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.