirium tremens
_Third Order_:—Vesania Maniaca (Mania).
Varieties:
A. According to types:
1. Mania transitoria or subita—acute
a. M. s. a febre—encephalitic delirium
b. M. s. a potu—alcoholic mania
c. M. s. ex affectu—affective mania
d. M. s. e partu—puerperal mania
e. M. s. e mordo occulto—amentia occulta, which includes the
above forms.
2. Mania continua—chronic mania
3. Mania remittens—remittent mania
B. According to degree:
1. Mania adstricta seu instinctiva—partial or limited mania. (Mania
sine delirio of Pinel.) (Moral insanity, monomania.)
2. Mania sparsa—general mania.
This is said to have been based on Jacobi's somato-aetiological
theory (1830) that "there is no disease of the mind existing as
such, but that insanity exists solely as the consequence of disease,
either functional or organic, in some parts of the body system."
Heinroth[137] saw in the various mental disorders a disturbance of one
or the other of the normal functions of the mind which he divided into
three classes. "If the cause of derangement is in relation to one of
these manifestations of mental existence—and to one or another it
must belong, since the mind is ever occupied with phenomena related
to one out of the three classes—we have only to inquire to which
modification the disorder actually refers itself, or whether it affects
the feelings, the understanding, or the will. Since one of these has
possession of our consciousness, or is at least predominant at every
point of time, whichever function of the mind happens to be that which
is falling into disorder, by it the form of insanity is determined."
Griesinger[138] in 1845, on the other hand, was of the opinion that
all classifications must in the end return to the principal forms
previously described—mania, melancholia and dementia. In 1860 Morel
announced his well-known classification: Hereditary Insanity, which
included imbecility and idiocy; Toxic Insanity (alcohol, lead, mercury,
etc., as well as cretinism); Insanity produced by the transformation
of other diseases (hysterical, epileptic, hypochondriacal); Idiopathic
Insanity (general paresis, etc.); Sympathetic Insanity, and Dementia,
"a terminative state."
Maudsley spoke of Affective or Pathetic, and Ideational Insanity.
The former was divided into maniacal perversion, melancholic
depression and moral alienation. The latter included general forms
(mania or melancholia), partial forms (monomania or melancholia),
dementia (primary and secondary), general paralysis and imbecility.
Régis described five forms of mania, five of melancholia, two of
insanity of double form, and a systematized progressive insanity.
In addition to these, he divided constitutional insanity into two
groups—the degeneracy of evolution and the degeneracy of involution.
Krafft-Ebing[139] included melancholia, mania, primary dementia,
exhaustion psychoses and terminal conditions in his group of
psychoneuroses. Under the heading of degenerative forms he described
constitutional affective insanity, paranoia and periodical insanity.
Neurasthenic, epileptic, hysterical and hypochondriacal psychoses were
grouped together under the constitutional neuroses. In addition to
this he described chronic intoxications, organic brain diseases and
arrested development. At a meeting of the International Congress of
Alienists in 1889 the following classification was adopted: 1. Mania;
2. Melancholia; 3. Periodical Insanity; 4. Progressive Systematical
Insanity; 5. Dementia; 6. Organic and Senile Dementia; 7. General
Paralysis; 8. Insane Neurosis (hysteria, epilepsy, hypochondriasis,
etc.); 9. Toxic Insanity; 10. Moral and Impulsive Insanity; and 11.
Idiocy. Ziehen[140] had a classification scheme which represented an
advance in some respects. Mania and melancholia were described as
affective psychoses, and paranoia as an intellectual disorder. He also
referred to mixed or combined forms. Imbecility, general paresis,
terminal deteriorations, etc., were grouped together under the general
heading of psychoses with intellectual defects.
The British Medico-Psychological Association has had an official
classification for many years. This was quoted by Savage[141] in 1907 as
follows:—
1. Congenital or infantile mental deficiency (idiocy or imbecility)
occurring as early in life as it can be observed:
(1) Intellectual
a. Without epilepsy
b. With epilepsy
(2) Moral
2. Insanity arising later in life:
(1) Insanity with epilepsy
(2) General paralysis of the insane
(3) Insanity with the grosser brain lesions
(4) Acute delirium (acute delirious mania)
(5) Confusional insanity
(6) Stupor
(7) Primary dementia
(8) Mania
a. Recent
b. Chronic
c. Recurrent
(9) Melancholia
a. Recent
b. Chronic
c. Recurrent
(10) Alternating Insanity
(11) Delusional Insanity
a. Systematized
b. Non-systematized
(12) Volitional Insanity
a. Impulse
b. Obsession
c. Doubt
(13) Moral Insanity
(14) Dementia
a. Secondary or terminal
b. Senile
An elaborate classification was also officially adopted by the Royal
College of Physicians of England[142] about the same time. This
recognized seven varieties of mania, seven of melancholia and six of
dementia. The subject of classifications would not be complete without
a reference to Kraepelin. His eighth edition (1910-1915) showed the
following:—
1. Psychoses accompanying Injuries to the Brain:
Concussion
Traumatic delirium
Traumatic epilepsy
Traumatic enfeeblement
2. Psychoses accompanying Diseases of the Brain:
Meningitis
Brain tumors
Abscesses
Hemorrhages
Thrombosis
Embolism
Encephalitis
Multiple sclerosis
Lobar sclerosis
Huntington's chorea
Amaurotic idiocy
3. The Intoxication Psychoses:
Acute:
Endogenous—Uraemia, Eclampsia, Acute yellow atrophy of the liver.
Exogenous—Ether, Santonin, Hashish, Nitrous Oxide Gas, Atropin,
Hyoscin, Carbonic Oxide Gas, etc.
Chronic:
Alcohol:
Delusional (jealousy)
Delirium Tremens
Korsakow's Psychosis
Acute Hallucinosis (paranoid)
Alcoholic paralysis and pseudo-paralysis
Morphine
Cocaine
4. The Infectious Psychoses:
Fever delirium
Infection delirium
Acute confusion (amentia)
Infective exhaustive conditions
5. The Psychoses of Syphilis:
Syphilitic neurasthenia
Gummatous growths
Syphilitic pseudo-paralysis
Syphilitic apoplexy
Syphilitic epilepsy
Paranoid forms
Tabetic psychoses
Hereditary syphilis
6. Dementia Paralytica:
Paralytic, Depressive, Expansive and Agitated forms
7. The Senile and Presenile Psychoses:
Presenile psychoses
Arteriosclerotic psychoses
Senile deterioration
8. The Thyroigenous Psychoses:
Basedow's Disease
Myxoedema
Cretinism
9. The Endogenous Dementias:
Dementia praecox:
Dementia simplex
Hebephrenia
Depressive dementia
Circular form
Agitated form
Periodical form
Katatonia
Paranoid form
Schizophasia
Paraphrenia:
Systematica
Expansiva
Confabulans
Phantastica
10. The Epileptic Psychoses.
11. The Manic Depressive Psychoses:
Manic form
Depressive form
Mixed form
12. The Psychogenic Disorders:
Nervous exhaustion
Dread neurosis
The Induced psychoses
The psychoses of the Deaf
The Accident or Traumatic neuroses
The Psychogenic disorders of Prisoners
The Querulants
13. Hysteria
14. Paranoia
15. The Constitutional Disorders:
Nervousness
The Compulsion neuroses
The Impulsion neuroses
Sexual perversions
16. The Psychopathic Personalities:
The Excitable
The Unstable
The Impulsive
The Eccentric
The Liar and Swindler
The Antisocial
The Quarrelsome
17. Defective Mental Development (oligophrenia)
At the annual meeting of the American Medico-Psychological Association
in 1869 Nichols called attention to the statistical studies proposed
by the International Congress of Alienists in 1867. As a result of
his efforts a series of twenty-one statistical tables was prepared
and used unofficially for several years, although never formally
adopted. A committee reported again on this subject in 1896, but
without any definite action being taken. The Italian psychiatrists have
had a classification which has been in general use by them for some
time. Interest in this subject has been stimulated by the frequent
publications of Kraepelin during the last thirty years. Meyer and Hoch
have been largely responsible for bringing his work to the attention
of the profession in this country, and Kraepelin's classification with
some modifications has come into very general use here. It was not
until the publication of its twenty-first annual report in 1909 that
the New York State Commission in Lunacy adopted a modern classification
of psychoses.
At that time there were practically as many different forms of
statistical reports in the United States as there were hospitals. In
the meanwhile almost every textbook published during the last fifty
years has announced a new classification of mental diseases. They have
been based on etiology, pathology, symptomatology and psychology.
English, French, German, Italian and American classifications
have appeared, each representing, as a rule, different schools of
psychiatry. Kempf[143] would discard the term psychosis altogether
and speak only of neuroses as "more consistent with the integrative
functions of the nervous system." For diagnostic purposes he proposes
to separate the benign from the pernicious processes and classify them
according to their psychological mechanisms as suppression, repression,
compensatory, regression and dissociation neuroses. The easiest way
out of all these difficulties, as Southard[144] has said, would be "to
deny the existence of entities in mental disease. There are two forms
of this contention; first, that mental disease is nothing more or less
than insanity, an entity itself, a genus with but one species, or
secondly, that all victims of mental disease are individually to be
provided with entities, that is, all examples of mental disease are sui
generis. The development of psychiatry has killed the former contention
stone dead, but the latter contention still flourishes to an extent
among those who overstress the individual factor. And this latter
contention is bolstered up by the existence of so many psychopathic
patients of whom a diagnosis cannot be rendered for practical or
theoretical reasons. However, there are no really consistent advocates
of the sui generis plan of classification." It is interesting to
note that he concedes ... "that the American Medico-Psychological
Association's classification, adopted as it has been by a great number
of American institutions and by the United States Government for war
purposes, is a reasonably good classification and aware that its
constituent elements fairly well correspond with what all American
psychiatrists agree upon."
Southard[145] raises the question as to how this classification can
be used for diagnostic purposes. He answers this query by suggesting
"A key to the practical grouping of mental diseases"[146] ... "to be
followed, when necessary, like a botanical key in the search for
the classification of a plant."... "It is a key to study and not an
analytical classification with any pretence to finality."... "The plan
is not so much an excursion into nosology as an essay in the technique
of psychiatric diagnosis for the tyro."
The problem presenting itself in the adoption of a classification
purely for statistical purposes was not a question of a scientific
grouping of the psychoses based on either etiological, anatomical,
pathological, clinical or prognostic considerations. It was a question
of compiling a tabulation or list of clinical entities recognized
generally by American psychiatrists, subject to such changes and
modifications as may be necessary to make it conform to accepted
standards. As a matter of fact, no adequate reason for a classification
of mental diseases for any other than statistical purposes has even
been advanced by the authors of our textbooks on psychiatry. They
do not contribute anything of value whatever to our knowledge of
symptomatology, diagnosis or treatment. Practically the only point
on which the writers of our textbooks agree is that there is no one
fundamental principle upon which a satisfactory classification can be
based. It is unfortunate that tradition seems to demand the serious
consideration of a problem which many believe admits of no solution and
which would mean little or nothing to the future of psychiatry if it
were solved. The views of the Committee on Statistics are shown by a
quotation from the report made to the Association at its meeting in
New York in 1917:—"Your Committee feels that the first essential
of a uniform system of statistics in hospitals for the insane is a
generally recognized nomenclature of mental diseases. The present
condition with respect to the classification of mental diseases is
chaotic. Some states use no well-defined classification. In others the
classifications used are similar in many respects but differ enough
to prevent accurate comparisons. Some states have adopted a uniform
system, while others leave the matter entirely to the individual
hospitals. This condition of affairs discredits the science of
psychiatry and reflects unfavorably upon our Association, which should
serve as a correlating and standardizing agency for the whole country.
The large task of your Committee therefore has been the formulation of
a classification which it could unanimously recommend for adoption by
the Association. The task was accomplished only after several prolonged
conferences at which classifications now in use in various states
and countries, and the recommendations of leading psychiatrists were
considered. The classification finally adopted is simple, comprehensive
and complete; it copies no other classification but includes the strong
features of many others; it meets the demands of the best modern
psychiatry but does not slavishly follow any single system. In short,
your Committee has endeavored to formulate a classification that could
be easily used in every hospital for the insane in this country and
that would meet the scientific demands of the present day."
Since the compilation of statistical data relating to the various
activities of the hospitals for mental diseases in this country was
definitely decided upon by the Association at its meeting in 1913,
the membership of the Committee on Statistics has from time to time
included the following:—Dr. Thomas W. Salmon, Medical Director,
National Committee for Mental Hygiene; Dr. Owen Copp, Physician in
Chief and Superintendent, Pennsylvania Hospital, Department for
Nervous and Mental Diseases; Dr. E. Stanley Abbot, Medical Director,
Public Charities Association of Pennsylvania; Dr. Henry A. Cotton,
Medical Director, New Jersey State Hospital, Trenton; Dr. L. Vernon
Briggs, Boston, former member of the Massachusetts State Board of
Insanity; Dr. Adolf Meyer, Professor of Psychiatry, Johns Hopkins
University; Dr. Albert M. Barrett, Professor of Psychiatry and
Neurology, University of Michigan; Dr. George H. Kirby, Director
of the Psychiatric Institute, New York City; Dr. Samuel T. Orton,
Professor of Psychiatry and Director of the Psychopathic Hospital,
University of Iowa; Dr. Frankwood E. Williams, Associate Medical
Director, National Committee for Mental Hygiene; Dr. Elmer E. Southard,
Director of the Massachusetts State Psychiatric Institute; Dr. C.
Macfie Campbell, Director of the Boston Psychopathic Hospital, and the
writer. Associated with the committee officially were: Dr. August Hoch,
formerly Director of the Psychiatric Institute, New York; Dr. H. M.
Pollock, Statistician of the New York State Hospital Commission; Miss
Edith M. Furbush, Statistician of the National Committee for Mental
Hygiene, and various others.
The Association's classification of mental diseases at this time (1921)
is as follows:
1. Traumatic psychoses:
(a) Traumatic delirium
(b) Traumatic constitution
(c) Post-traumatic mental enfeeblement (dementia)
(d) Other types
2. Senile psychoses:
(a) Simple deterioration
(b) Presbyophrenic type
(c) Delirious and confused types
(d) Depressed and agitated type
(e) Paranoid types (f) Pre-senile type (g) Other types
3. Psychoses with cerebral arteriosclerosis
4. General paralysis
5. Psychoses with cerebral syphilis
6. Psychoses with Huntington's chorea
7. Psychoses with brain tumor
8. Psychoses with other brain or nervous diseases:
(a) Cerebral embolism
(b) Paralysis agitans
(c) Meningitis, tubercular or other forms (to be specified)
(d) Multiple sclerosis
(e) Tabes dorsalis
(f) Acute chorea
(g) Other diseases (to be specified)
9. Alcoholic psychoses:
(a) Pathological intoxication
(b) Delirium tremens
(c) Korsakow's psychosis
(d) Acute hallucinosis
(e) Chronic hallucinosis
(f) Acute paranoid type
(g) Chronic paranoid type
(h) Alcoholic deterioration
(i) Other types, acute or chronic
10. Psychoses due to drugs and other exogenous toxins:
(a) Opium (and derivatives), cocaine, bromides, chloral, etc., alone
or combined (to be specified)
(b) Metals, as lead, arsenic, etc. (to be specified)
(c) Gases (to be specified)
(d) Other exogenous toxins (to be specified)
11. Psychoses with pellagra
12. Psychoses with other somatic diseases:
(a) Delirium with infectious diseases
(b) Post-infectious psychosis
(c) Exhaustion delirium
(d) Delirium of unknown origin
(e) Cardio-renal diseases
(f) Diseases of the ductless glands
(g) Other diseases or conditions (to be specified)
13. Manic-depressive psychoses:
(a) Manic type
(b) Depressive type
(c) Stuporous type
(d) Mixed type
(e) Circular type
(f) Other types
14. Involution melancholia
15. Dementia praecox:
(a) Paranoid type
(b) Catatonic type
(c) Hebephrenic type
(d) Simple type
(e) Other types
16. Paranoia or paranoid conditions
17. Epileptic psychoses:
(a) Epileptic deterioration
(b) Epileptic clouded states
(c) Other epileptic types (to be specified)
18. Psychoneuroses and neuroses:
(a) Hysterical type
(b) Psychasthenic type
(c) Neurasthenic type
(d) Anxiety neuroses
(e) Other types
19. Psychoses with psychopathic personality
20. Psychoses with mental deficiency
21. Undiagnosed psychosis
22. Without psychosis
(a) Epilepsy without psychosis
(b) Alcoholism without psychosis
(c) Drug addiction without psychosis
(d) Psychopathic personality without psychosis
(e) Mental deficiency without psychosis
(f) Others (to be specified)
PART II
THE PSYCHOSES
CHAPTER I
THE TRAUMATIC PSYCHOSES
Traumatic affections of the nervous system have been recognized in a
general way for centuries, although the psychoses resulting directly
from injuries have been given very little consideration or attention
in the past. Concussion of the brain, referred to in the writings of
Hippocrates, Galen and Celsus, was first studied postmortem in 1705 by
Littré. It is now discussed in all textbooks on surgery. Usually milder
forms are described with evidences of shock or collapse—a brief period
of unconsciousness, partial or complete, with visual and auditory
disturbances, dizziness, muscular relaxation or temporary paralysis,
respiratory symptoms, dilated pupils, weakness of the pulse, lowered
temperature, etc. Delirium and stupor or coma are associated with more
severe injuries. If the cortex is lacerated, twitchings or convulsions
often occur. Returning consciousness shows various reactions—headache,
vomiting, amnesia, etc., and may be succeeded by convulsions,
encephalitis or mental disturbances. DaCosta[147] says that some cases
are followed by a complete change in the personality, forgetfulness,
headache, insomnia, attacks of depression, lassitude and vertigo with
increased susceptibility to alcohol, heat and physical exertion.
Acute surgical injuries, and compression due to growths, hemorrhages,
fractures, etc., have been exhaustively studied. Compression has been
differentiated surgically[148] by the later appearance of a gradual
unconsciousness, more definite paralysis, usually on the side opposite the
injury, slow pulse and stertorous respirations, unequal immobile
pupils, choked disc, convulsive movements, etc. Traumatic encephalitis
and meningitis have long been recognized but present no definitely
characteristic symptoms which distinguish them from simple inflammatory
reactions.
One of the earliest accurate descriptions of brain injury associated
with mental symptoms was that of the well-known "crowbar" case. It will
be recalled that while blasting in Vermont in 1848 a man by the name of
Gage had an iron bar driven through the frontal region of his skull,
making a complete recovery and living for over twelve years after
the accident. An autopsy showed that only the prefrontal cortex was
involved. A very interesting report on his mental condition was made by
Dr. John M. Harlow:[149] "His contractors, who regarded him as the most
efficient and capable foreman in their employ previous to his injury,
considered the change in his mind so marked that they could not give
him his place again. The equilibrium, or balance, so to speak, between
his intellectual faculties and animal propensities seems to have been
destroyed. He is fitful, irreverent, indulging at times in the grossest
profanity (which was not previously his custom), manifesting but little
deference for his fellows, impatient of restraint or advice when it
conflicts with his desires, at times pertinaciously obstinate yet
capricious and vacillating, devising many plans of future operations,
which are no sooner arranged than they are abandoned in turn for others
appearing more feasible. A child in his intellectual capacity and
manifestations, he had the animal passions of a strong man. Previous
to his injury, though untrained in the schools, he possessed a well
balanced mind, and was looked upon by those who knew him as a shrewd,
smart business man, very energetic and persistent in executing all his
plans of operation. In this regard his mind was radically changed, so
decidedly that his friends and acquaintances said he was 'no longer
Gage.'"
Various other cases reported have established the fact that mental
deterioration usually follows extensive injuries to the frontal lobes.
Witmer[150] summarizes this as consisting of "slight intellectual
degradation, moral and emotional perversion, deficiency of attention,
and volitional inefficiency."
A work by Ericksen in 1866 on "Railway Injuries to the Nervous
System" and Page's book in 1882 on "Injuries of the Spine" pointed
the way to an extensive study of the so-called traumatic neuroses.
This characterization of the functional disturbances of the nervous
system following injuries was apparently the result of a monograph by
Oppenheim on that subject in 1889. They had previously been considered
as purely organic in origin. Traumatic hysteria was discussed very
fully at various times by Charcot, whose work is so well known as to
require no comment. In 1892 Friedmann described a vasomotor complex
due to concussion. This is accompanied by such symptoms as headache,
dizziness, loss of capacity for both physical and mental work with
an increased fatigability, irritability, memory defects, and changes
in personality, such as sensitiveness and eccentricity with a marked
intolerance to alcohol. This condition appears some time after the
symptoms of concussion and shock have subsided and may last for some
months. Friedmann looked upon this as purely a vasomotor disturbance.
It is probably an important factor, in some cases at least, of
"shell shock". Traumatic epilepsy may result from foci of softening
or other local areas of injury to the brain. Neurasthenia, hysteria
and other neuroses are now generally looked upon as being essentially
functional and not organic in origin, although they may follow a
trauma. The simulation of these conditions has led to a great deal of
discussion, notwithstanding the fact that Oppenheim found them in only
about four per cent of his cases. Köppen (1897) made a very elaborate
study of the postmortem lesions in the "traumatic neuroses". He found
that violence to the skull often resulted in small injuries at the
base of the frontal area, at the apices of the parietal lobes or in
the occipital region. The pathological changes involved represented
localized encephalitis with hemorrhagic infiltration. Foci of softening
were often found in the cerebral cortex. He noted coma and convulsions
with only minute areas of destruction of the basal cortex at autopsy.
This would indicate a severe irritation, probably due to circulatory
disturbances. The resulting symptoms he thought were very likely to be
confused with general paresis. In cases of extreme dementia following
traumatism he often found no pathological lesion other than a cicatrix
in the cerebral cortex.
One of the most important contributions to the literature of traumatism
as associated with psychoses was made by Adolf Meyer[151] in 1903.
Notwithstanding the statements of such observers as Savage, appearing
as late as 1905, he expressed the opinion that traumatism and general
paresis are not directly related except that injuries may rarely act as
precipitating factors. He does not expect to find psychoses resulting
from small lacerations or other similar lesions in the cortex. As a
result of his observations Meyer[152] described the following forms of
traumatic disorders:—
1. The direct post-traumatic deliria with the following subdivisions:
a. Preeminently febrile reactions;
b. The delirium nervosum of Dupuytren, not differing from deliria
after operations, injuries, etc.;
c. The delirium of slow evolution of coma, with or without alcoholic
basis;
d. Forms of protracted deliria, usually with numerous tabulations,
etc. (with or without alcoholic or senile basis).
2. The post-traumatic constitution:
a. Types with mere facilitation of reaction to alcohol, grippe, etc.;
b. Types with vasomotor neurosis;
c. Types with explosive diathesis;
d. Types with hysteroid or epileptoid episodes, with or without
convulsions (such as most reflex psychoses);
e. Types of paranoic development.
3. The traumatic defect conditions:
a. Primary defects allied to aphasia;
b. Secondary deterioration in connection with epilepsy;
c. Terminal deterioration due to progressive alterations of the
primarily injured parts, with or without arteriosclerosis.
4. Psychoses in which trauma is merely a contributing factor:
a. General paralysis, with or without traumatic stigmata;
b. Manic-depressive and other transitory psychoses, catatonic
deterioration and paranoic conditions, with or without traumatic
stigmata.
5. Traumatic psychoses from injury not directly affecting the head.
The most interesting feature perhaps of this classification is the
post-traumatic constitution. Meyer[153] quotes Köppen's excellent
description of this condition as follows:—"Men who have suffered from
a cranial lesion in which there has been a severe damage of the brain,
with or without an injury to the cranial bones, on their recovery from
the immediate results complain especially of all kinds of sensations
in the head, which they describe either as pain or as pressure with
feeling of crawling or dullness of the head, more or less definitely
located at the point where they were hit. They frequently become
dizzy, and at times even faint for a short time without any epileptic
attack. Although slight attacks of dizziness may recur frequently,
epilepsy with typical attacks need not develop. There is further in our
patients a great irritability and nervosity. The formerly good-natured
or even-tempered persons become irascible, hard to get along with;
formerly conscientious fathers cease to care for their family. The
irritability at times increases to excessive violence in which actions
occur of which they have no remembrance; the nervous system is not only
under the influence of psychic irritation but especially susceptible
to the influence of alcohol or tobacco, in even small quantities. The
working capacity of our patients is very poor. It suffers variously,
although such individuals often give an impression of perfect capacity;
and since the morbid symptoms are essentially subjective, they always
arouse doubts whether they could not do something at least, even if
they are unable to work in a noisy shop or on a high scaffolding. It
is, however, certain that the patients are very forgetful; in giving
orders or doing errands they make the most incredible blunders;
frequently everything must be written down. Their capacity for thought
has suffered, as is sometimes shown, especially in the great slowness
of thought. These patients are unable to concentrate their attention,
not even in occupations which serve for mere entertainment, such as
reading or playing cards. They like best to brood unoccupied; even
conversation is rather obnoxious. This point is so characteristic that
it gives a certain means of distinction from simulation, which as a
rule does not interfere with taking part in the conversations and
pleasures of the ward and playing at cards, which means as a rule too
much of an effort for the brain of actual sufferers. The patients are
usually advised to take light physical work, but even there they are
perfectly useless. Excessive sensitiveness of their head obliges them
to avoid all work which is connected with sudden jerks, bending over is
especially troublesome; and there is hardly any physical work in which
this can be avoided; the blood rushes to the head, headache increases,
dizziness sets in and the work stops. Patients feel best when in the
open air, inactive and undisturbed. There are but few objective signs,
such as increase of pulse, flushing of the face, dermatographia,
trembling and uncertainty in the Romberg position, such as is shown
in all general nervosity. But the complaints are so exceedingly
uniform that the uniformity of the subjective complaints justifies the
conclusion that they are well founded. The picture thus is briefly
that of a mental weakness shown by easy fatigue, slowness of thought,
inability to keep impressions, irritability, and a great number of
unpleasant sensations, before all headaches and dizziness."
It is exceedingly interesting to note that Schläger in discussing
disorders resulting from concussion of the brain, in 1857, as quoted by
Griesinger,[154] makes the following comment on these cases:—"Very often
the character and disposition changes; in 20 cases great irascibility,
an angry, passionate manner even to the most violent outbursts
of temper was remarked—less frequently over-estimation of self,
prodigality, restlessness, disquietude; in 14 cases there were attempts
at suicide, frequently weakness of memory, confusion." Meyer found,
furthermore, in his analysis "all the possible degrees of episodes
of more or less dazing and dream states; from a temporary dazed
feeling to episodes of hysteriform or epileptoid absences. Apart from
the subjective feeling of haziness, the characteristic trait is the
occurrence of complete dream interpretations and peculiar fabrications,
which color the primary traumatic insanity as well as the subacute and
episodic types, and even the paranoic type."
Kraepelin[155] describes concussion and compression, traumatic
delirium, traumatic epilepsy and traumatic mental enfeeblement. He
finds these conditions due to concussion, compression or injury to
the brain substance either at the site of traumatism or at some
point opposite. There may be contusions, lacerations of the brain
tissue or hemorrhages, usually in the frontal, occipital or parietal
regions. Injuries to the cortex are not demonstrable in all cases. The
circulatory disturbances he considers an important factor and thinks
that they account for smaller lesions of the cerebral tissue in many
instances where no gross changes are apparent. More or less disturbance
of consciousness is to be expected in these conditions. The patient is
somewhat dull, drowsy, clumsy, forgetful and absentminded. Memory is
sometimes much affected. In more severe cases there is a complete loss
of consciousness which may last a few minutes only or be a matter of
hours or days. On waking, the patient is bewildered and confused, with
a marked disturbance of apprehension. Perception is involved as in the
recognition of complicated pictures or the understanding of long and
detailed statements. A clear comprehension of events and surroundings
is lacking. The patients may know that they are in a hospital without
knowing what hospital it is or why they are there and are unable to
recognize persons around them. Occasionally hallucinations of sight
or of hearing occur. At times delusional ideas are expressed, usually
of a depressive type. They have no realization whatever of their own
condition. The memory disturbance may take the form of a Korsakow's
complex. Memory gaps appear sometimes for events just before the
accident and in other cases cover long periods of time. While as a rule
events of the remote past are retained, recent impressions are quickly
lost. They cannot repeat what is read to them, do not remember
the names of persons about them, and sometimes show evidence of
falsification of memory with fabrication. All idea as to time is
usually lost. Mental reactions become noticeably difficult. The patient
is distractible, cannot count accurately, has difficulty in repeating
dates and numbers and forms no correct judgment as to his own personal
affairs. Many express themselves, however, on the other hand, with
great facility and readiness. Some show considerable fatigability.
The mood is often elated with a tendency to facetiousness, although
frequently tearful and anxious, particularly at night. Irritable,
faultfinding trends usually appear later. As a rule they are talkative,
restless, sensitive, abusive or even insolent. Bonhöffer has reported
stereotypies as well as stuporous and other catatonic types. In speech
the patients often become incoherent, make mistakes, forget words
or coin new ones. Similar mistakes appear in reading and writing.
Asymbolism and parapraxia are observed. Residual symptoms of the brain
injury are headaches, dizziness, fainting attacks and convulsions. The
pupils are contracted and do not react properly to light. The pulse is
frequently very slow.
In fractures at the base of the brain there is likely to be a
hemorrhage from the ears and deafness from injuries to the labyrinth.
Involvement of the pyramidal tracts may cause unilateral weakness or
even paralysis, with increased knee-jerks and occasionally a Babinski
reflex. Usually the mental symptoms appear promptly after the injury.
Sometimes, however, there is for a while only a slight dulness.
The patients are unable to go about the house unassisted, and act
peculiarly, becoming clouded or delirious after a few hours or days.
Improvement begins to show itself in a few weeks as a rule unless
some intercurrent affection intervenes, but the symptoms may persist
for several months. Meningitis or abscess formation often causes
death. These developments are usually indicated by a marked delirium
or coma. There may also be paralysis, convulsions, disturbances of
speech, rise of temperature, etc. The subsidence of active delirious
symptoms is sometimes succeeded by Kraepelin's traumatic neurosis.
Following the traumatic delirium or concussion psychosis described,
mental enfeeblement sometimes appears. Clouding of consciousness is
not a factor in this condition. There is usually a complete change
in the psychic personality. The patients tire easily, are incapable
of sustained mental efforts, forgetful, absentminded, complain
of dizziness, dulness, noises in the ears, pressure in the head,
migraine, palpitation, etc. Or they may be irritable, with outbursts
of anger often alternating with apathy. Some are depressed, anxious or
hypochondriacal. There is a greatly increased susceptibility to alcohol
and intoxication often induces excitements, epileptiform attacks,
stupors or rarely actual dreamstates.
Wildermuth found a history of traumatism in 3.8 per cent of his cases
of epilepsy. The statistics of the German Army show 4.2 per cent. When
the convulsive manifestations are in the foreground and the picture
is one of traumatic epilepsy, advanced mental deterioration may be
exhibited, with impairment of mental capacity and disturbance of
memory. These cases remain apathetic, forgetful, dull, irritable and
childish. At autopsy there are often no evidences of any great injury
to the brain. Occasionally extensive areas of softening may, however,
be found. Usually there is a widespread destruction of the nerve cells
and their associated fibres. There is often a proliferation of the
glia, with changes in the vessel walls which may be thickened and
dilated, with capillary hemorrhages and softenings. Extensive areas
of the cortex may be involved. Bleuler's description of the traumatic
psychoses is not essentially different from that of Kraepelin.
The differentiation of these conditions as suggested in the statistical
manual of the American Psychiatric Association is as follows:—
"The diagnosis should be restricted to mental disorders arising as a
direct or obvious consequence of a brain (or head) injury producing
psychotic symptoms of a fairly characteristic kind. The amount of
damage to the brain may vary from an extensive destruction of tissue
to simple concussion or physical shock with or without fracture of the
skull.
"Manic-depressive psychoses, general paralysis, dementia praecox, and
other mental disorders in which trauma may act as a contributory or
precipitating cause, should not be included in this group.
"The following are the most common clinical types of traumatic
psychosis and should be specified in the statistical record of the
hospital:—
"(a) Traumatic delirium: This may take the form of an acute delirium
(concussion delirium), or a more protracted delirium resembling the
Korsakow mental complex.
"(b) Traumatic constitution: Characterized by a gradual post-traumatic
change in disposition with vasomotor instability, headaches,
fatigability, irritability or explosive emotional reactions; usually
hyper-sensitiveness to alcohol, and in some cases development of
paranoid, hysteroid, or epileptoid symptoms.
"(c) Post-traumatic mental enfeeblement (dementia): Varying degrees of
mental reduction with or without aphasic symptoms, epileptiform attacks
or development of a cerebral arteriosclerosis.
"(d) Other types."
We have not as yet, unfortunately, sufficient data at our disposal to
warrant intelligent conclusions as to the frequency of the various
forms of traumatic psychoses. One hundred and twenty-seven cases
reported from the New York state hospitals during a period of six years
were classified as follows:—
_Form_ _Number_ _Per cent_
Traumatic delirium 38 29.32
Traumatic constitution 32 25.19
Post traumatic mental enfeeblement 32 25.19
Others, not specified 25 19.70
Undoubtedly with a more definite understanding as to the delimitation
of these different conditions more complete information will be
available later. We are nevertheless justified in feeling that the
frequency of the traumatic psychoses considered as a group can be
determined with a fair degree of accuracy. Of 49,640 first admissions
to the New York hospitals during a period of eight years, 161, or .32
per cent, were definitely ascribed to traumatism. Twenty-one other
hospitals in fourteen different states reported forty-five cases of
traumatic psychoses (.24 per cent) in 18,336 admissions. Two hundred
and seventeen cases (.3 per cent) have therefore been reported in a
total of 70,987 first admissions to forty-eight state hospitals for
mental diseases in this country.