Transcriber's Note:

Punctuation and possible typographical errors have been changed.

Archaic, variable and inconsistent spelling have been preserved.

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

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

MENTAL DISEASES

A Public Health Problem

BY

JAMES V. MAY, M.D.

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

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

WITH A PREFACE BY

THOMAS W. SALMON, M.D.

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

BOSTON

RICHARD G. BADGER

THE GORHAM PRESS

Copyright, 1922, by Richard G. Badger

All Rights Reserved

Made in the United States of America

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

PREFACE

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

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

Thomas W. Salmon.

Larchmont, New York,
January 11, 1922.

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:

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):

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:

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:

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:

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:

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:

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:

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:

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:

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).