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THE KINGDOM OF EVILS 
 
f^^^ 
 
 THE MACMILLAN COMPANY 
 
 NEW YORK • BOSTON' • CHICAGO • DALLAS 
 ATLANTA • SAN FRANCISCO 
 
 MACMILLAN & CO., Limited 
 
 LONDON • BOMBAY • CALCUTTA 
 MELBOURNE 
 
 THE MACMILLAN CO. OF CANADA, Ltd. 
 
 TORONTO 
 
 
THE KINGDOM OF EVILS 
 
 Psychiatric Social JVork Presented in One Hundred Case Histories To- 
 gether with a Classification of Social Divisions of Evil 
 
 BY 
 
 E. E. SOUTHARD, M.D. 
 
 Late Bullard Professor of Neuropathology, Harvard Medical School; Pathologist 
 
 Massachusetts Commission on Mental Diseases; Director, Boston Psychopathic 
 
 Hospital; President, American Medico-Psychological Association 
 
 MARY C. JARRETT 
 
 Associate Director, Smith College Training School for Social Work; formerly Chiei 
 of Social Service, Boston Psychopathic Hospital 
 
 WITH AN INTRODUCTION BY 
 
 RICHARD C. CABOT, M.D. 
 
 Professor of Social Ethics, Harvard University 
 AND 
 
 A NOTE UPON LEGAL ENTANGLEMENT 
 AS A DIVISION OF EVIL BY 
 
 ROSCOE POUND 
 
 Dean of the Harvard Law School 
 
 BOSTON COLLEGE LI BRAKY 
 CHESTNUT HILL, MASS. 
 
 THE MACMILLAN COMPANY 
 1922 
 
 All rights reserved 
 
PRINTED IN THE UNITED STATES OF AMERICA 
 
 Copyright, 1922, 
 By the MACMILLAN COMPANY. 
 
 Set up and printed. Published October, 1932. 
 
 Press of 
 J. J. Little & Ives Company 
 New York. U. S. A. 
 
 14 
 
To 
 
 The Memory of 
 
 JOSIAH ROYCE 
 
 WHOSE WORK ON 
 
 THE SOCIAL CONSCIOUSNESS 
 
 THE PROBLEM OF EVIL AND 
 
 THE PRINCIPLES OF ORDER 
 
 HELD OUR OWN WORK 
 
 IN SOLUTION. 
 
PREFACE 
 
 The writing of this book had been completed, with the excep- 
 tion of a few passages, and the form of it had been planned 
 before Dr. Southard's sudden death from pneumonia in Feb- 
 ruary, 1920. He had said that he would do no more work 
 upon it after February first, for one might continue indefi- 
 nitely to elaborate a book such as this. We felt that its chief 
 value would lie in the suggestiveness of the ideas presented and 
 not in their completeness. It was not intended that the book 
 should be either a treatise or a text-book, but a record of ex- 
 perience with comment. Such a work might serve several 
 purposes, — to suggest ideas to social workers, to reveal to other 
 professional persons the nature of social work, and to throw 
 light upon the problems of mental hygiene for all persons inter- 
 ested in human life. Mr. Pound has said that "it is a book 
 to quarry in." 
 
 Among the passages that Dr. Southard had not written were 
 some on medical subjects, which his friend. Dr. Harry C. 
 Solomon, was kind enough to write in accordance with views 
 held by Dr. Southard. 
 
 The cases were not chosen as examples of successful social 
 work, but were selected because they were believed to be in- 
 structive, whether by reason of success or failure. 
 
 The work of the social service of the Psychopathic Hospital 
 during the period that this book records was the sum of much 
 earnest and thoughtful effort on the part of many workers, 
 assistants, students, and volunteers, to whom I wish that I 
 might make personal acknowledgment at this time. Among 
 the assistant social workers who had most to do with the de- 
 velopment of the work were Mrs. Helen Anderson Young, 
 Mrs. Maida H. Solomon, Miss Helen Wright, and Miss 
 
viii PREFACE 
 
 Dorothy Q. Hale. Among the physicians who helped most to 
 develop the social work of the hospital were Dr. Herman M. 
 Adler, Dr. A. Warren Stearns, Dr. Abraham Myerson, Dr. 
 Frankwood E. Williams, and Dr. Harry C. Solomon. 
 
 Mary C. Jarrett. 
 Boston, 
 
 July 22,, 1922. 
 
INTRODUCTION 
 
 This book should appeal to a very wide pubhc because it is 
 a vivid transcript of poignant human experience — a record of 
 human misfortunes and their healing. But this record should 
 be especially illuminating because it is written by a man who 
 was many men at once. He gathered these human documents 
 as a student of mental disease and mental suffering; but he 
 saw them also with the sympathies of a social worker and the 
 insight of a philosopher. Philosophers do not often go to 
 psychiatric hospitals. Psychiatrists are rarely of a philosophic 
 turn of mind. Neither philosophers nor psychiatrists have 
 until lately been concerned with concrete, moral, educational, or 
 juristic problems, with which the authors here deal. 
 
 But Dr. Southard has in this book given us the mirror image 
 of his many-sided mind, incurably interested in all human suf- 
 fering, no matter where it led or whence it came, unwilling to 
 confine his interest within any boundaries, — scientific, profes- 
 sional, or temperamental, — until he had understood a sufferer's 
 troubles to the bottom. He has given us, therefore, a book 
 full of cross-lights. He lights education from the side of medi- 
 cine, law, and economics. He shows the doctor how he looks 
 to the educator, to the lawyer, and to the social worker. He 
 brings medical habits of thought into jurisprudence, economics, 
 and education. 
 
 The book is full of technical terms not all of which are 
 translated. But their meaning is soon clear from the context 
 and their inclusion, — unexplained, — gives one a stimulating 
 sense of looking straight into a busy workshop and gathering 
 there the unexpurgated details of the situation. A heightened 
 sense of reality and frankness results. Meantime, we get a sat- 
 isfactory familiarity with the psychiatric jargon with which 
 ere long pretty much all professions must be familiar. Army 
 men will have to know it — since so many malingerers are psy- 
 chopaths and so many mental tests (psychologic) are sure to 
 be incorporated in the army routine of the future. 
 
 Judges and lawyers have for some years past been getting 
 
X INTRODUCTION 
 
 inoculated with the terms, the mental habits, and concepts of 
 the psychiatrist, since defective delinquents, epileptics, and the 
 feeble-minded, as well as the insane, so often are before the 
 courts. 
 
 Politicians and lawmakers must be familiar with the 
 methods and concepts employed in this book. For our laws 
 on sedition, our problems of free speech, the purposes and per- 
 formances of our prison officials, almshouse superintendents, 
 and asylum attendants can be judged only in the light of psy- 
 chiatric tests and psychiatric results. 
 
 * * * * 
 
 The book is written in part to illustrate how doctor and 
 social worker can co-operate in the care of the mentally 
 deranged. It also illustrates, I think, how fruitful such co- 
 operation can be, because the doctor, whose long suit is diag- 
 nosis, gets the aid of one much stronger than he on treatment, 
 — namely, the social worker. After the diagnosis there is 
 often little that the doctor, unaided, can do. The social worker 
 comes to the front just there. Provided she can get a diagnosis 
 and prognosis to start from, she mobilizes for the patient's 
 good resources altogether out of the doctor's reach. 
 
 This has been part of Miss Jarrett's contribution to the book. 
 She has been co-author of the text throughout. But her in- 
 fluence and her point of view as well as her diagnostic and 
 therapeutic efforts have been active in the daily dealings witli 
 the patients here pictured, as well as in the printed pictures 
 themselves. 
 
 I think, myself, that if the psychiatrist were yet a little more 
 broad-minded, he would call the clergyman as well as the 
 social worker to his aid and would find his patients thanking 
 him for a new sort of help now given by neither doctor nor 
 social worker. But that is for the Utopian future when the 
 clergy get their rights and come to earn almost the wages of 
 
 hodcarriers. 
 
 * * * * 
 
 One fact certified to in this book is alone and of itself worth' 
 reading the whole for, — the fact that more than one man who 
 was too crazy to get along at all in the community outside an 
 asylum did perfectly well in the army! The army, apparently, 
 is sometimes wiser than the doctors and social workers in its 
 environmental guidance of certain poor chaps, who, as soon 
 
INTRODUCTION XI 
 
 as demobilized, must again be clapped into an insane asylum. 
 Surely this sheds light both on the army and on the asylum. 
 Even though such cases are admittedly rare, even though many 
 more are driven into asylums by army life, it is surely an 
 arresting bit of information, that army life is good for the 
 wits of some. Does this mean that the army provides more 
 discipline or less than the non-military life, more work or less, 
 more interest or less, more variety or less? All these possi- 
 bilities are open. Indeed, I have seen them all fulfilled. But 
 in any case a new remedy is added to the therapeutic accoutre- 
 ment of the average psychiatrist when he learns (and if he 
 believes) that army life did really suit some of the mentally 
 diseased patients studied by the authors. 
 
 ^ ^jc ^ ^ 
 
 Dr. Southard saw his profession as others see it. That is 
 a rare and valuable power. He did not "claim everything" for 
 psychiatry. Yet he claimed more, perhaps, than anyone else 
 ever did, up to his time. For since he included "mental hy- 
 giene" in the domain of his art and believed that labor dis- 
 putes, family rows, and international ambitions, as well as 
 crime, alcoholism, and school-backwardness, belong in the field 
 of mental hygiene, — it might at first sight appear that he set 
 no limits to his profession or its scope. But in point of fact, 
 limits, definitions, clear dividing-lines between adjacent fields 
 of professional work, were almost a hobby of his, — as this 
 book abundantly proves. He divides the science of psychology 
 from the art of psychiatry, and the alienist from the psychia- 
 trist. He refuses to confound (as psychiatrists and psycholo- 
 gists often do) the sphere of immorality with the sphere of 
 disease. Not all sinners are sick — in his view, nor all criminals 
 psychopaths. 
 
 This admirable clearness of definition is one of the out- 
 standing merits of the book. He ranges everywhere through 
 the emotions, struggles, diseases, weaknesses, delusions of 
 humanity. We are beside him in the courtroom, in the labora- 
 tory, and in the homes of some very queer people. But he 
 always keeps a clear head. He is never swept into a panic nor 
 into a wide glittering generalization, never tempted into mer- 
 gers that obliterate valuable differences. He has nothing of 
 the fanatic or the doctrinaire except their energy, nothing of 
 the imperialist except his sweep of vision. 
 
Xll INTRODUCTION 
 
 I Wish he could have lived to compress this book some- 
 what. It is perhaps too literal a transcript from his daily life 
 and work. Yet there is an advantage in his very copiousness 
 and reiteration. It is like life and teaches like experience. Its 
 faithfulness to fact is in some ways more impressive than it 
 would have been had he cut and selected his material more 
 rigidly. Who reads this book will learn, — as the writer him- 
 self learned, — a body of balanced and cautious doctrine, docile 
 under the "bludgeonings of chance." We can hardly forget 
 teachings reiterated from so many points of view — just as real 
 life reiterates them. In the end we are landed square in the 
 middle of a moving train of thought, orderly and progressive, 
 but by no means at the end of its run. We are abreast of the 
 same difficulties, equipped with the same solutions that Dr. 
 Southard and Miss Jarrett were daily presenting to the current 
 army of workers, — doctors, judges, social workers, parents, — 
 who weave themselves in and out of these pages. 
 
 That is what he would have wished. 
 
 Richard C. Cabot. 
 
CONTENTS 
 
 BOOK I— THE THREE MAJOR SPHERES OF SOCIAL 
 WORK (Cases i to 7) 
 
 Public, Social^ Individual 
 
 NojE — The literal formulas (P, S, I; P, S; etc.) stand for Public, Social, 
 
 Individual. 
 
 PAGE 
 
 5 
 
 Agnes Jackson, pathetic nuisance (P, S, I) 
 
 Richard Sully, morbid altruist (P, S) 8 
 
 Jennie Walton, peculiar thievery (P, I) 17 
 
 Henry Loyal, "black sheep" ; devoted, irresponsible 
 
 father (S, I) 22 
 
 Nora Campbell, ladylike adventuress (P) 29" 
 
 Alfred Mack, industrial disabilitj^ due to alcoholism 
 
 (S) 35 
 
 James Bailey, "shell-shock" analogue (I) 42 
 
 BOOK n— THE FIVE MAJOR FORMS OF EVIL IN 
 
 THE REGNUM MALORUM (Cases 8 to 38) 
 
 Six Complex Cases {One Pentadic, Five Tetradic) Analyzed 
 by Forms of Evil 
 
 Note — The literal formulas (M, E, V, L, P; M, E, V, L; etc) stand for 
 Morbi, Errores, Vitia, Litigia, Penuriae. 
 
 8. Rose Talbot, highly intelligent sex delinquent 
 
 (M, E, V, L, P) 51 
 
 9. Thomas Fuller, moron who set a fire (M, E, V, L) 65 
 
 10. Bertha Greenwood, hysterical sex delinquent (M, 
 
 E, V, P) 69 
 
 11. Lewis Goldstein, illiterate, industrially disabled 
 
 (M, E, L, P) 83 
 
XIV CONTENTS 
 
 PAGE 
 
 12. Elsa Albrecht, mother of illegitimate children 
 
 (M, V, L, P) ■ 87 
 
 13. Agnes O'Brien, moron, divorcee, devoted mother 
 
 (E, V, L, P) 95 
 
 Ten Less Complex Cases ( Triadic Combinations of Evil) 
 
 14. Margaret Hersey, deaf, suspicious (M, E, V) 98 
 
 15. Bessie Polski, "mystery girl," hysterical (M, E, L) 103 
 
 16. Mark White, grown-up "spoiled child," psycho- 
 
 pathic (M, E, P) 107 
 
 17. Eva Collins, weak-willed, alcoholic, syphilitic 
 
 (M, V, L) 109 
 
 ■ 18. Hamilton Green, "ej-e case," alcoholic, spoiled child 
 
 (M, V, P) 113 
 
 19. John Flynn, industrial traumatic neurosis (M, L, 
 
 P) . . . "5 
 
 20. Dora Hadley, intelligent sex delinquent (E, V, L) 121 
 
 21. Bessie Silverman, ambitious for an education (E, 
 
 V, P) 126 
 
 22. Elliot Calderwood, so-called "little fiend," quite 
 
 amenable (E, L, P) 128 
 
 23. Julia Brown, who lived as a man (V, L, P) 133 
 
 Ten Binary Combinations of Evil 
 
 24. David Stone, who feared open spaces (M, E) 137 
 
 25. Alfred Stevens, pilferer (M, V) 142 
 
 26. Kevork Ardinian, "work or fight" problem (M, L) 146 
 
 27. Herman Simonson, psychoneurotic clothes-presser 
 
 (M, P) 151 
 
 28. Aimee Prevost, suicidal psychopath (E, V) 154 
 
 29. John Manaos, technical deserter (E, L) 158 
 
 30. Emma Marburg, poor housekeeper with scolding 
 
 husband (E, P) 161 
 
 31. Alice Nardini, married to a "black sheep" (V, L) 167 
 
CONTENTS XV 
 
 PAGE 
 
 32. Catherine O'Connor, quarrelsome wife (V, P) 172 
 
 33. Ignatz Simanski, forger (L, P) 177 
 
 Five Simple Cases of Evil 
 
 34. Daniel Griffin, afraid to go out alone (M) 178 
 
 35. John Henry, lad kept a prisoner by his mother (E) 182 
 
 36. Clara Perkins, fabricator, mother of illegitimate 
 
 children (V) 189 
 
 37. Nathan Blumberg, frugality or non-support (L) 192 
 
 38. Margaret Dolan, poor, old, overworked (P) 195 
 
 BOOK III— ELEVEN MAJOR GROUPS OF MEN- 
 TAL DISEASES (Cases 39 to 100) 
 
 /. Syphilopsychoses 
 
 39. Greeley Harrison, costly delay of diagnosis in gen- 
 
 eral paresis 203 
 
 40. Greta Meyer, widow with syphilis, depressed 205 
 
 41. Walter Heinmas, familial syphilis, revealed by 
 
 routine examination 207 
 
 42. David Collins, foreman in machine shop with gen- 
 
 eral paresis 211 
 
 "43. Carl Spindler, paretic soldier 215 
 
 44. Thomas Scannell, steady young soldier began to 
 
 sing, dance, and fight 215 
 
 45. Archibald Sherry, twelve-year-old victim of con- 
 
 genital locomotor ataxia 2 16 
 
 46. Harold Gordon, industrial disability caused by 
 
 syphilis 218 
 
 //. Hypophrenoses 
 
 47. Florence Warner, high-grade moron "football of 
 
 environment" 219 
 
 48. Bessie Newman, psychopathic family of ten mem- 
 
 bers, each an individual problem 223 
 
XVI CONTENTS 
 
 PAdE 
 
 49. Nathan Rosenthal, imbecile kept at work 229 
 
 50. Bernard Bomstein, moron street-car conductor in 
 
 the navy 232 
 
 51. Howard Driscoll, recidivist with honorable dis- 
 
 charge from the army 233 
 
 52. Beatrice Cellini, subnormal girl called "vain, idle, 
 
 lazy, selfish, untruthful, immoral" 234 
 
 ///. Epileptoses 
 
 53. Luigi Silva, alcoholic epileptic once a reliable 
 
 workman 236 
 
 54. Patrick Donovan, epileptic who killed his mother 238 
 
 55. Charles Lovell, drafted but discharged 240 
 
 56. Frank Wayne, enlisted man with seizures after In- 
 
 oculation 241 
 
 57. John Bristol, policeman, enlisted, had night attacks 
 
 following inoculation 242 
 
 IV. Pharmacopsychoses 
 
 58. John Logan, alcoholic, expert physicist; valuable 
 
 employee 244 
 
 59. Patrick Nolan, delirium tremens during wife's ab- 
 
 sence ■ 250 
 
 60. John Sullivan, discouraged real-estate agent with 
 
 alcoholic hallucinosis 252 
 
 61. Margaret Murray, the root of family dissension, 
 
 alcoholic hallucinosis 257 
 
 62. Michael Piso, jealous, feeble-minded teamster with 
 
 family in need 262 
 
 63. Marian Spring, psychopathic woman with drug 
 
 habit 267 
 
 F. Encephalopsychoses 
 
 64. Thomas Warren, salesman with moments when he 
 
 "lost himself" 270 
 
CONTENTS XVll 
 
 PAGE 
 
 65. Helen Fitzpatrick, choreic girl with illegitimate 
 
 child 273 
 
 VI. Somatopsychoses 
 
 66. Ethel Murphy, unmarried mother with mild men- 
 
 tal disease 276 
 
 67. Joseph O'Brien, mind affected after influenza 277 
 
 VII. Geriopsychoses 
 
 68. Jeanette Burroughs, widow who saw her dead son 279 
 
 69. Catherine Cudahy, enraged by the vindictive tick- 
 
 ing of the clock 283 
 
 VIII. Schizophrenoses 
 
 70. Dana Scott, a chore-man in the country suffering 
 
 from dementia simplex 284 
 
 71. Ralph Johnson, compensated schizophrenic, once a 
 
 vagrant 29 1 
 
 72. Manual Rizzo, litigious vagrant and counterfeiter 294 
 
 73. Paul Ernst, salesman who lost his position through 
 
 an acute attack 295 
 
 74. Nora McCarthy, spoiled child who made attempts 
 
 at suicide 299 
 
 75. Clara Goldberg, girl committed after three years' 
 
 observation. 301 
 
 76. George Stone, soldier with croix de guerre who 
 
 developed paranoid conditions after discharge 306 
 
 77. George Mullen, left a state hospital and enlisted 308 
 
 78. Paul Dawson, soldier who claimed to be faking 
 
 mental disease 308 
 
 79. Howard Lancaster, corporal with dementia praecox 310 
 
 80. James Hill, army captain with dual personality 310 
 
XVlli CONTENTS 
 
 IX. Cyclothymoses 
 
 PAGE 
 
 8i. Winifred Reed, young woman with wandering 
 
 spells 312 
 
 82. William Donahue, came as an out-patient because 
 
 he "lacked initiative" 317 
 
 83. Marie Dubois, governess who needs hospital care 
 
 occasionally 319 
 
 84. Joe Marino, mischievous boy on probation 321 
 
 85. Robert MacPherson, sailor given to "excited 
 
 actions" 323 
 
 86. Clarence Adams, discharged soldier restless and 
 
 over-talkative 326 
 
 X. Psychoneuroses 
 
 87. Maurice Eastman, psychoneurotic cigar-maker with 
 
 financial worries 328 
 
 88. Sadie Strauss, hysterical convulsions in a young girl 335 
 
 89. Joseph Fangillo, periodic voluntary^ patient 337 
 
 90. Dennis O'Donnell, industrial accident case 339 
 
 91. Walter Nelson, naval machinist with traumatic 
 
 hysteria 341 
 
 92. Martin O'Hara, feeble-minded soldier discharged 
 
 for hysteria 342 
 
 93. Joseph Levenson, drafted soldier discharged for 
 
 physical incapacity, is case of psychasthenia 344 
 
 XI. Psychopathoses 
 
 94. Harriet Farmer, psychopathic typesetter, at- 
 
 tempted suicide, trained to competence 347 
 
 95. Louis Sand, educated Belgian, wandering and ir- 
 
 regular worker 352 
 
 96. Theresa Beauvais, girl of bad heredity, victim of 
 
 hypersexualis 353 
 
 97. Leon Blumer, borderline psychopath, quarrels with 
 
 his wife 356 
 
CONTENTS XIX 
 
 FAGS 
 
 98. Francis Corcoran, boy discharged from the navy 
 
 sick and "nervous" 359 
 
 99. Manuel Giordani, band sergeant who broke dovrn 360 
 100. Henry Allen, draughtsman v^^ho had to work alone 361 
 
 BOOK IV— EPICRISIS 
 
 I. Relations of Social Work to Sociology and Psychiatry 367 
 
 II. Method of Approach 375 
 
 III. The Method of Book I: Spheres of Influence 385 
 
 IV. The Method of Book II : Kingdom of Evils 390 
 
 1. Comparison of the Kingdom of Evils with Other 
 
 Schemes of Sociological Analysis 402 
 
 2. Definitions of the Five Groups of Evils 408 
 
 (i) Morbi (Diseases and Defects of Body and 
 
 Mind) 409 
 
 (2) Errores (Educational Deficiencies and Mis- 
 
 information) 411 
 
 (3) Vitia (Vices and Bad Habits) 412 
 
 (4) Litigia (Legal Entanglements) 413 
 
 (5) Penuriae (Poverty and Other Forms of Re- 
 
 sourcelessness) 415 
 
 3. Causes of Error 41^ 
 
 4. The Problem of Evil 423 
 
 5. Applications of the Five-Fold Classification of Evils 
 
 Outside the Field of Social Work 430 
 
 V. The Method of Book III: Main Groups of Mental 
 
 Diseases 436 
 
 1. Neurosyphilis 455 
 
 2. Feeble-mindedness 463 
 
 3. Epilepsies 469 
 
 4. Mental Diseases Caused by Alcohol and Drugs 470 
 
 5. Brain Disease 472 
 
 6. Bodily Disease 472 
 
 7. Old Age 472 
 
 8. Dementia Praecox 473 
 
 9. Manic-Depressive Psychoses 477 
 
XX CONTENTS 
 
 »AGE 
 
 10. Psychoneuroses 483 
 
 11. Dubious and Special Psychopathias 486 
 
 VI. Recent Applications of Mental Hygiene 492 
 
 1. Mental Disease in the Great War 492 
 
 2. Mental Hygiene of Industry 498 
 
 3. Out-Patient Service 512 
 
 VII. Psychiatric Social Work 517 
 
 1. History 517 
 
 2. Organization and Functions of the Social Service 
 
 at the Boston Psychopathic Hospital 523 
 
 3. Social Case Records 534 
 
 4. Technique of Social Diagnosis and Treatment 538 
 
 5. Medical Treatment in Social Case Work 549 
 
 6. Education for Psychiatric Social Work 552 
 
 A Note upon Legal Entanglement as a Division of Evil, by 
 
 Roscoc Pound 565 
 
 Appendices 
 
 A. Social records (full text) of cases 46, 89, and 94 571 
 
 B. Social service forms 671 
 
 C. Legislation in relation to mental disease, by Frankwood 
 
 E. Williams, M.D. 677 
 
 Bibliography 683 
 
 Index 699 
 
THE KINGDOM OF EVILS 
 
^ 
 
BOOK I 
 
 THE THREE MAJOR SPHERES 
 OF SOCIAL WORK 
 
 Public (Governmental) 
 Social (Voluntary) 
 Individual (Personal) 
 
 ANALYZED IN SEVEN SPECIMEN PSYCHIATRIC CASES 
 
Then Job ansivered and said, 
 
 Be it indeed that I have erred, 
 Mine error remaincth with myself. 
 
 Behold, I cry out of zvrong, 
 
 but I am not heard; 
 I cry for help, but there is no justice. 
 
 All my familiar friends abhor me. 
 
 And they whom I loved are turned against me. 
 
 Have pity upon me, ye my friends; 
 For the luind of God hath touched me. 
 
 Job, Chapter 19, Verses i, 4, 7, 19, 21. 
 
WOMAN ART STUDENT 
 IMMIGRATION SERVICE 
 
 In England 
 
 Bad Heredity 
 Quarreling 
 
 Estrangement from Family 
 Threats Against Family 
 "Nervous Breakdown" 
 Irregular Occupation 
 Sex Delinquency 
 
 In U. S. ' 
 
 Convalescent Care 
 Unemployment (Voluntary) 
 Insufficient Income 
 Charitable Aid 
 Suicidal Threats 
 Public Nuisance 
 Deportation 
 
Undesirable immigrant and pathetic nuisance: vicissitudes; 
 deportation. Effects of a faulty diagnosis and therefore 
 prognosis (neurasthenia in a woman not at all neurasthenic). 
 To illustrate public, social, individual problems. 
 
 Case I. Miss Agnes Jackson was sent to the Psychopathic 
 Hospital for observation from the Immigration Station at 
 Boston. She was a "mental" suspect and rather an appealing 
 figure. She herself said that in England she had had a "nerv- 
 ous breakdown." It seemed doubtful whether she could main- 
 tain herself on the small income she possessed, an allowance 
 from her family and a scholarship to cover art school tuition. 
 But finally she was admitted to the country in the joint care 
 of the director of the school she was to attend and the social 
 service of the hospital. 
 
 Correspondence with England shortly proved her the daugh- 
 ter of a professional man who had committed suicide a year 
 before. It appeared that her mother, brother, and sister were 
 living in England; but that she could not get on with them 
 and believed that they were persecuting her. Several years 
 earlier she had had a spell of bad temper and quarrelsomeness 
 after a love affair that did not come off. She won a scholarship 
 to study art in London, but had not fulfilled her contract. 
 About this time she had been observed in a London hospital, 
 where the (erroneous) diagnosis "neurasthenia" was made. 
 The parish rector wrote that she was "thought to be not right 
 in her head and her work as an artist was considered very 
 moderate." At the art school here, however, she was said to 
 have some unusual native ability. 
 
 After a week in the hospital she was sent to the country to 
 recuperate (through funds raised for the purpose) because 
 she complained of feeling weak and distraught as a result of 
 her detention at the Immigration Station under uncongenial 
 conditions. At the boarding house where she stayed she made 
 unreasonable demands and complaints, was untidy, and alto- 
 gether made herself a great nuisance. She returned to begin 
 
 5 
 
6 THE KINGDOM OF EVILS 
 
 her studies at the art school, boarding at a working-woman's 
 hotel. But in a few weeks she took to her bed and insisted 
 on having her meals brought to her, saying that she would not 
 return to her work, as she couM not stand the atmosphere of 
 the school. It was found that she had been very rude to her 
 associates there. 
 
 Yet she went back after a time and gave no trouble for nearly 
 six months. A piece of her work was exhibited at a well- 
 known shop. As the pound-a-week allowance from England 
 had stopped a friendly artist helped her out with small sums. 
 Miss Jackson herself made no effort to sell her work and 
 showed no industry. She talked a great deal about what would 
 be done for her by this friend and another young woman, a 
 fellow student, who had become interested in her. She con- 
 tinually talked about wanting to meet men, insisting that her 
 friends should help her find a husband. She wrote volumi- 
 nous rambling letters to them, and also to a physician at the 
 Immigration Station, telling of her misfortunes and her 
 unhappiness. 
 
 Meanwhile, she had turned against the social worker; but 
 finally she came to the hospital, weeping and distraught, and 
 was taken in as a voluntary patient. After a brief stay she 
 was discharged, but pursued the same tactics. After two 
 months the more serious step was taken of committing her to 
 a state hospital for longer observation. In the course of time 
 she was sent to England in care of a special attendant, to be 
 returned to her family. This ends the American story of 
 Agnes Jackson and the whole story so far as it has yet 
 unfolded. 
 
 The American history of Miss Agnes Jackson thus lasted 
 hardly over a year. The nucleus of these troubles was beyond 
 a doubt psychopathic. Although a psychopath ought to engage 
 one's sympathy and although Miss Jackson at the outset pulled 
 every one's heartstrings, she remains in the minds of all more 
 a pest than a patient. 
 
 Erom the immigration office standpoint she was an undesir- 
 able citizen, because a small art scholarship and the pound-a- 
 week allowance plainly could not support her in America. 
 
 Erom the point of view of the social worker, the initial ap- 
 peal of a young English art student of refinement, dropped 
 from a Cunarder into the detention quarters of the United 
 
THE KINGDOM OF EVILS 7 
 
 States Immigration Office, was extreme. Yet whatever was 
 done for her by officials or by new-found private friends, all 
 ended in a pathetic tangle of minor troubles, amounting to a 
 bit of a tragedy. Whether in England there had been anything 
 really tragic may never be knbwn, though our full accounts 
 from London leave Love largely out of account and minimize 
 the part that Money might have played in the unfolding of 
 events. What tragedy may in future come to her in England 
 we cannot say; but no doubt the same initial appeals and the 
 same lapses into misunderstanding will continue to be her lot. 
 
 What after all is she from the medical point of view? Is 
 the fact significant that an elder brother is badly affected with 
 a disseminated sclerosis? On the whole, the hereditary taint 
 in Miss Jackson strikes one as rather slight. Ample studies 
 of her personality both here and abroad fail to place her case 
 beyond cavil in any major group of mental diseases, though 
 no doubt can attach to considering her in some wise psycho- 
 pathic, and even possibly amongst that group of degenerative 
 diseases so unfortunately termed dementia praecox. 
 
 As we study the case in detail we are not only able to bring 
 out the governmental, social, and medical troubles, of which 
 this "pathetic nuisance" was a paradigm, but we also find her 
 more or less the vehicle of many, if not all, of the major sorts 
 of evil that the world (according to our classification) has to 
 face. As we hope to show in the sequel of this book, there are 
 evils and evils. But amongst these, we may distinguish at least 
 five great classes. There is, for example, the class of Diseases 
 into which Miss Jackson readily falls by virtue of her psychop- 
 athy. Again, there are the evils of Ignorance ; that is, of poor 
 education, of misinformation, of the improper digestion of 
 facts through lack of judgment, not necessarily in itself psycho- 
 pathic, and of these, our paradigm case is not without good 
 examples, of which her coming to America at all may serve 
 as the greatest. There are also evils of which the sequel will 
 supply far more striking examples in which various Bad Habits 
 and Vices, non-psychopathic, form the chief constituents. Con- 
 cerning these in the case of Miss Jackson, it may be difficult 
 to disengage her laziness and tactlessness from the effects of 
 psychopathy; but at first sight at least these ways of hers struck 
 her friends and acquaintances as the effects not of disease, but 
 of poor training. Sometimes again, the individual victims of 
 
8 THE KINGDOM OF EVILS 
 
 trouble fall into the clutches of the Law or of public service in 
 sundry ways. Miss Jackson was a good enough example of an 
 "undesirable immigrant." Again there are evils of a purely 
 economic nature, Poverty and other forms of resourcelessness 
 — and it may be well supposed that under certain circumstances, 
 if the Jackson family in England had been on a higher eco- 
 nomic level, the life of Miss Agnes would not have been cast 
 in its peculiar way, and in particular she might never have 
 undertaken her American journey. 
 
 Hours spent by Medical record, 65 pages 
 
 Social record, 26 pages 
 Physician, 145^^ Social work : 
 
 Visits. 13 
 Psychologist, i Interviews at hospital, 14 
 
 Telephone calls, 20 
 Social worker, 36 Letters, 20 
 
 Morbid altruist and boys' club organiser. Delinquency ex- 
 plained as due to mental disease (psychopathic personality). Re- 
 covery, in all public and social senses. 
 
 Case 2. Richard Sully was a kind of morbid altruist. Like 
 Agnes Jackson, Richard was beyond a doubt psychopathic, 
 yet the psychopathic difficulty — a mild defect of the group of 
 so-called constitutional inferiority — was not of such a sort as 
 to perturb Richard's peace of mind or any other of his internal 
 relations and self -adjustments. The trouble seemed almost 
 wholly one of a social nature with occasional public contacts, 
 
 Richard first came under expert observation at fourteen. 
 He became beset with the idea of starting boys' clubs. It dis- 
 tressed him, he said, to see boys idle on the street — they ought 
 to get into clubs where they could read. He would hire a 
 room, or perhaps a building, and give orders for suitable furni- 
 ture. Sometimes he bought refreshments, hid them in his own 
 house, and ended by eating them himself, as the proposed boys' 
 clubs had as yet no members ! Between these organizing efiforts 
 he worked hard, helping about the house and helping in neigh- 
 bors' houses. He so helped his church janitor that he was even 
 
THE KINGDOM OF EVILS 9 
 
 finally made janitor of the church at $3 a week. His earnings 
 he gave to his mother. 
 
 His school work had been lapsing for about two years. A 
 psychological examination at the age of fourteen showed him 
 to be by the Binet Scale actually of a higher mental age level 
 than his actual age ; namely, fifteen. A test a year later showed 
 a Binet rating of 12 2/5, but by the Point Scale he still rated 
 at fifteen; in fact at the highest level which the Point Scale 
 of Yerkes was at that time able to register. The psychological 
 examiner reported that Richard was not feeble-minded and 
 yielded no evidence of deterioration, that he was quick and 
 accurate in learning. His analytic ability was especially good. 
 So far as tests went, he was perhaps slightly limited in his 
 power to interpret complexities (so-called "apperception" 
 tests). As for the other mental faculties tested, they were of 
 satisfactory quality, nor would one perhaps often find in a 
 youthful psychopathic suspect like Richard so regular a test. 
 In particular, he had grasped and retained his school knowledge 
 well. On the basis that his imaginative and planning powers 
 were not quite as strong and rapid as normal, the examiner 
 risked the suggestion that Richard might possibly be a patient 
 defective on the side of the will (and hence not defective within 
 the range of many of the tests) and normal as to emotions and 
 intelligence. 
 
 We here specify, concerning these psychometric tests, a little 
 more detail than is strictly necessary; for we want to stress 
 the great negative value of the mental tests. The patient's com- 
 paratively high intelligence is a factor to reckon with in ex- 
 plaining the peculiarity of his delinquencies, and a factor to 
 be considered in building up a treatment procedure and a 
 prognosis. 
 
 Now the outcome, at least in the six years during which 
 Richard has been under observation, seems a comparatively 
 good one. During the past four years there have been slight 
 ruffiings of the surface (occasional inquiries as to whether it 
 was not now time to organize another boys' club), but these 
 suggestions have been readily nipped in the bud by his 
 advisers. Once even he went so far as to utter a small 
 check, so that there is no doubt that the defect of will is 
 still latent. 
 
 Along with Richard's rather minor individual difficulties, 
 
10 THE KINGDOM OF EVILS 
 
 chiefly a defect of will, it is plain that the bulk of his diffi- 
 culties are in his relations with his family, with the church 
 people, with the boys whom he tried to steer into his vaguely 
 altruistic clubs, and with the tradesmen and others from whom 
 he tried to obtain money. The public — that is, governmental — 
 aspect of Richard's case was, with respect to the courts, rather 
 more a matter of the "eternal not quite" (when brought to 
 court the judge would tend to file the case, or not consider it, 
 on the score of Richard's youth and the peculiarity of his of- 
 fense) ; yet Richard was a pretty well-known figure to the local 
 police, who would from time to time step in as good neighbors 
 and help his mother straighten out his tangles. Another public, 
 or governmental, feature of Richard's case was his commit- 
 ment to a state hospital, which seemed advisable upon his at- 
 tempt to float his fifth club enterprise. That he had a definite 
 psychosis was perhaps never actually proved. 
 
 Richard entered the Psychopathic Hospital under the volun- 
 tary relation in a rather peculiar way in his fourteenth year. 
 He arose from bed at home one night very late, took sixty 
 cents from his mother's purse, climbed out of the window, 
 hatless and coatless in a pouring rain, and reached the hospital 
 drenched. 
 
 There was a kind of suggestion of the epileptic fugue in this 
 and similar escapades, yet no convincing epileptic features were 
 otherwise discernible. According to Richard, he read too 
 much and got to day-dreaming. The physicians who com- 
 mitted Richard to the state hospital (under Massachusetts law 
 physicians not connected with the state hospital staff must in 
 the interest of the patient be called in) perhaps suspected that 
 he was an early case of schizophrenia, (dementia praecox), as 
 they called attention to a change in Richard's nature at the age 
 of twelve, wherein he became less thoughtful and began to have 
 things bother him. He told the committing officers that he did 
 not sleep for six months at a time. He told them that he had 
 formed about fifty boys' clubs of the same general nature. He 
 was accordingly sent to a state hospital, and thence went home 
 on a visit after a period of six months, for the greater part of 
 which he was granted parole and helped about the laundry, a 
 good and willing worker. He was there regarded as a "con- 
 stitutional inferior." He was carried on the books of the hos- 
 pital for six months and then discharged, with a request to 
 
THE KINGDOM OF EVILS II 
 
 report from time to time at the Psychopathic Hospital. There 
 he took baths, as prescribed, somewhat regularly. 
 
 With the exception of the two small upsets mentioned above, 
 he now became and still remains an industrious and faithful 
 shoe worker in a factory. The clubable side of Richard's 
 nature has now got its satisfaction in sundry church societies. 
 Richard has always been on good terms with the Psychopathic 
 Hospital and continually brings magazines for the patients, 
 and at one time brought over his church club to entertain them. 
 
 We are not here attempting to expound the entire medical 
 story of Richard Sully; yet it is clear that the diagnosis "con- 
 stitutional inferior," accurate though it may be, might well 
 give the wrong impression to laity and to physicians of the 
 prognosis. At the age of tw^elve a boy undergoes a change 
 of character and develops a sort of morbid altruism, endeavor- 
 ing to organize boys' clubs and breaking rather obvious busi- 
 ness rules in the process. He gets into medical and social 
 hands, both under the voluntary relation and under the legal 
 cjmmitment relation in the state hospital system, and somehow 
 works out of his psychopathic phase into a comparatively nor- 
 mal status. To be sure, in this normal status traces of his altru- 
 istic trend persist; he joins church clubs, sings in the church 
 choir, is a member of the Massachusetts State Guard, of the 
 Young Men's Christian Association and the like. Yet at pres- 
 ent he cannot be regarded as much, if at all, outside the range 
 of the normal. 
 
 Were there any features in Richard's earlier life which 
 might have given a warning? It is said that he had been some- 
 what seclusive from early childhood, not caring to play with 
 other children and preferring to read and study alone. He 
 cared for no games or sports except skating. He rather early 
 attempted to assume responsibility in his family and always 
 wanted to escort his mother to the street cars and the like. He 
 was for a long time troubled with tonsillitis, for which he was 
 operated upon. Antitoxin administered for diphtheria at eight 
 years of age partially paralyzed him for a time. The sex side 
 was regarded as normal. 
 
 The boy's father deserted his mother, and during the father's 
 numerous unexplained absences (before the final desertion and 
 imprisonment) Richard grieved greatly and sat by the window 
 to watch for his father. After the final desertion, the boy con- 
 
12 THE KINGDOM OF EVILS 
 
 ceived and stated that he now had a family to support, though 
 he was then but eight years of age. It is possible, or at least 
 conceivable, that a precocious ripening process in the boy's 
 mind was somehow started after his father's desertion of the 
 family. Both the father and the paternal grandfather were sex 
 delinquents, and the paternal grandfather was a suicide. The 
 paternal grandmother and two siblings were respectively un- 
 social, suicidal, and sex delinquent. A younger sister of the 
 patient is choreic. Upon the maternal side there seems to be 
 no taint, unless a certain tendency to vascular disease. So far 
 in Richard's history the other sex has not appeared, save in 
 his normal relations with his sisters. His interests have con- 
 stantly attached themselves to persons of his own sex. A psy- 
 choanalyst who examined him was inclined to regard him as 
 showing a "conflict, somewhat homosexual." This diagnostic 
 suggestion was thought to be supported by the so-called "intel- 
 ligence complex" shown in association tests, wherein twenty- 
 eight per cent proved to be "logical definitions." The thought 
 that after his father's desertion he must now be the head of 
 the family was also regarded by the psychoanalyst as supporting 
 the above mentioned "conflict." It seems that at the age of six 
 Richard had been excluded from some club of boys of his own 
 age, whereupon he had begun to dream of a club of his own, 
 which dreams may possibly have started the club forming habit 
 of his early teens. 
 
 The social worker at the state hospital where Richard spent 
 six months several years ago still supervises him. She wrote 
 us the following report recently : — 
 
 "Since I reported to you in March 1919, Richard has been 
 getting on exceedingly well. He has been working regularly 
 at Gordon's Shoe factory in East Boston and is now on piece 
 work and earns an average of four or five dollars a day, and 
 sometimes makes as much as seven dollars a day. He has not 
 attempted to take any responsibility in the Church, although he 
 has attended their young people's meetings faithfully and still 
 enjoys his associations there. 
 
 "During the summer he had a vegetable garden in one of the 
 lots given out by the City, in which he worked after returning 
 from the factory at night and during other spare hours. This 
 proved to be very beneficial, as it kept him outdoors and gave 
 him healthful exercise, as well as helping the family with the 
 food problem. His mother helped him in this. 
 
THE KINGDOM OF EVILS 13 
 
 "Although he had secured his discharge from the Local State 
 Guard Company, in which he had been a Corporal, — upon our 
 suggestion, — when the Police Strike occurred in September the 
 men asked him to re-enlist and he felt it his duty to do so. He 
 served with them during this trouble, but when the worst was 
 over, he resigned again upon our urging him to do so, as it 
 was keeping him from getting as much sleep as he needs. 
 Because of his mental condition we did not approve of his doing 
 a thing of that sort, although we did not know he was out on 
 duty until he had been there a few weeks. As it was, nothing 
 happened and he quite enjoyed the experience, and the factory 
 made up his weekly pay to the average of what he was making 
 at the plant. 
 
 "The local Red Cross Home Service has been visiting the 
 family during the past year as Mrs. Sully discovered that her 
 husband was in the Canadian Army and they helped her 
 to get money from Canada. They have kept strictly off the 
 problem of Richard individually, but I am glad to have them in 
 closer touch with the family than I could be." 
 
 We have to deal, then, with a boy who apparently passes 
 through a minor psychopathic phase for a period of three or 
 four years about the time of adolescence, but before and after 
 this phase shows but few signs of such a trend. Various 
 diagnoses from the medical side, such as constitutional inferior, 
 predementia praecox, early dementia praecox, even epilepsy and 
 manic-depressive psychosis, were from time to time offered. 
 The committing officers, bound to act on concrete data, were 
 nevertheless in not the slightest doubt as to their duty to com- 
 mit him to a state hospital. Before this latter decision w^as 
 arrived at, all sorts of doubts had reigned concerning the diag- 
 nosis, some physicians proposing that he was not demonstrably 
 psychopathic, but was, on the contrary, a rather pure example 
 of a delinquent, deserving prison bars rather than the comforts 
 of an asylum. 
 
 We analyzed the case of Agnes Jackson not only from the 
 standpoint of the description of her troubles as public, social, 
 and individual, but also (anticipating the considerations of 
 Book H) from the standpoint of the kinds of social evil, of 
 maladjustment, which she displayed. Following a similar plan 
 with Richard Sully, we find him falling, of course, in the class 
 of Morhi (Diseases) by virtue of his mild psychopathy. 
 Whatever be the trend, or eventual outcome, of this psychop- 
 
14 THE KINGDOM OF EVILS 
 
 athy, (schizophrenic, epileptic, or otherwise), Richard Sully 
 has at all events what physicians call a forme fruste of some 
 sort of mental disease or defect. 
 
 How shall we classify Richard with respect to Err ores, the 
 evils of Ignorance? Unlike Agnes Jackson, who did show the 
 effects to some extent of poor education, misinformation, and 
 lack of judgment, Richard not only tested well by the set psy- 
 chological tests, but seems, on the whole, to have been rather 
 well educated and well informed. An adult insight and judg- 
 ment should not be expected. 
 
 On the side of the Vitia, that is, the Bad Habits and Vices, 
 Richard must be regarded as equally without pronounced de- 
 fect, unless we regard with some authors any sort of exagger- 
 ated altruism as a form of vice ! Shall we regard the forgeries 
 and other delinquencies as at all the effects of moral perversion? 
 Certainly, the tendency of the Psychopathic Hospital staff in its 
 analysis of Richard was to regard these defects as rather more 
 psychopathic (that is. 'falling within the group of mental dis- 
 eases), than morally vicious. (We do not care to take up here 
 the question of an eventual proof that some one may bring 
 that moral perversion is in and of itself psychopathic. Such 
 a proof may possibly arrive. For the present, however, we are 
 employing the group of the Vitia to contain such bad habits 
 and vices as might conceivably be drilled out of the bearer by 
 proper moral training, or even prevented by proper early man- 
 agement. It is in this latter sense of the group of the Vitia 
 that we do not regard Richard Sully as a morally dishonest or 
 immoral person.) 
 
 Clearly Richard's case falls in the group of the Litigia, that 
 is, of legal and similar entanglements ; for as we have seen, he 
 was frequently at least within the shadow of the courts. 
 
 It is true that the economic status of the family was at best 
 "marginal," but no special effect upon the psychopathic status 
 of the boy can be ascribed to the plight of domestic economy. 
 
 Hours spent by Medical record, 47 pages 
 
 Social record, 10 pages 
 Physician, 7 Social work: 
 
 Visits, 4 
 Psychologist, i Interviews at hospital, 4 
 
 Telephone calls, 8 
 Social worker, 12 Letters, 13 
 
PSYCHOPATHIC THIEF 
 WOMAN (ILLEG.) 27 
 
 1Q16 19 1 y 
 
 Arrest Discharged from Probation 
 
 Poor Health Care of Body (incl. Teeth) 
 
 Cut Off from Family Living with Friends 
 
 COMPLICATION : CHILDHOOD SEX TRAUMA 
 
Thief. Infantile sex experience. Physical and psychical 
 waves of disease. "Empathic index" question. "The patient's 
 confidence." Public and individual problems. 
 
 Case 3. Jennie Walton's mother is said to have had some 
 Indian blood. Jennie was an illegitimate child, and her pater- 
 nity was never established. We present her as a paradigm of 
 mental disorder leading to public (governmental) rather than 
 family or other social complications. Medically, she should 
 probably be placed amongst the psychopathies. She was 
 arrested for stealing, and, although one might be tempted to 
 make a diagnosis of kleptomania, on the whole the delinquency 
 is probably a minor incident rather than the effect of a strongly 
 marked special instinct, and the fact that simple and obvious 
 social service measures served to straighten out the Walton 
 case (without resort to elaborate and specially designed reedu- 
 cation or moral reformation) permits us to think that her psy- 
 chopathy was of a minor degree. Such merely social (non-gov- 
 ernmental) complications as did exist were so slight as to be 
 negligible. 
 
 Jennie Walton came under hospital observation at the age of 
 twenty-seven, having been arrested for stealing patients' 
 clothes, linen, a fur coat, and utensils from two hospitals, 
 where she had been employed as a domestic for half a year 
 previous. The girl had been of such exemplary character and 
 had so many intelligent, good friends amongst previous em- 
 ployers that the arrest came as a shock to these friends, one of 
 whom wrote that the arrest must be a "fearful mistake" due to 
 a "conjunction of circumstances seeming to implicate her." 
 
 However, it appeared that her work at the hospitals from 
 which she stole had not really been satisfactory and that for 
 a period of some five years those who knew her well thought 
 her disposition peculiar in that she was "almost morbidly sensi- 
 tive, heedless, impulsive, and reckless with money." As for a 
 previous history of stealing, there was none; but she was noted 
 for collecting and hoarding buttons, ribbons, clippings, and 
 
 17 
 
l8 THE KINGDOM OF EVILS 
 
 poems. She seemed to be rather ambitious and of the type 
 known as a "born leader." She had a certain skill in making 
 clothes out of cast-off things, but no motive of self -adornment 
 could be traced in several of her pilferings. In thirteen years 
 of work in various families she had saved no money what- 
 ever. One might naturally inquire whether such a patient as 
 Jennie was more or less hypophrenic (feeble-minded). Mental 
 tests led the psychologist to say that the patient was certainly 
 not feeble-minded. She yielded a fairly even rating at the four- 
 teen year level, losing some points on her association tests and 
 on the tests for logical and practical judgment ; that is, the see- 
 ing of analogies and absurdities and the like. Should she be 
 regarded as, if not a moron, then perhaps a border-line or sub- 
 normal person, in the sense of being above the moron level but 
 below the normal? The psychologist remained in doubt, but 
 went so far as to say that the patient graded somewhat below 
 expectation for her age and class. Now her "class" looked 
 better to the psychologist and to any casual observer than it 
 proved to be. She had a shell of special information, having 
 taken special courses in domestic science and in first aid for the 
 injured, but in the meantime had never completed her grammar 
 grades. 
 
 When the girl was a baby, her mother was married to a man, 
 not the girl's father, an alcoholic and abusive person who 
 allowed the mother to support the family. Sex relations (age 
 seven to fourteen) with this alcoholic stepfather formed a 
 rather extraordinary episode in the girl's history, according to 
 her own story. In the girl's conscious life this history played 
 a considerable part. She complained bitterly of the robbery 
 "of all that is dear to a woman." She would readily tell neither 
 about the larceny nor about the sex history, nor was any one 
 of several medical approaches successful in starting a stream 
 of confidences. Finally a friend and confidante was found to 
 whom enough of both stories was confessed that the main out- 
 lines of the situation were clear. 
 
 The medical side of the story was not without bearing on 
 the patient's estimate of herself and upon the psychiatric diag- 
 nosis. She had had many and various children's diseases. At 
 eighteen she described herself as having had a kind of general 
 debility from overwork. Whether this was connected with her 
 engagement to a man at nineteen, broken off when the man 
 
THE KINGDOM OF EVILS 1 9 
 
 shortly afterwards entered a forced marriage with another 
 woman, remains doubtful ; but the old incest story and the 
 breaking of this engagement "soured her," she said, "on all 
 mankind," so that she was in a way "to become a man-hater." 
 In this nineteenth year it appears that she had a sort of exhaus- 
 tion attack for a fortnight. She was operated on at the age of 
 twenty-four for appendicitis, and in her twenty-fifth year re- 
 sorted to an osteopath for exhausted muscles. In her twenty- 
 fifth year she was operated on for peritoneal adhesions; her 
 ovaries were removed at this time. Concerning the oophorec- 
 tomy, she claimed that it was. in the opinion of her physicians, 
 made necessary by the trauma of her childhood. She had then 
 woven her incapacity to bear children into the general situation 
 of disgust with the world. 
 
 Yet, despite all this checkered history and interweaving of 
 embittered comment by the victim and although for the first 
 part of after-care by the social service her behavior was in 
 some respects queer and even psychopathic, at the end of a 
 year she had so far restored herself to a normal attitude that 
 her case was closed by the hospital social service and was placed 
 on file by the court. 
 
 One's prediction about the future of such a case as that of 
 Jennie Walton might well be influenced by preconceived no- 
 tions. If we took her for an inborn psychopath of mild degree 
 — the psychopathia being, as it were, stamped in by childhood 
 sex experiences and at last emerging in the overt act of lar- 
 ceny — we might give her a rather unfavorable prognosis. At 
 the time of hospital observation she was in rather poor health. 
 Her teeth, especially, were bad. It transpired also that she 
 had been for eighteen months at a state hospital for tubercu- 
 losis (pulmonary, no longer in evidence), ^\'e must remember 
 the occasional spells of exhaustion, dating from the late teens, 
 which though ill described, may possibly represent some sort of 
 periodic or wave eft'ect in her physique, reflected also in her 
 mental life. 
 
 We have recorded that the psychometric rating left case 
 Walton as certainly not a moron and as not clearly subnormal 
 in a milder degree. Psychiatrically examined she proved not 
 abnormal. She was, to be sure, somewhat sad at times, but a 
 psychopathic depression could not be proved. The only ques- 
 tion raised was that of delusions, as lennie told a storv of the 
 
20 THE KINGDOM OF EVILS 
 
 conspiracy of fellow employees, suggestions to inaugurate a 
 strike, refusal to admit sex advances by hospital employees, 
 placement of articles in her room by fellow employees wishing 
 to do her injury, and the like. These stories were interpreted 
 by us as part of the defense-reaction of one charged with 
 delinquency. 
 
 A systematic review of her case by physicians and social 
 workers in staff meeting led to the diagnosis of "psychopathic 
 personality," but without especial grounds therefor, except the 
 patient's history and the general impression that somehow she 
 was psychopathic rather than delinquent. Several physicians 
 thought the outlook was medically bad. Some physicians 
 thought she might be merely psychopathic in the mild sense of 
 the so-called psychopathic personality, but that she might even- 
 tually turn out to be psychotic (in the sense of having a definite 
 mental disease). 
 
 After the first six months of her period of social supervision, 
 she seemed to bear out this idea of poor prognosis. In a vari- 
 ety of domestic places the girl did on the whole rather poorly, 
 and from time to time rather suspicious things happened. A 
 pin or two disappeared, which she might have stolen ; a fire 
 was set, possibly by her. One night she moaned in bed for 
 hours and stayed in bed the next day. She sometimes resorted 
 to osteopathy, and got a diagnosis at a general hospital out- 
 patient department of "chronic arthritis (teeth)" whereupon 
 she went regularly to a dental clinic. She came down with 
 German measles and had a bad cold and the grippe. Mean- 
 time she kept endeavoring to get work and to do it as well as 
 possible, and by the end of a year she seemed to have worked 
 out of her susceptibility to illnesses and got upon a better level 
 of physique (all this helped out by a pleasant summer with 
 friendly people). There were no further suspected stealings or 
 other bits of odd behavior. Accordingly, as above noted, her 
 case was put upon file. 
 
 We note that the exceedingly few social complications in 
 Jennie Walton's case rendered social service relatively easy, as 
 throughout her adult life it still proved possible, after her mis- 
 adventures, for her to find good and highly appreciative friends. 
 It took some six months for her psychopathic phase (if it was 
 such) to pass and for the social workers to establish them- 
 selves on a confidential basis. This was not so much a ques- 
 
THE KINGDOM OF EVILS 21 
 
 tion of continued or increasingly clever efforts at gaining Jen- 
 nie's confidence as it was a matter of the passing of what we 
 finally concluded to be a pretty definite psychopathic phase. 
 Whereas it would not be safe to think of Jennie Walton as 
 clearly a periodical psychopath (in the sense, e.g., of the so- 
 called cyclothymic constitution), nevertheless a review of her 
 entire history yields traces of such a phasic course. 
 
 Should she again appear in the courts or in the hospital and 
 fall again within the medical and social service range, no doubt 
 the procedure would be much clearer. In the meantime it would 
 be medically impossible to say either that she is definitely peri- 
 odic or that she is at all certain to have a further episode. 
 Amongst the ill-defined psychopathias which fall short of the 
 full-blown psychoses (which latter we find typically in insti- 
 tutions), there may be a kind of psychopath with a periodical 
 trend, a sort of forme fruste of the out-and-out "manic-depres- 
 sive" psychosis. Yet various other psychoses have periodical 
 or phasic tendencies. After all, the psychologist did find a 
 certain subnormality about- the case, a certain lack of logical 
 and practical judgment. Sundry misspellings and a certain 
 simplicity characterize her letters. Thus (after receiving a 
 Christmas present) : 
 
 "I simply cannot find a thank you big enough to tell you 
 how delighted I was with the dear little book you sent me. 
 When I read it my delight was doubled threefold, for I think 
 the good fairy whispered to you that it was a set of my favorite 
 quotations which I have scattered around on scraps of paper 
 and which never can be found when needed most to drive a 
 cloud of the blues away." 
 
 Again we may try to resolve this case from the standpoint 
 of the distribution of social evils. We have sufficiently dis- 
 cussed her disease and its rather doubtful end, yet there are 
 plain somatic as well as psychic factors therein. As for poor 
 education, there is a certain evidence of this, and a certain 
 superficiality in the education which she had actually received ; 
 .but it does not appear that her comparatively poor education 
 really contributed much to her difficulty, nor is it easy to ascribe 
 to her any altogether unfortunate moral attitude, despite the 
 fact that her interpretation of her childhood misfortunes and 
 of her later psychopathic complications were not always sound. 
 Yet it is probable that the unsoundness of these interpretations 
 
22 THE KINGDOM OF EVILS 
 
 is to be attributed rather to her psychopathy than to any actually 
 poor moral training. Her legal difficulties are obvious and 
 no doubt tended to obscure the physician's interpretation of 
 her case on account of the defense-reactions so natural to men 
 and women when entangled in court. Nor was the Walton case 
 particularly a case of economic disability, though her state was 
 "marginal" rather than on the so-called "comfortable" level. 
 Nor was the will to earn her living ever lost. The difficulties 
 facing the social workers in their general attitude to such a 
 case are not easy to state. In the face of a rather poor medi- 
 cal prognosis (to say nothing of the prevailing general, though 
 baseless, feeling of doubt as to the outcome in all psychopathic 
 cases), the social workers had the duty of keeping up their 
 supervision steadfastly until somehow the patient's mental 
 state cleared up. This process of clarification of Jennie Wal- 
 ton's mind, running pari passu with a great improvement in her 
 physique, took about a year to bring itself about. 
 
 Hours spent by Medical record, 33 pages 
 
 Social record, 26 pages 
 Physician, 6 Social work: 
 
 Visits, 66 
 Psychologist, i Interviews at hospital, 4 
 
 Telephone calls, 17 
 Social worker, 112 Letters, 40 
 
 Black sheep. Generalized psychopathia sexualis. Neuras- 
 thenia elements removed. Moral improvement ("more of a 
 man" suggestions) . Social and individual problems. 
 
 Case 4. Henry Loyal was a steamfitter. He had been for 
 many years, at least since puberty, in constant social difficulties. 
 Looking back over his life up to the age of forty-eight, one 
 was tempted to relate these difficulties to drunkenness, gambling 
 habits, sex escapades, and a sort of general irresponsibility in 
 life. He was the acknowledged black sheep of a middle-class 
 American family. An analysis of this so-called black sheep 
 will prove conclusively that he was a psychopath, and that all 
 his troubles, medical and social, could be, and have in fact been, 
 greatly improved by the hard work of his official friends. 
 
 His friends, whether medical, social, or casual, could not 
 
THE KINGDOM OF EVILS 23 
 
 fail to be impressed with the profound irresponsibility of the 
 steamfitter. What with the fit fulness of his trade and the 
 numerous occasions in which his psychopathy would break out, 
 the task of adjusting him to an environment was not easy. 
 Nevertheless, in the end, what with advice to the man, advice to 
 his wife, and an unusually close supervision, he has now become 
 what, without straining the point, may be called an encourag- 
 ing example of psychiatric social work. 
 
 The case was most unpromising, and, throughout our four 
 years' supervision, it was never possible to avoid an occasional 
 lapse into destitution on the part of the family, and recurrent 
 dissipation on the part of its central figure. There was a slack, 
 profane wife, who was alternately devoted and jealous, and 
 there were four children, all variously affected by disease or 
 defect (one choreic, another tuberculous). 
 
 The husband had long been so hopeless a figure that one's 
 first impulse would naturally be to sever him from the family, 
 try him a while, and perhaps finally set him adrift (as one says, 
 "close the case"), and do one's best with the wife and children. 
 The family, however, despite the centrifugal tendencies of the 
 father and the profanity and extraordinary jealousy of the 
 mother, was close knit with profound affection. The paternal 
 affection was, in fact, the main social lever. The existence of 
 this lever was all the more astonishing as the man had for 
 years come home drunk and surly, or stayed away from 
 home in irregular sex life, or loafed about for days, 
 weeks, and months, gambling: every now and then subject to 
 violent spells of rage and cruelty. When one learned from 
 the history in his teens of all manner of unspeakable sex prac- 
 tices, and an early development of thoughtless and irregular 
 tendencies, one was the more convinced that really nothing 
 could be done. When one looked into the family history and 
 discovered psychopathic taint in several near relatives, one could 
 only feel the more certain that, after all, one's efforts might well 
 be wasted. 
 
 What shall we term Henry Loyal medically? The strong 
 heredity, though it strengthens our idea that there exists some 
 unusual blot in this social defective, does not point to a particu- 
 lar group of mental diseases having a particular prognosis. 
 When the man came before the Psychopathic Hospital staff, it 
 showed diagnostic leanings in many directions. For example. 
 
24 THE KINGDOM OF EVILS 
 
 he was suspicious of his hospital friends and rather apprehen- 
 sive. If one stretched a point, one might think of him as sub- 
 ject to the so-called paranoid trend, and therefore almost think 
 of dementia praecox. Yet on the whole, the suspiciousness and 
 apprehensiveness of the man were hardly more than might be 
 expected. Again, Loyal had been markedly depressed and his 
 depression was in sundry details not inconsistent with the diag- 
 nosis of manic-depressive psychosis (in fact, he had feared 
 that he was going to commit suicide about three weeks before 
 he was observed in hospital). On the whole, however, there 
 was no good reason for regarding the depression as psychic, 
 and suicide might, with a certain type of mind, be regarded 
 almost as a natural thought in the family abyss. Again, Loyal 
 might be regarded as inclined toward the group of the psycho- 
 neuroses on account of his hypochondria and headaches. Head- 
 aches had been, in fact, for him the main medical feature in 
 his life. Once, too, he had fallen and had an attack which, 
 owing to his being drunk at the time, was called delirium tre- 
 mens. Whether this attack was actually alcoholic, whether it 
 was not in part hysterical, or whether it may have been at bot- 
 tom epileptoid, was another group of questions. Amongst the 
 ten or eleven great groups of mental disease recognized by 
 most modern psychiatrists, one might therefore think of ade- 
 quate reasons for putting him in more than half.^ 
 
 When a case with numerous psychopathic features does not 
 strike one as definitely epileptic, psychoneurotic, schizophrenic 
 (dementia praecox), or cyclothymic (manic-depressive), one 
 is likely to let it fall into a group for which the favorite psychic 
 designation of the present day is "psychopathic personality." 
 Though the psychiatrist might be put to it to define this term, 
 it is enough to say here that the so-called psychopathic person- 
 alities are rather apt to bear traits that look in one or other 
 of the directions just mentioned, and on the whole to strike 
 even the lay observer as in some degree childish. This latter 
 idea of the childishness of these patients is expressed by some 
 authors by the phrase "infantilism," as if the "below par" level 
 (Minderzvcrtigkeit of the Germans) was somehow an expres- 
 sion of a slight lack of development. Some classifiers use the 
 phrase "constitutional psychopathic inferiority" for these cases, 
 
 ' See pages 436-491 for general discussion and charts dealing with the main 
 groups of mental diseases. 
 
THE KINGDOM OF EVILS 25 
 
 and this phrase is even to be found in our American immigra- 
 tion laws. 
 
 But when we choose to term a man a psychopathic personahty 
 or a psychopathic inferior, we must constantly bear in mind 
 the dififerent directions which the mild infantilism may take. 
 There was always a doubt in the Loyal case just what particular 
 direction we could describe the psychopathy as taking, espe- 
 cially since there was, in addition to the suspiciousness, the 
 depression, the hypochondria and headaches, and the possibly 
 epileptoid attacks, also a tremendous hypersexuality, so that 
 one might almost think of terming the man a sort of diffuse 
 psychopathia sexiialis. In most of these directions he was 
 somewhat influenceable, and on the whole the psychoneurotic 
 trend is perhaps to be preferred, if we must press Loyal into a 
 single compartment. How profoundly important the choice of 
 a diagnosis may be is to be seen from the fact that by pursuing 
 the way of therapy (even in this very unpromising case), the 
 year-long tendency to worry and the habit of headaches (fifteen 
 years) were actually terminated by treatment. 
 
 At this point let us try to throw Henry Loyal into contrast 
 with Agnes Jackson. Miss Jackson was for us a paradigm of 
 medical, social, and governmental troubles, a victim perhaps of 
 mild schizophrenia (dementia praecox), the primary solution 
 of whose troubles lay in the proper adjustment of medical and 
 social work to the Immigration Office rules and regulations. If 
 we try to analyze the case of Henry Loyal from this standpoint, 
 we find his troubles chiefly medical and social. To be sure, 
 from time to time the Loyal family would fall into destitution 
 and require public or semi-public aid mechanized by more elastic 
 means than are ordinarily possible for strictly public agencies. 
 In short, Henry Loyal was a public or governmental case only 
 in an incidental or occasional way. He is a fairly pure com- 
 pound of medical and social troubles, with the emphasis per- 
 haps more upon the social than the personal side. 
 
 The case of Miss Jackson we found more or less the vehicle 
 of all the major sorts of evil that we tried to classify under 
 the five headings of disease {Morhi), ignorance {Err ores), 
 vices and bad habits (Vitia), legal entanglements (Litigia), 
 and poverty or other forms of resourcelessness (Penuriae). 
 Studying the case of Henry Loyal, we find that, as in the 
 majority of instances in this book, he is the victim of disease; 
 
26 THE KINGDOM OF EVILS 
 
 at all events, of a degree of psychopathy that is sufficient to 
 bring him into all sorts of personal and social difficulty. Shall 
 we charge him also with being the victim of the evil we call 
 ignorance? We found him on the verge of feeble-mindedness 
 by tests, but the psychologists felt that on the whole he must 
 be regarded as of normal mental level. He was neither a good 
 nor a poor scholar. He was an adequate steamfitter. He 
 proved amenable to persuasion if not to conviction, and no 
 elaborate reeducation or implantation of totally new ideas had 
 to be carried out in the process. His sex irregularities cannot 
 on the whole be said to be due to ignorance or poor intellectual 
 training. On the whole, there was a good deal to go upon 
 in the practical handling of Henry Loyal, and we must count 
 him as not falling to any extent into the evil-group termed 
 ignorance. 
 
 Re the third group of evils, as in our paradigm case of 
 Agnes Jackson, so in the present case, it is difficult to disengage 
 the bad habits and vices shown from effects of disease. H our 
 separation of the bad habits and vices, on the one hand, from 
 the diseases and character defects on the other, is a logically 
 sound separation, then there ought to be some cases in the 
 world of persons who unfortunately have not been properly 
 trained and given the proper moral set-up in life; and these 
 persons ought, by hypothesis, not to be instances of mental 
 disease or defect. Such persons ought to be trainable by suit- 
 able methods, either by way of telling them or showing them 
 what to do, by precept, example, reward, or punishment. So 
 far as mere precept and mere example and the common methods 
 of reward and punishment were concerned, hardly anything 
 could have been done with Loyal. Punishment would no doubt 
 have failed. The kind of reward offered was the pleasing sense 
 conveyed to him of increased responsibility for a family to 
 which he was tremendously though interruptedly devoted. He 
 was made to feel more of a man. That Loyal had sundry bad 
 habits and vices aside from his psychopathia, we do not know 
 for certain. But whether we are dealing merely with psycho- 
 pathic instability or with the eft'ects of poor moral training, no 
 doubt the plan of reeducation is at first identical for a victim of 
 either form of evil. 
 
 Of legal entanglements, our first paradigm, Jackson, was a 
 prime example in that she was an "undesirable immigrant." 
 
THE KINGDOM OF EVILS 27 
 
 Loyal's succession of predicaments for the most part failed to 
 lapse into the legal group, though he was in court four times 
 for non-support and wife-beating. The wife never had to 
 appear in court to make her point, and his official friends and 
 supervisors made use of the point once only, when he was 
 threatened with the prospect of a separation. 
 
 How far can the Loyal family difficulties be regarded as 
 purely economic? That is, how far does the evil in question 
 fall into the group of poverty and other forms of resourceless- 
 ness? We said that if the Jackson family had been on a higher 
 economic level, the life of Miss Jackson would not have been 
 cast in its peculiar way and that she might never have become 
 an immigrant, desirable or otherwise. What can be said of 
 this point in the Loyal case? The family as a whole is on a 
 fairly high middle-class level, with a number of relatives re- 
 garded.as well-to-do. Some non-psychopathic relatives are suc- 
 cessful in their professions. The courses in life of some of 
 the psychopathic relatives indicate that their economic level, 
 high or low, has little to do with the behavior adopted. Hence 
 the social treatment of this case or of the Loyal family group 
 ^s a purely economic problem would quite miss the point. In 
 point of fact, Henry Loyal while at work could earn, both 
 before and during war time, exceedingly good pay. 
 
 We shall now turn to a few further details of the case 
 Loyal. Note should be taken of the slow and slight, but steady, 
 and on the whole uniform, stabilizing which Loyal's character 
 is undergoing. Doubtless he would have to live several lives 
 tandem to get sufficiently stabilized so that he would no longer 
 require supervision ; but our general principle of hope for stabil- 
 ization even in the most difficult cases remains a principle. Our 
 records run to over a hundred pages, but for the purpose of 
 this exposition we will limit ourselves to a few of the more 
 striking episodes in the Loyal history. 
 
 Loyal first came to the Psychopathic Hospital on the advice 
 of a social worker in a general hospital where his little daughter 
 was under treatment for chorea. He was out of work ai the 
 time and for years had failed to support his family. The oldest 
 girl was fifteen, the second one, who was choreic, was twelve, 
 and the youngest child, also a girl, was five years old. A 
 fourth girl was born four months later. At this time the 
 family was living in a shack on the outskirts of a suburban 
 
28 THE KINGDOM OF EVILS 
 
 town, and their economic condition was acute. On the ground 
 that there might be a nervous cause for his headaches, which 
 he claimed prevented him from 'working steadily. Loyal was 
 persuaded to come to the out-patient department for an exam- 
 ination and even consented to enter the hospital for a week's 
 observation. 
 
 He got a job and moved to a good neighborhood. Some of 
 the debts were paid off, and a much coveted piano was obtained 
 on the installment plan. All went well for about eight months, 
 when Loyal again became irregular in all his habits. He con- 
 tracted gonorrhea and his wife became infected. Meanwhile, 
 one of the children had developed a tuberculous hip, required 
 long, patient treatment in a hospital, and was later boarded out 
 in the care of a children's agency. Throughout her illness Mr. 
 Loyal was in a state of anxiety and excitement which threatened 
 to interfere with the child's proper care, but in the end the 
 social worker prevailed and the little girl made a good recovery. 
 The second child recovered from her attack of chorea under 
 the exceptionally good nursing given her by her mother. The 
 baby too was sick, but not seriously. 
 
 Work became slack and the landlady threatened prosecution 
 for arrears of rent. From time to time it was necessary to 
 give financial assistance, for which funds were given anony- 
 mously by a relative. Finally public aid had to be sought. In 
 time, Mr. Loyal found new work on government buildings and 
 had no more difficulty in getting employment, although he was 
 likely to be idle for short periods between jobs. It was never 
 possible to find out what he did with the high wages he re- 
 ceived. Certainly the results were not evident. In one of these 
 intervals of unemployment, nearly four years after the family 
 became known to us, a crisis arose. Mrs. Loyal was sick and 
 in need of hospital care (she had been having serious trouble 
 with varicose veins), funds were exhausted, and the landlord 
 had set a date for eviction. Loyal had a job in view, but could 
 not get it until he was restored to good standing in the union. 
 The way out was found by sending one of the girls to a rela- 
 tive, Mrs. Loyal to a hospital, and the two younger children to 
 the public authorities for temporary boarding-out. The oldest 
 girl by this time was married to a man considerably older than 
 she, a distant relative with some means. She had developed 
 a character much like her father's. Nevertheless with the fam- 
 
THE KINGDOM OF EVILS 29 
 
 ily provided for and his financial condition revamped, Mr. 
 Loyal started for his new job. In a few months he was able 
 to take the children from public care to their mother, who went 
 to live with her sister in a city near the scene of work. At 
 last report, he and his wife were making efforts to get together 
 ■a home again. 
 
 Hours spent by Medical record, 42 pages 
 
 Social record, 106 pages 
 Physician, 15 Social work : 
 
 Visits, 120 
 Psychologist, i Interviews at hospital, 57 
 
 Telephone calls, 105 
 Social worker, 245 Letters, 75 
 
 Adventuress, thief, liar — psychopathic persofiality. Mental 
 level testing very high. A "public" problem in hands of the 
 law, sent for observation by alienist. 
 
 Case 5. We possess numerous newspaper clippings about 
 the possible deportation of the supposed wife of a famous 
 British army officer. "Lady" Nora Campbell was brought 
 to the Psychopathic Hospital by a social worker. Mrs. Camp- 
 bell had been doing voluntary war work. Her husband, she 
 said, had been a major in the army, killed on service in the 
 war, leaving her a child, which about six months since had 
 died at the age of eighteen months. Now, it chanced, she 
 said, that she was the goddaughter of the King, a niece of a 
 well-known general, had given from her ample estate a hos- 
 pital for the use of English soldiers and had had some seventy 
 per cent of her money taken over by the British Government. 
 She said at one time that she was the illegitimate child of a 
 person high in English society, who was paying her seven 
 thousand pounds a year as sort of hush money. , 
 
 From various physicians and Boston people with whom the 
 patient had had dealings, a number of stories were collected 
 concerning Mrs. Campbell. The biggest story hung upon the 
 loss of a brooch by a fellow war worker, who had known her 
 for two or three months and regarded her as a quiet, ladylike 
 victim of the war who was only to be pitied for her wanderings, 
 the loss of her husband and baby, and her present loneliness. 
 To be sure, Mrs. Campbell it seems had flirted with a son of 
 
30 THE KINGDOM OF EVILS 
 
 one of the war workers, and had on sonae pretext obtained 
 twenty dollars from him. There also was a somewhat unlikely 
 story about a man's coming to get two hundred dollars hush 
 money and making away with eight hundred dollars more which 
 was in her purse. Finally, a valuable brooch disappeared under 
 very suspicious circumstances, and shortly thereafter Mrs. 
 Campbell tried to sell a brooch on account of its "evil associa- 
 tions." Detectives were finally called in. Several inconsistent 
 stories were told them. In the end the brooch was found, and 
 after sundry vicissitudes, also the central stone, which at one 
 time Mrs. Campbell tried to isolate by burying it. 
 
 The eventual diagnosis from the psychopathic point of view 
 in the case of Mrs. Nora Campbell was that of psychopathic 
 personality, a phrase intended to convey the idea that she was 
 not a mere delinquent but that her tendencies were in large 
 part psychopathic. Of course, there were numerous and sun- 
 dry defense reactions of the true delinquent in Mrs. Campbell, 
 who told many forms of tales and lied more or less expertly on 
 all occasions (never, even in the end, confessing her theft of 
 the brooch) about her life and status. Physically, there was 
 no certain evidence of there having been a child born, and 
 conditions were, on the whole, rather consistent with the idea 
 that no such obstetric history could ever have occurred. The 
 physical examination proved, in fact, to be practically normal 
 in all respects. 
 
 Psychologically, she rated extremely high, achieving 95 
 points in a possible 100. She did many of the tests exception- 
 ally well, was perhaps somewhat over-suggestible and fell off 
 particularly in certain performance tests. Whether or not on 
 account of her intentional and unintentional lying, she gave the 
 impression of a slight memory defect. 
 
 The case of Nora Campbell is schematically simple. To be 
 sure, from one point of view, if Mrs. Campbell was a psycho- 
 path, then it is clear that we must logically conceive that she 
 possessed "individual difficulty." There is presumably no 
 psychopath who is not a "damaged individual." In the first 
 place, there remains judicial doubt and also doubt in the lay 
 mind whether this adventuress, liar, and thief was really a 
 psychopath at all. For example (the judge or the layman 
 might say) an adventuress, thief, and liar might be such from 
 faulty education, as the criminals taught by Fagin in Oliver 
 
THE KINGDOM OF EVILS 3 1 
 
 Twist were victims of faulty education rather than of disease 
 or moral deficiency. So it might be that Mrs. Nora Campbell 
 had been educated under conditions which made a life of ad- 
 venture with the fleecing of society, subject to the accompani- 
 ment of picturesque lying, a natural career for a woman. Ad- 
 mittedly, this would be doubtful, but the hypothesis must neces- 
 sarily be entertained, if only to be dismissed. A far more 
 likely hypothesis concerning the intra-individual blemishes of 
 Mrs. Campbell would be that she was a vicious person, a per- 
 son of faulty mental and moral habits who had slipped into a 
 life of crime of this "grafting" sort more than half intention- 
 ally. Such a hypothesis would, no doubt, fit a good deal of 
 what we term crime (in the minds of the laity). 
 
 However all this may be, the point in not classifying Nora 
 Campbell as a case in the "individual" group is that she did not 
 fall under the sphere of authority which deals with the indi- 
 vidual as such. She was and remained an almost purely legal 
 case, despite the fact of her observation at the Psychopathic 
 Hospital under much more lax conditions than most com- 
 munities permit. 
 
 Should we not classify Mrs. Campbell as falling under the 
 sphere of social influence or authority? To be sure, many 
 interested society people and many social workers became inter- 
 ested in her and spent some time upon her devious ways. 
 Nevertheless, throughout the whole situation, the hand of the 
 law and the penetrative technique of the detective drew the red 
 herring of public influence over all the social and individual 
 interests which might otherwise have prevailed. The point for 
 the general or psychiatric social worker to bear in mind is that, 
 whatever may be the medical information concerning the pro- 
 found and delicately balanced psychopathic interior of the case, 
 nevertheless a case like Campbell is without the range of the 
 physician to influence thoroughgoingly, simply because the iron 
 of the situation remains in the hand of the law. Again, what- 
 ever the social worker may think as to the excellence of her 
 own technique in managing a case like Campbell, she must 
 always remember that the case remains one under public author- 
 ity. She may supply a good deal of velvet for the outside of 
 the glove, but the iron remains therein. Upon whatever logical 
 or profoundly sentimental grounds the physician or the social 
 worker may want to proceed, he or she is forthwith stopped, 
 
32 THE KINGDOM OF EVILS 
 
 in all authoritative procedure, by the hand of the law. There 
 are public interests here which are organized and crystallized 
 from the habits of centuries on the part of the legal world. 
 These old, crystallized judicial and institutional habits must 
 prevail until they are bowled over or turned into dead letters 
 by the new knowledge which may accrue in future systematic 
 studies of delinquency and near-delinquency. 
 
 We concede that we have presumably no right to draw such 
 heavy conclusions as the above from the case of the adventuress 
 Campbell. Throughout the rest of the book, however, we shall 
 find these public interests interwoven through the social and 
 individual interests that we are tempted to think ought often 
 to have the right of way. The interests of the state as a juris- 
 tic person and the interest of the state as guardian of social 
 interests (phrases of Dean Roscoe Pound) are interests often 
 paramount to the individual interests in personality, domestic 
 relations, and economic circumstances, and paramount over 
 such general social interests as the security of social institu- 
 tions, the maintenance of general morality, the conservation 
 of social resources and general progress — all of these phrases 
 borrowed from a legal statement of certain fundamental con- 
 ceptions of the "legal order." "The legal order," writes Dean 
 Pound, is "an adjustment of human actions and relations in 
 order to conserve the goods of existence, prevent friction in 
 human use and enjoyment of these goods, and eliminate waste 
 of them." In the case of Campbell, it is a question of a brooch, 
 borrowings of money, etc., an enormous waste of good people's 
 time, and a question of prevention. Aside from imprison- 
 ment, it must be granted that the legal order does not seek the 
 methods of prevention that social workers and physicians 
 would be eager to establish. Punishment and redress are far 
 more prominent in the legal order than prevention. But that 
 is another story and one calculated to be extraordinarily devel- 
 oped by a systematic attack on the problems of general and 
 psychiatric social work. 
 
 Hours spent by Medical record, 6i pages 
 
 Social record, 9 pages 
 Physician, 9 Social work : 
 
 Visits, 4 
 Psychologist, I Interviews at hospital, I 
 
 Telephone calls, 3 
 Social worker, 9 Letters, 15 
 
ALCOHOLIC PSYCHOSIS 
 
 IN A PACKER 
 
 November, 1915 November, ipi6 
 
 Inebriety Sobriety 
 
 Unemployment Steady Work 
 
 Physically Disabled Good Health 
 
 No Income Good Wages 
 
After-care of an alcoholic. Rationalisation. Point of view 
 of a hospital organization knozvn as tlw Men's Club. Non- 
 psychiatric social ivorker likely to miss the point of such a 
 case. Patient now better than lie ever was. Problem social, 
 rather than public or individual in the special senses of those 
 terms. 
 
 Case 6. Alfred Mack, an Irish elevator man, is now al- 
 most forty years old. We describe him, with some misgivings, 
 as a paradigm of social troubles, occurring practically pure, 
 that is, without any public (governmental) complications and 
 without special medical difficulties. Mack was under our social 
 supervision for some three years. A recent inquiry has shown 
 him socially adequate, after a period of about five years since 
 the medical incidents that brought him to the hospital. 
 
 Possibly the layman would not regard the episodes which 
 brought him to the Psychopathic Hospital as mere "incidents," 
 since he there got a definite diagnosis of mental disease, due to 
 alcoholism, and since doubts were there raised as to whether 
 he might not be a victim of very severe mental disease leading 
 possibly to deterioration. No such deterioration has set in. 
 The mental tests, in point of fact, yielded, five years ago, 
 according to the Yerkes Point Scale, an age level of fifteen 
 years plus. It is true that the Binet tests left him at an eleven 
 year level at the time he was first examined; but the psycho- 
 logical examiners even then attributed his deficiency to the 
 alcoholic traces which he still showed. 
 
 The alcoholic mental disease, severe as it was (he had definite 
 delusions of persecution and even hallucinations of hearing, 
 possibly of vision) ended in a relatively perfect recovery, so 
 that he could be discharged recovered in nineteen days. Ac- 
 cording to the usual psychopathic hospital technique, Mack 
 was discharged to the out-patient department of the hospital, 
 where he has since been carried on the books. 
 
 Upon a further study of his situation, another bothersome, 
 but rather banal medical condition was drawn into the fore- 
 ground. He had, for a number of years, had ulcers of his feet 
 which had been variously treated in general hospitals and which 
 
 35 
 
36 THE KINGDOM OF EVILS 
 
 have left him, up to date, quite unable to do certain kinds of 
 work. At various times a packer and a shipper's assistant, he 
 has finally settled into being an elevator man. (As to actual 
 nature of the disorder of his feet there is doubt. The ulcers 
 were apparently treated at one time as syphilitic, but our blood 
 tests proved negative in this regard. On the whole, the dis- 
 order seems to be almost purely orthopedic.) 
 
 Far more serious than the severe, acute episode of mental 
 disease through which he was carried, and of less consequence 
 than the orthopedic disorder just noted seemed, at first blush, 
 his twenty years' history of alcoholism. 
 
 Mack was a somewhat appealing little man, looking rather 
 old for his years, with a pigeon breast, trouble with both arches 
 of his feet, and poor teeth. A study of his heredity left one 
 much concerned for his outcome. Both parents (the mother, 
 a Roman Catholic, had married a Church of England father) 
 were alcoholic, and the father died of cirrhosis of the liver, the 
 mother of paralysis following five years "of being peculiar 
 after her first stroke." 
 
 The father had been a sex delinquent and nothing was known 
 of his brothers and sisters if, indeed, there were any. The 
 mother's brothers and sisters were all alcoholic, two dying of 
 paralysis (one of the aunts had a kind of mental disorder at 
 menopause and died at a hospital for the insane after a para- 
 lytic stroke in the sixties). It is difficult to choose a general 
 epithet for the family, whether "alcoholic," "paralytic," or 
 "cardiac," though possibly these conditions are in this particu- 
 lar family closely interrelated. Nevertheless, Alfred Mack, him- 
 self alcoholic and given inordinately to tobacco, despite his 
 somewhat melancholic self-depreciative and rather unsocial 
 frame of mind, was always considered a man of normal in- 
 telligence and a fair worker. He held his first position for 
 eighteen years and was not known by his employer to be the 
 steady alcoholic that he really was. He may have been held 
 in this position somewhat out of pity for himself and his 
 mother, whom he helped to support for ten years. The rheu- 
 matism and ulcers of the toe were said to have followed a 
 severe attack of scarlet fever in childhood. There is history 
 of a supposed concussion of the brain from a fall at the age 
 of seventeen. (The psychiatrist is apt to think of such con- 
 cussion cases as subject to unusual intolerance for alcohol.) 
 
THE KINGDOM OF EVILS 37 
 
 There is a still more obscure history of a supposed love affair 
 in the teens, but for the rest of the patient's life, at least, he 
 showed no interest in girls, had a few male chums, but was 
 never "hail fellow, well met." 
 
 In his thirty-fifth year. Mack had an attack which it would 
 seem safe to describe as one of delirium tremens. The second 
 attack, which came on at a general hospital to which he had 
 reported for an operation on his foot, brought him to the 
 Psychopathic Hospital. 
 
 Up to the time of development of the first attack called 
 delirium tremens, there appears to have been no sign of mental 
 or nervous disorder save that, apparently at about the age of 
 thirty-two, he once had a sudden attack of blindness lasting a 
 quarter of an hour. For the rest, in early life he may or may 
 not have had certain fainting fits in the course of the "rheu- 
 matism" which followed his scarlet fever. 
 
 In this analysis we are intentionally overemphasizing and 
 throwing into relief sundry minor points in Mack's medical 
 history with the idea of showing that the main complications 
 which social treatment had to face were either not medical or 
 else were perfectly obvious matters to deal with. In short, if 
 we are searching for a case of practically pure social difficulty 
 and confine ourselves to drawing upon hospital cases, we shall 
 rarely find a purer instance of social difficulty without public 
 complications and with rather obvious medical indications. 
 
 Let us contrast the problems as they faced the medical man 
 and the social worker respectively. The physician confronted 
 a rather prematurely aged alcoholic of twenty years' standing 
 who had had two rather serious attacks of an acute mental 
 disease due to alcohol. The heredity was in several respects 
 poor and the stock in general given to disease of the blood 
 vessels. The situation was complicated by rheumatism, ulcers, 
 and some obscure though slight nervous phenomena, appar- 
 ently attributable to a severe scarlet fever in childhood. The 
 general medical indications were merely those of proper hygiene 
 (possibly with special reference to work that might spare the 
 heart). 
 
 Confronting Mack's case in the same general way, the social 
 worker found him on a basis of (a) inebriety, (&) a case of un- 
 employment of about a year's duration, and hence (c) without 
 income and even possibly (d) disabled industrially. 
 
38 THE KINGDOM OF EVILS 
 
 As for the industrial disability of orthopedic origin, the cure 
 was relatively easy, and general hospital care soon helped his 
 feet so that he could undertake a new job as elevator man. 
 Meantime, until the disability for work could be removed, small 
 sums of money were got for him (this the very well-inten- 
 tioned man later repaid) and the next step was to get him an- 
 other permanent job. As the man's general nature was such 
 that he liked to work in one place (his "occupational orbit" 
 was very small) and as, moreover, the foot trouble helped de- 
 fine the issue, it was fitting that he should go back to an ele- 
 vator job. But the desirable permanent job did not come until 
 he had tried several temporary ones. Yet to remove the foot 
 trouble, tide him over his convalescence and to get him a job, 
 was not to abolish his inebriety. For this purpose he was com- 
 pliant with a plan of coming to the so-called "Men's Club" 
 which ran at the Psychopathic Hospital for several years (up 
 to war emergencies) and was a most effective agency for hold- 
 ing certain recovered alcoholics to a program of abstinence or 
 temperance. Mack took no especially prominent part in club 
 meetings, but drank his coffee and ate his cake with the other 
 social convalescents every evening after the club business was 
 discussed, namely — how to beat inebriety. The Psychopathic 
 Hospital Men's Club would be worth a detailed elaboration as 
 an interesting application of the class method in psychotherapy. 
 Mack was simply "one of the boys" at these meetings, which 
 were presided over by convalescents elected to their jobs and 
 run in the presence of a social worker or two. From month 
 to month the program of the meetings varied, but as a rule 
 some physician would help lead the attack on alcohol. A deep 
 analysis of the operations of such a club would have to take 
 into account the frequent successes of a psychotherapy for 
 alcoholism which did not utilize music, religion, or even ethics 
 in the common manner of so-called "uplift." In fact, a plain 
 rationalization of the alcoholic's plight was the mainstay of 
 these meetings where each man's endeavor was to some extent 
 bolstered by a certain sense of competition with his brother 
 convalescents. As for spiritual appeal, the case of Alfred Mack 
 might have been difficult. With a Roman Catholic mother and 
 a Church of England but sexually delinquent father, a boy who 
 had been embraced rather than guided into the Baptist church 
 
THE KINGDOM OF EVILS 39 
 
 was no specially suitable vessel for spiritualization, unless in- 
 deed some complete conversion could have been undertaken. 
 
 The elements in getting hold of a case like Mack's were not 
 complex. To adjust the simple medical care, to get him a 
 little money in the meantime, and to get him temporary, and 
 at last permanent jobs, to rationalize and support a proper at- 
 titude (through the Men's Club) to alcoholism, were measures 
 to which but one other had to be added. It was necessary to 
 secure and maintain a proper attitude on the part of Mack's 
 family to his history and his outlook. This family consisted 
 of a sister and her husband. The brother-in-law was not a 
 drinking man and was friendly to Mack. It did not take long 
 to patch everything properly up. It is worth noting that the 
 patient's sister had herself, at one time, been a charity case on 
 account of the drinking habits of her mother. But married, as 
 she finally was to a non-alcoholic painter, she herself had made 
 what might be called a social recovery. All of which leads 
 one to ponder upon the entire family background of the Mack 
 case which, absolutely black as it was from alcoholism and 
 tendencies to blood-vessel disease, nevertheless gave room for 
 successful social measures. 
 
 We must not say that the insight of the psychiatric social 
 worker is extraordinarily more penetrative in a case like Mack's 
 than that of the medical social worker approaching the problem 
 from more general ground. Nevertheless we think it safe to 
 say that many a case with as black a heredity and family back- 
 ground, a history of years of social failure, might well drop 
 into the discard in the presence of ever so many more "prom- 
 ising" cases. Of course one does not know what, for example, 
 the orthopedic division of a social service department would 
 have accomplished for Mack. It is a little bizarre, yet profit- 
 able, to think that without an attack of outspoken alcoholic 
 mental disease. Mack might thus have been handled by an 
 orthopedic social worker after a successful course of foot treat- 
 ment at a general hospital. It is a question whether his alco- 
 holism would have been handled as intensively as the Men's 
 Club allowed it to be handled at the Psychopathic Hospital. 
 Perhaps we unduly malign the non-psychiatric social worker in 
 the above reflection, but it seems safe to say that without a 
 good bit of experience with the temperaments of alcoholics 
 
40 THE KINGDOM OF EVILS 
 
 and of more pronounced psychopaths, the routine social worker 
 of economic bent or with the everyday philanthropic point of 
 view would scarcely be tempted out of the ordinary run of 
 measures. The concrete thing which the psychiatric social 
 worker here did was to utilize the Men's Club for rationalizing 
 the patient's outlook on life, but more than that, to employ the 
 entire fundamental plan of attack which underlies the Men's 
 Club and all other social psychiatric measures — namely, the 
 temperamental or characterological point of attack. To be 
 sure, any human being with insight into human nature and 
 considerable experience therein might have seen through the 
 slight unsociableness of the patient, marked out his native 
 timidity as an avenue of approach, and fed his waning self- 
 respect in a variety of ways. 
 
 We cannot claim that the church has not accomplished as 
 much or more with equally alcoholic patients. But the church 
 would probably have been of lesser service in this man of mixed 
 religious antecedents. Nor do we deny that the technique of 
 conversion or regeneration by the process of the "twice born 
 men" would have been applicable. The social psychiatric ques- 
 tion is, as the child W. K. Clifford used to say, "What is the 
 particular go of itf" At all events, whatever the technique, 
 we can safely say that Mack is at this time medically a much 
 sounder unit in the world than he was at the time of his alco- 
 holic psychosis and for many years preceding. Whether on 
 the account of the social treatment or by reason of unknown 
 factors, there has been a decided up-gradient in Mack's life. 
 For years, during his early employment, he was something of 
 an object of pity and might have been thrown completely out 
 of employment had his steady alcoholism been known. Now 
 Mack is one of the most reliable and efficient minor employees 
 in a big shop. 
 
 We need no extended analysis in the case of Mack to show 
 how the major sorts of evil that we have classified in the pre- 
 vious cases fall out. Into the class of diseases readily fall the 
 tendency to blood-vessel disorder, rheumatism, and other effects 
 of scarlet fever, and more probably (although not demon- 
 strable) a certain tendency of mind which naturally led him 
 into alcoholism. With such a heredity as Mack's it would be 
 impossible to deny that there was not at least more latent 
 tendency to disease in him than in the majority of men. 
 
THE KINGDOM OF EVILS 4I 
 
 Turning to the matter of ignorance or errors of education, 
 we find Mack singularly free from these. To be sure, two 
 parents not agreeing upon religion probably gave him little 
 enough of true home education or moral training. Despite 
 these lacks, the man is relatively free of their concrete effects. 
 A long controversy might be waged as to whether Mack's 
 alcoholism was a vice or a bad habit into which he was led 
 by nature on one hand or by imitation on the other. The pres- 
 ent tendency is to underscore the hereditary standpoint and to 
 scout somewhat the factor of mere imitation of parental ideas 
 and habits. As to the tentacles of the law, Mack failed to be 
 caught thereby, save in the benign circumstances that the tem- 
 porary care law (that mildest of all legal adventures for the 
 psychopath) became available when he was out of his head at 
 the general hospital. The existence of such a law as the tem- 
 porary care law (see Appendix C) is, no doubt, of extraordi- 
 nary importance in the potentialities of social service for 
 psychopaths and psychopathic suspects in any community. But 
 that is another story. 
 
 As for the fifth group of evils which we have discussed, the 
 economic factor was drawn only temporarily into view. We 
 are dealing then with an almost purely social case whose minor 
 complications are, to be sure, medical, but whose central fea- 
 ture, the alcoholic tendency, must be regarded as a kind of 
 psychopathic tendency, whose effects are distinctly curable. 
 This, indeed, is a frequent lay point of view toward the alco- 
 holic unfortunate. It does not do to throw the alcoholic out 
 at the door, even if his history be a long and sad one and his 
 hereditary taint even more terrible. 
 
 We must here leave the large question of temperament un- 
 analyzed. Below we shall meet many instances of a more 
 striking temperamental make-up which the disease itself will 
 have brought out in exceeding sharp relief. 
 
 Hours spent by Medical record, 36 pages 
 
 Social record, 15 pages 
 Physician, 4 Social work : 
 
 Visits, 12 
 Psychologist, I Interviews at hospital, 5 
 
 Telephone calls, 6 
 Social worker, 23 Letters, 15 
 
42 THE KINGDOM OF EVILS 
 
 Industrial injury (shell-shock analogue from civilian life). 
 Looked highly ''organic." Problem chiefly individual: the 
 mans relation to himself. Resentful of sympathy. 
 
 Case 7. James Bailey, a Jewish laundryman, twenty-four 
 years old when he was first seen, is presented as a case of almost 
 purely medical interest, whose social aspects (both from the 
 standpoint of diagnosis and from the standpoint of treatment) 
 were of an obvious nature and who presented no public serv- 
 ice aspects whatever, (his coming voluntarily to an out-patient 
 clinic in the Massachusetts State Hospital system may be re- 
 garded as putting him in contact with governmental agencies : 
 and his damage case against the Elevated Railway was in the 
 hands of a lawyer). 
 
 Medically speaking, James Bailey was a rather intriguing 
 case, since his disorder not only followed a definite street rail- 
 way accident, but also looked to the neurologist like an "or- 
 ganic" case. Yet, Bailey's nervous system was really reacting 
 (as was eventually determined) to a tuberculous pleurisy. This 
 pleurisy, we came to think, formed a perfectly genuine nucleus 
 of pain in the back, around which the peculiar, at first sight 
 "organic," disorder crystallized. 
 
 It was somewhat with Bailey's case as with sundry shell- 
 shock hysteria cases of the war group, in that there was a 
 genuine focus of pain of organic origin around which the 
 functional, and perfectly curable, disease grew. Many func- 
 tional disorders of the back and legs in the war neurosis group 
 have apparently developed in precisely this way around strained 
 ligaments, small hemorrhages, or other lesions incidental in 
 the strains, falls, or "windage" of war service. 
 
 Here, then, we were dealing medically with a "shell-shock 
 analogue" ; but the military factor in the situation is replaced 
 by a pleurisy which was perhaps, although not certainly, 
 lighted up by the railway accident. Curiously enough, Bailey 
 developed his peculiar gait and reactions (somewhat at first 
 sight resembling an ataxic paraplegia) in camp. For Bailey, 
 about a month after his railway accident, in which two ribs 
 were fractured in alighting from a car, was drafted into the 
 United States Army and sent to camp. Six weeks later he had 
 to be discharged on the ground of physical disability, as he 
 
THE KINGDOM OF EVILS 43 
 
 could not keep up with the drilHng and dragged his foot. It is, 
 of course, post facto obvious that Bailey should not have been 
 accepted for military service. Yet even in the light of these 
 subsequent developments, the draft board physician now as- 
 sures us that there was certainly nothing demonstrable about 
 the man which could possibly have led to his rejection as a 
 draftee. 
 
 We present this case as an almost purely medical case. The 
 social work of the case might be characterized as supportive, 
 as a sort of splint to Bailey's will, to keep him in contact with 
 medical officers who only could cure him. 
 
 Bailey is of rather a refined and meticulous nature. Al- 
 though a laundry worker in this country, he had been a teacher 
 in Russia (whence he had emigrated at the age of nineteen) 
 and had nourished ambitions to become a physician. With 
 characteristically racial intensity, he had tried to improve his 
 status in the world, had studied hard and gone to evening 
 school. It appears that his mother was a worrier, or as one 
 might technically say, somewhat "psychasthenic." She also 
 had the history of developing at one time a paralysis ; whether 
 this was of hysterical nature or not is unknown. The ambi- 
 tions for medicine were interfered with by the accident, and 
 Bailey lost some of his savings. The army service set him 
 further back. He was now, as one might say, on the defensive 
 and in the passive voice. He felt that, after all, he was not 
 entitled to sympathy and resented any signs of it in others. 
 Bailey looked with suspicion on jobs suggested for him be- 
 cause he did not want to take a "charitable" job. 
 
 Upon the examination table his lameness and peculiar posture 
 of back and legs were no longer in evidence. The whole situa-. 
 tion, with the exception of the hypothesis of something "peri- 
 organic" (the pleuritic pain above mentioned) seemed to the 
 physicians hysterical. 
 
 Bailey is now somewhat better ; his condition is theoretically 
 curable. The function of the social service is to keep him in 
 contact with the sources of proper psychotherapeutic sugges- 
 tion. The black side of the problem is merely that, after all, 
 he has a definite tuberculous condition of his pleura. This 
 can, no doubt, be cured, whereupon the whole hysterical situa- 
 tion would have no longer any possible organic basis. But, if 
 we are to give him the regime suitable to a case of tubercle. 
 
44 THE KINGDOM OF EVILS 
 
 we must clearly somewhat alter his mental attitude, which, 
 though unlike that of his worrying mother, is of a somewhat 
 psychasthenic trend. After all, the relation of the patient to 
 himself is the most important point here. 
 
 We thus conclude our exposition of seven cases chosen to 
 illustrate the three major spheres of mental hygiene, public, 
 social, and individual, into which psychiatric cases (as well, 
 doubtless as all other cases falling within the purview of social 
 work) in general fall. • We do not intend to rehearse at this 
 point the main features of these cases, reserving such general 
 considerations to the main summary at the end of this book. 
 Briefly taken, however, our considerations descended in com- 
 plexity from (a) the immigration case of Agnes Jackson 
 through (b) three somewhat less complicated cases of Richard 
 Sully (the boys' club organizer), Jennie Walton (with her 
 peculiar thievery) and Henry Loyal (the steamfitter of psycho- 
 neurotic trend), a series of three cases in which but two of the 
 major mental hygienic spheres of interest are illustrated (Sully, 
 public and social ; Walton, public and individual ; Loyal, social 
 and individual) to (r) three cases of still simpler nature, 
 namely, — Nora Campbell whose offense and nature was such 
 as to make her dominantly a public service case with social and 
 individual features overshadowed by her apparent criminality; 
 Alfred Mack, an alcoholic, without special public-service com- 
 plications, with comparatively simple diseases and charac- 
 teristics to contend with and whose handling was a practical 
 matter of straight social work ; James Bailey, the subject of the 
 present sketch. 
 
 How can we justify placing James Bailey amongst cases that 
 .are chiefly individual in their mental hygienic problem? The 
 grounds of this claim are that Bailey's relation to the public 
 service was of the most tenuous, consisting merely of his rela- 
 tions w'ith the psychopathic hospital out-patient department, 
 that the social work involved was relatively obvious, and that 
 all the work involved led very directly back to the medical situa- 
 tion (injury, "functional" lameness and gait) and his char- 
 acter, somewhat resentful of sympathy. 
 
 The previous cases in this present group of seven have been 
 analyzed also briefly according to the peculiarities and special 
 aspects of the maladjustments or "evils" which they presented. 
 
THE KINGDOM OF EVILS 45 
 
 The analysis of numerous cases upon this schema of evils is 
 to be pursued in the second part of this book and to be further 
 synthesized in our summary at the end. In this first part of 
 our analysis we have discussed cases from the standpoint of 
 their falling into one or other or even into two or perhaps three 
 of what may be called the major spheres of interest and of 
 authority in mental hygiene. We have in this first part of our 
 book discussed the practical status which the personality of a 
 psychopath, with all its internal and environmental complica- 
 tions, possesses in the existent human world, subdivided as 
 this world is into interests maintained by (a) organized gov- 
 ernment (courts, state hospital societies, etc.), (b) community 
 interests of a less organized character (voluntary social agen- 
 cies, and other efforts of citizens at large), (c) and the interests 
 of the individual himself (as mainly controlled by physicians 
 and by other personal guides endeavoring to effectuate such 
 changes inside of the personality as may straighten out the 
 entire tangle). 
 
 However, even in these cases, presented from the aspect of 
 the three main spheres of authority or applied influence into 
 which they fall, we have seen the main divisions of social mal- 
 adjustment stand out. To take this last case, James Bailey, 
 for example, we find him afflicted first with some obvious med- 
 ical complaints requiring rather obvious attention. But he is 
 much more importantly afflicted with a special attitude to life, 
 a definite slight defect of character requiring very particular 
 attention for its correction or compensation. Re educational 
 defect, this young Russian Jew is rather well informed, despite 
 his feeling that he is not as well educated as he should be. It 
 would be a nice point to determine whether we shall regard 
 Bailey's educational question as a matter of character defect 
 or as a matter of a true deficiency in knowledge of how a 
 young man in his plight ought to look upon his future. Of 
 course, in a general way also, Bailey is (from the so-called 
 middle-class standard in America) not too well informed, and 
 this may be regarded as an effect of his origin in the Russia 
 of recent years and his transplantation to the American soil 
 of today. 
 
 From the moral point of view, Bailey is exemplary; from 
 the standpoint of legal entanglements he has entangled himself 
 
46 THE KINGDOM OF EVILS 
 
 somewhat in lawsuit preparations over his railway injury. As 
 for Bailey's economic plight, he groups with the so-called 
 "marginal" cases and would not prominently classify in the 
 group of poverty and resourcelessness. 
 
 Hours spent by Medical record, 7 pages 
 
 Social record, 21 pages 
 Physician, 3 Social work : 
 
 Visits, 14 
 Psychologist, Interviews at hospital, 21 
 
 Telephone calls, 21 
 Social worker, 42 Letters, 21 
 
BOOK II 
 
The land of the shadozv of death, 
 without a}iy order. 
 
 Job, Chapter lo, Verse 22. 
 
THE FIVE MAJOR FORMS OF EVIL 
 IN THE REGNUM MALORUM 
 
 Arranged for the Purposes of 
 General and Psychiatric Social Work 
 
 Diseases and Defects of Body and Mind Morbi (M) 
 
 Cure! 
 Educational Deficiencies and Misinformation Errores (E) 
 
 Teach ! 
 Vices and Bad Habits, Non-psychopathic Vitia (V) 
 
 Train ! 
 Legal Entanglements In and Out of Court Litigia (L) 
 
 Counsel ! 
 Poverty and Other Forms of Resourceless- Penuriae (P) 
 ^^ss Provide! 
 
 ANALYZED IN 
 THIRTY-ONE SPECIMEN PSYCHIATRIC CASES 
 
 Note. — The order of evils here adopted is proposed for the purposes 
 of orderly exclusion in psychiatric and other branches of social case 
 diagnosis. - - . .. 
 
Intelligent sex delinquent. Difficulties in public, social, in- 
 dividual spheres. Medical, educational, moral, legal, economic 
 factors: Morhi, Err ores, Vitia, Litigia, Penuriae. Psychiatric 
 point of viezv. 
 
 Case. 8. Rose Talbot is one of those rare examples 
 amongst women of the very intelligent sex delinquent. She 
 is an emotional and unstable girl with strong sex desire, now 
 twenty-four years old, with a record of marriage at seventeen, 
 the contraction of syphilis from her husband (dead two months 
 after marriage), the birth of a syphilitic child (still living and 
 apparently normal after elaborate and intensive salvarsan treat- 
 ment), and a second marriage at twenty-two with a divorce a 
 year later, said divorce being procured by her new husband, a 
 respectable man, on account of her sex delinquency. 
 
 The immediate medical problem was the cure of the syphilis 
 which went forward as well as usual (or perhaps better than 
 usual in psychopathic cases, whom it may be difficult to make 
 appear at due intervals) to a practical cure, but back of the 
 problem of the acquired syphilis is the problem of the patient's 
 own emotions and will, whose disorder expresses itself from the 
 legal point of view as sex delinquency and comes to the clinic 
 for diagnosis. It is worth eternally insisting that not every 
 sex delinquent is by the same token necessarily a psychopath. 
 If psychiatry is likely some day to prove that sexual and other 
 delinquencies are somehow expressions of psychopathy, never- 
 theless psychiatry has not, up to date, proved that crime is 
 always and necessarily a disease. It does help the task of the 
 mental hygienists when overenthusiastic theorists make ex- 
 travagant claims to the effect that crime is always disease, and 
 criminology, accordingly, a part of medical science. Perhaps 
 more than half of all sex delinquents that come publicly to the 
 surface are in one way or other psychopathic (that is, either 
 severely or mildly psychotic or more or less feeble-minded). 
 
 How does it stand with Rose Talbot? We have mentioned 
 her considerable intelligence, which was eventually to be proved 
 by her becoming an expert telegrapher. The psychological ex- 
 
 51 
 
52 THE KINGDOM OF EVILS 
 
 amination taught us at once that from the standpoint of avail- 
 able tests, she was of high intelligence. This mental level, thus 
 scientifically indicated by the psychologist, was at first sight 
 not at all borne out by her history when she came to the hos- 
 pital. She then struck the ordinary eye as a hopelessly unde- 
 pendable, probably incorrigible instance of an oversexed woman 
 with the added complication of acquired syphilis and a syphilitic 
 child also to be cared for. As a social problem of fitting into 
 some occupation. Rose Talbot was difficult. As soon as she 
 was a woman grown she had married ; she had learned no 
 trade; she was of an intelligence rather superior to the level 
 of the kind of work which she could readily procure ; a lapse 
 into sex life had been easy, and a continuation of it was to 
 be expected. It is a matter of interest that social conferences 
 held over this case left most of the conferees in a dubious 
 frame of mind. Upon reference to medical experts, one could 
 only point out the dangerous menace of the girl's syphilis to 
 the community, whilst another physician, upon clinical data 
 alone, felt inclined to think that the girl must be somehow 
 "feeble-minded," and still another advised a reformatory. 
 Rose was, in fact, for a time maintained in a home for way- 
 ward girls, but had such spells of violence here that she could 
 not be managed. 
 
 The technique of the social treatment of Rose Talbot was 
 briefly as follows: The girl left her husband one day in 191 5 
 in a temper (due to the suggestion that she live with her 
 mother-in-law) and tried, as a waitress, to support herself and 
 child. She made application to the charity authorities for the 
 support of her child several months later and the child was 
 boarded out. She was thus under the eye of social workers, 
 one of whom, under a misapprehension (as we now see the 
 problem) had her arrested as above noted. She was then put 
 on probation and placed in a home for wayward girls where 
 came those spells of violence which now began to indicate that 
 Rose Talbot was not to be a simple case of delinquency. At 
 a special conference the majority of social workers agreed that 
 her case was, for the present at least, a hopeless one and that 
 although there were definite psychopathic elements, the only 
 available policy was to wait for the "overt act" which would 
 eventually allow her commitment and internment in some recep- 
 tacle for delinquents. Meantime, the baby would, of coufs^.,. 
 
THE KINGDOM OF EVILS 53 
 
 become a public charge and minor ward of the state. It was 
 already obvious to the social worker specializing in the man- 
 agement of psychopathic cases that this hopeless point of view 
 was logically not well founded. Not only had there been pre- 
 vious experience of relative, and often absolute, social read- 
 justment in cases of this general group of psychopathic sex 
 delinquents, but also there were special features (considerable 
 intelligence and well-developed self-respect and good general 
 judgment in most matters outside the sex sphere) that made 
 the social prognosis of Rose Talbot not absolutely dark. 
 
 Nevertheless, no psychiatric social policy was at once 
 adopted. Rose was still carried on the books of the probation 
 office. A job for her as waitress in the country was got, and 
 she paid her child's board. She had promiscuous sex relations 
 with boys about the place. (With unwarranted hope for sex 
 hygiene and with a technique not advocated by social workers, 
 an internist who had known the girl wrote a letter to the public 
 health authorities of the town where she was ; rather naturally 
 nothing came of this letter.) Social workers, without psychiat- 
 ric training or point of view, had previously made an endeavor 
 to have the girl arrested as a prostitute. 
 
 However, it happened that Rose had already become friendly 
 with a psychiatric social worker and had become well disposed 
 to the Psychopathic Hospital on account of the unexpectedly 
 gracious way in which she had been met by the physicians. In 
 friendly, unofficial correspondence, Rose would write such 
 sentiments as the following: — 
 
 July 24, 1916 
 
 "But perhaps I'd better tell you my honest, way-down-deep 
 reason for writing. You did seem to understand me so well 
 while I was there. Now please, Miss Carroll, I am trusting you 
 so thoroughly. Please don't tell. Oh, I know I shouldn't write 
 or tell anyone, but it does so prey on my mind. I'm trying so 
 hard to be good. Course it's lots easier than at first, but I want 
 so much to be bad. I actually get sick fighting temptation. 
 Why it's almost like a curse or horrible misfortune. I'm afraid 
 I didn't inherit a very good supply of will-power. One thing I 
 am learning good is to control my tongue. And that's what 
 puzzles me. Now, my tongue is learning to behave quite 
 nicely, but my passions are the most unruly I ever encountered. 
 And it is by the most tremendous effort that I keep good. But 
 
54 THE KINGDOM OF EVILS 
 
 then I can be thankful that there's a Httle improvement. My first 
 month at Trinity House was a veritable night-mare. A most 
 hideous month. And I know if I give in now I shall have the 
 fight to do all over again, or else continue to be bad, and with 
 no helping hand near, it is impossible to be good, once I start 
 bad. But then, I shan't, because I vowed to God that I never 
 would. He will keep me good, won't He ? Do answer soon cause 
 I'm so tempted. And it's impossible to leave. I'm most 
 stranded and Betty's board one month in arrears. Do think 
 over the possibilities of my becoming a nurse and advise, your 
 sorely tempted, trusting friend." 
 
 July 28, 191 6 
 
 . . . "But I will be good, for if I give in I might just as 
 well throw up my hands. And besides, God would punish me 
 if I broke my oath, wouldn't He? When I was in my cell at 
 James Street, waiting for trial, I swore to God never to commit 
 adultery or fornication again. I couldn't break that, could I ? 
 Yet if He wishes me to be good why, oh why, will he allow me 
 to have such horrible unruly passions. And after all my 
 prayers ! I want so very much to be bad. At times I ache all 
 over, I feel if I only could be bad just once, awfully bad, I'd be 
 quite happy and satisfied. He's a student. Treats me with an 
 almost brotherly affection. It is such a relief to be able to tell 
 you everything. . . . And I'd give in so quickly only I do want 
 to be good, and am scared too. I was so much happier before 
 in my ignorance than I am now with my eyes open. I do feel 
 so sick and miserable all the time." 
 
 August 3, 1916 
 
 "Mrs. W. is going to send me a couple of pictures of Betty. 
 I can hardly wait for them. I shall be so glad when I am home 
 with her again. I'm just crazy about the little kiddo. I just 
 love to work for her now. At one time I was feeling kind of 
 provoked to think I could never spend much for clothes, but 
 since I came so near losing her, and after being confined at 
 Trinity House, it's just wonderful to be free and working for 
 her. I'm being so awfully good, not even thinking bad. You 
 see, it is just once in a while I have those spells, and they seem 
 so terrible at the time they frighten me, but now, looking back, 
 it was nothing and confiding in you has helped so very much. 
 I am so glad I have you for a friend and true confidant. It is 
 just like a headache (a thing I rarely have) but when I do ! 
 think I'm killed. But there, I've troubled you long enough 
 with 'I.' " 
 
THE KINGDOM OF EVILS 55 
 
 August 28, 19 16 
 
 "I've read Casqueline's (I think it is spelled) Truth about 
 Woman and Havelock Ellis' Psychology of Sex which quite 
 knocked all my good resolutions to smash. You see it was 
 really the religious side of me that was keeping me good, and 
 my fear of God. But Casqueline states that religion has nothing 
 to do with a woman being bad. — So you see it is not wicked to 
 have sexual intercourse with other men than your husband. It 
 is merely not the fashion. 
 
 "Now with you saying to be good and this book to give 
 free rein to any and all impulses and passion, what is one to do ? 
 Especially when there is so much bad in them, and if I was bad 
 it would be to satisfy my own natural cravings. And I feel so 
 much more fit, mentally and physically. 
 
 "But, my gracious, please don't tell Miss Ford, that I've been 
 talking in this strain or they'll become alarmed, which is quite 
 unnecessary since I've no intention of being bad yet. 
 
 "Grandma says she'll be very glad to see me and I'm going 
 to live with her and Betty." 
 
 September 24, 191 6 
 
 "Sometimes I'm almost tempted to marry him. Oh, dear, I 
 do hope I keep a level head and not do any more foolish stunts. 
 And besides I simply cannot marry. Anyhow, I merely like 
 him and am by no means fond of him. Now, aren't you pleased 
 to hear I'm not going to be bad, I mean, give in to sexual 
 desire?" 
 
 November 6, 1916 
 
 "Now, Miss Carroll, this is an honest fact, that just as soon 
 as I start my prayers at night and feel spiritually good, some- 
 thing always turns up to make me doubly bad. Last evening I 
 felt awfully good and said my prayers with the baby and felt 
 that I'd never be bad again, and behold, this morning, I awoke 
 worse than ever." 
 
 January 5, 191 7 ^ 
 
 "I really don't think I'll be bad, maybe once in a great, great 
 while, but not in the promiscuous manner I have been. I just 
 wish I could explain. I don't think I can, yet you're the only 
 one to whom I could begin to explain. It is all on account of 
 working in the rubber shop and wearing that peachy dress you 
 gave me. Don't think that I'm all fussed up over myself, but 
 just the same, I am nicer than any worker in my department, 
 or in fact, that I've seen here. 
 
56 THE KINGDOM OF EVILS 
 
 "My thoughts run ahead of my pen. Of course I couldn't 
 make it clear anyhow because it's not quite clear to me. I've a 
 great conceited bump on myself. Just a wee bit too nice to be 
 bad. I've thought of it a good deal and seems to me I've had 
 symptoms a way back, but lately they are becoming no end 
 developed !" 
 
 March 17, 191 7 
 
 "We have broken partnership, it really was that you know. 
 There we were, two perfectly mated, physically and mentally — 
 human beings, each desiring one of the opposite sex without the 
 binding and restraining tie of marriage. It really is too bad. 
 He was awfully decent and I liked him thoroughly, in fact could 
 almost say it was a good like. And again I say it is too con- 
 founded mean that one can't have free love, or at least until 
 the children come. But there, I shall have to see you to tell you 
 all about it." 
 
 July 4, 1917 
 
 "Am going to dress Miss Betty up and take her for a visit. 
 Oh, I do love her so much, so very much, that I have no room 
 for any one else, which is rather good, considering I have been 
 thru so many 'puppy loves' !" 
 
 October 14, 191 7 
 
 "Yes I do (i.e. love her divorced husband) and suppose I 
 always will. Time hasn't done much healing in my case, but I 
 do think that God has given me a pretty poor hand, perhaps in 
 the next deal it may be filled with brightness and I shall live and 
 enjoy a happy old age, that is, if I do live. I strongly contem- 
 plate suicide in every moody spell, and I feel quite justified for 
 does not our Lord say 'Come ye who are weary and heavy-laden 
 and I will give ye rest.' So why not accept such a wonderful 
 invitation. Still I rather think I am too much of a coward." 
 
 There seems to be no reason why the sentiments of these 
 letters should not be taken on their face value. When Rose 
 was dropped from the books of the Probation Office, she felt 
 that she still required counsel and voluntarily applied to the 
 Psychopathic Hospital for supervision. During a period of 
 two years that she has since been under the hospital's official 
 care her life and aims have pursued a gradual up-gradient. 
 She became aware that her intelligence was superior to that 
 of her fellow mill workers (she had betaken herself to work 
 
THE KINGDOM OF EVILS 57 
 
 In a rubber factory, somewhat against her wish for less con- 
 fining work) and herself got the idea of going into telegraphy. 
 She is now, at the end of these two years, getting seventy-five 
 dollars per month, is paying for the maintenance of her child 
 in the (paternal) great-grandmother's home, and is living a 
 much more promising and orderly life than anyone could have 
 predicted. A peculiarity of the situation is that she is now 
 living with her divorced husband once more. The question 
 of marriage has indeed been raised, but it is the girl, rather 
 than her former husband, who remains in doubt of the wisdom 
 of the procedure. To be sure, her syphilis is as well in hand 
 as can be contrived; at all events, her blood serum test has 
 now remained normal for some time. 
 
 Let us now analyze the Talbot case in two ways. First let 
 us analyze it briefly, after the manner of the first part of this 
 book, namely, as to the existence of public, social, and indi- 
 vidual factors in the case, and their relative importance. We 
 may then follow the analysis, according to spheres of com- 
 munity influence, with a further analysis according to the dis- 
 tribution of the various evils shown by the case, thus intro- 
 ducing the topic of Book II. It goes almost without saying 
 that a case as complicated as that of Rose Talbot must have 
 planes of contact of both a public and a private nature. We 
 may count as of a public nature, for example, her arrest for 
 adultery, socially ill advised as that arrest may have been. As 
 of a social (non-public nature) we must count her promiscuity 
 in sex relations and her quarrelsomeness with her spouse. The 
 divorce complications touch both governmental authorities on 
 the one hand and the more private social relations on the other. 
 As the history of the case shows, very possibly the sex promis- 
 cuity and even the girl's quarrelsomeness, socially difficult prob- 
 lems though they are, may well be regarded as fundamentally 
 of a medical nature. If hypersexuality and irritability are not 
 regarded in the lay mind as necessarily examples either of 
 mental disease or of mental defect, nevertheless, from the 
 psychiatric standpoint and from the standpoint of the psychiat- 
 ric social worker, these tendencies are coming more and more 
 to be regarded as essentially psychopathic. Even if we, in the 
 end, come to regard them as eccentricity rather than psychop- 
 athy, nevertheless cases of sex appetite and cases of anger 
 instinct can best be understood in psychopathic terms. The 
 
58 THE KINGDOM OF EVILS 
 
 public and private factors of this case, or (to use our preferred 
 tri-partition of factors) the pubhc, social, and individual factors 
 of ihis case are not only all well represented but are commingled 
 in such wise that it is extremely difficult to "factor" them out, 
 as they say in books of arithmetic. The factors unite in a 
 complex unit which is not the result of summation as much as 
 of multiplication. 
 
 Without delaying upon the further analysis of the Talbot 
 case from the standpoint of community influences (see, for 
 examples of such analyses, cases of Book I, e.g., case 4) let 
 us consider her from the standpoint of the evils. This is not 
 the place to descant either upon the completeness of our list of 
 evils or upon its exactitude. The appraisal of this manner of 
 analysis may be postponed, nor shall we be prepared to discuss 
 it fully until the medical data of Book III are well in mind. 
 As briefly in Book I, we proceed to a study of the medical, 
 educational, moral, legal, and economic factors, under the guise 
 of the evils of disease (Morbi), ignorance (Errores) vices 
 and bad habits (Vitia), crime and delinquency and other forms 
 of legal entanglements (Litigia), and poverty and other forms 
 of resourcelessness (Penuriae). The medical side of Rose 
 Talbot is evident; character defects and certain overemphases 
 of instinct, to say nothing of syphilis. The educational de- 
 ficiency in Rose Talbot is most obvious and stands out the 
 more clearly because she was by no means feeble-minded and, 
 in fact, responded notably well to the instructions given her, 
 at first by the psychiatrist and later by the psychiatric social 
 worker. It was clear, too, that in addition to an educational 
 deficiency (both in the matter of school life and home instruc- 
 tion) there was a pronounced moral deficiency It is not in- 
 cumbent on us to determine here (or perhaps anywhere in this 
 book) whether there is a distinction between intellectual and 
 moral education, and no doubt many of the moral deficiencies, 
 so obvious in these cases, are not only grounded in lack of in- 
 formation or in misinformation, but can be abolished, almost 
 at a blow, by suitable teaching of a very ex-cathedra type. But 
 Rose's moral deficiencies were in spheres of emotion, which 
 mere instruction out-of-hand could not relieve. In point of 
 fact a good deal of her difficulty may be assigned to disease 
 and not to mere inadequacy of moral training. It will be re- 
 membered that there was much to go upon. There was the 
 
THE KINGDOM OF EVILS 59 
 
 girl's rather lively self-respect in all matters save those of sex; 
 and even in the sex sphere there was finally developed the 
 monogamous trend. The rather extraordinary improvement in 
 what one might term the individual "morale" of Rose Talbot 
 when a certain blue serge dress was given her (see letter in 
 text) cannot readily be ascribed to education of the intellectual 
 sort. That singularly successful step on the part of the psy- 
 chiatric social worker was an ethical, rather than a psycho- 
 logical, step. 
 
 It is clear that in trying to distinguish between the medical, 
 intellectual, and moral deficiencies in a case like this we ap- 
 proach fundamentals in the definition of medicine, education, 
 and ethics, definitions which are not always easy to get in text- 
 books of these disciplines. When we approach the fourth 
 group, delinquencies, we naturally find the plot to thicken 
 appreciably, as we have, indeed, the choice of regarding the 
 delinquencies of Rose as, on one hand, purely medical in origin, 
 and therefore not delinquencies, or on the other hand as due 
 purely to faulty education (and therefore hardly matters for 
 which she could be called to serious account), or even as mat- 
 ters of poor moral training (wherein again, the handling of 
 the case as criminal or legal would not serve the turn). But 
 in what consists the delinquency or legal entanglement in this 
 broad sense ? We are using the idea in a purely practical way. 
 We shall find it desirable to analyze each case in succession 
 from all of these standpoints. For practical purposes, no one 
 can deny that it is important for the psychiatrist and for the 
 psychiatric social worker to consider the legal entanglements 
 and the methods of fighting them which are brought up 
 by any case which demands social consideration and social 
 management. 
 
 So again, when we consider the economic disabilities of Rose 
 Talbot (with her lack of knowledge of a trade at the outset, 
 her syphilis to be medically and perhaps expensively treated, 
 and her child, also syphilitic) we need not deny that another 
 lot in life would have entirely altered the complications of her 
 particular fate, but the fact that good middle-class surroundings 
 would have changed this particular fate does not necessarily 
 mean that economics is the sole, or even the leading, feature in 
 the whole circumstances. Accordingly, we find in Rose Talbot, 
 good examples of what, upon common-sense grounds, we must 
 
6o THE KINGDOM OF EVILS 
 
 regard as deficiencies in all five fields of evil, as we have chosen 
 to name them. The order in which these fields of evil have 
 been laid down is also, we surmise, not more ultimate than the 
 fields of evil themselves. In fact, in social work at large, it 
 has always been thought that the economic factor must take 
 a leading place. It is our impression that even in general social 
 work (and many social workers agree with us) the economic 
 factor is often, if not in a majority of cases, outweighed by one 
 or more other factors of evil that we here list. 
 
 Perhaps it is worth while to make one or two further com- 
 ments upon Rose Talbot. Her improvement under social- 
 psychiatric treatment was remarkable enough, particularly as 
 she had been an unsolved problem zvith no less than three agen- 
 cies before she was studied and treated from the psychiatric 
 point of view. It would be less easy to define exactly in what 
 the social-psychiatric treatment of Rose Talbot consisted, and 
 perhaps we had, at this point, best fall back on saying that the 
 fons et origo of the success lay just in the "point of view." It 
 might also be inquired how genuinely successful the treatment 
 has been, and no doubt the Greek warning, that we can scarcely 
 assign happiness to a life until it is ended, is a warning that 
 we should particularly heed in social work. At the risk of 
 repetition, let us insist again upon the extraordinary contrast 
 between the girl's genuine self-respect and her amoralia, or 
 what the old English psychiatrist Pritchard might have termed 
 "moral insanity." 
 
 It is of subordinate nature, perhaps, that during the years 
 of psychiatric social treatment, Rose has been under the per- 
 sonal charge of four social workers in succession and has, 
 nevertheless, responded properly to all four, despite their own 
 differences in personality. This brings out strongly the point 
 we above made, namely, that the success in treatment depends 
 more upon the point of vieiv than upon the personality of 
 the worker. We know that such a statement as that in the 
 previous sentence may well be regarded as revolutionary by 
 some authorities who very particularly point out the great im- 
 portance of the personal relation, the relation of being en 
 rapport in these subtle forms of psychotherapy. (Of course 
 another way of controverting this revolutionary point of view 
 of ours would be to say that all four of our workers were, as 
 it were, of a superior quality! This the psychiatrist might 
 
THE KINGDOM OF EVILS 6l 
 
 be compelled to concede. Yet it is true that persons of a very 
 special nature are just the persons that remain in psychiatric 
 social work, at least in its responsible phases.) It is not so 
 much the point of view of the worker as it is difficulties in 
 effecting the new contacts entailed by the shifting. This at 
 least is our general experience, into which we cannot here 
 farther go. In point of fact, it would be singularly unlucky 
 if the only personal relation which the psychiatric patient could 
 successfully maintain with social work should be a relation with 
 but one human soul, since, in the nature of things, in the course 
 of years (and these cases are year-long in their symptoms and 
 demand for treatment) there must be effected a number of such 
 transfers of control. 
 
 Another subordinate point in the technique of social work 
 in the case of Rose Talbot, is the singularly small part which, 
 in appearance at least, the psychiatrist plays in the details of 
 treatment, in fact, the general course of social treatment is not, 
 in this case, one specially conducted by the psychiatrist; it was 
 rather, the duty of the psychiatric social worker, on the basis 
 of the medical diagnosis, to proceed to establish proper general 
 lines of treatment. It is entirely doubtful in our minds whether 
 a physician, either male or female, could have gotten into the 
 right relations with Rose Talbot. 
 
 Hours spent by Medical record, 23 pages 
 
 Social record, 49 pages 
 Physician, 4 Social work : 
 
 Visits. 37 
 Psychologist, l Interviews at hospital, 1 1 
 
 Telephone calls, 14 
 Social worker, 102 Letters, a8 
 
FEEBLE-MINDED YOUTH 
 
 24 YEARS 
 (BY MENTAL TESTS 9.3) 
 
 191 5 
 Unemployment 
 Homelessness 
 No Income 
 
 Estrangement from Relatives 
 Recidivism (Larceny) 
 Arrest (Arson) 
 Probation 
 
 ig)i6 
 Employed 
 Good Home 
 Good Wages 
 Reconciled to Relatives 
 
 Stealing 
 Disappeared 
 
 1917 
 U. S. Marine 
 
Feeble-fninded recidivist who set a fire. On probation ran 
 away. Later corporal of marines. 
 
 Case g. Thomas Fuller's real name was Michael Kelly. 
 Thomas was a reformatory boy and after he left the reforma- 
 tory chose to avoid its stigma by assuming his mother's name. 
 He was twenty-four when we first came into contact with him 
 after his arrest for "maliciously burning a dwelling-house." 
 We present him as a paradigm of evils, not quite so progressive 
 as his predecessor in this series, Rose Talbot, for Thomas 
 Fuller, despite the fact that he measured less than ten years 
 by the psychometric tests, got on well enough in the econornic 
 sphere. He showed signs, however, of trouble in each of the 
 other four fields, medical, educational, moral, and legal. 
 
 To be sure, there was no obvious sign of disease in Thomas. 
 He looked younger than his years, but was of a stocky and 
 well set-up build, as indeed, the United States government was 
 eventually to find and to exult in. But from our chosen point 
 of view, we must regard his low mental age as a medical 
 disability. 
 
 Thomas Fuller's father had long since disappeared, leaving, 
 at the time of our first observation of Thomas, three sisters in 
 the late teens. The mother, who had cared for the children 
 until Thomas was fifteen, had died in an almshouse; the 
 younger children had been left in an orphan asylum by the 
 father, who then vanished from the scene. Thomas got no 
 schooling until his twelfth year, with a little further schooling 
 at the age of fourteen, and with three years of reformatory 
 life in the late teens. The boy's moral training had suffered 
 throughout such a life. The marvel is that his moral adequacy 
 could, in the long run, be maintained. His arrest for "will- 
 fully and maliciously burning a dwelling-house" was but a 
 single episode, and unlike phenomena in some of our psycho- 
 paths, could not be regarded as in any case a perversion of 
 instinct such as may be found in pure pyromania. 
 
 65 
 
66 THE KINGDOM OF EVILS 
 
 Fuller, one day, in a fit of despondency, set fire to his por- 
 ter's uniform which lay on the bureau in his room. He had 
 been discharged from his porter's job and apparently decided 
 to let that whole part of his life go up in smoke. The under- 
 standing how this might be both the first and the last episode 
 of this identical nature (as against the story of so many pyro- 
 maniacs who keep on kindling fire after fire, apparently for the 
 gratification of a particular instinct) is made a bit easier by a 
 study of sundry facts in Thomas's past life. Without going 
 into these in detail, we may mention that he had at times stolen 
 money and again clothing, and had even participated in a small 
 "break" into a house with companions. He was, in short, a 
 sort of youthful recidivist in a variety of not extremely serious 
 crimes. It was as if a feeble-minded boy, not educated even 
 up to his mental capacity, and with poor and fragmentary moral 
 training, had become a delinquent despite himself. 
 
 In point of fact, the case, from the legal standpoint, was 
 quickly resolved by the psychometric observations — Point 
 Scale 9.3 years, Binet 9.2 years. His deficiency of mind was 
 of what may be termed the truncated variety. The defect wa'^ 
 an even and regular one, not affecting the years above the grade 
 registered. Whatever intellectual and moral education could 
 be given to Thomas Fuller must reckon with this fundamental 
 mind lack. There could hardly be a stronger contrast than that 
 between the cases of Rose Talbot and Thomas Fuller. The 
 one was an intelligent woman, with much to build upon, both 
 intellectually and morally, despite her hypersexuality and tan- 
 trums; the other was a moron boy, with no special sex pro- 
 clivities. Both enjoyed, however, good physique, and both 
 proved singularly accessible to social work. 
 
 Probably, in a large part because of his exemplary sex record, 
 the judge who dealt with the charge of "burning a dwelling- 
 house" did not even commit Fuller on the hospital determina- 
 tion of his feeble-mindedness, but on probabilities (or perhaps 
 as a matter of speculation) he was put on probation and proved 
 a ready subject of social work and remained a faithful super- 
 visee for the six months that he was on probation. He was 
 somewhat disheartened by the extension of his probationary 
 period for a further six months, and a month after the exten- 
 sion was granted he disappeared from view after a charge 
 (correct or false) that he had again stolen clothing. Letters 
 
THE KINGDOM OF EVILS dj 
 
 from no address not infrequently appeared at the hospital 
 assuring the workers of his continued success in life. 
 
 The denouement was now to be altered by the World War. 
 He enlisted in the marines and he wrote that he was now "some 
 man" ; that he was "satisfied and at peace with the world" and 
 that he would "never forget his friends at the hospital." 
 
 We have a number of Thomas's letters, written in a large 
 round hand. Almost always he begins "I write you a few 
 lines 'hopping' to find you well as I am." Some extracts from 
 letters with the war fervor are as follows : — 
 
 September 14, 191 7 
 
 "My Dear Friend: I write you a very few lines. I hope 
 to find you well, as I am. And that you will time to read the 
 letter, or when you read it you may call it a book. I know that 
 you like to read books so that all right. Well I like to write to 
 friend's, So you are one that I could not forget. The old saying 
 it a treasure to have friends. Well you would like to know all 
 about me. Well hear gos. In the frist plase, I have maked 
 good without no one help. It noting like trying to make good 
 that me. I thought I like to be a marine, so I went in the 
 U. S. Marine Corps, for luck. And I have luck all the way, so 
 good. And I am going to tell you that I am now out off the 
 past, and I don't mind tell you, that I am now "some man," And 
 I feel like a man who has eaten a real dinner, very much satis- 
 fied and at peace with the world. What do you think off that. 
 And let me tell you my friend, that I have not forgotten your 
 kind advice yet. It is very indeed profitable to me. And 
 started out to make good, I did you know. Well the last time 
 that seen you, I have traveled over this world a bit, I rought it 
 to france. Washington D. C. and I seen the best man that the 
 big world of our love him, tell me the one that I mean see if you 
 know the one man I mean. I love him with all my heard. And 
 I don't mind tell you that I am now a man with some good 
 experience. And I have live a pretty hard life. And I've been 
 down pretty low, and now I am up, and that is what counts. 
 And I have won out, I am going to forget the methods I used 
 in the past life. I am going to make everybody else forget 
 them. I want to enjoy the remainder of my earthly existence. 
 "Well Dear friend I will come to a close with this letter 
 very. I am now in the U. S. Marine. And I am not Thomas 
 Fuller, but I am the Private Michael Kelly. I would like very 
 much to hear from a good friend like you Miss Carroll. And 
 the 25th of Dec. 1917 you get sum thing from me, and if I go 
 
68 THE KINGDOM OF EVILS 
 
 to war, you will have sum thing remmber by. Write and tell 
 me how you are, and how very one. On my 27th birthday 
 not one send me a brithday card. As I have no more to say 
 this time I will come to a close. 
 
 "And to you My sincere appreciation to you and the good 
 worker at the hospital. 
 
 "Wishing you all success." 
 
 September 21, 191 7 
 
 "Well my Dear friend. I take the greates in writing to you 
 these few lines to you dear friend. And was very glad to hear 
 from you too. It was your postcard that you send to me, it is 
 the boston state house, some place you know. And the State 
 House looks very good to me, you bet. And I know that you 
 wrote that card. I remember your good hand off writing, that 
 you write, write again plase. Well dear friend I do not very 
 well when I will be send to france but I may go any time to 
 france to fight for freedom, and peace. And let me tell you 
 that I will fight in earnest for our be love and dear presidend 
 Wilson, the man off the hour. I like him with all my heart. 
 
 "And I will not forget my friends. I will think off them 
 when I am over in france. and now I will not forget you as 
 you are one off my friends. You said that they are knitting 
 at the hospital for the soldiers. And you asked me if I could 
 used and thing. Well I can used and thing that you send. I 
 would be glad to get anything that you send to me. Will close 
 hopping to hear from you." 
 
 March 29, 19 18 
 
 "I write you a few lines hopping to find you well as I am. 
 Well I have make good, as I am now an corporal in the U. S. 
 Marine Corp. that mean that I am to get $6. more an month. 
 So I am now getting $36. an month now. Well I am doing 
 the best I know how, that whi I was make an corporal in 
 corps. I hope that you will write me an letter and tell me how 
 you like the way I am making good." 
 
 Hours spent by Medical record, 25 pages 
 
 Social record, 34 pages 
 Physician, 4' Social work: 
 
 Visits, 18 
 Psychologist, i Interviews at hospital, 23 
 
 Telephone calls, 40 
 Social worker, 50 Letters, 45 
 
THE KINGDOM OF EVILS 69 
 
 Hysterical sex delinquent, a persistent social problem. 
 
 Case 10. Bertha Greenwood is a case which we present 
 as a paradigm of troubles in the medical, educational, moral, 
 and economic fields. She is the second of a group of five cases 
 in which the troubles are fourfold. Bertha Greenwood's case 
 is less complex by one field of evil, according to our proposed 
 classification, than was Rose Talbot (case 8) whose troubles 
 were fivefold.. Theoretically we should be able to subtract from 
 the difficulties of Rose Talbot the legal entanglements and 
 arrive at the case of Bertha Greenwood ; so theoretically ought 
 we to have been able to subtract the social difficulties of eco- 
 nomic nature from the case of Rose Talbot and arrive at some- 
 thing like the degree of complication found in Thomas Fuller 
 (case 9). Taken another way, the phenomena of Bertha 
 Greenwood will have, in common with those of Thomas Fuller, 
 three kinds of factor, and will differ in but one factor : both 
 cases are fourfold with respect to their distribution of troubles; 
 both have difficulties in the medical, educational, and moral 
 fields, but whereas Fuller's difficulties were legal. Bertha 
 Greenwood's difficulties were economic. 
 
 Bertha Greenwood, we must confess, for the present, after 
 three years of social observation and attempted treatment, to 
 be a good deal of a failure from the standpoint of psychiatric 
 social work, but it is no province of this book to put necessarily 
 the best foot foremost. Perhaps it is better to deal with the 
 grounds of failure in sundry cases than to congratulate our- 
 selves unduly over the most striking success. 
 
 The reasons for the failure of our social methods in Bertha 
 Greenwood are obscure, but probably based upon our lack of 
 grasp upon her attitude. That attitude is, no doubt, a psycho- 
 pathic one. Her temperament is one of ups and downs that 
 are apt to occur in waves of considerable length as well as 
 amplitude. The term "psychopathic personality" which is, in 
 general, a proper designation for this, as for many other cases, 
 does not duly specify the peculiar difficulties, which are, per- 
 haps, a compound of hysterical tendencies, with a cyclothymic 
 (manic-depressive) tendency, expressing itself rather more in 
 periods of depression, of weeks' or months' standing, than in 
 any periods of pronounced elation. 
 
70 THE KINGDOM OF EVILS 
 
 In her periods of comparative normality, Bertha is extremely 
 manageable, and amenable in some degree to suggestion, al- 
 though there is not much doubt whether her promiscuity of sex 
 life is continuously maintained; in fact, we are pretty confident 
 that in her periods of what we term "normality" she shows 
 neither any evidence of oversexedness, nor any continuation of 
 sex irregularities as a matter of habit. Like Rose Talbot, with 
 whose case, as above mentioned, that of Bertha Greenwood 
 falls somewhat into line. Bertha shows a kind of monogamous 
 trend; at all events she, for a long period, bore in mind and 
 descanted upon a certain married man with whom she pro- 
 claimed herself to have lived in sex relation. Our best evidence 
 is that this ideal, or paramour, of Bertha's was fictitious. At 
 one time she even showed a bruise of the face which she said 
 was got at the hands of this paramour whom, however, the 
 police failed to trace. We assume that her tales about him 
 sufficiently indicate a degree of monogamous trend. In general 
 she has been, and is, promiscuous in sex relations, and has even 
 been pregnant twice (abortions). Except at times of economic 
 stress, as after recovery from influenza, we believe that Bertha 
 Greenwood, like Rose Talbot, has shown a large degree of 
 self-respect, at least in the matter of not taking money for her 
 irregularities. She is of good physique, and of considerable 
 intelligence, at least of such a degree as to be able to support 
 herself properly in her normal periods. 
 
 Medically speaking, we might wonder whether the diagnosis 
 "psychopathic personality" was not, after all, far more vague 
 than two other diagnoses which we might be entitled to make, 
 namely — "hysteria" and "feeble-mindedness." To take the 
 latter, and simpler, hypothesis first, we find that she grades 
 psychometrically on the Binet Scale at 11.3 (actual age, at 
 the time of examination, twenty-three), but on the otiier hand 
 we find by the Yerkes Point Scale that she grades up to the 
 adult level, or at least to fifteen years plus, which was the maxi- 
 mum to which any person could attain by the type of test then 
 employed. The educational test of the Binet type probably 
 yielded poorer record for Bertha Greenwood than her general 
 efficiency would point to ; moreover, we have in our possession 
 a pathography or partial autobiography written by her which 
 exhibits much more insight into men, women, and things than 
 a moron is entitled to exhibit. The psychologists, it may be 
 
THE KINGDOM OF EVILS 7I 
 
 stated, despite the Binet grade of 11.3, gave it as their opinion 
 from the psychological point of view that she was not feeble- 
 minded. It may be parenthetically stated here that persons 
 clearly feeble-minded (let us say in the moron division) may 
 be sufficiently complex to show what is termed psychopathic 
 personality. That issue we are not here raising ; we are claim- 
 ing for the concrete case of Bertha Greenwood that she is prob- 
 ably not at all feeble-minded and may perhaps be an uncompli- 
 cated case of psychopathic personality. Dismissing the idea 
 of feeble-mindedness in the metric sense of that term, let us 
 ask whether we could further define the case by stating that 
 Bertha Greenwood is hysterical. It is recognized, on all hands, 
 that the psychopathic personality may show hysterical trends; 
 that (as French authorities call it) there may be a forme fruste 
 of psychopathic personality which looks in the direction of 
 hysteria. We mentioned above her appearance one day with a 
 bruise on the face which she attributed to her ideal, but prob- 
 ably fictitious, paramour, a certain married man. That this 
 affair was an hysterical one might be thought from the fact 
 that she was picked up unconscious, or half unconscious. There 
 are other, somewhat less well-defined episodes, such as fainting 
 spells upon the street, and the resort in wild terror, to the house 
 of a woman unknown to her. One night, in Boston, in fact the 
 very first time that she devolved upon the medical scene, she 
 was in a kind of stupor, out of which she emerged telling of her 
 terror at a certain man. Could we see into the psychic interior 
 and be sure of our observations, we might think of Bertha 
 Greenwood as leading a sort of ideal double life, with an 
 idealized monogamous companion of whom she stood in a sort 
 of fear, that the light literature of the day is inclined to at- 
 tribute to the so-called "cave-woman." 
 
 It will be remembered that in the case of Rose Talbot syphilis 
 was early acquired. There might be more reason to suspect 
 the arrival of syphilis upon the docket here than in the simpler 
 sex life of Rose Talbot. Our serum reactions in Bertha 
 Greenwood have constantly been negative. This is despite the 
 fact that a medical consultant in private practice concluded 
 from his examination that Bertha was suffering from local 
 syphilitic disease of the pelvis of long standing. This physi- 
 cian went so far as to say that the nervous side of Bertha's life 
 was secondary to the disease of her pelvis. He counseled opera- 
 
72 THE KINGDOM OF EVILS 
 
 tion and indeed thought such to be imperative. Another 
 hypothesis concerning the nervous spells in Bertha Greenwood 
 is that they are due to dysmenorrhea. 
 
 In point of fact, whatever be the pelvic complications in the 
 Greenwood case, there is ample evidence from her early life 
 that the psychopathic trend far antedates the immediate effects 
 of her sex life. As a child she had hysterical spells of rolling 
 upon the ground, and these began at about the tenth year and 
 are thought by the patient herself to have followed a criminal 
 sex assault. In the eleventh or twelfth year she is said to have 
 become subject to certain sleeping spells about which we know 
 little, although one of them is said to have lasted for some 
 two weeks. Whether these indications proved hysteria as 
 against some more vaguely defined psychopathic entity may 
 be left undecided. 
 
 Let us now take up in order the items of Bertha Green- 
 wood's case distributed amongst the four fields of difficulty. 
 It has been a classical idea, somewhat shaken by the war data, 
 that hysteria is essentially a hereditary disease, or, at all events, 
 that amongst the relatives of hysterics will be found other 
 psychopathic or neuropathic persons. We find in the Green- 
 wood girl the second of five children of a rather alcoholic 
 father, who worked irregularly and finally deserted the family, 
 and of a rather slack mother, certainly ignorant, and possibly 
 defective. The family was, -accordingly, constantly known to 
 a variety of agencies such as The Family Welfare Society, The 
 Society for the Prevention of Cruelty to Children, the Chil- 
 dren's Aid Society, and the like. In fact, we find that no less 
 than thirteen agencies had to do, at one time or other, with the 
 members of this family. With respect to heredity, we may 
 conclude that neither the alcoholism, nor the wandering ten- 
 dencies of the father, nor any actually known features of the 
 mother, thoroughly prove psychopathic heredity, but at least 
 there is a considerable ground for suspicion thereof. As for 
 Bertha's own mentality, we must remain in doubt whether she 
 is finally to be termed psychopathic, in some indefinite sense 
 of the term, hysterical, or something else. Probably the 
 psychiatric doubt which still exists as to Bertha is responsible, 
 in a measure, for our inability to handle the case with as much 
 success as the hours spent might seem to warrant. 
 
 Physically she might be regarded as an example of hyper- 
 
THE KINGDOM OF EVILS 73 
 
 thyroidism. The thyroid is palpably enlarged, the pulse is 
 rapid, respiration is rapid, and there is a fine tremor of the 
 fingers. Whether this thyroid situation is secondary to the 
 sex-gland situation must remain doubtful, although modern 
 work upon the effects of glandular secretions upon the tem- 
 perament might be consistent with the idea. 
 
 If we turn to the educational field, we find Bertha's mother 
 ignorant and Bertha at the age of eight with three other chil- 
 dren placed out in various homes for some four years. There- 
 upon, at the age of twelve, she attended trade school for a time 
 and then got a job which suited her. At the age of fourteen 
 she began to work in factories in and about Boston and lived 
 in lodgings, and at this time her sex delinquency began. Some 
 quotations from her autobiography, which we give below, indi- 
 cate her present educational status. She, in practical ways, has 
 learned a good deal and has become able to earn twenty-five 
 dollars a week in hat-making, and has held a variety of posi- 
 tions, ranging from six dollars a week up, for various periods 
 of weeks or months, until such time as her alterations of tem- 
 perament set in. As for her moral training and status, she has 
 always been an affectionate, though not always truthful, girl. 
 She has rather made it a point to keep her promises. There 
 was, as is frequent with hysterics, a good deal of the histrionic 
 about her attitude; for example, she would, half in earnest and 
 half dramatically, instigate the appearance of social workers 
 and a detective upon Boston Common to meet the alleged man 
 who might be going to do her harm. Possibly this histrionic 
 trend is more an intellectual matter than a matter of moral at- 
 titude; but the trend seems to be central in her moral life. Of 
 course it would be possible to assert that her interest in the 
 Ideal Man is a gigantic bit of camouflage; but if so, this inter- 
 pretation would only be in line with our general suspicion that 
 she is, if not hysterical, at least hysteroidal in her make-up. It 
 is open to question how much proper moral training she got 
 in her placings-out ; or if she got proper training in these homes, 
 she may also have got much improper training. Her knowledge 
 of sex life she herself claimed to be practically nil at the time 
 of her first intercourse, said to be at the age of sixteen (of 
 course there was that other story of an assault at ten). If we 
 classify the patient as falling importantly into the group of 
 vices and bad habits, we ought, in all conscience, to be able to 
 
74 THE KINGDOM OF EVILS 
 
 recommend some proper steps in moral training which might 
 be taken, or at the least show why further moral training would 
 be fruitless. As a matter of fact, we "closed" the case no less 
 than three times on the basis of what might be termed its social 
 incurability; but each time, at the patient's request, the case was 
 reopened. 
 
 One of our most powerful lines of management was to find 
 work and to secure good associates. These procedures were 
 singularly successful for periods of a few weeks, whereupon the 
 familiar lapse into depression and into the necessity or ten- 
 dencies of sex life would emerge once more. The facile prop- 
 osition for her disposal would be to place her in some sort of 
 new-fangled and perhaps not-yet-invented institution, which 
 could analyze her with absolute thoroughness and could secure 
 some technique for overseeing the temperamental changes that 
 are central in the social debacle. We can put the question 
 whether the irregularities of sex life are matters of poor train- 
 ing, to be reasoned out by better education or smoothed out by 
 improvements in tests, standards, companions who might be 
 better models, and in general the entire morale. Whatever else 
 be true, there can hardly be any doubt that the sex irregularity 
 is grounded in something somatic, something temperamental. 
 Whether this "something temperamental" is ingrained in the 
 nervous tissues themselves, i.e., in the modern medical lan- 
 guage an endocrine matter, is doubtful. 
 
 The situation with Bertha is somewhat like that with Rose 
 Talbot (case 8) ; but with Bertha there is far less of a nucleus 
 of self-respect and far less will-power has been yet developed 
 in her than in Rose who in the end was made to acquire the 
 idea of "success in life." 
 
 Extracts from an autobiography that Bertha wrote for the 
 benefit of one of the physicians are here inserted. Although 
 falsifying was a leading tendency with her, she sticks reason- 
 ably well to the truth in this story of her life : — 
 
 "It seems that life has been one hard knock after another. 
 If I had a few happy days there were double the days of sorrow 
 afterward to make up for the happy ones. And yet we must 
 live and endure till the end. 
 
 "My father was a good father in lots of ways, but like other 
 people he had his faults. One awful fault which was responsible 
 for all our unhappiness and the breaking up of our happy home 
 
THE KINGDOM OF EVILS J75 
 
 was his liking for liquor. He drank terribly. I don't like to 
 say it, but I feel it is the truth. My mother was to blame for 
 my father's drinking, because she was so mean to him, always 
 nagging and finding fault. He got discouraged and didn't care, 
 then started to drink and went so far he couldn't stop it. I can 
 remember when my father was good and never drank. He 
 worked hard for us and was always kind to Mamma and us 
 children. Then too later I can remember how he used to come 
 home, at first only on Saturday nights so drunk he couldn't 
 find the house and all his pay gone. Then he got so he was 
 always drunk. Poor Dad, it was .awful and I am so sorry for 
 him. My mother hates him. Well, she may have reasons for 
 it that I don't know anything about. I don't think my father 
 is dead, and I have often wished I could meet him on the 
 street sometime, somewhere when I am out. I would love to 
 see him again. Poor father. That is another thing I don't 
 understand in this life, is why people who love each other and 
 should be happy together have to be separated. I will never 
 forget the day my father went away for good. We were all 
 in the house together (with the exception of my father). My 
 mother was sick in bed, she had just given birth to my sister 
 Jessie, who was only a week old then. My three brothers and 
 I were in the kitchen sitting around the table, telling stories. It 
 was early in the evening. We were right in the middle of a 
 story when we heard a rap on the door. We all knew it was 
 Dad, because he had a knock of his own, three little taps. We 
 all ran to the door to let him in. We hadn't seen him for a 
 week and we were awfully glad to see him then. My mother 
 cried when she saw him, and she told him to go away and never 
 come back, that she couldn't have him around any longer on 
 account of his drinking. He didn't say a word, but we begged 
 Mamma (as best we could) to .give him another chance. But 
 she wouldn't. She told him to go, so finally he started. I will 
 never forget it. We all clung to him crying. I know he must 
 have felt bad. He went away that night and none of us have 
 ever heard from him or seen him since. That left Mamma 
 with five of us children to take care of and none of us were old 
 enough to work. So of course it was up to my mother to 
 provide for us. She worked in restaurants or anywhere she 
 could find employment. I being the oldest girl most of the 
 house duties fell on me. I had to dress the others mornings 
 and get them off to the nursery. We were awful children and 
 I don't blame my mother for losing patience with us, as she 
 often did. She would warn us to go to school in the morning 
 before she went to work, and one of my brothers and I used to 
 
76 THE KINGDOM OF EVILS 
 
 go oiif by ourselves and play all day, and then go home to 
 Mamma dirty at night. We never even saw the school house 
 from one day to another. The trwant officer was always after 
 us but Ma was never home to see him. Well, we were proud 
 kids and we did not have clothes like other children had, and 
 we felt bad about it, so thought we would stay away from 
 school. I remember one uniform I had, my mother's shoes size 
 six. Can you imagine a girl of eight wearing shoes of six, my 
 mother's skirt tied around the waist with a string and pulled up 
 over the top to make it short, and one of her old waists. I must 
 have been a picture, oh dear ! When I think of how I used 
 to race the streets and all the things I used to do and the places 
 I went, I wonder that I am even half as decent as I am today. 
 Besides not having clothes, we very seldom had a square meal. 
 We were always hungry. In the morning I always got up 
 (because I was made to, not from choice). I had the job of 
 blowing the fire to keep it going to make a cup of tea for my 
 mother. There was never more than one piece of wood in the 
 house and often only one match. 
 
 "There was a crowd of us kids who always went together on 
 hikes. One day my brother and I got lost and Ma found us in 
 Cambridge police station. I was the only girl, and there were 
 eight boys with me, two of them were colored. When Ma came 
 to take me home I didn't want to go. One of the policemen had 
 made a bed on one of the benches for me and the matron had 
 given me a doll. I felt quite at home there. It was much more 
 bright and cheerful than my own home, even though it was a 
 police station. I was always getting into mischief. One day I 
 stole a red and white tablecloth l)elonging to one of our neigh- 
 bors. They had their pulley line fastened to our window and 
 I took the cloth. I got arrested for it. The policeman scared 
 me and told me if I stole again he would put me away. We 
 didn't have a tal)lecloth and I thought it would be kind of nice 
 to have one. As long as we couldn't afford one, I thought the 
 next best thing was to steal it, but I decided afterwards that it 
 was better to do without one. 
 
 "After a while Frank and I were taken away from Ma and 
 put in a private family. We were very homesick. The people 
 were nice to us, but we missed the others at home. We were 
 sent to school in the morning and we went into the woods and 
 stayed till school was out, trying to plan how we would get back 
 to see Mamma. The people we lived with couldn't do anything 
 with us, so our guardian had to find us another place to live. 
 The second family we went to live with were not as nice to us 
 as the others were but we had to stay there. We were there 
 
THE KINGDOM OF EVILS 77 
 
 four years. We were on a farm. We were awful lonesome 
 and homesick. Ma only came to see us twice in four years, and 
 she had tickets sent to her to go every month if she wanted to. 
 We went to school while with these people and helped with the 
 work after school, I with the house work and my brother with 
 the farm work. After four years we had to be separated. I 
 had a chance to go to Hammond School, but Ma wanted me to 
 go home and live with her. She cried and took on so, I felt bad 
 for her and said I would. (That was one step I took that I 
 have always regretted.) My guardian didn't want me to stay 
 with her, but I thought if I could help Ma I would, she had to 
 work so hard. I'll never forget the first day I came home, I 
 was so glad to see her, I ran to her and threw my arms around 
 her neck and was going to kiss her. She pushed me from her 
 and said she never kissed me when I was a baby and she 
 wouldn't kiss me then. I felt awful, I wanted her to love me ; 
 I was hungry for love. I would have done anything in order to 
 win her love. But she didn't care for me. I couldn't stand it to 
 stay with her. Everything seemed so upset and dirty to what 
 it had been in the country. I went to my guardian and told her 
 I couldn't stay. She made arrangements for me to go back and 
 stay with the people I had been with for so long. But when the 
 time came for me to go, Ma cried terribly and begged me to 
 stay with her. I didn't want to stay because I wanted to mak?. 
 something of myself and I knew I never could do it there. 
 But I didn't have the heart to leave her (another step in the 
 wrong direction). There were James, Jessie and myself at 
 home then. James and Jessie went to school and I worked. 
 Ma treated my brother James so mean he didn't want to stay 
 in the house in the evening. She was always nagging. He 
 started to go out evenings and got in with a bad crowd of boys. 
 They stole something one night and all got arrested. My 
 brother was sent to a reform school. He stayed there for a 
 while and ran away. They got him back and made him stay 
 twice as long to pay for it, and the poor kid has been in reform 
 schools and jails all of his life since then, up to a month or two 
 ago, when he enlisted. He says now that as hard as it is, it is 
 the happiest time he has known in his life. 
 
 "My sister Jessie started to stay out nights for the same 
 reason my brother did. I couldn't bear to see her have the 
 same thing happen to her that happened to James. I took her to 
 Court and she was sent to a private family to live. The people 
 have adopted her and as far as I know she has everything she 
 wants and is happy. I am glad for her. 
 
 "When I was about sixteen years old I went out of town to 
 
yS THE KINGDOM OF EVILS 
 
 work in an institution for my board, room and clothes, just for 
 the summer. It was on a town farm. There were all kinds of 
 people there, sick, well and old. The people who ran the place 
 had four hired men working for them. One of them liked me 
 pretty well, or at least he thought he did. He tried his best to 
 go with me, but I wouldn't let him. I did almost as bad 
 though. He gave me five dollars not to say anything about it 
 and I didn't say anything. I didn't fully realize then what it 
 meant, but I realized soon afterward. I liked him and I let 
 him do that right along all the time I was there. When I left 
 there I was always lonesome for him, but wouldn't give in. I 
 came to New York and tried to forget him. I tried to find 
 someone to take his place. I was lonesome and unhappy all 
 the time. I lived with my mother for a while, but she was 
 mean to me and I left her. I met a girl that I grew very fond 
 of. She liked me too. She was older than L She was a bad 
 girl, but I didn't care, I liked her. But she didn't love me as I 
 wanted her to, so I had to make her love me. I didn't care 
 how I did it. After a time I told her I had gotten in trouble 
 with a fellow, so that she would sympathize with me. I knew 
 she would. She did, but I had to pay the price. I had to go to 
 bed and stay there for two weeks (until I was sick). I had all 
 the blankets and hot water bottles in creation on me to make me 
 sweat, and I had to take nasty medicine every half hour. I did 
 this all for love and I would not give in and tell her I had lied. 
 I bore it and kept quiet. She gave me the affection I longed 
 for and that was all I wanted. She was awfully good to me 
 from then on. I was quite happy while I had her to go to. She 
 satisfied me in every way and we loved each other. I didn't 
 want anybody else. Then she went away and I only hear from 
 her now. She is so far away I can't see her. She is in Texas. 
 Since then I have never found anyone to take her place, and I 
 am lonesome and unhappy. I have lived an awful lie and I can't 
 get away from it, one little lie has led to another till now it 
 seems as big as a mountain. I have lied to so many people I 
 don't know what I will ever do, and everybody thinks I am 
 bad." 
 
 We have chosen to regard Bertha Greenwood as a fourfold 
 rather than a fivefold case, and to think of her as minus the 
 delinquency aspect; that is, the aspect of legal entanglements. 
 To be sure, in one sense to be sexually aberrant is to be a delin- 
 quent (the terminology is still a little doubtful), but we are 
 talking of important spheres of contact with the law. There 
 were no practically important legal contacts in the case. There 
 
THE KINGDOM OF EVILS 79 
 
 were one or two minor court appearances which have not in- 
 fluenced the main Hues of her social treatment by the various 
 agencies. It might be inquired whether the kind of authorita- 
 tive supervision which courts could exert would be of value in 
 such a case as Bertha's. We mentioned above that some sort 
 of institution might be devised that would help, although in 
 such institution we suspect cases like Bertha's would have to 
 be the central figures. It is doubtless unlikely that the state will 
 find itself able to build institutions around single figures of this 
 sort. We are of opinion that, despite our relative unsuccess 
 in handling the case, nevertheless no better results could have 
 been obtained by judicial methods; that is, it would not have 
 helped to have treated this patient as a prostitute and to have 
 maintained her in prisons from time to time for punitive or 
 correctional purposes. It must remain an open question 
 whether, in so difficult a case, the "iron in the velvet glove" that 
 might be afforded b}^ a probation system would have helped. 
 In some modern systems, the psychiatric viewpoint is, of course, 
 maintained. 
 
 We turn to the economic sphere. Getting her work was, as 
 above stated, one of our best lines of handling. Would Bertha 
 Greenwood have been another person had she been supplied 
 with a good-sized annuity; had she been, in short, sorriewhere 
 in the third estate of the well-to-do? We do not see how either 
 her histrionic tendencies or her depressive phases, to say nothing 
 of the "man crazy" trends into which she would lapse from 
 time to time, could have been ordered by a change of social 
 level. Still it must be granted that financial worries may have 
 had their subtle effects upon the body's functions, and in some 
 indirect way have changed perhaps the thyroid gland, or even 
 the sex life. Perhaps we should not reckon this case as very 
 fundamentally an economic one. For example, it appears that 
 no more than thirty-eight dollars were ever spent out of avail- 
 able funds directly upon the Greenwood girl ; still her psychop- 
 athy, with its phases, was continually throwing her upon the 
 brink of destitution. 
 
 We now turn from Bertha Greenwood to three other cases 
 which will in succession demonstrate the fourfold distribution 
 of the social evils according to our classification. From Thomas 
 Fuller, in whom the economic factor did not come in question, 
 and from Bertha Greenwood, in whom the legal contacts were 
 
8o THE KINGDOM OF EVILS 
 
 minus or slight, we turn to case ii (Lewis Goldstein) a com- 
 plicated case of traumatic neurosis, in whom moral difficulties 
 were practically nil, to case 12 (Elsa Albrecht), a case very 
 possibly of dementia praecox, whom we may regard as educa- 
 tionally without particular social flaw, and to case 13 (Agnes 
 O'Brien), a case in whom the medical difficulties were subor- 
 dinate or exceedingly slight. 
 
 Hours spent by Medical record, 13 pages 
 
 Social record, T2. pages 
 Physician, 4 Social work : 
 
 Visits, 133 
 Psychologist, I Interviews at hospital, 19 
 
 Telephone calls, 80 
 Social worker, 293 Letters, 47 
 
TRAUMATIC PSYCHOSIS 
 FOLLOWING INDUSTRIAL ACCIDENT 
 
 19 1 5 19 16 
 
 Industrial Disability Compensation 
 
 Insufficient Income Investment 
 
 Debts Business Failure 
 
 1917 
 Irregular Employment 
 Minor Injuries 
 Charitable Aid 
 
 BEFORE 191 5: illiteracy; IRREGULAR EMPLOYMENT; 
 BUSINESS FAILURE 
 
Steady, illiterate workman disabled hy industrial accident. 
 Family case. Sloiu social recovery. Mental hygiene of in- 
 dustry. 
 
 Case II. We take up, in Lewis Goldstein, the third of 
 our five cases, showing not the full display of evils in their 
 fivefold distribution, but exhibiting situations in some respects 
 less complex, namely a fourfold distribution. Whilst Ful- 
 ler (case 9) showed no economic disability, and whilst 
 Greenwood (case 10) was not, in any important way, le- 
 gally entangled, the present case of Lewis Goldstein is one in 
 which another element or factor of evil was lacking, namely 
 the factor of moral disability. In fact this young Russian Jew 
 of twenty-three years proved to be a man of high moral stand- 
 ards and ambition. (It would be almost true to say, curiously 
 enough, that his high ambitions interfered a little with his social 
 cure.) Goldstein was working as a roofer's helper one day 
 when a twenty-five pound tar bucket fell from the fifth floor 
 upon his head. He sustained a compound, depressed fracture 
 of the skull. He lived for a time upon the weekly compensa- 
 tion granted him under the Industrial Accident Laws and did 
 no work. The Industrial Accident Board, not being sure of the 
 degree of disability or even of the existence of a permanent 
 injury, sent him to a general hospital out-patient department, 
 whose medical authorities assured him that he had not been 
 seriously injured by the tar bucket and ought to go to work 
 once more. In due course he was referred to the Psychopathic 
 Hospital by the Industrial Accident Board, coming, as is usual 
 with these cases, as a voluntary patient. Here the psychological 
 examiners found that despite his twenty-three years of actual 
 age, his mental age by the Binet tests was but eight and one- 
 fifth years. To the psychological examiners he seemed to be 
 a man of poor comprehension, diminished learning ability, prac- 
 tically no planning ability (so far as tests went), poor powers 
 of observation and apperception, a memory of narrow span and 
 retarded free associations. We mentioned these details of the 
 
 83 
 
84 THE KINGDOM OF EVILS 
 
 psychological results to show how general, or as we are accus- 
 tomed to say, regular, was the mental loss ; in fact, the exceed- 
 ingly competent examiner thought that Goldstein's reactions 
 throughout were those of a feeble-minded person of low moron 
 grade. 
 
 Now such results obtained by the psychologists are, in these 
 cases, of extreme value, particularly when we come to com- 
 pare the results of one year with those of later years. Some- 
 times it is possible to trace the improvement of a patient recov- 
 ering from brain injury most precisely by means of successive, 
 properly spaced, psychological tests, but in the present mstance, 
 the psychiatric social worker examining the man's past would 
 have been entitled to wonder how the diagnosis of low moron 
 could have been made in a man who had been reasonably suc- 
 cessful in a variety of positions and had even, at one time, 
 managed a small business. He had been a steady and depend- 
 able fellow of good habits, cheerful, even-tempered, fond of 
 his family. At a pinch it would appear, however, that every- 
 thing he had actually undertaken to do could have been per- 
 formed by a moron of a high grade. It would be a pretty in- 
 quiry, and one which should be carried out by scientific employ- 
 ment managers or the administrators of business schools, to 
 classify types of occupation, particularly industrial occupation, 
 with respect to the degree of mental capacity necessary for 
 their carrying out. Possibly many of these industrial occupa- 
 tions range in their mental age capacity around ten years. 
 Goldstein, however, made eight and one-fifth years. 
 
 Accordingly, although the mental level and the manner of 
 its reduction both signify feeble-mindedness, the social inquiry 
 inclines us to the belief that either the accident, or some other 
 element in Goldstein's history, had reduced his mental level 
 somewhat. The psychiatrist, reporting upon Goldstein to the 
 Industrial Accident Board, putting together the psychological 
 and sociological data, said that "accordingly it seems doubtful 
 whether the patient could have been a low-grade moron before 
 his accident and that it is probable that the accident is a large 
 factor, if not the entire factor, in his present condition." 
 
 The medical examination showed some evidence of a skull 
 depression in the u])per occiput and there was a minor disorder 
 of the reflexes upon the right side of the body, comporting 
 with the probable site of the brain injury inflicted by the tar 
 
THE KINGDOM OF EVILS 85 
 
 bucket. Upon investigation, it appeared that, after being struck 
 down by the bucket, he had become unconscious, was cared 
 for six days at the Rehef Station, became bhnd a few days, 
 later was cared for at a general hospital, and thereafter had 
 been in bed for a period of five or six weeks, so that the total 
 history of bed- fast debility was something like two months. 
 
 The prognosis given by the hospital was that "the patient 
 cannot at present work, and for some time he will be unable to 
 make anything like eighteen dollars a week" (his wages as a 
 roofer's helper). 
 
 Although this is not a textbook of psychiatry, it may be of 
 interest to the reader to learn how many symptoms such a 
 patient as Goldstein may show between eight and nine months 
 after injury. He came to the Psychopathic Hospital complain- 
 ing of insomnia, of loss of appetite, of backache, of an almost 
 constant headache ; his vision was greatly impaired and he was 
 most seriously troubled with attacks of blindness that would 
 last a few minutes and be attended with dizziness. He would, 
 under such circumstances, fall into the street and then take to 
 weeping. He had become restless, irritable, readily angered by 
 trifles, and thereafter lachrymose. His incapacity to earn 
 money made him depressed and apprehensive. He described 
 himself as having a tendency to chills and said that his memory 
 was impaired. Several features of this catalogue of symptoms 
 belong to the so-called vasomotor neuroses of certain authors, 
 characteristically found after injury; the facile spells of anger 
 perhaps belong to the so-called explosive diathesis of authors. 
 Upon these data, the Industrial Accident Board, after a time, 
 fixed a lump sum settlement, and the money awarded was put 
 into a small store. The business, however, failed in a few 
 months. Possibly its failure was due to the patient's becoming 
 upset by complications following his wife's pregnancy and con- 
 finement in a hospital. He shortly became well enough again 
 to work, but refused to take a job that paid less wages than 
 he was used to. 
 
 We had Goldstein under supervision for some three years. 
 By slow degrees he got back to habits of regular work in his 
 oH roofer's trade. About three years ago (1918) the case was 
 closed, partly because other cases seemed to demand more from 
 the social service than did Goldstein's. As a matter of the 
 technique of social work, it is interesting to point out that no 
 
86 THE KINGDOM OF EVILS 
 
 fewer than eleven agencies were called upon to deal with Gold- 
 stein. No single relief agency was available that could supply- 
 all the funds necessary for his family, which was ever on the 
 poverty line. Steady relief for the rest of the family would 
 have been the ideal background for the psychiatric social worker 
 in the Goldstein case, but it is permissible to point out that 
 there would have been no family problem of moment had there 
 not been a central psychopathic figure on the scene, namely the 
 traumatic neurosis or psychosis of the bread-winner. At one 
 time we attempted to transfer the Goldstein family relief ques- 
 tion to a general relief agency, but the psychiatric features of 
 the whole situation failed to be grasped by that relief agency 
 and the case had to be reopened by us. 
 
 Certain minor psychopathic complications are worth a word. 
 Thus, the man's feeble-mindedness, or queer equivalent thereto, 
 had something to do with the temporariness of his different 
 jobs. Thus Goldstein might promise to apply for some 
 vacancy and then do nothing further about it; then again he 
 would, in working, run a nail into his foot, or strain his back, 
 or fracture his wrist, in fact have so many kinds of accident 
 that there can be little doubt that the complications were largely 
 due to his low mental capacity. It is this kind of thing which, 
 in industry, would go to make up a genuine problem that 
 might be called the nienfol hygiene problem in industry, for 
 it is clear that feeble-minded persons who have not had their 
 mentalities diminished by the fall of tar buckets on their heads, 
 may nevertheless very frequently be subject to accident. Of 
 course, throughout all this talk about Goldstein's feeble-mind- 
 edness, it must be remembered that he is a fairly well built, well 
 developed, v/ell nourished man who presented so good a gen- 
 eral appearance that, no doubt, any employer would be in- 
 clined, and properly inclined, to hire him on sight. 
 
 Our analysis of Goldstein from the standpoint of the dis- 
 tribution of troubles may be brief. The medical features dom- 
 inate, whether on the one hand we point to Goldstein's original 
 moronity or to his queer lack of mental capacity. The educa- 
 tional disability was not alone that of the feeble-minded person, 
 but was also that of the Russian immigrant. With respect to 
 vices and bad habits we can find no evidence thereof, except 
 phenomena that might be explained more readily on the patho- 
 logical, or poor education, basis. The legal entanglements with 
 
THE KINGDOM OF EVILS 87 
 
 the Industrial Accident Board had a strong bearing upon the 
 rate of social "cure" and medically there is at least a strong 
 suspicion that the law's delay contributed not a little to the 
 fixation of his neurosis. Economically he was forced to drop 
 from eighteen or twenty dollars per week to nine dollars per 
 week. When the lump sum melted, Goldstein was worse off 
 than before. It is plain that all the phenomena in this case 
 are so closely bound up with one another that the cure or 
 removal of no single element in the complex will turn the 
 trick completely. 
 
 Shall we regard him as a "successful" case of psychiatric 
 social work ? As hinted above, we should not have, under ideal 
 conditions, closed Goldstein's case. At all events, we must say 
 that he is decidedly upon the up-gradient once more. Whether 
 we attribute this improvement to subtle mind changes due to 
 the passing of the effects of his brain injury three years before, 
 or whether we attribute the up-curve to environmental effects 
 of assiduous social work may and ought to be left undecided. 
 We say "ought" to be left undecided because scores more of 
 such cases as Goldstein's ought to be on the social work record 
 books of the world. Had not eleven agencies had to do with 
 Goldstein, and had not the thread of psychiatric insight. been 
 shown in the social work, it is easy to picture the collapse in 
 several fields of social trouble of the entire family. 
 
 Hours spent by Medical record, yj pages 
 
 Social record, 41 pages 
 Physician, 11 Social work: 
 
 Visits, 61 
 Psychologist, i Interviews at hospital, 9 
 
 Telephone calls, 50 
 Social worker, io6>^ Letters, 10 
 
 Mother of two illegitimate children. Mental disease sus- 
 pected. Referred as a ''terrible case." 
 
 Case 12. The fourth of our five cases that are less com- 
 plex by one element than Rose Talbot (case 8) is the case of 
 Elsa Albrecht, who came under our observation first at the age 
 of twenty-six. This case is one free from educational defi- 
 ciency, and is, in fact, a girl of rather superior education. She 
 
55 THE KINGDOM OF EVILS 
 
 came to us as of the group sometimes referred to as "terrible." 
 During her three years in this country she had had two illegiti- 
 mate children. She could hold no job; she was very shifty 
 and undependable in her accounts of her life: her responsibil- 
 ity was a grave matter of question. As for the illegitimacies, 
 she showed little or no concern over them, nor was the truth 
 ever learned concerning them. To make a long story short, 
 she was eventually dismissed from the Psychopathic Hospital 
 with the diagnosis of "paranoid dementia praecox," a diagnosis 
 which should probably be revised on the basis of further 
 observation. 
 
 We find in the hospital the following evidence which under- 
 lay the diagnosis that we now regard as erroneous : The little 
 concern which she showed over the illegitimacies, irritability, 
 resistiveness, overemotionality, hallucinations (history of three 
 years' standing), double thinking (heard her own thoughts). 
 Psychometrically she was regarded as of adult mental age, 
 tested by norms for non-English-speaking persons. Perhaps 
 the most striking feature in the psychiatric situation was the 
 alleged hallucinations. She claimed to hear distinctly the voice 
 of some unknown woman and sometimes other voices that 
 were talking about her in English, French, or German. When 
 the question of voices was brought up with her she would grow 
 somewhat disturbed. Toward the close of her stay she said 
 that she was not now hearing these voices so much since con- 
 fessing about a false name that she had used. She talked more 
 or less about her conscience and its troubling her about this 
 assumption of a false name and of "voices" accusing her of 
 being false to herself and to God. Whether we are dealing 
 with definite hallucinations of hearing or whether we are deal- 
 ing with pseudo-hallucinations is a fine psychiatric question, 
 but it would not do medically to ground a diagnosis of demen- 
 tia praecox upon so slender a basis. 
 
 This diagnosis of dementia praecox must be accepted as a 
 serious thing in any social case, for once let the diagnosis 
 dementia praecox be grafted on any case and a sort of taint 
 seems to cling to the case for all time. This is no doubt largely 
 on account of the sweeping implications of the term "dementia." 
 Where the case should be put medically remains in doubt. We 
 are certain of many of the so-called psychogenic features, fea- 
 tures that are found to some extent probably in all kinds of 
 
THE KINGDOM OF EVILS 89 
 
 mental disease, but which, when developed alone and inten- 
 sively, place their victim somewhere in the group of the psycho- 
 neuroses or the psychopathic personalities with psychogenic 
 features. 
 
 Rather unlike the victim of dementia praecox, and rather 
 more like sundry of the psychoneurotics, Elsa made friends 
 easily and even lay friends stuck by her through thick and 
 thin, and especially through the complications of the two illegiti- 
 mate births. Although she made Jay friends so easily, Elsa 
 was, in the eyes of social agencies, a good deal of a menace, 
 perhaps the more so as she made friends so readily. At one 
 time an attempt was made to deport Elsa as an undesirable alien. 
 However, upon investigation, it appeared that she had, after 
 all, taken fair care of her children for whom, indeed, she never 
 failed to exhibit her love. Amongst other contrasts with which 
 this case was so rife we should mention Elsa's own division 
 of mind over herself, her future, and her children. She was, 
 for the most part, self-confident in asserting her ability to care 
 for herself and her children, worked as a governess to support 
 them, and, for a long time, held the ideal of bringing them up 
 as sisters should be brought up ; namely, together. Again she 
 showed a deep depression, in fact, such a degree of emotionality 
 as was suited to her situation so that the psychiatrist would 
 very naturally question her being a victim of dementia praecox. 
 Another contrast in Elsa's case was that between her excellent 
 general intelligence and her inability to keep a job. It might 
 even be thought that a slight degree of wandering tendency 
 was herein shown, although the obvious cause for each loss of 
 a job seemed to be matters of her high temper and inability 
 to stand critique. As intimated above, perhaps the strongest 
 contrast lay between her general self-respect and her curious 
 light-heartedness concerning the illegitimate births. She ex- 
 plained that she was, in each case, engaged to her lover and 
 seemed to feel that these sins were comparatively minor. 
 
 The history of the social care of Elsa Albrecht is rather 
 unusually exciting because of factors thrust in from without. 
 Somehow Elsa veered from her attitude of keeping the children 
 together for their growing up and decided to have them both 
 adopted, if possible. The older girl, now four years old, was 
 adopted by friends. The younger one, now two years old, 
 went through the process of adoption, but there came about an 
 
90 THE KINGDOM OF EVILS 
 
 annulment in the following manner : When these sudden 
 developments forthwith came to the attention of the social 
 workers, the warning was given to the intermediator for the 
 younger child (who happened to be a physician) that the foster 
 mother might properly know something of the situation. The 
 physician agreed readily with this idea, and in fact, set about 
 forthwith to have the adoption annulled. Whether Elsa had 
 at this time contemplated the marriage with an Oriental that 
 she now promptly executed is in doubt; at all events what hap- 
 pened was that she went to a distant city and got work. The 
 social technique consisted in requiring her, on moral grounds, 
 to come back and assume responsibility for the now unadopted 
 baby. She came back, took the baby, and repaired once more 
 to the distant city, where she married. The baby was then 
 placed out, and provision made for her board to be paid for by 
 the husband. 
 
 As a matter of the progress of psychiatric social work in the 
 country, it is interesting to know that we were able to get 
 cooperation with workers in the city where Elsa now is, so 
 that due attention could permanently be paid to the upbringing 
 of the child and to any complication which might ensue in the 
 married life of a woman who seems to be undoubtedly some 
 sort of psychopath. After an interval of two years the follow- 
 ing report came from the social agency : — 
 
 "We have had a report on this case within the last month 
 showing that the patient is fairly happy in her home which is 
 comfortably furnished and well kept. You must have had a 
 
 previous report on her marriage to Mr. R , her subsequent 
 
 worry over the fact that he did not make as much money as he 
 did prior to their marriage, and also her upset over the death 
 of her youngest child, Gretchen. In October, 1918, she had 
 frequent fits of crying and was grieving over the death of this 
 child and the adoption of Frieda the older one. In May, 1919, 
 she gave birth to a little boy, Charles. The birth of this child 
 has seemed to compensate her for the loss of the other two. 
 Her husband is now in a better financial position than formerly; 
 and when the patient's children were spoken of she showed no 
 emotion whatever and seemed to have no regret for the death 
 of the one nor the adoption of the other. She was very affec- 
 tionate to her new baby and seemed very proud of it. About 
 three weeks ago she wrote us that the baby was progressing 
 
THE KINGDOM OF EVILS 9 1 
 
 satisfactorily, is now walking and talking and she herself is 
 getting along nicely with her husband and is in good spirits." 
 
 To sum up from the standpoint of the distribution of evils, 
 we have here a medical, moral, legal, and economic problem, 
 without important educational complications. 
 
 Hours spent by Medical record, 17 pages 
 
 Social record, 17 pages 
 Physician, 3^ Social work: 
 
 Visits, 7 
 Psychologist, i Interviews at hospital, 15 
 
 Telephone calls, 45 
 Social worker, 28 Letters, 31 
 
MORON, 29 
 HYSTERICAL, POOR HOUSEKEEPER 
 
 1915-1916 
 Forced Marriage 
 Jealousy : Separation 
 Another Child 
 
 Estrangement from Relatives 
 Unemployed 
 
 igi6-igiy 
 
 Child with Husband'^ 
 
 Relatives 
 Under Public Care 
 Reconciled 
 Employed 
 
Hysterical moron, divorced, with an illegitimate child. Such 
 cases often known to social agencies. 
 
 Case 13. It is now our duty, for the sake of logical com- 
 pleteness, to describe a case without special medical complica- 
 tions, but one which shall show the four other types of com- 
 plication with which we have become familiar. In a book on 
 social psychiatry it is, of course, in the strict sense not proper 
 that we should describe any non-psychiatric, or indeed non- 
 medical, cases. Agnes O'Brien did show, as a perfectly proper 
 ground for her appearance at the Psychopathic Hospital, an 
 attack which it is probably safe to regard as hysterical; but 
 thereafter her social care contained, although many difficult, no 
 special medical complications. 
 
 Let us at first make her out as medical and psychiatric as 
 possible. When she arrived, it was with a.history that her face 
 had become twisted; that she was unable to chew or swallow 
 and that she had been crying a good deal. These things had 
 been going on for a day. She said she was going to commit 
 suicide by taking poison; she said she was going to throw a 
 pocketbook into the fire. Her sister-in-law thought that Agnes 
 hardly knew what she was doing. She was a rather frail 
 woman of twenty-nine who looked almost girlish. Her sister- 
 in-law said that five years ago, when pregnant, Agnes had had 
 somewhat the same symptoms. It seemed plain that they were 
 hysterical in part. Examination showed that the girl was 
 pregnant. Detailed medical examination showed the con- 
 tracted or tubular vision characteristic of hysterics. Although 
 Agnes claimed that she was unable to speak, and spoke of oc- 
 casional paralysis of one side of her face, it was found that, 
 when her attention was distracted, she could enunciate per- 
 fectly and showed no sign of facial paralysis whatever. 
 
 Thus, the first medical point to make is that the patient was 
 clearly, though mildly, hysterical. The psychological exam- 
 ination showed that she was a subnormal person grading at 
 1 1.3. Her grading was fairly even; that is, she showed the 
 
 95 
 
g6 THE KINGDOM OF EVILS 
 
 "truncate" deficiency of mind which is more characteristic, 
 statistically speaking, of feeble-mindedness than it is of ac- 
 quired mental disease. Perhaps, therefore, we should classify 
 her as a more complicated case of social trouble ; namely, as the 
 fivefold case in which medical, as w^ll as educational, moral, 
 legal, and economic difificulties confront the social adapter. 
 However, we are convinced that many a social agency deals 
 on non-medical grounds, and certainly upon non-psychiatric 
 grounds, with case after case of this order. We believe that the 
 records of social agencies the country over will be found to 
 contain such cases as Agnes O'Brien's treated, and with con- 
 siderable or perfect success, by the usual social technique. 
 When perfect success is achieved in cases of this order, appar- 
 ently from a non-psychiatric angle, we suspect that the technique 
 implied is, at bottom, that of the psychiatric social worker. In 
 the practice of social work, and especially in the practice of 
 medical social work, the psychiatric viewpoint sometimes gets 
 implanted subconsciously in the social worker's mind. It is a 
 part of the program for progress in psychiatric social work to 
 point out the tremendous percentage of situations demanding 
 social work that encloses as a core some psychopath. Concern- 
 ing Agnes O'Brien, we then insist that her case is not an unfair 
 sample of cases handled sometimes successfully, perhaps more 
 often unsuccessfully, by agencies that employ neither the medi- 
 cal point of view nor the psychiatric point of view. 
 
 The social technique had to take account, for Agnes O'Brien, 
 of some place in wliich she could await her confinement. The 
 attitude of the family, especially of the in-laws, was not too 
 pleasant, as might be supposed when it is noted that the preg- 
 nancy was illegitimate. The priest's interest was enlisted. 
 The first pregnancy, five years before, had led to a forced 
 marriage, and now that the new child was on the way by 
 another father, there was a threat of divorce by the husband. 
 The legitimate child required care. This was managed by 
 placing the child with the husband's relatives. Prenatal care 
 was arranged for. Care during the confinement, care of the 
 baby in its early days, and placing-out of the baby, were other 
 steps. It was a little hard to convince the municipal authorities 
 that this seemingly relatively normal mother could not well take 
 care of the new child. However, the child was finally placed 
 out. There was also the important question of proper counsel 
 
THE KINGDOM OF EVILS 97 
 
 and encouragement for the woman herself. Aside even from 
 the complication of her pregnancy, Agnes O'Brien was a rather 
 frail, inert person, a little sullen and stubborn. At the end of a 
 year the situation was somewhat as follows : The legitimate 
 child was under the care of her husband's relatives; the illegiti- 
 mate child was under public care ; the girl had become recon- 
 ciled with her own relatives, and to some extent with her hus- 
 band's relatives. She could, from time to time, see her child 
 with them. She can, of course, also see her child that is under 
 public care. ( Parenthetically we may remark that the monthly 
 or bi-monthly "pass" system by which children under public 
 care are allowed to come to the vision of their mothers by the 
 public authorities of some of these institutions may be a neces- 
 sary, but certainly seems a somewhat inhuman system : the bet- 
 ter agencies so individualize their systems that the parents who 
 would not be disturbing elements in the foster situations are 
 allowed due access.) Agnes is, for the most part, sufficiently 
 devoted to her children, at least to the first, or legitimate child, 
 yet her temperament is such that a letter of the following 
 description was sent to her husband : — 
 
 "Dear William : As long as you don't intend to do the 
 straight thing by me, I don't by you. So come up and get your 
 old kid or I will leave her some where on the street. I am half 
 dead from everything and can't stand taking care of her any 
 longer. Don't send that rotten old Jew up to me Saturday or 
 I will insult him. I can't give him any money and try to pay 
 back milk bills and back rent and everything. Come take your 
 kid quick or you will see what I will do with her. I am smash- 
 ing her, she is a regular pest. If I am going to live by myself 
 I can't have a good time with her tagging after me. 
 
 "Your neglected 
 "Wife." 
 
 But these sentiments oi me neglected wife are entirely incon- 
 sistent with her actually idolizing the child. 
 
 Shall we regard the analysis of this case as essentially free 
 from medical factors? It is facile enough to point out the 
 moronity of this girl and say that feeble-mindedness leads to 
 such complications as forced marriages and illegitimacies, yet 
 it would be more accurate to say that feeble-mindedness is not 
 infrequently followed by such complications. Certainly, how- 
 
98 THE KINdDOM OF EVILS 
 
 ever, no one can fail to be aware of sundry equally moving 
 instances of forced marriage, illegitimacy, etc., that dot the 
 lives of persons that are not feeble-minded, possibly not even 
 psychopathic. Whatever be the truth of these contentions, we 
 present the case as one in which four types of factor are pre- 
 dominantly in evidence, whereas the fifth, or medical, factor did 
 not particularly influence, save in the most subtle way perhaps 
 the social treatment. 
 
 Hours spent by Medical record, 15 pages 
 
 Social record, s^ pages 
 Physician, 4^ Social work : 
 
 Visits, 43 
 Psychologist, i Interviews at hospital, 8 
 
 Telephone calls, 34 
 Social worker, 86 Letters, 25 
 
 Deaf, syphilitic, unstable. Abusive and psychopathic hus- 
 band. 
 
 Case 14. With case 14 we begin our group of threefold 
 cases ; namely, cases in which two of the five fields of social 
 trouble are not predominantly in evidence, and we choose, for 
 the first case, one with medical, educational, and moral diffi- 
 culties, but without special legal or economic disabilities. The 
 case is that of Margaret Hersey, whose social symptoms 
 might be listed as follows : Marital discord, seclusiveness, 
 deafness, suspiciousness. Margaret was an illegitimate child. 
 Her husband was a sex delinquent and one of her stepsons was 
 also a sex delinquent. It is of note ( re general progress in the 
 mental hygiene of the community) that Margaret Hersey came 
 to the attention of the social service indirectly. First came to 
 us the delinquent stepson who had gotten into some sex diffi- 
 culties, not here to our point. 
 
 Abstracting, for the moment, from the difficulties of the 
 rest of the family, let us consider the situation depicted in 
 marital discord, seclusiveness, deafness, and suspiciousness. 
 The psychiatric viewpoint would immediately try to connect up 
 some of these phenomena. Psychiatrists believe that there is 
 actually to be found in the world at times a so-called "psycho- 
 
THE KINGDOM OF EVILS 99 
 
 sis of the deaf"; that is, a more or less well-defined mental 
 disease directly depending upon sense-deprivation, viz., deaf- 
 ness. But psychosis of the deaf is not actually in question with 
 Mrs. Hersey. The deafness was extreme enough and made 
 communication very difficult with other members of the family. 
 Mrs. Hersey may have been, to start with, a Httle paranoid; 
 that is, given to ideas of being put upon, of being persecuted. 
 If so, the at first indefinite ideas of persecution were, no doubt, 
 driven further into her make-up by the deafness and her lack 
 of power to verify or disprove sundry hypotheses about her 
 husband and son. 
 
 Mrs. Hersey had been married at the age of twenty and was 
 now thirty-eight. The very first night of her marriage, her 
 husband was violent and abusive, and from him she promptly 
 also contracted syphilis. Whether her deafness is syphilitic 
 remains in question. It began about eight years after her mar- 
 riage and grew worse some years later after her husband had 
 struck her a bad blow upon the head. At one time (age thirty- 
 three) the poor woman even attempted to commit suicide. 
 
 Medical examination showed that Mrs. Hersey had, besides 
 sundry minor nervous symptoms, a positive Romberg sign 
 and an ataxia of gait, both signs suggesting, with the rest of 
 her history, a syphilitic involvement of her nervous system. 
 In fact she had been treated at two general hospitals for this 
 complication of syphilis, and at the time when she came under 
 Psychopathic Hospital observation her spinal fluid had become 
 negative — a finding which does not necessarily show that there 
 is not still some active syphilis. There were also, in her history, 
 two miscarriages, which might be thought consistent with the 
 history of syphilis (though one of these miscarriages followed 
 a trolley accident). 
 
 Deafness, incommunicability, suspiciousness, seclusiveness, 
 formed a complex serious enough in itself ; but it appears that 
 from time to time she also had definite hallucinations of hear- 
 ing, hallucinations, however, which she quite well understood 
 to be perceptions of an imaginary character. 
 
 Our investigations showed that the family was economically 
 upon a reasonably high level and that with proper family coun- 
 sel that level could be well maintained. Perhaps we can indi- 
 cate the kind of social treatment adopted in this case by the 
 following notes ;— 
 
lOO THE KINGDOM OF EVILS 
 
 9/28 Interview with husband to assist in persuasion for ex- 
 amination. 
 10/ I Interview with patient. Reassurance. 
 10/ 2 Interview with patient's mother. Encouragement and 
 
 advice. 
 10/ 7 Interview with husband. Attempt to improve insight 
 into patient's condition. SHght gain in cooperation. 
 " Interview with patient's son. Object: To appeal to his 
 
 sense of chivalry. 
 " Interview with patient's daughter. Object: To suggest 
 
 consideration for patient. 
 " Interview with husband. Object: Attempt to gain his 
 cooperation by agreement to assist him in making a re- 
 vision of his budget. 
 10/10 Interview with patient. Advice and encouragement. 
 
 " Interview with patient's mother. Reassurance. 
 10/17 Conference with entire family. Aims: 
 
 1. To straighten out difficulties in misunderstanding 
 over family finances. 
 
 2. To give constructive advice along this line. 
 
 3. To prompt a more friendly family relationship. 
 
 4. To have all sides of the question presented impar- 
 tially and thrashed out. 
 
 5. To persuade that reconstructive measures should 
 "let bygones be bygones." 
 
 6. To encourage patient by suggestion of lip-reading. 
 ** Dr. Basch interviewed to enlist cooperation and acquire 
 
 possible evidence. 
 10/22 Conference at Horace Mann School to enlist interest of 
 
 teachers and lay constructive plans for lip-reading. 
 11/ 4 Patient and husband interviewed. Aims: 
 
 1. Financial advice given. 
 
 2. A dietary manual given patient to stimulate her 
 interest and enlist her cooperation in plan. 
 
 3. General advice and encouragement. 
 
 11/10 Patient and mother interviewed. Advice and encourage- 
 ment. 
 
 11/15 Patient and mother interviewed. Encouragement, ad- 
 vice, and reassurance. 
 
 11/22 Letter. Advice and encouragement. 
 
 11/25 Interview with patient and mother. Much reassurance. 
 
 11/30 Patient interviewed. Aims: 
 
 1. To make plain continued friendliness. 
 
 2. To encourage and advise. 
 
 3. To give patient relief of fully expressing herself. 
 
THE KINGDOM OF EVILS lOI 
 
 12/13 Letter. Encouragement. 
 
 12/14 Mother and stepmother seen in New York. Object: To 
 secure cooperation. 
 
 12/23 Christmas gifts to the family. 
 
 12/28 Letter thanking patient for Christmas gifts. Encourage- 
 ment, 
 
 1918 
 
 1/16 Letter. Education. 
 
 1/17 Talked with husband. Cooperation. 
 
 1/24 Lip-reading teacher talked with. Education. 
 
 1/25 Telephoned. Education. 
 
 1/26 Family seen at home. Advice, encouragement, coopera- 
 tion, education for children, reassurance about treatment. 
 
 1/29 Letter urging treatment. 
 
 2/ 4 Same. 
 
 2/ 9 Same. 
 
 Letter to husband urging treatment. 
 
 2/12 Telephoned (same as above). 
 
 2/13 Patient at hospital. Received treatment. 
 Patient on wards. Encouragement. 
 Telephoned husband. Education. 
 
 2/15 Husband seen. Cooperation. 
 
 2/16 Son, William, seen. Education of William in attitude 
 toward patient. 
 
 2/18 Mother written to. Reassurance. 
 Letter ; arrangements for meeting. 
 " Mother written to. Arrangements for starting patient 
 on trip to New York. 
 
 2/19 Letter to husband urging generosity toward patient. 
 
 2/20 Patient taken to South Station and put on train for 
 New York. Reassurance. 
 
 3/1 1 Letter to patient. Object: To give her courage to tell 
 husband that she had lost her money. 
 " Daughter taken to Dental Infirmary for dental treat- 
 ment. 
 
 3/21 Telephoned to get patient to hospital for treatment. 
 
 4/ 3 Letter urging treatment. 
 
 4/10 Same. 
 
 4/24 Same. 
 
 4/29 Letter preparatory to visit. 
 
 5/ 2 Interview with patient and mother. Advice, encourage- 
 ment, education. 
 
 5/ 8 Letter to husband urging that William report at out- 
 patient department and that patient come for treatment. 
 
I02 THE KINGDOM OF EVILS 
 
 5/14 Letter to patient urging treatment. 
 
 5/18 Patient and mother interviewed at hospital. Patient is 
 
 finally persuaded to take treatment. Encouragement. 
 
 Reassurance. 
 
 Let us call attention especially to the notes in the above 
 abstract under October 17; namely, those that deal with the 
 conference held with the entire family. That conference seemed 
 to straighten out a great many of the tangles. A very difficult 
 situation, the social care has now pretty well succeeded in all 
 respects, except in securing proper continuous treatment of Mrs. 
 Hersey's syphilis. 
 
 The reliance of patients upon the professional character of 
 the social worker irrespective of her maturity or personal ex- 
 perience was illustrated well in this case. The first worker 
 after several months of work with the Hersey family left the 
 department and the case fell to a young woman out of college 
 but a few years. The complications of marital discord with a 
 sex-delinquent husband might have caused the assignment of 
 the case to a more mature worker, if there had been a trained 
 and mature worker free to take it. The result, however, jus- 
 tified our faith in the ability of young women well trained to 
 deal with situations of even such deep-seated complexity as 
 Mrs. Hersey's. At one point Mrs. Hersey wrote the young 
 worker as follows : — 
 
 "You phoned Mr. Hersey last week — it had some effect, but 
 soon wore off, when he heard yovi had not been here. I do not 
 like to Imrden a young girl like you with my troubles but you 
 seem to know how to treat such affairs." 
 
 In analyzing this case for its distribution of difficulties, we 
 have tried to make it a paradigm in the threefold group. There 
 is no economic disability of importance. There is, in the patient 
 herself, no complication worthy of the term "legal entangle- 
 ment." Of course, the characters of the husband and son 
 must be taken into account; these are doubtless also, in some 
 ways, psychopathic and may lead to important legal complica- 
 tions, even to separation or divorce. Yet all the complications, 
 aside from purely family ones, converge upon Mrs. Hersey's 
 sheaf of diseases : namely, syphilis, deafness, suspiciousness, 
 and hallucinations. In addition to these we found her some- 
 what deficient in general judgment and of a certain extrava- 
 
THE KINGDOM OF EVILS IO3 
 
 gance in managing her household, but these deficiencies were 
 such as to be rather corrigible by training. It would be rather 
 difficult to draw the line in this counsel between a belated edu- 
 cation, true moral training, and psychotherapy itself. So deaf 
 a person should, long since, have been taught lip-reading, and 
 her deficiency therein must be mentioned as one of Mrs. Ker- 
 sey's educational disabilities. As will be noted from the above 
 extract of the treatment records, steps were taken to teach her 
 lip-reading. She was something of a moral problem for us, in- 
 asmuch as she seemed not to have the will to stand to her treat- 
 ments persistently. Moreover she had been a nagging sort of 
 wife. 
 
 On these scores we have made her a paradigm of medical, 
 educational, and moral deficiency, but we regard her social 
 problem as centering in her diseases. 
 
 Hours spent by Medical record, 35 pages 
 
 Social record, 35 pages 
 Physician, io}i Social work: 
 
 Visits, 15 
 Psychologist, o Interviews at hospital, 24 
 
 Telephone calls, 13 
 Social worker, 53^ Letters, 45 
 
 ^'Mystery girl" of the newspapers. Sleeping spells on the 
 street. Feeble-minded, hysterical. 
 
 Case 15. Bessie Polski figured in the newspapers as a 
 "mystery girl." The police officer found the nineteen-year-old 
 Polish girl in a faint and brought her to the Associated Char- 
 ities. Bessie said that she had been going to commit suicide. 
 She had a letter which reads as follows : — 
 
 "I am awfly sorry, and am a Catholic girl, and know that I 
 will lose my heart, but I cant help it because I am so hungry 
 that I dont know what to do. I'm afraid to take poison but I 
 cant help it because I cant live. I cant give another to my 
 cousin because he said I am not his cousin [untrue]. I have 
 not one cent and no money and I dont know how to live. I dont 
 know where to go, and the next day I did not eat nothing for 
 the whole day. I am a young girl, I dont eat nothing, only cry 
 all the time. I have hurt my hand and didn't work for five 
 
I04 THE KINGDOM OF EVILS 
 
 weeks. Pleas who will help me. I am so poor that I sleep on 
 the street, no one knows me, and I don't eat at all." 
 
 The statement about her cousin has been noted above as 
 untrue and a variety of other statements failed to hold water. 
 The day after the police found her she was brought to the Psy- 
 chopathic Hospital and there was determined to be not insane 
 (that is, in the medico-legal sense of not being committable to 
 some receptacle for the insane) but to be hysterical. Bessie 
 said that she was subject to long attacks of unconsciousness. 
 Her "sleeping periods" lasted from a few hours to ten days, 
 with convulsive attacks of laughing and crying and a localized 
 anesthesia of the skin of the neck. Early in her stay at the 
 hospital she apparently had another psychopathic sleeping spell 
 which lasted about a day. 
 
 She now went from the hospital into the care of an agency, 
 which agency tried to have her go to a state institution for 
 treatment of syphilis, which she was supposed to have con- 
 tracted (the blood serum reaction was positive according to 
 the Wassermann test, and there was a slight, though distinct, 
 evidence of inflammatory reaction, if we are to trust the cell 
 count in the spinal fluid ) . Whether these findings indicate the 
 acquisition of syphilis by this girl, or whether they possibly 
 indicate that she was a victim of congenital syphilis (victims 
 of congenital syphilis are not infrequently without any labora- 
 tory sign whatever of their syphilis) must be left in doubt. In 
 any event, Bessie did not reach the state institution and further 
 blood specimens proved negative to syphilis two months and a 
 half later. 
 
 She went back home, and the case dropped out of social 
 service contacts for about two months, when a rather extraor- 
 dinary episode took place. ^Vhile Bessie was going along 
 the street, she was accosted by a man, to whom she said she 
 was looking for work. The man said that she might go with 
 him to a tenement house to meet his brother, the foreman of 
 a candy factory who would get work for her. What happened 
 in the tenement house was rape by three men. Bessie's outcries 
 drew the police. The men escaped. The girl was held as 
 witness. 
 
 Some convulsions shortly ensued and Bessie was brought 
 once more to the Psychopathic Hospital, whence she was dis- 
 
THE KINGDOM OF EVILS IO5 
 
 charged, ten clays later, with the same diagnosis as before, 
 hysteria. She was observed in a so-called convulsion while in 
 the hospital. The seizure lasted three minutes, during which 
 she got red and gritted her teeth. She did not bite her tongue 
 or froth at the mouth. Her attacks would in general begin 
 with a feeling of pressure in the chest and a palpitation of the 
 heart; then there would be a choking sensation in the throat, 
 whereupon, apparently, unconsciousness would supervene, for 
 the patient could not describe the rest of the attack during 
 which she would laugh, cry, and toss her arms about. Curi- 
 ously enough, the loss of sensation observed upon her first 
 visit to the hospital was not now at all in evidence. 
 
 She went out to live at home, had an operation for appendi- 
 citis, and did not come under observation again until four 
 months later. Then came the following newspaper clipping 
 which may serve to show the attitude of newspaper men to the 
 so-called "mystery girl." 
 
 "girl defies doctors' efforts to waken her 
 
 "Going to Sleep for Long Periods Has Become Habit with 
 Bessie Polski. 
 
 "Bessie Polski, who goes to sleep for periods that vary from 
 
 a few days to several weeks, is at the Hospital in sound 
 
 slumber and puzzling the doctors. She lies in bed calmly, with 
 her eyes wide open, and takes food when it is offered, but 
 seems unconscious. 
 
 "About a year ago she had another long sleep at her home 
 
 in , and was in a far more serious condition, as she was 
 
 unable to take food, and had to be fed through the nose. Dr. 
 
 of who attended her at that time, thought she 
 
 was suffering from a form of hysteria. Her history, he says, 
 shows a similar sleep of several weeks' duration when she was 
 living in . 
 
 "She went to sleep on the sidewalk at Park and Madison 
 Streets and was taken to a drug store, where attempts were 
 made to revive her. Later she was taken to the hospital, where 
 one of the nurses [sic] remembered that she was brought to 
 the hospital several months ago in similar circumstances. At 
 that time she was asleep for the greater part of five days. 
 
 "It is said that she has met with several accidents in places 
 where she was emploved, and that about two weeks ago she fell 
 from a car at Street." 
 
I06 THE KINGDOM OF EVILS 
 
 She was again observed at the Psychopathic Hospital, but 
 had no longer any seizures and showed no further sleeping 
 periods. There were no stigmata of hysteria. It was, how- 
 ever, decided that she might best be committed to a state hos- 
 pital. The basis for such commitment was, not so much the 
 hysteria, as the feeble-mindedness which she showed upon psy- 
 chological examination. There were no marked irregularities 
 in this examination, which gave her a Point Scale age of nine 
 years, actual age nineteen years. Her attention was unstable 
 and she was oversuggestible by the tests employed. In other 
 respects she was rather generally deficient. 
 
 After a time she was released from the state hospital and 
 placed out, but she could make very poor wages and was even- 
 tually allowed to go back to her family whom she aided by 
 working in a restaurant. At last accounts she was earning a 
 little money by working in a restaurant. 
 
 This case we present as a paradigm of triple disorder, medi- 
 cal, educational, and legal. The medical fraction of the count 
 is clear : the two years' history of hysteria and the low mental 
 capacity, not necessarily in alliance with one another in all 
 cases, are no doubt combined in Bessie Polski to confuse results 
 of social treatment and to complicate the economic situation. 
 The educational deficiency was a marked one, centering chiefly 
 upon a language difficulty, which was not merely the girl's own 
 but was shared by all her relatives. A galaxy of Polish- 
 speaking social workers might have been necessary to have 
 made all the points desirable with Bessie's relatives. The 
 legal complications with the police by reason of the rape at- 
 tempts were dominant. It is perhaps well to say that not all 
 the "mystery girls" who form so striking, if so small, a part 
 of the psychopathic hospital clinic are feeble-minded. It might 
 be inquired whether this girl, a probable victim of rape, a pos- 
 sible sex delinquent prior to her first period of observation at 
 the Psychopathic Hospital, should not be considered as some- 
 what of a moral problem. Our evidence is, however, that she 
 was, in general, not immoral in the popular sense of this term. 
 We are not even sure that syphilis was ever acquired. In any 
 event the problem of social care did not seem at any time to 
 involve moral training. Bessie's "immorality," if such we may 
 call it, was no doubt a matter of ignorance, and the total prob- 
 lem here was one of adjustment to the community, with due 
 
THE KINGDOM OF EVILS IO7 
 
 regard to the feeble-mindedness and hysteria on the one side, 
 and the language difficuhy and educational deficiency on the 
 other. 
 
 There was no proper guardian for Bessie save the public 
 institution from whose iron she might be saved by the velvet 
 glove of social service. The only relative of this girl in this 
 country was a well-meaning, friendly, but ignorant cousin, 
 whose wife could, of course, not understand Bessie's feeble- 
 mindedness, to say nothing of her hysteria, and assumed a 
 rather hostile attitude to her. The proper answer to the Bessie 
 Polski question was evident resort from time to time to a pub- 
 lic institution. Obviously we cannot count this case as one of 
 highly successful social practice, yet it is as well to demonstrate 
 failures and negative results from time to time as always to 
 put the very best foot forward. We above spoke of the desir- 
 ability of public institutional care ; but it is worth further speci- 
 fying that the public institution in question should uncondi- 
 tionally be a medical institution and not of the prison system. 
 The chief social service contribution in the case of Bessie Pol- 
 ski, then, may be summed up in the words "public care and 
 supervision under medical auspices." 
 
 Hours spent by Medical record, 34 pages 
 
 Social record, 8 pages 
 Physician, 9 Social work : 
 
 Visits, 6 
 Psychologist, I Interviews at hospital, 3 
 
 Telephone calls, 3 
 Social worker, 11 Letters, 10 
 
 Grown-up "spoiled child." A motherly landlady found. 
 
 Case 16. Mark White is now nearing thirty-one years, 
 but strikes one still as a rather overgrown boy. He is rather 
 an inferior-looking shipping clerk, who came of his own initia- 
 tive to the Psychopathic Hospital. He said he was afraid of 
 crowds and that his memory was not as good as it had been. 
 He dated his troubles from a time when his express wagon 
 had run into a street car and stunned him. Pie had a darnage 
 suit brought after this accident. He told of hallucinations of 
 several sorts, the absurdity of which he said he now realized. 
 
Io8 THE KINGDOM OF EVILS 
 
 Once he had thought a doctor had hypnotized him. He had 
 very pecuhar ideas about masturbation, which he said that he 
 had done as a rebel against God and to displease God. The 
 patient was a Roman Catholic. We found him to grade at 16.5 
 years on the Point Scale and to show few failures except in the 
 memory tests; but in his memory he was more erratic than 
 actually deficient. The question was raised whether he might 
 be a psychoneurotic, or possibly a victim of dementia praecox. 
 
 A study of his family relations showed that he had been for 
 many years rather ext'"aordinarily dependent upon his doting 
 mother's care; but she had died four months before he came 
 to us. Up to this time he had been thrown only in the society 
 of women of his mother's age and had made no friends amongst 
 his own sex or amongst younger women. He was a sort of 
 overgrown, spoiled child, a rather seclusive and very self -accusa- 
 tory person. As for the hallucinations above mentioned, it is 
 a question how gravely they are to be taken in the matter of 
 the diagnosis of schizophrenia ( dementia praecox). Certainly 
 the notions about hypnotism and about masturbation are 
 peculiar enough to suggest schizophrenia, and the so-called 
 ideas of reference (people pursuing him on the street) might 
 be used in building up that diagnosis. 
 
 He was discharged to the social service without a definitive 
 diagnosis between schizophrenia and psychoneurosis. The 
 ideal in such a case as that of Mark White might be to give 
 him, in a popular phrase, some sort of "sublimation." The 
 best social service could do appears to have been to give him 
 compensation. A landlady of maternal type was secured 
 through a room registry. Upon due explanation of Mark's 
 plight, the landlady undertook his care. A position was found. 
 The end crowned the landlady's work. Mark is now at least as 
 well off as ever, perhaps better. Latterly he has even developed 
 some fresh contiguities and interest in women of his own age. 
 He became particularly interested in the nurse who took him 
 through influenza. Formerly made fun of where he worked, 
 he has now become well liked and sociable both with men and 
 women of his own age. The socializing problem is going 
 apace with the aid of church measures, the community chorus 
 and the like. Aside from irritabilities at the doctors, Mark 
 White seems to be approximating the normal. 
 
 Briefly analyzed, Mark White appears to be a threefold case 
 
THE KINGDOM OF EVILS IO9 
 
 of social difficulty in which neither moral nor legal difficulties 
 appear. His medical category must remain in doubt ; but there 
 can be no doubt that he is in some sense psychopathic. His 
 curious up-bringing and maternal spoiling form an equally 
 prominent part of the story; indeed some might claim that the 
 medical difficulty traced absolutely and entirely back to his 
 curious home environment. He was economically in the need 
 of aid during the first months of observation, coming to us as 
 an object of charity, with the history of being in debt and of 
 having received aid from a relief society. 
 
 Hours spent by Medical record, 42 pages 
 
 Social record, 38 pages 
 Physician, 9^ Social work : 
 
 Visits, 26 
 Psychologist, i Interviews at hospital, 13 
 
 Telephone calls, 55 
 Social worker, 57^ Letters, 25 
 
 Alcoholic and syphilitic woman under the influence of di- 
 vorced delinquent husband. Refused treatment. Ahoulia 
 ( weak-willedness ) . 
 
 Case 17. Eva Collins, a sales clerk, thirty-one years old. 
 is presented to illustrate the threefold combination of social 
 difficulties : medical, moral, and legal — the educational and 
 economic elements being absent or negligible. The prime medi- 
 cal reasons for her hospital observation were alcoholism and 
 neurosyphilis. Indeed, her first diagnosis was that of locomo- 
 tor ataxia (now universally recognized to be a syphilitic dis- 
 ease) and a "psychotic episode" due to alcohol. Mrs. Collins 
 had acquired her syphilis from a sex delinquent and otherwise 
 criminal (forger) husband, whom she had married twelve years 
 before our observation of her, namely at the age of nineteen. 
 It is probable that we must regard her as a rather indecisive 
 and weak-willed person, and this native hypoboulia was at last 
 to interfere gravely with her fate. She was for various medi- 
 cal reasons regarded as a most promising case for antisyphilitic 
 treatment; but, owing to her indecisiveness of character and to 
 a more or less ill-grounded desire to get away from the Psycho- 
 
no THE KINGDOM OF EVILS 
 
 pathic Hospital atmosphere and sundry drawbacks of its pub- 
 licity, she continued for but ten months under our social care 
 and medical treatment. Despite continual efforts our contacts 
 with her grew fewer and fewer during the last few months 
 before her case was closed on the score of her recalcitrance. 
 
 It is interesting to note that a poorer patient who could not 
 have begun to pay for antisyphilitic treatment would doubtless 
 have remained under our care despite objections on her part 
 to being hospitalized. 
 
 Doubtless under ideal conditions of social work, recalcitrant 
 cases of this sort would be pertinaciously pursued into the com- 
 munity so far as the rights of privacy of the individual would 
 permit. Relative to these selfsame rights of privacy, it is of 
 course a modern point of view that syphilitics of whatever sort 
 are hardly entitled to so much privacy as that which normal 
 persons enjoy. The house of a syphilitic is not his castle. 
 Moreover, we have to deal with a delinquent and vicious hus- 
 band. It has for years been plain that only the very poor and 
 very rich get adequate medical treatment. Here Mrs. Collins 
 offers a peculiar instance of failure on the part of the moder- 
 ately well-to-do person to get continued treatment from a mix- 
 ture of pride motives, indecision of character, and husband's 
 influence. 
 
 Mrs. Collins felt that she was well-to-do enough to employ 
 a private physician, and this was no doubt the case, but in our 
 experience the proper tenacity of antisyphilitic treatment is 
 rarely shown in private practice partly for reasons grounded 
 in the old-time attitude of physicians to the syphilis problem 
 and partly because a patient without marked symptoms slackens 
 his interest in treatments that are on the whole rather annoying. 
 
 We have noted that the difficulties of moral adjustment 
 here were perhaps grounded in a degree of psychopathic inde- 
 cision and perhaps also in part in the neurosyphilis itself. 
 There were also sundry divorce complications. When Mrs. 
 Collins first reached the hospital, she was endeavoring to secure 
 a divorce. Although she was prevailed upon to abstain from 
 her husband's company for a period of six months and although 
 the divorce proceedings were carried through, she reversed her 
 attitude shortly and began to get her alimony at the personal 
 hand of her former husband. How intimate her relations with 
 
THE KINGDOM OF EVILS III 
 
 the former husband now became is ar matter of doubt. Before 
 we lost track of her, however, she had lost contact with her 
 former husband and announced to us that she was now keeping 
 company with another man, to whom she said she was to be 
 married. Permanent loyalty to husband, relatives, physicians, 
 or hospitals was apparently inconsistent with Mrs. Collins' char- 
 acter. These shifts in allegiance were regarded as probably 
 part and parcel of the weak-willedness (aboulia) noted through- 
 out, but it may be that there is a slight general tendency in 
 Mrs. Collins of the sort sometimes termed paranoic, a tendency, 
 that is to say, to the development of delusions of persecution. 
 She was rather childlike in her attitude to ordinary affairs 
 such as her money. After she was in straits about money, she 
 fell into a sort of depression and thence into alcoholism. She 
 drank with her husband. This lapse into drinking became in- 
 grained and what might be called a conditioned reflex upon 
 seeing her husband. Seeing him would precipitate a bout. 
 
 We have not up to this time mentioned the hereditary taint 
 in Mrs. Collins; but when we put together the medical and 
 moral features of her case, we are not unprepared to find that 
 her mother and a sister had actually been committed cases to an 
 institution for the chronic insane. The mother had suffered 
 from involution melancholia and the sister from dementia prae- 
 cox. Other brothers and sisters were normal enough. We 
 have spoken of her as childlike in worldly reactions, yet she 
 made an exceedingly high score upon her psychometric test, 
 namely i8-\-', with a score of 93 points on the Point Scale. 
 The only item of her psychometric record at all noteworthy 
 was a certain degree of oversuggestibility. How far "over- 
 suggestibility" of routine psychometric tests can be correlated 
 with Vv^eak-willedness (aboulia) remains doubtful, and it is a 
 stock and justified complaint that routine psychological tests 
 have so far not quite measured up to our hopes of definite 
 means of judgment concerning moral capacities and poten- 
 tialities. 
 
 To justify our calling this case a combination not only of 
 medical and moral troubles but of serious legal ones, we need 
 refer only to the divorce complication. As a sample of record 
 of social treatment we insert the following entries for three 
 months : — 
 
112 THE KINGDOM OF EVILS 
 
 I917 . . . , .. 
 
 8/30 Interview for purpose of enlisting patient's cooperation 
 
 for future treatment by appealing to her intelligence 
 and for purpose of bracing her up to point of decision of 
 living away from husband. Friendliness of patient 
 clinched by offer of visit to mother with view of arrang- 
 ing her treatment at home and incidentally gaining access 
 in natural manner to patient's relatives. 
 
 8/31 Purpose of visit to patient's mother carried out. Family 
 cooperation enlisted largely through offer of medical 
 assistance to mother. Investigation made easy through 
 this method. 
 
 9/ 5 Letter to patient to show continued friendly interest. 
 
 9/ 6 Encouragement of patient continued. 
 
 9/ 8 Patient's confidence strengthened by friendly advice 
 which leads naturally to frank discussion on the subject 
 of patient's use of alcoholics. 
 
 9/1 1 Lawyer interviewed for purpose of establishing good 
 working cooperation with him and with idea of clearing 
 his mind of any misapprehensions in regard to social 
 service connection with case. Cooperation secured and 
 constructive plan leading toward future change of work 
 outlined. 
 
 9/12 Encouragement. 
 
 9/18 Evening call on patient for purpose of showing social 
 friendliness as well as for purpose of sizing up patient's 
 living conditions. 
 
 9/21 Visit to Mrs. Smith (an acquaintance of visitor) in hope 
 of connecting her up with patient on friendly basis. 
 
 9/25 Letter to lawyer for purpose of keeping him informed 
 in regard to social service interest. 
 
 9/29 Encouragement. 
 
 10/ I Encouragement and advice in regard to patient's family 
 situation which is reacting upon patient. 
 
 10/15 Business course started according to plan of 9/1 1. 
 
 10/18 Encouragement. 
 
 10/20 Arrangement made for outside examination of patient 
 by oculist in order to save working time and make exam- 
 ination as little of a nervous strain as possible to patient. 
 
 10/22 Encouragement and advice. 
 
THE KINGDOM OF EVILS 1 13 
 
 10/29 Call to show friendly interest. 
 
 11/ 3 Encouragement and reassurance in regard to situation in 
 family of patient's sister. 
 
 11/12 Call for purpose of friendly advice and encouragement. 
 
 11/21 Conference with Visiting Nursing Association in order 
 to gain their cooperation through explanation of mother's 
 eccentricities. 
 
 11/23 Visit to patient's sister for purpose of getting over to her 
 the fact that there is an intelligent and constructive treat- 
 ment possible to use in the case of a boy of the make-up 
 of her son. Patient reassured by this interview and co- 
 operation of sister gained in making better plan for her 
 nephew. Opportunity taken to straighten out situation 
 existing between district nurse and mother. 
 
 11/27 Arrangements made with Dr. Jones in order to insure 
 interest and reliable medical advice for patient's nephew, 
 on which to base future social action. 
 
 Hours spent, by Medical record, 30 pages 
 
 Social record, 2)1 pages 
 Physician, 4 Social work : 
 
 Visits, 27 
 Psychologist, i Interviews at hospital, 16 
 
 Telephone calls, 30 
 Social worker, 46^ Letters, 25 
 
 Psychasthenic atmosphere about an eye trouble. Alcoholic, 
 spoiled child. 
 
 Case 18, Hamilton Green, a rather under-sized, boyish- 
 looking man of twenty-nine, came voluntarily to the Psycho- 
 pathic Hospital at the suggestion of the social service of a gen- 
 eral hospital. It was plain that he was in some important diffi- 
 cult way an "eye case," but the medical story would sound a 
 good deal more complex if one took into account the indigestion, 
 constipation, headache, dizziness, nervousness, fearfulness on 
 the street, whisperings heard when going to sleep, temporary 
 drinking to excess, "gas on the heart," and the like. Compe- 
 tent ophthalmological examination showed the man, who had 
 recently been a porter and elevator boy, to have an actually 
 severe astigmatism, such that exceedingly strong lenses were 
 
114 "^^^ KINGDOM OF EVILS 
 
 required. There was no small degree of hereditary taint; 
 namely, a question of mental or nervous disease in the father, 
 epilepsy in certain paternal cousins, and stammering in ma- 
 ternal relatives. 
 
 The second element in Green's case is the moral one. He 
 was at times excessively alcoholic. But a more fundamental 
 moral deficiency lay in his irresponsibility to his mother. Per- 
 haps this is to be laid in part to his being a spoiled child. He 
 was an only child. His mother helped him financially. Other 
 relatives helped out also. Yet applications to the Associated 
 Charities were from time to time made, but had to be refused 
 because of these family resources. Finally, however, the 
 mother ran through the small capital sunk in their house and 
 mother and son became partial public charges. That there was 
 a necessity, therefore, in Green's mental or medical condition 
 is not likely. There was a question of moral attitude involved. 
 This moral deficiency has now been in part made up through 
 the counsels and insistence of the social workers. At this time 
 it is fair to say that Green's own interior ambition has been 
 aroused so that the social service splint may not for all time 
 be necessary for him. 
 
 As for the economic deficiency, we have discussed it in gen- 
 eral terms in the above paragraphs. After some two months of 
 handling by the social service, no further grants of money were 
 required for Green. 
 
 The situation now shows in the foreground the eye trouble, 
 which is not only objectively somewhat serious, but has shown 
 no signs of disappearing as an object of careful subjective con- 
 cern. Green continually complains of the drawing of his 
 glasses, of his not desiring to walk up a hill for fear of its 
 rising to strike him, of his often misjudging distances, and so 
 on. However, he has been prevailed upon to stick closely to a 
 single eye clinic, and no doubt in the long run the subjective con- 
 cerns, which now seem almost obsessive, will atrophy or gradu- 
 ally retire. Here we have an example of what is sometimes 
 termed a "periorganic" situation. The term periorganic refers 
 to the actual objective existence of a serious somatic trouble 
 (in this instance astigmatism) around which develop by almost 
 natural processes an obsessive or a psychasthenic atmosphere. 
 Reference to the first paragraph of our discussion gives a cata- 
 logue of complaints forming this psychasthenic atmosphere. 
 
THE KINGDOM OF EVILS II 5 
 
 Remarkable therein are the actual hallucinations, the hearing of 
 whispers as he goes to sleep. These so-called hypnagogic hallu- 
 cinations of hearing are interesting also in connection with the 
 flashes of light which Green says he imagined after he had 
 been dreaming about his landlady, whose rent was two months 
 past due. Whether these phenomena are to be regarded as 
 genuine hallucinations or as vivid fancies of a dreamlike world 
 remains still in doubt. Some observers of Green have thought 
 of him as possibly a victim of schizophrenia (dementia praecox) 
 and would no doubt look upon these hallucinations or pseudo- 
 hallucinations as consistent with that far more serious disease, 
 schizophrenia, than the one we have elected to ascribe to this 
 man. However this may be, practically all of the constellation 
 of symptoms first set forth has now vanished, leaving astigma- 
 tism and its immediate sequelae in the center of the stage. We 
 should make one exception. Green will still occasionally lose 
 a job through getting drunk. Green claims that his drinking 
 is somehow connected with his eye trouble, or at all events 
 that the drinking habit is in general a matter of the last five 
 years during which time the astigmatism came to the surface 
 of his life. 
 
 Hours spent by Medical record, 9 pages 
 
 Social record, 17 pages 
 Physician, 5I/2 Social work : 
 
 Visits, 16 
 Psychologist, Interviews at hospital, 3 
 
 Telephone calls, 9 
 Social worker, 28J/2 Letters, 12 
 
 Industrial traumatic neurosis in a competent steady family 
 man. Family problem. Slow recovery with graded light work. 
 
 Case 19. John Flynn we present as combining medical, 
 legal, and economic elements of trouble. 
 
 The legal elements in question are Industrial Accident Board 
 complications. Although we have all along stressed the cen- 
 trality of the individual in social psychiatric cases, we have not 
 intended to give the impression that the family group is not 
 equally in the practical eye of the social worker. John Flynn's 
 problem would, no doubt, be very properly regarded as a fam.- 
 ily problem by the non-psychiatric social workers. The psy- 
 
Il6 THE KINGDOM OF EVILS 
 
 chiatric social worker regards it also as a family problem 
 (with even sundry psychiatric complications produced by the 
 wife's ignorance or feeble-mindedness as indicated by her 
 rating of 11.6 by the Point Scale) but finds the hub of the diffi- 
 culty, after all, to lie in the psychopathic central figure. 
 
 The psychopathy in question was traumatic neurosis. By 
 neurosis we mean a functional, that is, a theoretically curable 
 disease, which, under proper treatment, ought to revert to the 
 normality of the man before his accident. (It may be as well 
 to say that traumatic psychosis, also at times suspected in John 
 Flynn, means a disease of more serious character, often a con- 
 dition of defect directly consequent upon brain injury, and 
 hence, not to such a degree recoverable ; and the rather poor 
 prognosis early offered by the physicians for John Flynn him- 
 self was probably due to the suspicion that, in addition to trau- 
 matic neurosis, there might be some irrecoverable brain defect 
 in him. The traumatic neuroses may be best classified under 
 the psychoneuroses, though the traumatic forms of psycho- 
 neurosis offer rather special features. 
 
 A hundred pound weight struck a glancing blow on Flynn's 
 head, causing a scalp wound. Flynn was not made unconscious 
 by the blow. He has always stuck to the idea that the weight 
 hit not only his head, but his back, and explains the persistence 
 of pains in the head and back from that circumstance. Flynn 
 was, at the time, in the midst of some rather complicated ma- 
 chinery. He saved liimself by dropping some thirty or forty 
 feet to another part of the machinery. He was able to work 
 a day or two, but then had to give it up by reason of severe 
 headaches and dizziness. The dizziness passed, and to some 
 extent the headache, but he could not work, or felt that he 
 could not work, on account of persistent backache. He did not 
 arrive for treatment at the Psychopathic Hospital until seven 
 months after the accident. 
 
 Meantime he had been in contact with the Industrial Acci- 
 dent Board, through which compensation was granted him at 
 the rate of ten dollars a week, being six dollars less than his 
 previous earnings. Some small savings he quickly used up. 
 
 There was no mauvaisc volontc about Flynn. He wanted 
 to be cured and made several unsuccessful attempts to work. 
 The background was not bad. He had once been a hatter, 
 earning as much as twenty-four dollars a week at one time. 
 
THE KINGDOM CF EVILS 11/ 
 
 Later he had become a machine oiler. He was interested in 
 machinery, had been ambitious enough to attend evening classes 
 for firemen, read and studied a good deal and had saved several 
 hundred dollars. He was a good family man, amiable in dis- 
 position, energetic, and strong. Now, since the accident, he 
 had become apathetic and seclusive. He read no more and was 
 apt to be irritable when approached. His sleep was poor. He 
 felt tremblings all over his body and felt sometimes as if his 
 legs were going out from under him. 
 
 Meantime pressure was being brought upon the Industrial 
 Accident Board to have his compensation stopped, as the medi- 
 cal examination by the company's insurer led to the view that 
 there was no reason why he should not work. It appeared to 
 his examiner that there was, or might be, a fixed idea of in- 
 ability to work. Accordingly he was sent to the Psychopathic 
 Hospital. There it was found that he showed some tubular 
 vision, or so-called limitation of visual fields, a condition which 
 seemed to us to indicate that he was either hysterical or inclined 
 to hysteria. 
 
 The idea that he was suffering from a traumatic hysteria, 
 that is, a traumatic neurosis of a rather particular nature, was 
 also supported by finding evidence in him of sudden spells of 
 sweating, sometimes confined sharply to one side of the body. 
 This so-called "vasomotor neurosis" was another point looking 
 in the direction of traumatic hysteria. There was also some 
 evidence of diminution of sensory power, although no definite 
 anesthesia. On the more psychic side of the man, his irritabil- 
 ity, his fear of falling, and a newly acquired fear of walking 
 in the open, to say nothing of a reluctance to working further 
 with machinery, were other points fairly consistent with the 
 idea of a traumatic neurosis. In short, John Flynn showed sun- 
 dry features with which we have become so familiar in the so- 
 called shell-shock group of war cases, cases in which, either 
 with or without actual direct violence to a part of the body, 
 symptoms of a general or special nature occur (the war neu- 
 roses, war hysteria, war-shock, shell-shock) and as in many 
 of the war cases, the symptoms were somehow determined to 
 a side of the body on which or near which the blow (windage) 
 or sound occurred. 
 
 The medical diagnostician's impression of a case as psycho- 
 genic is, of course, tremendously heightened by the determina- 
 
Il8 THE KINGDOM OF EVILS 
 
 tion of symptoms to the side on or near which the exciting 
 cause was delivered, since, by and large, a blow on one side 
 (say the left) of the head, with injury to underlying tissues, 
 should ordinarily lead to symptoms on the other side (say the 
 right) of the body. This is not the place in which to go into 
 the question of the so-called "mechanisms" of hysteria, yet it 
 is of importance for the psychiatric social worker to know upon 
 what a delicate knife-blade the diagnostic decision now and 
 then depends. Another obvious point, here worth mentioning, 
 is that amongst physicians themselves all such cases as John 
 Flynn's deserve attention by special physicians. 
 
 As in all Industrial Accident cases, (particularly in view of 
 their later possible improvement), the psychometric level was 
 determined. He was not regarded as feeble-minded or as 
 having shown intellectual deterioration, grading at 11.3 by the 
 Binet Scale and 12.5 upon the Point Scale. (These differences 
 are due to certain differences in the tests, which do not argue 
 any fundamental divergence of opinion as to psychometric 
 rating, but simply go to show that the methods of determining 
 psychic levels are not yet absolutely established. The results 
 are found trustworthy within certainly a year or so of the 
 figure given. It is, of course, worth while eternally insisting 
 that the determination of even a low level of intellectual capac- 
 ity does not argue that the status is original ; that is, that the 
 patient is a feeble-minded person. The decision whether we 
 are dealing with inborn lack or acquired loss of mind remains 
 a delicate one, based upon psychiatric estimate of symptoms that 
 pull down the patient's memory capacity below his normal level 
 and of course must depend upon data as to the patient's social 
 status. No doubt the previous record of John Flynn's life 
 would absolutely prove that he was not feeble-minded in any 
 ordinary sense of that term, in fact we felt that it was a cer- 
 tain psychopathic depression that pulled Flynn down even to 
 the 12.5 level at the time he was examined.) 
 
 The prognosis was rendered that John Flynn would spon- 
 taneously clear to a large extent "within an unknown period," 
 and it was added that our tests indicate that his feeling of in- 
 adequacy was rather an objective one, despite the fact that he 
 had subjectively added a great deal of what the old books used 
 to term "hypochondria." This suggestion of an actual objec- 
 tive feeling of inadequacy meant to show that the insurer's 
 
THE KINGDOM OF EVILS II9 
 
 physician was, perhaps, not right in thinking that the patient 
 was objectively able to work to full capacity. A diagnosis of 
 plain traumatic neurosis would, on the contrary, have meant 
 that Flynn would have been set down as a man objectively able 
 to work though subjectively unable. There was, consequently, 
 between the physicians, no issue as to adequacy for work at 
 the moment subjectively. 
 
 The insurer would appropriately take the attitude that a man 
 objectively able to work might soon become subjectively able 
 (that is with the proper social or medical technique) and thus 
 relieve the insurance company from its burden. There was, 
 of course, no question throughout of simulation or a conscious 
 "faking," as the man in the street has it. We are therefore 
 dealing with a most delicate question of diagnosis, wherein 
 the personal equation and acquired professional slant of the 
 diagnostician must inevitably operate. But whether the pa- 
 tient is objectively unable to work, subjectively unable to work, 
 or even (as in not a few Industrial Accident Board cases) ac- 
 tually simulating, at all events, the man is not at work. The 
 Industrial Accident Board itself, having semi-judicial powers 
 and impartiality of view (all sides of the compensation ques- 
 tion being represented as a rule in its make-up) of course acts 
 as a stabilized social service mechanism ; that is, as a bit of pub- 
 lic machinery that has rather recently grown out of the de- 
 mands of modern social service. As is now familiarty known. 
 the Industrial Accident Board representatives can be of direct 
 community help and individual help in the advice they offer 
 to the victim of injury as to whether he should or should not 
 take a "lump sum" settlement or continued compensation. 
 Which of these lines is technically better depends upon the case, 
 and "dependence upon the case" means that adequate modern 
 social investigation has to be before long undertaken. 
 
 A decision was made in John Flynn's case, whether for bet- 
 ter or for worse, (and whether permanently for better or worse 
 remains still in question), to grant continuing compensation 
 decreasing with his wages. So judicial and authoritative is the 
 Industrial Accident Board that an admixture of social work 
 not of quite such public nature is often advisable in cases like 
 John Flynn's. We at first sent him, whilst still in a state of 
 almost complete inability to work, to a cement shop conducted 
 on principles of occupational therapy at a near-by hospital. 
 
I20 THE KINGDOM OF EVILS 
 
 Here he was able to work for only a quarter of an hour at a 
 time. He was rather irritable when others were about and 
 had to be given work by himself. The occupational therapy 
 was so far successful that at the end of three months he had 
 become ready for light employment. He became an elevator 
 man in a college dormitory. He told his employer about his 
 dizzy spells and gave the impression that he was likely to faint 
 rather often. At first the prospective employer was fearful. 
 The social workers explained the man's exaggeration of his 
 own trend, and he got the job. With the help of one of the 
 college boys he was kept under constant supervision, for he 
 needed daily encouragement. The work was light and the boss 
 favored him as much as possible. Days when he felt he could 
 not go to work alternated with more hopeful days. He suffered 
 from nausea, weakness of legs, dimness of vision. By almost 
 imperceptible degrees he has improved, until now a year and 
 seven months since he came under treatment, he is almost 
 restored to a firm industrial footing. 
 
 He did not lose confidence when the college dormitory closed 
 for the summer, but with guidance found another suitable job 
 running an elevator in an apartment house. Recently his tene- 
 ment was burned, and he lost many of his household goods; but 
 he met the situation competently and with the help of relatives 
 has gotten together another home. For over a year he has 
 been in great anxiety about his baby, who is threatened with a 
 serious illness. He still has spells of stomach trouble, which 
 has improved under treatment. 
 
 In spite of all these difficulties he is practically well, except 
 for minor pains and feelings of discomfort, and slight spells 
 of irritability, symptoms which he has learned how to control. 
 
 That this case is a psychiatric one in the sense of a psycho- 
 neurosis there can be no doubt. It is worth the social worker's 
 while to remember that all depends upon the point of view of 
 the physician whether certain psychiatric cases are regarded 
 as psychiatric. For instance, the nausea and indigestion of 
 John Flynn secure treatment for him at a high-grade general 
 hospital under the diagnostic terms "hyperacidity and gastropto- 
 sis." No doubt, good clinical proof was available for said hy- 
 peracidity and gastroptosis, but no doubt also, the bull's-eye 
 was hardly punctured by the treatment. 
 
 The general lines of treatment in John Flynn's case may be 
 
THE KINGDOM OF EVILS 121 
 
 summed up as follows : — First in line comes encouragement. 
 Work of graded difficulty to comport with the terraces in his 
 improvement was indispensable ; correlative arrangements with 
 the Industrial Accident Board had always to be examined; 
 Flynn's eyes had to be examined and payment arranged for by 
 the Industrial Accident Board, to say nothing of the treatment 
 just mentioned and payment therefor at reduced rates. No 
 less than sixteen visits to the wife in her household were made 
 in the period of thirty-two months. The wife we found to be a 
 woman of even, pleasant disposition, well-meaning, but rather 
 ignorant (her mental level stood, on examination, at about 
 1 1.6), a good and thrifty housekeeper. There were two chil- 
 dren. A third came for whom some arrangements had to be 
 made with the Milk and Baby Hygiene Association. Advice 
 had to be given about the confinement, and a visiting house- 
 keeper was called in. 
 
 It is unnecessary to rehearse the evidence for placing this 
 case amongst cases of medical, legal, and economic difficulty. 
 It might be questioned whether Flynn should not also be re- 
 garded as belonging in the group of educational difficulties. 
 Certainly more or less advice had to be given to him and his 
 family along lines of everyday information. Nevertheless, the 
 educational defect in Flynn himself was no doubt directly 
 medical ; that is to say, traumatic in origin. Morally speaking, 
 Flynn was throughout a good risk. Our latest advices about 
 him are that he has now undertaken a more complex and diffi- 
 cult job, which he performs successfully. 
 
 Hours spent by Medical record, z^4 pages 
 
 Social record, 63 pages 
 Physician, 14 Social work : 
 
 Visits, 32 
 Psychologist, i Interviews at hospital, 34 
 
 Telephone calls, 137 
 Social worker, 89 Letters, 15 
 
 Intelligent sex delinquent. High empathic index. Six months 
 in a state hospital. Voluntary institution care. 
 
 Case 20. Dora Hadley, like Rose Talbot (case 8), be- 
 longs to that relatively small group of persons, the intelligent 
 sex delinquents, — at least we may speak of them as relatively 
 rare from their toll in clinic records. 
 
122 THE KINGDOM OF EVILS 
 
 We classified Rose Talbot as a psychopath. Presumably she 
 would fit in the heterogeneous group known as psychopathic 
 personalities. Perhaps we should classify Dora Hadley also 
 here. It is clear that the term sex delinquent, like the term 
 delinquent in general, makes no kind of psychiatric diagnosis. 
 There are delinquents and delinquents, and it helps to solve no 
 problem to call all delinquents a priori psychopathic. The plane 
 which separates cases like Talbot from cases like Hadley is 
 perhaps imaginary. Nevertheless around the circle of obvious 
 psychopaths is another circle (or is it a matter of wider and 
 wider circles?) containing persons who are merely in some 
 sense eccentric and to a lesser degree off-center than the 
 acknowledged psychopaths. 
 
 We are endeavoring in this section of cases to report all 
 tertiary combinations of social symptoms. If we stretch a 
 point in regarding Dora as unmedical, we shall not damage the 
 main contention, which is that Dora Hadley presents no par- 
 ticular economic problem but is predominantly a moral problem 
 with a train of legal entanglements (eventually leading to state 
 hospital care for six months) and with the problem of moral 
 and, perhaps more important still, intellectual instruction in 
 the mid-center of the picture. 
 
 We shall give below the rather long summary of Dora's case 
 as a sample of actual case records which the student may use 
 for analytic purposes in preparation for the still more difficult 
 analyses of original records on which such summaries are based 
 (at the end of this book are examples of such complete records 
 for analytical purposes), l)ut before presenting the summaries 
 we may give a still briefer resume of Dora Hadley's case as 
 follows : — 
 
 Dora Hadley was a girl of respectable family of fairly good 
 New England stock. Dora's mother died in childbirth. Al- 
 though very intelligent (her own psychometric tests gave her 
 an adult age level) she got expelled from school for insubordi- 
 nation. She was an inmate of many homes which were scarcely 
 "homes" to her. She lost jobs, ran bills, and resorted to prosti- 
 tution. Under psychiatric social treatment there was at first 
 little progress. She remained a slack worker and mischief- 
 maker. She still lost jobs which were got for her. She re- 
 mained promiscuous in sex relations. She even took to drink- 
 ing. She rather naturally got blue at times over her plight. 
 
THE KINGDOM OF EVILS 12^ 
 
 The Story would not be properly told if Dora's beauty of 
 physique and vivacity of behavior should not figure therein. 
 Everybody's empathic index (as someone has called it) for 
 Dora was high — one somehow liked to see oneself in such a 
 guise. 
 
 Here follows the summary of her history quoted from the 
 social record : — 
 
 Social History: 
 
 Patient is a girl of nineteen, of American birth and parentage. 
 Her father works in an eyelet factory. Her mother died when 
 patient was one week old. From that age to two years, she was 
 brought up by paternal grandmother, where she remained until 
 fifteen. There were two half-sisters only a little younger than 
 herself. From the age of fifteen to nineteen patient tried 
 high school, but flirted with boys, whispered and did not do 
 her work, so that she was asked to leave. She lived with sev- 
 eral different relatives, and two families in which she worked. 
 She spent six months at the Middlesex State Hospital. She 
 tried factory work three times but was discharged for poor 
 work and bad conduct, singing, talking, and disturbing others. 
 In the spring of 1914 she became acquainted with Elsie Rich 
 (also a patient here) of the State Reform School, who taught 
 her prostitution. She and the other girl met men in a ravine 
 and had intercourse for money. Went to hotels in Worcester 
 for dinners. This period was of several weeks duration. Dur- 
 ing the summer, while working in a family she formed an 
 acquaintance of a Harvard student of good reputation which 
 lasted all summer. One time she was found in a dark hall 
 dressed in a kimono sitting in his lap. In January she was 
 sent to Trinity House by the Children's Society who had been 
 trying to help patient's family to care for her in the past two 
 years. 
 
 Physical History: 
 
 Patient was a seven months' baby but developed normally. 
 She was six months in care of Middlesex State Hospital as a 
 voluntary patient in 1912. Was in Psychopathic Hospital 
 January 27 to February 15, 191 5. 
 
 Her mother died of "peritonitis" ten days after her birth. 
 She is reported to have had "queer spells" every few weeks, 
 when she did not lose consciousness but was unable to speak. 
 The attacks were preceded by a vision of her mother or hearing 
 the voice of her mother. An aunt on the maternal side was 
 
124 "rHE KINGDOM OF EVILS 
 
 demented before her death in old age. The paternal grand- 
 mother was said to be a "gossip and trouble-maker." 
 
 The patient is lazy, but nervously active. She is strong and 
 in good health, but is very susceptible to pain. 
 
 Mental History: 
 
 Patient went to school from six to fifteen years. When in 
 the ninth grade she whispered and disturbed other students so 
 much that she had to sit in the sixth-grade room because that 
 teacher was better able to control her. She had one year of 
 piano lessons. Reads some good classics. 
 
 She has been unsuccessful at work because she cannot apply 
 herself continuously to one task. In housework she failed be- 
 cause she was unsystematic and careless. She bothers others 
 at work by talking or singing or direct conversation. The 
 patient has no trade but wishes to be a nurse. 
 
 She takes very strong likes and dislikes but is fickle and 
 turns against a person as soon as she finds he is no longer 
 useful to her own ends. She is extremely vindictive and spends 
 a great deal of thought on how she can "get it back" at anyone 
 for a supposed injury. She says she must have excitement. 
 
 She is untidy in her personal appearance and takes no care 
 of her clothes or room. She is nervous and fidgety, quick to 
 anger and very fluent in expressing her anger. She is com- 
 pletely wrapped up in herself and her own pleasures and ends, 
 and considers no one else's feelings. The patient holds lewd 
 telephone conversations with men. picks up men, deceives, and 
 lies. She runs up bills. She spends her earnings on clothes. 
 
 From infancy she has had crying spells and when younger 
 would hold her breath until she was blue in the face. She has 
 always shown a brutal strain and a desire to torment someone 
 or something — pinched a baby she cared for till he was black 
 and blue. In the same way she makes up stories to injure 
 people she knows. Insinuated to a woman for whom she 
 worked that her husband made advances to her. 
 
 Patient thinks she has been ill treated and that her half-sisters 
 have been given more privileges than she. Everyone has 
 knocked her about she thinks. Has no fondness for parents, 
 whom she considers hypocrites. 
 
 There seemed to be no change in her at time menses began, 
 but a gradual development of this character from early child- 
 hood. 
 
 In the light of most of the story above given the following 
 letter, restrained and stable as it plainly is, is a bit astounding, 
 
THE KINGDOM OF EVILS I25 
 
 the more so as Dora actually did make good her promises 
 therein. 
 
 "My Dear Miss Adams : 
 
 "I'm very sorry I went away from you as I did Wednesday 
 afternoon. I was feeling bad, and rather cross too, because of 
 the way things had turned out in the last week. You'll forgive 
 me, won't you? 
 
 "I have made up my mind at last, Miss Adams. I am tired 
 of leading the life I have led for the last month. Now I have 
 given up my freedom, my friends (?) and am going to put in 
 six months here at Trinity House. I want to be good. I simply 
 cannot trust myself as much as I hate everything immoral. I'm 
 not immoral, Miss Adams, — I hate it. I've been unmoral, that's 
 all. You understand me, don't you? And I think you believe 
 in me. I want to be a real, true woman. I'm going to be one. 
 I'm going to try so hard to please everyone. Miss Ellis is 
 beautiful and good. I love her and Miss Mansfield and I want 
 to be like them, just the kind of a girl they want me to be. I 
 can do it. 
 
 "I shall miss heaps of things. I want to see someone but can- 
 not. I shall be lonesome too — but I'll stick it out, if it will only 
 help me to be what I want to be. 
 
 "I want you to come out and see me, and surely you will 
 write to me ? 
 
 "Sincerely, 
 "Dora," 
 
 She not only at our suggestion made voluntary resort to an 
 institutional home, putting herself under its control for six 
 months, but stayed with the home for six months longer than 
 she promised. The Psychopathic Hospital social service was 
 then emboldened to close her case. She is now doing well as 
 a nurse in training. In a period of eighteen months or, if we 
 count the state hospital term as sharing in her progress, two 
 years, Dora climbed a considerable terrace educationally and 
 morally. Lest we be regarded as over-optimistic, we may 
 remind the reader that the White Slave Traffic Investigation in 
 Massachusetts some years since — an investigation headed by 
 Dr. Walter E. Fernald — gavt a number of examples of prosti- 
 tutes who if not highly intelligent were at all events not feeble- 
 minded. In fact the obviously feeble-minded among the pros- 
 titutes of that investigation were but slightly over fifty per 
 cent of those examined by strict mental tests. We are informed 
 
126 THE KINGDOM OF EVILS 
 
 by Dr. Fernald that the woman of intelhgence who resorts to 
 prostitution and whose case is not otherwise complex is very 
 often to be fomid in the course of a few years outside the tem- 
 porary field. Many known prostitutes of this intelhgent group 
 have settled into stable married lives. 
 
 Hours spent by IMedical record, 39 pages 
 
 Social record, 31 pages 
 Physician, li Social work: 
 
 Visits, 21 
 Psychologist, i Interviews at hospital. 32 
 
 Telephone calls, 43 
 Social worker, 54 Letters, 13 
 
 Unstable Jewish girl with obsessive ambition for education. 
 
 Case 21. Bessie Silverman, a nineteen-year-old Russian 
 Jewess, came to the out-patient department of the Psychopathic 
 Hospital of her own volition. She came by herself and said 
 that she wanted to find out her mental ability. She gave her 
 own history. Her family in Russia had been fairly well-to-do, 
 the mother was dead, and her father had married again, and 
 emigrated to America leaving Bessie in Russia. In her four- 
 teenth year Bessie herself came over and interspersed factory 
 work, which she shortly undertook, with periods of schooling. 
 The dominant issue with Bessie was to get an education. It 
 was rather a sharper issue with Bessie than with the typical 
 Russian Jew of the recent American scene. Bessie must needs 
 get an education and must go through college, and the issue was 
 still sharper when her ambitions were compared with those of 
 her father and stepmother, for the Silverman family had in a 
 sense come down in the world since their immigration to 
 America. Upon examination we found her to make a score 
 of 17.5 years with 87 points. There were no special features 
 in the examination to throw clearer light upon her character. 
 Her afiswers were rather slow and she seemed to be rather less 
 self-confident than most persons teking these tests. Physically 
 we found her to be negative except for a spinal curvature. On 
 the whole the best large category in which to place her seemed 
 to be that of the psychoneuroses. One of our reports speaks of 
 her showing a kind of fundamental disharmony in life, a dis- 
 
THE KINGDOM OF EVILS 12^ 
 
 harmony based on the incompatibiHty of her ambitions with 
 her immediate opportunities and perhaps with her own mental 
 capacity. 
 
 The principal of a high school became interested in her upon 
 our proffering him the case. He wrote that he thought he had 
 succeeded in arranging a reasonable program for her and found 
 her in a good frame of mind for work. Carrying this school 
 work (in which she really needed a private tutor according 
 to the school view), wearing a plaster cast for her lateral curva- 
 ture, and earning money outside formed a triple weight which 
 she was hardly able to carry. All the while she seemed to re- 
 sent the social crutch, and her nervous make-up never failed to 
 be in evidence. 
 
 The procedure was beset with difficulties. The central idea, 
 that of going to college, we eventually decided to indulge. She 
 must of course go through preparatory school first. A man 
 of means who had taken an interest in the Silverman girl (she 
 was rather adept at making friends) undertook to finance her 
 going to a suitable and expensive preparatory school. This 
 plan must needs fail on account of Bessie's determination not 
 to accept charity. We seem to have reached an impasse. She 
 says that if she only had money she could win in life, but as 
 she has not enough money and will not take it she therefore 
 denounces the American situation, particularly the school situa- 
 tion. In point of fact, the school work with the heavy col- 
 lateral burden had proved too much for her. She has now 
 reached a level of what we might from the general standpoint 
 call compensation. She is doing housework for weeks or 
 months at a time in different places. 
 
 We have not ticketed Bessie Silverman as distinctly a med- 
 ical case, finding her problem to be one of moral training and 
 of economic difficulty. Yet if pushed to explain her case we 
 should be inclined to think that in a very tenuous way there 
 are sundry medical difficulties at bottom. At all events there 
 are temperamental faults which can best be understood by 
 looking in the psychiatric direction. The social service and 
 the school authorities, to say nothing of her general American 
 experience, are teaching her, if not her level, then some poten- 
 tialities in the present world. It might be easy to charge up 
 her plight to something racial and it is indeed true that sundry 
 Russian Jews do appear from time to time upon the social scene 
 
128 THE KINGDOM OF EVILS 
 
 who have some features of Bessie Silverman. We are inchned, 
 however, to think of her as rather specially affected by a psycho- 
 neurotic trend. Whether her general disabling through incon- 
 sistent ambition is so much an educative as a moral affair is 
 also doubtful. The economic evidences are plain enough, but 
 the attitude toward them which Bessie assumes is still more 
 troublesome. It is easy to speculate upon the outcome. 
 
 Hours spent by Medical record, 12 pages 
 
 Social record, ^-J pages 
 Physician, 4 Social work : 
 
 Visits. 38 
 Psychologist, i Interviews at hospital, 64 
 
 Telephone calls, 123 
 Social worker, 139 Letters, 40 
 
 " Little fiend ," a neglected child, becomes "the pet" of a foster 
 household. 
 
 Case 22. Elliot Calderwood was brought to us as a "lit- 
 tle fiend." He came through the court. His aunt had found 
 him unmanageable and was so incensed with this boy of eight 
 years that she refused even to telephone to learn our findings 
 and refused to have him in her house another night. His aunt 
 told us that Elliot was wild in every way, could not eat like a 
 decent boy, shuffled his feet, ate like a gourmand, and was a 
 frequent and sometimes open masturbator who had attempted 
 sex relations with his four-year-old girl cousin. One reason 
 why the aunt felt so desperately concerning her nephew was 
 a variety of facts which she knew concerning his father and 
 mother, who both had somewhat checkered sex histories. 
 
 The small boy, observed in the hospital, was found to be a 
 likable afifectionate small boy, who admitted much, if not all 
 that his aunt maintained. He was. however, so far as we could 
 make out, in no sense a medical case. He measured up to nor- 
 mal psychologically. He had learned his sex practices from 
 various adults and said that he had been taught also by them 
 to steal. 
 
 The need of a careful education was represented to a chil- 
 dren's agency which assumed responsibility for the boy's sup- 
 port and thus avoided his becoming a public charge. There 
 
THE KINGDOM OF EVILS 129 
 
 was some likelihood that the father, who was now in the Cana- 
 dian Army, might perhaps be reached to help in payments. 
 (The father was located and actually did make an allotment.) 
 At all events, the children's agency's decision was greatly justi- 
 fied by the outcome in the Calderwood case. The boy was 
 circumcised and placed in a country town with a kind woman 
 who became very fond of him. With her he gave no trouble, 
 ceased masturbating and became the "pet" of the household. 
 We present this case as one of threefold disorder, minus the 
 medical, and curiously enough, the moral complication. We 
 say "curiously enough" because a case brought to us as a sort 
 of fiend of immorality might, perhaps, be regarded as one of 
 distinctly moral disorder. To be sure, the moral question had, 
 forthwith, to be brought up for discussion, but the mental tests 
 and the general hospital observation, to say nothing of his 
 smooth history on placing out, will not allow his being classi- 
 fied in the moral group. The whole situation seemed to be one 
 rather of education, and upon proper intellectual training, the 
 moral pseudo-difficulty disappeared. We place him in the legal 
 group because he came to the hospital through the court. He 
 was a neglected child and an economic charge. 
 
 Hours spent by Medical record, 12 pages 
 
 Social record, 3 pages 
 Physician, 3 Social work: 
 
 Visits, 2 
 Psychologist, i Interviews at hospital, I 
 
 Telephone calls, 7 
 Social worker, 5 Letters, 2 
 
WOMAN. 43, LR'IXG AS MAN 
 12 YEARS 
 
 IQI6 
 
 
 . 1916-18 
 
 Man's Dress 
 
 
 Woman's Dress 
 
 Inebriate 
 
 
 Drinking Spells 
 
 Irregular Work 
 
 
 Steady Job 
 
 Bisexual Delinq 
 
 uency 
 
 Books and a Pipe 
 
 
 Early History: 
 
 
 Married, 
 
 Deserted 
 
 
 Abandoned Child 
 
 
 Put on 
 
 Disguise 
 
Woman who lived as a man. Psychopathic sexualis. Alco- 
 holism. Became a steady worker, consoled by pipe and book. 
 
 Case 23. Julia Brown was a woman who lived as a man. 
 She was probably in the late thirties when she first came to 
 medical attention. Of old New England stock, she had lived 
 with her family, father, mother, and two sisters in country 
 towns to the age of eleven, whereupon Julia's mother died and 
 her father married again. Julia went to live with her aunt. 
 She left high school at the end of her second year to work in a 
 mill. After a year in the mill she married a hard-drinking man 
 who left her shortly after the birth of a baby boy. Putting 
 the baby (whom she was never to see again) in her aunt's care, 
 she went back to the mill and worked three years. In the late 
 teens or early twenties, Julia Brown put on men's clothes and 
 from that day forward never wore women's clothes again until 
 she came under care. According to her story she was con- 
 stantly teased for looking so much like a man. She thought 
 she could get work more easily and get better pay as a man. 
 Moreover she was very fond of girls. After donning rnen's 
 attire she assumed the name of Alfred Mansfield. She began 
 to drink and to smoke a pipe incessantly. She lost a series of 
 jobs on account of her drinking habit. There were no other 
 delinquencies except that she was once accused of stealing 
 fifteen dollars. To all public observation she was well behaved 
 and was seldom actually seen drunk. In general she led a 
 happy life according to her own conceptions, and was accepted 
 as a man, fitted into the social life on the chosen level, and sang 
 in a quartet with three men, etc. For a year she kept house 
 with a girl who for a time thought that Alfred Mansfield was 
 a man, but in general, according to her story, she lived alone. 
 
 About a year before our observation she came to Boston 
 with a clairvoyant for whom she had worked in another city. 
 She helped the clairvoyant for some weeks. When he left the 
 city she got work as painter and odd- job man, and then worked 
 as a press-feeder. 
 
 133 
 
134 'f'HE KINGDOM OF EVILS 
 
 Early In December, 191 5, Alfred Mansfield was overcome 
 by gas and next day found herself in a general hospital. She 
 had been unconscious in the interval. She denied that she 
 had turned on the gas with suicidal intent. The examination 
 at the general hospital revealed that Alfred Mansfield was really 
 a woman. She was shortly sent to the Psychopathic Hospital, 
 no doubt in part because of the history of concealment of sex, 
 but also because she had buzzings in the ear and complained 
 of hearing children's voices. There was never, at the Psycho- 
 pathic Hospital, any behavior which would suggest hallucina- 
 tions and no further complaint of voices. 
 
 We found her a tallish, well-developed, and rather poorly 
 nourished woman with somewhat heavy, masculine features, 
 short coarse hair, some slight evidence of beard, and a low 
 voice. She had a sizable scar on the left jaw. Her teeth were 
 in very poor condition. She suffered from flat feet but other- 
 wise showed little that was abnormal. There were striae of 
 her pregnancy. Her gait was masculine. 
 
 The gynecological examination proved bacteriologically 
 negative. She talked readily without reticence and gave a 
 fairly consistent story whose dates we have not been able in 
 all details to verify, but there was clearly no general tendency 
 to concealment of her vital record. 
 
 Psychometrically she stood by the point scale at 12.5 years 
 and by the Binet Scale at a slightly lower level; namely, 11 3/5 
 years. After the details of these tests, it seemed that her free 
 associations were retarded and her interpretative powers (in 
 the tests employed) rather poor. On the other hand, her 
 memory span was fairly wide and she exhibited a fair degree of 
 comprehension and powers of observation. Her learning ability 
 and perception of form proved good and her attention fairly 
 stable. She was noted as oversuggestible. The psychologist 
 concluded from the psychological standpoint at least she could 
 not be regarded as feeble-minded. 
 
 There was never any sign of a definite psychosis or of any 
 progressive condition suggesting mental disease. It was clear 
 that she belonged amongst the psychopathias or psychopathic 
 personalities, or possibly she could be put in a group of eccen- 
 tric persons that are not clearly psychopathic ; that is to say, 
 amongst a group of mild psychic anomalies. From her own 
 standpoint, however, her life was fairly self -consistent. She 
 
THE KINGDOM OF EVILS 135 
 
 on the whole felt that she had lived a happier life in her disguise 
 and had more money. She was certain, and quite tranquil in 
 her assertion, that she would forthwith go back to her life as 
 Alfred Mansfield. 
 
 Psychiatrically we found her without active symptoms of 
 any sort. She remained under observation at the Psychopathic 
 Hospital for a month. She then had to be transferred to a 
 general hospital owing to a throat culture positive for diph- 
 theria. She remained technically under our care for a few 
 more days, and was then discharged by court order to herself 
 and to our social service. We determined that she was not 
 insane and not feeble-minded, and expressed a question as to 
 her being a victim of psychopathic personality. 
 
 The situation was on the whole rather more pathetic than 
 ludicrous. The net result of the social work in her case is that 
 Alfred Mansfield has gone back into Julia Brown who so far 
 as we know (she was lost to notice for three months at one 
 time) has constantly worked and has betrayed no masculine 
 tendencies, unless persistence in smoking a pipe be so regarded. 
 It is true that she has for the most part lived in somewhat 
 questionable lodgings and that she has not been finically neat 
 in her life there. She has had a number of drinking spells. 
 One night she came home drunk. The next day a lodger missed 
 fifteen dollars and charged her with the theft. At all events, 
 the landlady turned her out. That morning she staggered away 
 drunk with two suitcases. She sat down upon a doorstep to 
 rest. Someone noted a pipe sticking out of her pocket. When 
 the police arrived, Julia had vanished, leaving the suitcase 
 wherein the police found men's underwear and quantities of 
 strong tobacco. There was no proof of the alleged theft, the 
 police on investigation found that she was giving satisfaction 
 in her mill work (she had become a checker of stock and was 
 well liked, even having been made secretary of an employees' 
 war savings stamp club) and dropped the case. 
 
 With the social service, Julia Brown has been on the whole 
 rather friendly and rather passive under treatment. When 
 she gets into a fix she calls upon the department to help her. 
 For example, her drinking at one time badly frightened her as 
 to its possible outcome and upon her desire for aid, arrange- 
 ments were made for sending her to a state hospital as an 
 inebriate. There she stayed for some three months and 
 
136 THE KINGDOM OF EVILS 
 
 emerged greatly improved. We feel that she has been restored 
 to that level of normality, or subnormality, which could in all 
 reasonableness be hoped for. 
 
 Apparently during her life as Alfred Mansfield this woman 
 was rather sociable. Now she is a good deal more seclusiye. 
 She reads classical fiction, smokes strong tobacco, and cannot 
 be broken of a desire for spirits which she drinks at home alone 
 We have closed the case so far as all active steps are concerned, 
 but naturally expect from time to time that she will resort to 
 the department for aid. She has developed an ambition for 
 learning some technical sort of work which can be performed 
 at home, the textile products of which could be sold by the 
 piece. The point seems to be that she wants to make a home 
 of her own. 
 
 A number of rather human questions might be raised by this 
 case. On the whole we feel that the present approximation of 
 normality is a good deal superior to the previous plight despite 
 the seclusiveness which has developed. A question might be 
 raised as to whether she should be put in contact with her son, 
 whom, as above stated, she has not seen since he was a few 
 weeks old. For the sake of the individual happiness of her 
 son, it has been for better or worse decided that no special 
 efforts were imperative to bring mother and son together. In 
 the course of a few years the mother's status may be so far 
 improved and the boy's character sufficiently stabilized to war- 
 rant a set attempt at reestablishing relations. The woman is 
 herself turning her thoughts to the boy and the family relation. 
 Recently one of the hospital social workers met Mrs. Brown 
 on the street. She seemed pleased by the encounter and stopped 
 for a chat. She was looking well in a new spring hat and 
 she seemed quite satisfied with life. One of her favorite ex- 
 pressions is : "Life is sweet to me." 
 
 We have presented the case as one of non-medical and non- 
 educational nature, although it would be easy to say that she 
 is so far a victim of psychopathic personality that medicine has 
 an important part in the plot, and it will also be easy to show 
 that her life has been such that a part of her plight was due 
 to ignorance. Nevertheless, we are not prepared to say that 
 she is definitely a psychopath in the sense of sundry cases of 
 overdeveloped instincts or of a definite psychopathia sexualis. 
 She may beloner as hinted in that wide and vague circle of 
 
THE KINGDOM OF EVILS 1 37 
 
 eccentrics and cranks that lie in the Umbo outside the circle of 
 the psychopathias. Educationally, the woman is well informed 
 and writes a good letter ; there is no obvious gap in education to 
 make up. On the other hand there was, of course, a large 
 moral problem and the question of readjustment of the entire 
 attitude of this woman to her life. We have purposely laid 
 little stress upon the sex delinquencies, heterosexual and homo- 
 sexual, which are suspected or implicit in some parts of Julia 
 Brown's history. With a case of congenital psychopathia 
 sexualis we question whether our social treatment would have 
 been so relatively successful and so quickly productive of re- 
 sults as the above account indicates. In short, the readjust- 
 ment problem was more a moral than a psychiatric one despite 
 the fact that the psychiatric point of view was no doubt of the 
 utmost service in picking the situation to pieces and parting 
 out the moral from the distinctly psychopathic elements of 
 Julia Brown. The element of delinquency needs no further 
 analysis than what the history reveals and the economic prob- 
 lem, though never desperate, required a good deal of help and 
 indeed from time to time actual money grants. 
 
 Hours spent by Medical record, 27 pages 
 
 Social record, 48 pages 
 Physician, 5 Social work : 
 
 Visits, 49 
 Psychologist, I Interviews at hospital, 14 
 
 Telephone calls, 53 
 Social worker, gs^i Letters, 21 
 
 Depressed cigar-maker; could not work; feared open spaces. 
 Low standard of living ; family problem. 
 
 Case 24. We now undertake a new group, the binary 
 combinations of social trouble. We shall find ten binary com- 
 binations, the first four of which will be combinations of dis- 
 ease with some other form of social trouble. 
 
 David Stone was a Russian Jewish cigar-maker who came 
 to this country at the age of five. We medically placed him in 
 the psychoneurotic group. 
 
 By way of exemplifying the routine summaries of social, 
 physical, and mental conditions with their results, we here 
 
138 THE KINGDOM OF EVILS 
 
 insert the actual text (as usual with the names and certain other 
 features changed) from the social record. The reader should 
 bear in mind that the summary is of the social records and not 
 of the medical records. 
 
 RESULTS : February 25-July 3, 1918 
 
 Social: 
 
 Work was found for patient in the stock room of a wholesale 
 cigar plant at fifteen dollars a week. Patient worked there 
 about three months and then he obtained work from the Stand- 
 ard Life Insurance Company, as an agent, on a commission 
 basis, earning about twenty dollars a week. Patient's wife has 
 not been working ; two hundred and twenty-five dollars security 
 for patient's new job had to be raised, patient's wife getting 
 this through the Jewish Free Loan, and by pawning a few arti- 
 cles as well as by borrowing from relatives. Patient is paying 
 back at the rate of five dollars a week on this. 
 
 After urging by social service family moved into better 
 quarters. 
 
 Patient's son Arnold was ill for a short time at the county 
 hospital. Made a good recovery, though he is still to report to 
 the out-patient department here. 
 
 Patient's wife has complained of a uterine disturbance for 
 which a private physician has treated her. Social service re- 
 ferred her to the county hospital for this. 
 
 Physical: 
 
 Nothing of note. 
 
 Mental: 
 
 Patient likes his new insurance work. Has grown less and 
 less timid about going about alone, declaring himself cured the 
 beginning of July, 1918, Dr. Myer saying he need not report to 
 the out-patient department unless he wanted to. He took this 
 new work as he saw in it more chance of advancement. Patient 
 has reported to the out-patient department several times. 
 
 July 3-October 3, 1 91 8 
 Social: 
 
 Family have moved to 47 Wall Street, Roxbury, a better 
 section, where they have three large rooms ; the rent being nine 
 dollars. 
 
 Patient's niece is wife of a cosmetic specialist who uses the 
 
THE KINGDOM OF EVILS 1,39 
 
 fourth room in front of the tenement as a store for his wares, 
 and reduces the rent to nine dollars in return for occasional 
 services of patient's wife in the store. Patient's wife is not 
 doing any other work. Social service arranged for her and the 
 children to have a vacation during the summer, which benefited 
 them considerably. 
 
 Patient's wife puts off her own treatment at the county hos- 
 pital or by her physician. She has not taken Arnold to the 
 county hospital as she should. 
 
 Patient is still working for the Standard Insurance Company, 
 earning twenty-one dollars a week. He works mornings, rests 
 in the afternoon, and finishes work in the evening. Patient is 
 still paying back at the rate of five dollars a week for the 
 amount borrowed for security. 
 
 Physical: 
 
 Patient's condition is about the same. He was overcome by 
 the heat in the summer but is able to do his work now. 
 
 Mental: 
 
 Patient's son or wife frequently accompanied patient at his 
 work, the heat having made patient afraid to go out alone for 
 fear of fainting. He has reported a few times to the out-patient 
 department. His work is still that of agent at the Standard Life 
 Insurance Company, which he enjoys very much. 
 
 October 3, 1918-January 3, 1919 
 Social: 
 
 Patient is still working for the Standard Life Insurance 
 Company as agent, earning twenty-three dollars for the past 
 quarter, which is almost up. He is still paying back his money 
 borrowed at the rate of five dollars a week, and is paying one 
 dollar a week on a fifty-dollar Liberty Bond recently taken out. 
 
 The family are still living at 47 Wall Street, Roxbury, which 
 is proving a very satisfactory home considering the cheapness of 
 the rent. They were very appreciative of the second-hand bed 
 and mattress provided through the social service. 
 
 Patient's wife still has not had adequate medical attention for 
 herself. She refused treatment in the county hospital because 
 she does not approve of the medical students being present in 
 clinic, and defers visiting the Norton Hospital on one ground or 
 another. She and the three children have had influenza recently 
 but did not have serious attacks. 
 
140 THE KINGDOM OF EVILS 
 
 Physical: 
 
 Patient probably had influenza in October, but did not have a 
 serious attack. Since then he has been feeling stronger than he 
 has for several months. 
 
 Mental: 
 
 Patient has been steadily improving in his ability to go out 
 alone, his wife accompanying him less and less frequently. Now 
 he goes to work alone practically all the time. For the past two 
 months he has worked very hard to make up for the time he 
 lost in the heat of summer. He works overtime when he takes 
 a holiday, such as Thanksgiving and Christmas. He is very 
 enthusiastic about his work and pleased with his increase in 
 salary. Patient has been in out-patient department once. Seen 
 by Dr. Jones, who prescribed medicine as a nerve tonic, which 
 Dr. Jones felt sure would have immediate results. 
 
 January 3-May 3, 1919 
 
 Social: 
 
 Patient continues to work for the Standard Life Insurance 
 Company from twenty-five dollars to forty dollars a week. His 
 debts are almost paid ofif. He still lives at the same address. His 
 wife has been examined In' the physician who attended her in 
 the first confinement. She thought she could afiford this luxury. 
 The doctor told her that she was in good condition, the only 
 pathological finding being a nervous stomach which she could 
 disregard. She is anxious to arrange a good vacation for the 
 children in some way and thinks it would help patient if they 
 could find a cheap summer home from which he could commute. 
 
 Physical: 
 
 Conditions are negative. 
 
 Mental: 
 
 Patient had one somewhat depressed spell in February, Dr. 
 Jones, out-patient department, thinking it pointed possibly to 
 manic depressive insanity as patient's real diagnosis. Patient's 
 wife explained it as his usual reaction when seasons change, and 
 as due also to the fact that his salary was not increased as much 
 as he had been led to believe by a mistake on his employer's part. 
 This did not keep him from work, however, and after a few 
 days he was as well as ever. He says his own mental attitude 
 has been his salvation since he came to the hospital. 
 
THE KINGDOM OF EVILS I4I 
 
 He is concerned lest he be unable to give his children a good 
 education. He came in willingly to be presented at a clinic for 
 employment managers in April, and impressed the group as a 
 fully recovered man. He says he likes to do anything he can tor 
 the hospital and for others ill as he has been, and he has inquired 
 with interest for a patient to whom he gave vocational advice 
 here six months ago. 
 
 We present this case as a combination of medical and educa- 
 tional difficulty. There is obviously very little actual character 
 disorder save that which is involved in the psychoneurosis it- 
 self : On this account we do not classify Stone as a case in 
 which moral measures need systematically to be explained. Nor 
 were there any legal complications of note. The observer who 
 found them living in their four dark rooms (five sleeping in 
 one room whose window had to be kept closed on account of 
 an odorous alley) might at first sight suspect moral difficulty. 
 This, however, was not at all in evidence save for the facts 
 noted above. The social symptoms summarized were as fol- 
 lows : spouse working, housing bad, employment irregular, 
 failure in business, debts, and selfishness. If it be objected that 
 "selfishness" is not in itself a social symptom in the strict sense, 
 nevertheless selfishness has such a marked social effect that it 
 may well stand for a whole sheaf of social symptoms. 
 
 David Stone's medical deficiency is plain. How can we 
 define the deficiency we regard as educational ? Here was a not 
 infrequent family type, strongly anticapitalistic and socialis- 
 tically well-read, yet their living and housing conditions were 
 bad (perhaps one ought not to say bad deliberately but bad 
 through a kind of lack of social sense, through a mind of 
 social apathy or thoughtlessness). Such living and housing 
 conditions obviously combined with David Stone's psycho- 
 neurosis to form in some sense a new compound sort of social 
 defect. Neither psychotherapy alone however skillfully leveled 
 at the psychoneurosis nor the cleverest neighborhood work di- 
 rected at the cubical contents of the Stone tenement would, by 
 itself, afTect that social cure of the family plight. It is the 
 obvious thing to say that David's fear of open spaces and the 
 family habit of living in a sort of crevice in the world is some- 
 how racial and a matter of the ghetto. How ingrained or how 
 superficial the alleged ghetto loves of this race really are, we 
 are not competent to discuss. Suffice it to say that not every- 
 
142 THE KINGDOM OF EVILS 
 
 body in the ghetto is psychoneurotic and that many a Russian 
 Jewish point of view gets in a rather brief time complete illumi- 
 nation on these and other matters in our American scene. Be 
 all this as it may, the low educational level of a family like the 
 Stone family was something social to be wrestled with. 
 
 Throughout these binary combinations of social trouble we 
 shall find ourselves inquiring whether the two conditions each 
 time in evidence are intimately or loosely combined. We shall 
 ask whether they are combined so intimately as to form, as it 
 were, a new compound such that the social treatment entailed 
 is not merely a subtraction, one by one, of the two problems 
 from the patient's life, but requires a novel form of handling. 
 It is clear in Stone's case that a strict agoraphobia or fear of 
 open spaces was primary in his psychoneurosis, was in some 
 sense identical with the intentions or motives underlying a 
 strictly unnecessary life in a tenement. We are tempted, there- 
 fore, to say that the Stone compound of disease and ignorance 
 was a rather intimate product of the two factors working upon 
 each other. 
 
 The Stone problem is now happily almost settled. Curiously 
 enough the main problem that exercises the mind of the now 
 stabilized paterfamilias is the education of his children. 
 
 Hours spent by Medical record, 6 pages 
 
 Social record, 21 pages 
 Physician, 14^ Social work : 
 
 Visits, 19 
 Psychologist^ o Interviews at hospital, 10 
 
 Telephone calls, 46 
 Social worker, 37^/2 Letters, 13 
 
 Steady employee of good character who pilfered. Epileptic 
 wife: marital discord. Social treatment depends upon correct- 
 ness of medical diagnosis. 
 
 Case 25. Alfred Stevens is, no doubt, a case of the so- 
 called cyclothymia group. He has been three times voluntarily 
 a patient at the Psychopathic Hospital and although the first 
 time there was a question between manic-depressive psychosis 
 and psychoneurosis the settled diagnosis was manic-depressive 
 psychosis. We are not in this book discussing the medical 
 
THE KINGDOM OF EVILS 1 43 
 
 aspects of psychiatry, yet it is important for the psychiatric 
 social worker to remember that the cyclothymic (manic-de- 
 pressive) group of disorders is on the whole theoretically quite 
 separate from the group of psychoneuroses. The psycho- 
 neuroses (hysteria, neurasthenia, psychasthenia) are on the 
 whole diseases both theoretically, and very often practically, 
 influenceable by psychotherapeutic methods. It would be al- 
 most safe to generalize that the psychoneurotic group is the 
 psychotherapeutic group par excellence. The cyclothymic 
 (manic-depressive) group of disorders is theoretically non- 
 influencable by the psychotherapeutic technique, although 
 cycloth3^mics, like all other persons normal or subnormal, are 
 to some degree influenceable in subordinate features. On the 
 whole the attacks of emotional disorder that characterize 
 cyclothymia and are expressed in its Greek designation are self- 
 limited in their course and not controllable in the degrees of 
 their severity. The typical cyclothymia (manic-depressive 
 psychosis) will show attacks of emotional disorder sometimes 
 depressive and sometimes maniacal (the medical denotation of 
 this term maniacal covers all degrees of excitement down to 
 mere psychopathic illusion or hypomania), but not all cyclo- 
 thymics show maniacal attacks and some of them never show 
 any phenomena that are not clearly depressive. Alfred Stevens 
 was in point of fact the victim of a sort of a constitutional 
 melancholia. He was of a brooding and seclusive tempera- 
 ment without outside interests. He was, however, not of a 
 complaining sort and had no tendency to feel persecuted. 
 
 For years he held a good job in a dry-goods firm, and, as 
 transpired in the sequel, he was given to continual small pil- 
 ferings, a habit of over ten years' duration. A moral compli- 
 cation of the Stevens case was that beyond question the wife 
 knew of these pilferings but on some ground condoned them, 
 A trunkful of ribbons, laces, collars, etc., was found in the 
 house. The firm did not press the pilfering issue but discharged 
 Stevens on another pretext. He was not without some sense of 
 the real reason of the discharge. 
 
 Can we connect the pilfering with the man's cyclothymic 
 temperament? Pilfering might on an oversimple schematic 
 basis be regarded as a sort of overdevelopment of the acquisi- 
 tive instinct. The acquisitive instinct might stand out in relief 
 on the general background. This at least is the hypothesis for 
 
144 THE KINGDOM OF EVILS 
 
 sundry of the special forms of psychopathia (kleptomania, 
 wanderlust, etc.) with which we are familiar. In this instance, 
 however, we are not so much inclined to attribute the pilfering 
 to any trend toward kleptomania as to the effects of a certain 
 weak-zvilledness or hypohiilia more closely related with the 
 man's general make-up. 
 
 He was a rather effeminate and timid man. Without sug- 
 gestion of homosexuality, he has always been "a regular sissy," 
 had been unduly finical about his clothing, had not smoked or 
 drunk, had no sense of humor, had no interest in religion, had 
 always preferred to be alone, made little sexual demands (sex 
 interest absent for ten years), and did not want guests about 
 the house. However, he did want to please his wife, and doted 
 on his little girl. The wife was frankly an epileptic and had 
 sundry seizures upon the street and elsewhere. Despite his 
 kindliness with his wife, there was a good deal of irritability 
 in the home, no doubt largely due to the wife's temperament. 
 Indeed this epileptic wife has twice left Stevens and had in fact 
 shortly before Stevens' appearance at the hospital definitely de- 
 cided to leave him for good. 
 
 Psychometrically Stevens stood at 11.3, making a general 
 intelligence score of 68 upon the Yerkes scale. At the time of 
 examination his chronological age was forty-six, the irregular- 
 ity in the tests stood at nineteen points, and the irregularities 
 stood out especially upon the supplementary tests. He made at 
 the time a very poor score on tests of immediate memory and 
 upon the construction puzzles, despite the fact that his coopera- 
 tion, interest, and attention were very good. The irregularity 
 of his examination was interpreted as suggesting psychosis 
 rather than inborn feeble-mindedness. 
 
 Manic-depressive psychoses and the cyclothymias in general 
 are rather characteristically hereditary in the sense that there 
 are frequently two or more relatives of a cyclothymic patient 
 that also show psychopathy; often indeed the psychopathy of 
 the relative is also cyclothymic. In point of fact, Stevens' 
 father had died in an English hospital for the insane, and a 
 sister's child has been fifteen or more years insane in an Eng- 
 lish hospital. However, two brothers are in the English Army 
 and so far as known normal, and there is a second sister who 
 is apparently without taint. The mother's cancer is, so far 
 as we know, without significance for heredity. 
 
THE KINGDOM OF EVILS I45 
 
 With respect to social treatment, it will be remembered that 
 the medical diagnosis upon his first appearance upon the hos- 
 pital scene lay in doubt between cyclothymia and psycho- 
 neurosis. Indeed the man's general appearance was rather 
 suggestive of psychoneurosis, and the constitutional melan- 
 cholia shown in his history got rather easily an interpretation 
 as psychoneurosis. Stevens' finicalness bore some resemblance 
 to the psychasthenic obsessions of that form of psychoneurosis 
 known as psychasthenia. He would sit in the out-patient de- 
 partment weeping, and strike the observer as greatly in need 
 of comfort and counsel along lines that might be called psycho- 
 therapeutic or common-sense lines, according to the termi- 
 nology preferred. Comfort and counsel would indeed cause 
 him somewhat to brace up, though the underlying tempera- 
 ment obviously persisted. 
 
 The first idea of the social work was to rationalize the atti- 
 tude of this supposed psychoneurotic pilferer to his stealing. 
 Some progress was made in this rationalization process. De- 
 spite minor successes of our counsel, on the whole no progress 
 was made in altering the man's entire attitude to his life, espe- 
 cially as to steadiness in employment and attitude to wife and 
 child. Before he came to the hospital he had had no less than 
 twelve jobs in eight months. 
 
 As soon as the medical diagnosis clearly pointed to cyclo- 
 thymia instead of psychoneurosis, hospital care could rationally 
 be advocated rather than out-patient counsel. He was sent, or 
 rather voluntarily went, to a state hospital and the situation in 
 the course of a few weeks "was so altered that although he left 
 against advice he had gotten upon another temperamental level 
 and was prepared for steady work. In fact, he found such 
 steady work for himself. Since this time no further special 
 steps in social treatment have been necessary, his wife has come 
 back, and a new home has been started. As to the pilfering 
 history, Stevens' conscience does not now trouble him. He 
 has rationalized the pilfering as due to his mental disease. 
 Whether this is profoundly true or not, a solid readjustment 
 toward his past has accrued. 
 
 It is plain that the treatment is not in any sense an "elabo- 
 ration of the obvious." The differential medical diagnosis 
 betwixt cyclothymia and psychoneurosis proved a most 
 important one for Stevens' quick restoration to self-sup- 
 
1^6 THE KINGDOM OF EVILS 
 
 port. Medical practitioners as a group are not too well-in- 
 formed with what they are rather apt to think a superfine dis- 
 tinction between mild degrees of mental disease. Many a 
 case of mild cyclothymia (manic depressive) and even of 
 mild schizophrenia (dementia praecox) has been diagnos- 
 ticated psychoneurosis over periods of months and years. 
 Close observation, psychological examination, and social his- 
 tory (including points got from the non-effect of some of the 
 early steps in social treatment) here combined in a compara- 
 tively brief period to assure the correct diagnosis, and the cor- 
 rectness of this diagnosis meant shifting the whole front of 
 treatment. 
 
 In summing up the analysis of Alfred Stevens, we need dwell 
 no further upon the importance of the medical side. There 
 was no important gap of ignorance to fill. Luckily the pilfer- 
 ing never reached a legal phase, the economic difficulties were 
 implaced in the medical situation, and on the whole rather 
 easily met. Whether Stevens is, narrowly speaking, an ethical 
 case might stand in question; yet we do not regard his pilfer- 
 ing as either implaced in the manic-depressive psychosis or in 
 any plain psychopathic trend. There was distinctively a moral 
 attitude assumed by him and by his wife toward pilfering 
 habits of ten years' duration. A new moral attitude toward 
 stealing had to be instilled. 
 
 Hours spent by Medical record, 53 pages 
 
 Social record, 36 pages 
 Physician, 10 Social work: 
 
 Visits, 21 
 Psychologist, 2 Interviews at hospital, 23 
 
 Telephone calls, 28 
 Social worker, 52 Letters, 9 
 
 Arrested under "work or fight" law; a case of mental disease. 
 Commitment. Provision for the family. 
 
 Case 26. Kevork Ardinian was suddenly arrested under 
 the "work or fight" law, but was shortly thereafter sent to 
 the Psychopathic Hospital, being committed from the court 
 for observation. The situation was somewhat strange. 
 Ardinian was an open-faced, smiling young Armenian who 
 
THE KINGDOM OF EVILS 147 
 
 had, until very recently, been a hospital porter. He worked 
 alongside his wife in a general hospital and he had saved a 
 little money so that they could be classed as "independent" 
 rather than marginal in our economic classification. Ardinian's 
 wife was already advanced in pregnancy when he was dis- 
 charged for refusing to do part of his assigned work. He 
 said that he had headaches, and stood about complaining on 
 the streets in an Armenian neighborhood. He occasionally 
 smiled to himself. (This causeless, silly smiling is a char- 
 acteristic symptom of the disease schizophrenia-dementia prae- 
 cox — from which Ardinian was later thought to be suffering, 
 but it does not do to draw definite conclusions from any single 
 symptom in mental disease.) As for any adequate reason 
 for his suddenly ceasing to work, Ardinian could give none, 
 but simply replied gently that he did not need to work as he 
 had enough money in the bank for a time. He said that more 
 money would come to him, possibly from the government. In 
 line with his silly smiling, he was observed to be rather de- 
 tached in manner and a bit playful, although not saucy, with 
 women. He had a somewhat oversweet manner with them. 
 He fell into silence when reproved, kept to himself, and was 
 inclined to tease his neighbors, for example, leaving laundry 
 baskets in the aisle for the fun of making the people walk 
 around them. 
 
 That a man could be both smiling and stubborn, as was 
 Ardinian, seemed to argue an abnormal mixture or compound 
 of emotions. Such queerly mixed emotions (sometimes termed 
 by the psychiatrists "parathymia" or even "schizothymia" hav- 
 ing reference to the dissociation or split in emotions found in 
 schizophrenia) would rarely appear in any other disease group 
 than the schizophrenia group. 
 
 Psychologically they found Ardinian to rate at 13.3. The 
 non-English norms were used, and an interpreter was present. 
 The psychologist reported that Ardinian would perhaps have 
 done better if he had not refused altogether to do the form 
 association test and the three-words-in-a-sentence test. His co- 
 operation was rather poor. When non-English norms are used 
 in determining the psychological level, the practice, of course, 
 is to allow sundry points for the supposed inability to do some 
 of the tests that require certain educational capacities. Ac- 
 cordingly it is always possible to allow too much or too little 
 
148 THE KINGDOM OF EVILS 
 
 to patients who are tested by the non-EngHsh norms. There 
 was no question, in any case, of moronity or feeble-mindedness, 
 which would argue a mental age from nine to eleven inclusive. 
 Here was a man with some deficiency on test. We are prob- 
 ably able to argue from his social history that he was not, at 
 the outset, feeble-minded even in the slight degree that lies 
 above moronity and below normality. 
 
 We are not, in this book, discussing psychological levels or 
 their determination, but it is clear that the social worker, like 
 the psychiatrist, must never view the psychological level as 
 determined completely out of its social-psychiatric setting. 
 Viewed in the social and psychiatric setting, these psychological 
 level determinations are amongst the most powerful agents we 
 possess in diagnosis. 
 
 Physically we found no special signs of disease or abnor- 
 mality. It would not do to regard overactive knee jerks and 
 irregular pupillary margins as of great importance. There 
 was, however, a slight protusion of the eyeballs that his friends 
 had latterly noted as unusual. Whether this slight exophthal- 
 mos could be regarded as pointing to some slight degree of 
 Graves' disease is doubtful. The thyroid was not palpable, 
 and the pulse was not increased. There were, however, some 
 tremors of hands and tongue. 
 
 Psychiatrically he proved, for the most part, normal. There 
 were of course the free, broad smiles upon insufficient occasion. 
 There was a certain resistiveness at times, though whether 
 Ardinian's refusal to have a bath on entrance should be re- 
 garded as suggestive of dementia praecox must be doubted. 
 He said that he ought not to be compelled to do anything he 
 did not want to do. That there was a certain delusional trend 
 seems possible if not probable. The government had not 
 treated him right. He should not be made to work unless he 
 wanted to. On being asked several times over why he had 
 refused to work, he replied "me too much work." 
 
 It seems that he had been born in Armenia twenty-five years 
 before; that one brother was an elevator boy at the hospital 
 where he himself had worked, and that another was in Russia. 
 He had worked in mills as a laundry helper. He had once gone 
 back to Russia and come around the world in returning. He 
 had been making eleven dollars a week. When he had first 
 
THE KINGDOM OF EVILS 149 
 
 come to Boston he had been remarkably ambitious and went 
 to night school a few months so that he might read and write 
 English. Although he was better coaxed than driven, he had 
 never shown stubbornness or lost his temper with his employer. 
 On the other hand, it appears that he was not at all liked by 
 his fellow employees as he was rude to them and swore at them. 
 On the whole, he was inclined to keep by himself. After he 
 brought his new wife back from Russia his employer noticed 
 a change. He had become moody, had begun to tease and irri- 
 tate other workers and refused to do anything beyond the bare 
 routine of his job. He "did not feel good," had shaking at- 
 tacks at night, and his eyes began to stare. The fact that his 
 wife was still working, although far advanced in pregnancy, 
 shamed him not at all. 
 
 At this time Armenians of the neighborhood arrested him 
 under the "work or fight" law. Ardinian was rather care- 
 fully examined and his case was placed before two staff confer- 
 ences at the Psychopathic Hospital. There seemed to be no 
 doubt that he was a victim of schizophrenia (dementia praecox) 
 yet the disease was of such slight degree that Ardinian was 
 not at first regarded as committable. It was thought that some 
 kind of close and effective social supervision might encourage 
 him to work. Supervision was imperative, however. 
 
 The fact that he had in the late teens or early twenties been 
 able to teach school, but had in recent years lost his capacity 
 to do more than such work as dish-washing, seemed to warrant 
 the assumption that there had been a slow-moving loss of 
 mental capacity over a longer period than recent facts indi- 
 cated. In short, the schizophrenia process may have been going 
 on even before Ardinian's marriage. 
 
 Ardinian showed, under social treatment, a somewhat pe- 
 culiar attitude to work. He took a great deal of interest in 
 the occupational worker (a graduate of one of the courses in 
 occupational therapy established for war work) and worked 
 rather effectively at weaving for her. He said that he would 
 work to please her, but that she was making him a great deal 
 of trouble. The moment the pilot was dropped, so to speak, 
 that moment he refused to work further. There was thus a 
 sort of psychopathic altruism of small dimensions, but there 
 was no ambition or effective egoism which could be worked 
 
150 THE KINGDOM OF EVILS 
 
 on. If the worker said "please" to him he replied "do not say 
 'please.' If you say 'please' I have to make and I cannot 
 make." 
 
 Ardinian became mildly but annoyingly flirtatious at the 
 end of three months. He asked his wife to go out and work 
 for him. He was making no progress in work for himself. 
 He got excited at times and even struck his wife. In playing 
 with the baby he swung it wildly about. 
 
 The money the Ardinians had saved was now practically 
 exhausted and no progress was likely toward immediate cure 
 or self-support. The psychopathic altruism which allowed 
 Ardinian to work a little on the immediate suggestion of the 
 worker was too tenuous to build upon in community life. That 
 Ardinian might become a fair worker under hospital condi- 
 tions was possible. The answer to the questions on this case 
 seemed to be "commitment." Ardinian was committed four- 
 teen weeks after he left the hospital. Looking back upon this 
 case, one might wonder whether Ardinian should not have 
 been committed to a state hospital forthwith upon his first 
 period of observation. There was no change in the medical 
 diagnosis during the fourteen weeks that elapsed between hos- 
 pital observation and eventual commitment. No doubt much 
 time now proves to have been wasted by the occupational 
 worker, who, save for her own experience, secured nothing in 
 exchange for her time, either for the world at large or for the 
 Ardinian family in particular. 
 
 The problem facing the court in a case like Ardinian's would 
 be exceedingly difficult if there were not adequate social super- 
 vision available, for the court would, on the one hand, not be 
 able to find enough in Ardinian's record to warrant commit- 
 ment. To be sure, he received from an acute medical observer 
 the diagnosis "dementia praecox," but this would not in itself 
 indicate commitment forthwith. On the other hand, the ex- 
 perienced court would bear in mind numerous cases in which 
 mild dementia praecox had blossomed into exceedingly dan- 
 gerous excitement, violence, or destructiveness. Such "waiting 
 for an overt act" is unfortunately the rule in sundry communi- 
 ties. Here, with the proper social supervision, there was less 
 likelihood that the advance of Ardinian's process would go 
 unobserved and catastrophes would very probably largely be 
 avoided. 
 
THE KINGDOM OF EVILS I5I 
 
 IMeantime, as a matter of social technique, the social care 
 of the wife and arrangements for her pregnancy and confine- 
 ment and for her offspring were carried out by a family agency. 
 Upon his commitment the family was then turned over to the 
 family agency on the ground that the psychiatric part of the 
 problem had been removed or sufficiently disposed of. 
 
 •\Ve have put the case of Ardinian amongst the binary com- 
 binations and classify him as a combination of medical and 
 le^al difficulty. The medical difficulty we have sufficiently 
 analyzed. Legally. Ardmian came to an arrest and was com- 
 mitted to the Psychopathic Hospital under a special law for 
 observation. He was thus a court case of mild mental disorder 
 whose problem got its solution in commitment to a permanent 
 receptacle for the insane. There were no special legal compli- 
 cations attending this commitment. Had Ardinian committed 
 some overt act of violence or destructiveness before his first 
 appearance in court and his observation at the Psychopathic 
 Hospital, no doubt he would have been forthwith committed. 
 His mental disease was such a peculiar one and in one sense 
 so mild at the outset, that this solution of commitment was de- 
 layed. In the long history of legal process, however, no doubt 
 we may think of Ardinian as a relatively simple case of a man 
 arrested under the "work or fight" law on the ground of be- 
 havior for which he was quite irresponsible. 
 
 Hours spent by ^iledical record, 30 pages 
 
 Social record, 21 pages 
 Physician, 5J/2 Social work: 
 
 Visits, 22 
 Psychologist, i Interviews at hospital, 6 
 
 Telephone calls, ^y 
 Social worker, 35 Letters, 7 
 
 Intelligent dothes-presser disabled by occupational neurosis. 
 Large family in Russia to support. 
 
 Case 27. Herman Simonson left his family in a little 
 village of Russia ten years ago and came to iVmerica to advance 
 his fortunes. He lived frugally and uprightly and was a man 
 of high character and some education. The work he found 
 to do, clothes-pressing, paid good wages, but yet not more than 
 
152 THE KINGDOM OF EVILS 
 
 enough to keep him and support the family in Russia — his 
 wife, six daughters, and the wife's aged parents. As the years 
 passed, he began to fear that he could not earn enough to bring 
 them over; they were growing restless and hard feeling began 
 to creep into their letters. 
 
 In the end Simonson acquired a severe neurosis with pains 
 in the legs that became unbearable when he worked at his trade, 
 and deprived him of strength to operate his pressing-machine. 
 When he came to our out-patient department he had been the 
 rounds of a number of general hospital clinics without im- 
 provement. His legs were cold and blue in spite of the five 
 pairs of stockings he wore. His mental state was one of utter 
 despondency; if he could not get well he could never see his 
 children again; he had lived for them and now they had not 
 enough to eat in that little Russian village and he could earn 
 nothing to send them ; would it not be best for him to commit 
 suicide while his life insurance was paid up? H he could not 
 be cured, almshouse life, never to see his wife or children 
 again, was a fate tragic enough. He was cured after three 
 years of persistent work. He first and last resisted treatment, 
 wanted to try another doctor, objected to every kind of light 
 work suggested and found fault with everything the social 
 workers did for him, but was restored to competency, one might 
 say, in spite of himself. 
 
 It was decided that the best prospect of making the patient 
 self-supporting lay in setting him up in business in a small 
 store, and a sum of money was raised for this purpose. After 
 many attempts to find a store that would be a safe investment, 
 an opportunity for trading in coal was arranged. Meanwhile 
 a number of temporary occupations were tried, which the 
 patient would give up after a brief effort. He was under treat- 
 ment as an out-patient continually, and for six weeks was in 
 the hospital as a voluntary patient. He complained that the 
 doctors did not help him ; thought that the lodge members who 
 were obtaining financial support for him were adding to their 
 reputation as charitable individuals by helping him ; claimed 
 that the money raised for him belonged to him and sb.ould be 
 given to him unconditionally ; repeatedly said he suffered "every 
 minute of the day" but had not the courage to kill himself, 
 though he would if it were not for his children. 
 
 As the pains in the legs decreased and he admitted feeling 
 
THE KINGDOM OF EVILS 153 
 
 better, we insisted that he take a position as porter in a small 
 factory in order to prevent his becoming completely disused to 
 work. This was a job that he considered beneath him, and 
 it paid only ten dollars a week, but it was the only thing open 
 that he could do. He still holds on to this job at higher wages, 
 although he has since developed the coal business. In the fac- 
 tory he is regarded as a man who must be humored, for every- 
 body near him must hold his opinion or none. The foreman 
 sums him up, "Well, you know, he's Simonson !" He has 
 been elected president of a benefit organization to which he 
 belongs. He is said to be "as cranky as ever" but is alert and 
 in good spirits. 
 
 We analyze Herman Simonson as a binary combination of 
 medical and economic disorder. W^e regard him medically as 
 belonging to the psychoneurotic group of disorders. His fleet- 
 ing pains, his rounder's history in several hospitals without 
 relief, and his constipation were features. Whilst in hospital 
 he woke up five or six times in the night worrying about his 
 family in Russia. He felt cold sensations in the legs and 
 sometimes had prickling sensations in the calves of both legs. 
 Sometimes his hands were overwarm and sweating. He com- 
 plained of a bad headache. He was neurologically normal. 
 
 The impression which Simonson conveyed to the physicians 
 was one of relatively hopeless psychoneurosis. Accordingly, 
 when it proved possible to get several hundred dollars to set 
 Simonson up in business there was considerable concern ex- 
 pressed by the physicians lest the money was being thrown into 
 the sea. The results above described speak for themselves. 
 
 It is worthy of particular medical inquiry whether there is 
 any adequate and obvious physical cause for such a psycho- 
 neurosis as Simonson's. Cases numerous enough in this col- 
 lection yield no such physical cause, but the failure to find such 
 on the surface does not mean that such may not really exist. 
 Moreover, there may be a kind of psychoneurosis due to spe- 
 cial physical causes working directly or indirectly upon the 
 mind. Thus in Simonson's case it may be inquired whether 
 the steady, hard work and confining work at clothes-pressing 
 with its persistent cramped postures may not have worked 
 after the manner of the so-called occupation neurosis. The best 
 example of occupation neurosis is, of course, the familiar 
 writer's cramp, but even in writer's cramp there is an admix- 
 
154 
 
 THE KINGDOM OF EVILS 
 
 ture of physical with psychic conditions, a mixture not always 
 easy to analyze. 
 
 Some authorities who have gone very deeply into the mat- 
 ter of occupational neurosis find physical causes in not a few. 
 We give below a partial list of occupations which have given 
 rise to occupation neurosis (Southard and Solomon in Kober 
 and Hanson's Diseases of Occupation and Vocational Hygiene, 
 1916) 
 
 Auctioneer 
 
 BicycHst 
 
 'Cellist 
 
 Cigar-roller 
 
 Clarionetist 
 
 Compositor 
 
 Cornetist 
 
 Dancer 
 
 Diamond-cutter 
 
 Enameler 
 
 Engraver 
 
 Flower-maker 
 
 Flutist 
 
 Gold-worker 
 
 Hammerman 
 
 Harpist 
 
 Knitter 
 
 Laborer 
 
 Lathe-turner 
 
 Letter-sorter 
 
 Lithographer 
 
 Locksmith 
 
 Mason 
 
 Microscopist 
 
 Milker 
 
 Miner's nystagmus 
 
 Money-counter 
 
 Nail-maker 
 
 Organist 
 
 Painter 
 
 Pianist 
 
 Preacher 
 
 Sailor 
 
 Sawyer 
 
 Scissors-sharpener 
 
 Seamstress 
 
 Sewing-machinist 
 
 Shaver 
 
 Shoemaker 
 
 Singer 
 
 Smith 
 
 Tailor 
 
 Tawer 
 
 Telegrapher 
 
 Tennis-player 
 
 Tinker 
 
 Trap-drummer 
 
 Treadler 
 
 Trumpeter 
 
 Turner 
 
 Walker 
 
 Watchmaker 
 
 Zitherist 
 
 Hours spent by 
 Physician, 55^-2 
 Psychologist, 
 Social worker, 35 
 
 Medical record, 18 pages 
 Social record, 22 pages 
 Social work : 
 
 Visits, 15 
 
 Interviews at hospital, 14 
 
 Telephone calls, 15 
 
 Letters, 12 
 
 Series of feigned suicides. Psychopathic girl who desired 
 to be some sort of heroine. 
 
 Case 28. Aimee Prevost stands on the Psychopathic Hos- 
 pital books as a psychopathic personality. Her history, with 
 its series of feigned suicides, some of them most neatly staged, 
 is possibly in some sense a history of instincts unchecked. 
 Aimee constantly saw herself in other people's eyes and re- 
 
THE KINGDOM OF EVILS 155 
 
 lentlessly tried a variety of expedients to succeed. The desire 
 to be some sort of heroine was Aimee's desire. We confess to 
 some hesitation in taking all such as psychopathic! In any 
 event, we have classified her as virtually non-medical in her 
 display of troubles and have regarded her as a combination of 
 educational and moral difficulty. 
 
 When Aimee first appeared on the hospital scene, she seemed 
 rather illiterate. In due time she was examined psychologically 
 on four different occasions, at periods about a year apart. It 
 was clear from the examinations that she was not feeble-minded 
 and had good native ability, yet in all four examinations the 
 variability of her attention and her lack of effort in carrying 
 out the tests were striking. So far as the mental tests went, 
 her difficulties looked in the general direction of a disorder of 
 the will. 
 
 If we choose to disregard the vague aspects of psychopathy 
 in the Prevost case, we shall see her problem as virtually the 
 combined problem of reeducation intellectually and retraining 
 morally. The legal contacts and even the economic problems 
 remain minor. 
 
 Aimee Prevost was the oldest of four children in a French 
 Canadian family living in a Massachusetts town. By the time 
 she was eight years old both parents had gone to hospitals for 
 the insane in Canada, and the children were scattered. Aimee 
 went to live with an aunt. At sixteen she was working in a 
 mill in another city and had begun her life of independence 
 with little or no knowledge of her family. She came to Boston 
 at seventeen and worked for periods from a few weeks to sev- 
 eral months in hotels, restaurants, and hospitals. 
 
 She was twenty when we first knew her in 191 3. A pre- 
 tended attempt at suicide brought her to the Psychopathic Hos- 
 pital. She had taken iodine and then gone to the police for 
 safety, no doubt reassured by a similar experience six months 
 before when she had sought the police after drinking chloro- 
 form liniment. Some months before she had swallowed a 
 corrosive tablet in the presence of a medical student, who had 
 carried her to an emergency hospital for treatment. She now 
 said that she was despondent because this same student, who 
 had lived with her as his wife, and whom she had expected 
 to' marry her, had left her. She said that she would "get re- 
 venge if it should take ten years." She had already written 
 
156 THE KINGDOM OF EVILS 
 
 with vindictive intent to his father and a girl he knew at 
 home. 
 
 When Aimee left the hospital the social service undertook 
 supervision. She was a likable girl with a certain sweetness 
 of disposition in her good moods, and with ability to reason 
 intelligently. She had a rather touching desire for refined 
 and attractive surroundings and surprising discrimination in 
 recognizing educated tastes and manners. She prided herself 
 upon holding a reputation for always having "classy fellows," 
 and was never without one or more students to take her about. 
 Her desire for "good times" was insatiable. Although the ex- 
 tent of her sex delinquencies could never be learned, by her 
 own admission they were many. She had had two gynecolog- 
 ical operations during the last three years, and was even now 
 in need of treatment for gonorrhea. The blood test for 
 syphilis was positive. 
 
 It was clear that the girl had had a poor chance in life, and 
 she herself felt bitter about her lack of opportunity. She said 
 she wanted "to take a fresh start" and to try with help pro- 
 vided by the social service "to make something of herself." A 
 comprehensive program was planned, for work, recreation, a 
 church connection through a sympathetic priest, treatment for 
 gonorrhea, and a good boarding place. The social workers 
 saw her frequently. Attempts to find recreation to compete 
 with the "good times" of the past fell flat. Jobs were found 
 and at once lost through the girl's incompetency. "We don't 
 want her type of girl," the report would be. She ignored the 
 church, found excuses for not Hving in the boarding places 
 chosen, and neglected her treatments. She refused to go into 
 an industrial school, to which there was no way of committing 
 her against her will. Untrained for any work that might ap- 
 peal to her intelligence and satisfy her ambition, she was 
 despondent because she had "no future." So after a few 
 months it was arranged for her to attend a trade school. Her 
 board was paid by a friend of the social worker, who had had 
 experience with girls in similar plights and undertook to help 
 in the reeducation of Aimee. For a few weeks she was happy, 
 but her work proved unsatisfactory, and in the second month 
 she gave it up. A commercial school was tried (to learn type- 
 writing and the use of the billing machine) and, when she was 
 discharged for f^oor work itnd bad conduct, a second school 
 
THE KINGDOM OF EVILS 157 
 
 was tried with the same resuh. "She made almost no prog- 
 ress, and was inattentive and troublesome, taking other stu- 
 dents' attention and not following rules or instructions. Her 
 personal appearance was much against her, as she was untidy 
 as well as painted." The three school attempts covered a year. 
 Meanwhile Aimee had improved a good deal in appearance 
 and manners. She took better care of her clothes and person, 
 although she was still rather inclined to be dirty. She had a 
 series of admirers, and "good times" continued. She was asked 
 to leave the girls' lodging house where she had been placed be- 
 cause she was "a bad influence on the girls." 
 
 Aimee had now to look again for an uncongenial job. She 
 was discouraged and unhappy, and wanted to be with her own 
 people. A sister had been located, well married and living in 
 comfortable circumstances in a rural neighborhood in Canada. 
 Aimee was sent to visit her. After a few days her brother- 
 in-law in righteous indignation turned her out of his home and 
 found her a refuge in the almshouse. We brought her back 
 and found her a position at housework. 
 
 Soon she announced that she was to be married to a college 
 senior, the son of wealthy parents from another state. The 
 boy came at once in response to a letter asking him to call and 
 said he did intend to be married to Aimee, and that, although 
 he had believed that he was the first man to have sexual inter- 
 course with her, he did not think the knowledge that he was 
 not would miake any difference. He said that he was willing to 
 "break it off," but Aimee seemed so unhappy at the idea of his 
 leaving her that he felt he ought to marry her, though he did 
 not exactly love her. He was a fine-looking lad with nice man- 
 ners. Learning that he was about to leave town, Aimee had 
 him arrested for breach of promise, but agreed to drop the case 
 under advice from the boy's lawyer. In compensation his 
 father gave her five hundred dollars, and she fitted herself out 
 at once with new clothes in remarkably good taste. The young 
 man on release from jail went directly to her room and spent 
 the night with her, again offering to marry her. He departed, 
 however, and Aimee followed him to New York and threatened 
 to bring another suit. But she came back and arranged the 
 most dramatic of her suicidal episodes. She left by the river 
 bank an old hat and coat with a note to the hospital saying that 
 she would be drowned when it was received, and later leturned 
 
158 THE KINGDOM OF EVILS 
 
 to the spot to join the crowd watching the river dragged. Two 
 days later the poHce, who had been notified, found her draw- 
 ing the last of her five hundred dollars from the bank and 
 brought her to the hospital. She was amused by the success 
 of her "frame-up," and somewhat consoled for the loss of her 
 lover by the newspaper notoriety she had gained, but she still 
 swore vengeance upon him. 
 
 After this Aimee refused to keep in touch with us and we 
 felt that our supervision would alter but little the course of 
 her life. She was clever enough to find work and make friends 
 and to keep out of court. The life of the professional prosti- 
 tute disgusted her and she would probably continue to have 
 promiscuous sex relations of a private nature and to work 
 intermittently. 
 
 We heard of her six months later as nurse in training in a 
 hospital for mental diseases in another state. A social worker 
 there who had known her said that she was doing well in her 
 work and seemed greatly changed. She appeared ambitious to 
 lead a regular life and intelligently interested in her work. But 
 soon she gave up the training and left claiming that she 
 was afraid her history would be known, since she had been 
 recognized. 
 
 Hours spent by Medical record, 33 pages 
 
 Social record, 51 pages 
 Physician, 9 Social work : 
 
 Visits, 35 
 Psychologist, 4 Interviews at hospital, 61 
 
 Telephone calls, 91 
 Social worker, 100 Letters, 75 
 
 Portuguese ivho got into a tangle over his draft papers and 
 was arrested for "desertion." Epilepsy. 
 
 Case 29, We found it hard to get a good example of 
 the binary combination of educational and legal troubles. It 
 actually seems as if this particular dyad of evils is statistically 
 very infrequent. At all events this is true for the Psychopathic 
 Hospital group of cases. Yet if we think of the matter in the 
 most general way, can the world be otherwise built than to 
 show many instances of persons who through ignorance are 
 unable to cope with legal difficulties? Naturally, plain com- 
 
THE KINGDOM OF EVILS I59 
 
 binations of educational and legal difficulty without psycho- 
 pathic or moral twists would not in the first instance get to the 
 Psychopathic Hospital clinic. 
 
 The Portuguese, John Manaos, whom we choose, was a 
 man of about thirty years, who may have been somewhat 
 feeble-minded, though there is no definite evidence of this. 
 He could speak English, but spoke it very imperfectly. Though 
 he had forgotten most of his Portuguese, he was fairly well 
 Americanized. Yet he got into a tangle concerning draft 
 papers in connection with his war service and apparently quite 
 through ignorance was unable to straighten out the techni- 
 calities. He was arrested and put in a guardhouse for failure 
 to fill out his draft paper. The fact was that he had really filled 
 out a draft paper and returned it. A second blank was given 
 him which he returned, saying that he had already filled out a 
 blank. Thereafter came the arrest, technically for "desertion." 
 
 At the police station he began to show a psychosis. In the 
 midst of normal talk with his relatives he would all of a sud- 
 den become mute and tense, staring fixedly at the wall. He was 
 tense and staring on admission to the Psychopathic Hospital 
 and was very resistive during the process of undressing. He 
 said he had been in the hospital ten minutes and immediately 
 afterwards said that he had been there all night. When asked 
 the date he said "January 5, era first year, that is what they 
 keep saying." He told of having fainting spells every week 
 with loss of consciousness. Something dropped in his throat, 
 he said. At other times he had been unable to talk. He said, 
 "My mind is getting blank." He had had influenza about 
 three weeks before admission. His eyes were somewhat prom- 
 inent, hands tremulous, and his knee jerks hyperactive. 
 
 Under observation he was at times overactive and talkative, 
 at times quiet and mute, at times hallucinated (women were 
 talking about him and voices called his name). After about 
 ten days he became pretty clear and began to take an interest 
 in time, place, and persons. Asked about his phrase concern- 
 ing the new era, he said : "They say the world is changing. 
 They were talking amongst themselves. There was the first era, 
 the Babylonian, Syrian, and Greek. I thought this was going 
 to be the German or something like that, you know." About 
 this time he seemed a case not only committable but deserving 
 commitment forthwith. He was accordingly committed Feb- 
 
l60 THE KINGDOM OF EVILS 
 
 ruary 5 (about three weeks after admission), but was suffi- 
 ciently well to be dismissed about seven weeks after admission 
 in a condition "improved." The diagnosis was epileptic psy- 
 chosis (clouded state). 
 
 Like so many psychopaths of various sorts, Manaos had 
 the reputation of being a nervous and delicate fellow. His 
 work record was studied rather intensively by a worker em- 
 ployed in industrial researches, and we therein find a history 
 of many jobs dropped for a variety of reasons, no one of them 
 particularly suspicious of psychopathy, yet taken on the whole 
 suggestive of general inadequacy. In less than three years he 
 had worked in ten different places as porter, car-cleaner, kitchen 
 boy, milling-worker, machinist's helper, etc. Manaos had the 
 idea of being a machinist. The bare record of condensed en- 
 tries concerning the various jobs and the periods spent on them 
 during the last three years fill five typewritten pages. 
 
 A record was found of his having been arrested as idle 
 and disorderly for hanging about street corners at the age of 
 twenty. The difficulty again seems to have been one of igno- 
 rance rather than of any moral defect. Of course, the hypothe- 
 sis might be raised that he was already epileptic at that time, 
 and if we felt that these episodes of arrest for idleness and for 
 "desertion" were really arrests of a man who was in a clouded 
 state of mind, then we should perforce have to regard Manaos 
 not as a combination of ignorance and legal trouble but as a 
 combination of disease and legal trouble. After giving due 
 prominence to the hypothesis of epilepsy and its accompanying 
 clouded states as a cause of Manaos's difficulties, we are still 
 inclined to think that he is a man who could be and can be 
 taught to do much better. For example, he was once employed 
 as a night watchman. The owner found him sitting with his 
 lantern on a curbstone outside. Upon being told that this was 
 not proper watching, Manaos was thereafter (so long as em- 
 ployed) a perfectly good watchman. He had not been a stupid 
 boy at school. He had started school late and left it at the age 
 of fifteen in the eighth grade. 
 
 This is of course a case whose outcome cannot be stated. 
 Many epileptics remain in this community doing perfectly good 
 work throughout their lives. Indeed, there are no doubt many 
 epileptics who accomplish unusual things and are actually emi- 
 nent men. This Portuguese was actually committed (although 
 
THE KINGDOM OF EVILS l6l 
 
 released after a few days) as a victim of epileptic psychosis, 
 and it may be thought that he will finally be committed once 
 more. In the intervals, however, aside from the persistence 
 for a few hours or days of a clouded state, Manaos is to our 
 minds much more of an educational than a medical problem. 
 
 A community that should elaborate its mental hygiene to the 
 last point would no doubt devise a means for light and non-dis- 
 turbing contact with Manaos for a period of many years and 
 no doubt the entire cost of such mental hygienic measures 
 w^ould be amply compensated for by the preserving of another 
 industrial life from undue interference either by his lack of 
 information or by the complications of epilepsy. 
 
 For a further account of epileptic phenomena, see Section 
 III in Book III. 
 
 Hours spent by Medical record, ii pages 
 
 Social record, ii pages 
 Physician, 6^4 Social work: 
 
 Visits, II 
 Psychologist, o Interviews at hospital, 4 
 
 Telephone calls, 9 
 Social worker, 23J/2 Letters, 7 
 
 Overworked young mother harassed by scolding husband. 
 
 Case 30. Emma Marburg came to the out-patient depart- 
 ment by the advice of another patient because she felt she 
 would not "be able to hold out much longer." She had married 
 at seventeen John Marburg, a Pole, ten years older than her- 
 self, and had never been happy with him. She was now twenty- 
 six and had five children. The family lived in three dark 
 rooms at the back of a ground floor tenement. Mr. Marburg 
 had earned only ten dollars a week as a mechanic until recently 
 when he began to make fifteen to nineteen dollars a week. He 
 had kept out of debt and his wife even suspected him of having 
 some small savings; but as the weekly expenses for mainten- 
 ance were between sixteen and seventeen dollars a week, their 
 life was a struggle for existence. A legacy of several hundred 
 dollars from Mrs. Marburg's father a few years earlier had 
 helped out. 
 
 Mrs. Marburg was frail and lacked vitality. Her chief 
 
l62 THE KINGDOM OF EVILS 
 
 symptoms according to the medical record were "fatigue, un- 
 happiness, and worry." She felt hopeless about her ability to 
 give the children proper care, and was terrified at the thought 
 of having more children. She had lost all ambition to keep the 
 house in order (it was unspeakably disorderly and filthy), for 
 their tenement was unwholesome and even the necessary house- 
 hold utensils were lacking. More fundamental than this ma- 
 terial resourcelessness was the poverty of her relations with 
 her husband, a man of good but peculiar disposition. He had 
 always "nagged her" and quarreled with her, complaining of 
 the disorder of the house and the poor quality of the food, and 
 blaming her for having so many children, which he attributed 
 to "her laziness." He suspected her of relations with other 
 men (without justification) and a year before had openly 
 accused her of sex relations with the godfather of one of the 
 babies, who left the house and never returned. He seemed 
 afraid of his wife : at night he would bolt the door of his bed- 
 room, he would make the children taste the food before he ate, 
 would move away if she came near, and look around if she 
 passed behind him. At one time he complained to a children's 
 agency that she neglected the children. No action was taken, 
 but Mrs. Marburg was deeply mortified, as she said she had 
 always tried to do her best by the children and stayed with her 
 husband only on their account. 
 
 Mr. Marburg had come to our out-patient department three 
 years before complaining of "nervousness and sleeplessness." 
 The examination showed no evidence of mental defect or psy- 
 chosis ; and his symptoms were attributed to excessive use of 
 coffee and tobacco. 
 
 The marital discord seemed to center around the question 
 of thrift. Mr. Marburg came of a family of frugal, successful 
 workmen and his mother had kept a clean, comfortable house in 
 Austria. Both he and his brother were disappointed in the bad 
 housekeeping of their American wives. Marburg wished to 
 live well and also to save money. He wanted his wife to take 
 lodgers, and to go out and work to earn stil! more money. He 
 could not understand her refusal nor her inability to give him 
 nourishing food and provide a clean home with the ten dollars 
 a week he gave her. He was fond of the children and helped 
 at times with their care; and he was fond of his wife to the 
 extent of saying that he could care for no other wom.an, but 
 
THE KINGDOM OF EVILS 163 
 
 he said that "the man must come first" and he was not so much 
 worried by the fact that the children were thin and undernour- 
 ished and the failure of his ambitions to have "a good home" 
 as he was by his inability to save. He was the only well-fed 
 member of the family. Yet he was a well-meaning man and 
 sincerely troubled about the state of his family affairs. He 
 had been many times to his physician with his tale of woe, 
 until he had become "a pest." He offered to pay a fee for these 
 social calls, which was not accepted, and finally the physician 
 had to refuse to see him. 
 
 Mrs. Marburg had not had a happy life up to the time of 
 her marriage at seventeen. Her mother died when she was a 
 baby and her stepmother was unkind to her and her sister and 
 fed them scantily, for the most part on bread and tea. She was 
 kept out of school to help at home, so that when she was taken 
 out of school at fourteen to be put to work she was in the 
 seventh grade. She graded well in the psychological examina- 
 tion. After three years in a rubber factory she married to get 
 rid of the "nagging" at home. Six years later her father com- 
 mitted suicide. 
 
 The social problem here was one ot educational and financial 
 deficiency, an untrained woman with an income insufficient for 
 the needs of her family, li Mrs. Marburg could be taught 
 good standards of living and educated in good housekeeping 
 and sufficient funds could be provided to maintain the family 
 suitably, it seemed probable that there would be no medical dif- 
 ficulty, and that the marital dissension would subside to a nor- 
 mal level. No question of conflict with public authorities ever 
 arose in this case. Our efforts were directed then toward the 
 better education of Emma Marburg and a more provident use 
 of John's wages. In time he should be earning more. Al- 
 though he sought to give the impression that he had saved a few 
 hundred dollars, it was pretty sure that he had only about sev- 
 enty-five dollars stored away. 
 
 The first steps toward this end were to secure John's sym- 
 pathy and cooperation, which he yielded fairly readily, with 
 occasional changes of mind ; to keep Emma's courage up ; and 
 to rally around the family the friendly interest of relatives, 
 physicians, teachers, and priest. A new tenement was found, 
 whereupon Mr. Marburg committed the extravagance of fur- 
 nishing a parlor in mission style, a hopeful sign we felt in a 
 
164 THE KINGDOM OF EVILS 
 
 man with habits of excessive thrift. Some gifts of household 
 goods and clothing were used to cheer Mrs. Marburg. There 
 was not enough clothing in the house to dress all the children 
 completely at the same time and Mrs. Marburg's apparel was 
 depressingly shabby. The children were taken to a hospital for 
 examination, and a tonsil operation was performed upon four 
 of them. The baby's feeding was regulated also. After tre- 
 mendous efforts to overcome Mr. Marburg's opposition to the 
 novelty of the idea, Emma was sent to a convalescent home for 
 a four weeks' vacation, while the children were boarded. In- 
 cidentally she acquired some housekeeping notions and brought 
 back a sheaf of recipes. A visiting housekeeper was secured 
 to undertake her instruction. Unfortunately one of the chil- 
 dren brought home an infection of scabies which ran through 
 the family and interrupted education ; and Emma was laid up 
 with a scalded foot. Then came the discovery that she was 
 again pregnant. In spite of the terror she had shown when 
 she first came to us a year before, she accepted the fact calmly. 
 She had become somewhat happier and more reconciled to her 
 husband, who showed a very much better disposition and took 
 more responsibility for making the home comfortable. He had 
 an occasional relapse into his scolding habits, but on the whole 
 had become fairly considerate. The case was left in the care 
 of a prenatal clinic. We felt that at least another year of inten- 
 sive social treatment would be required to effect any lasting 
 improvement in so deep-seated a case of ignorance and povertv, 
 but we could not carry the case longer because (according to 
 prevailing custom) our staff of social workers is not large 
 enough to carry one-half of the current work of the hospital, 
 and urgent and acute cases demand for the most part first 
 attention. 
 
 Hours spent by Medical record, 9 pages 
 
 Social record, 39 pages 
 Physician, 434 Social work : 
 
 Visits, 62 
 Psychologist, l Interviews at hospital, 6 
 
 Telephone calls, 18 
 Social worker, 100 Letters, 12 
 
SYPHILITIC DELINQUENT— I 
 GIRL, 21 
 
 1915 
 
 Poor Stock (Alcohol, Sex Delinquency) 
 Placed Out, 3 (Troublesome) 
 Kidnapped Home, 12 (Incest) 
 Reform School, 13 (Good Work) 
 Parole, 18 (Lewdness, Temper, Blues) 
 Suicidal Attempts 
 
 (syphilis congenital?) 
 
SYPHILITIC DELINQUENT— II 
 
 GIRL, 21-24 
 
 ipiyiQiS 
 
 Good Work at a Job but — 
 Unmanageable 
 
 Suddenly Married a Black Sheep- 
 Kept House Well 
 
 Baby Took a Prize 
 
 Illness — in Hospital 
 
 Discord 
 
 Another Baby Sick 
 
 Husband in Prison — Paroled 
 
 Third Pregnancy 
 
 Improvement Under In-Law's Care! 
 
Wayward, syphilitic girl married to a black sheep. In the 
 end a devoted mother. 
 
 Case 31. Alice Nardini, an American girl of twenty-one, 
 married in haste to Joseph Nardini, an Italian youth about her 
 own age (the "black sheep" of a good family) is presented as a 
 case whose outstanding features were moral and legal. She 
 had received a fair education, and although her early training 
 was of the poorest, a term in an industrial school had taught 
 her the essentials. Financially she could always "get along" 
 although fairly near the margin of poverty. Strictly speaking, 
 she was not without medical difficulties (presumably every case 
 under care at the Psychopathic Hospital has some medical 
 complication), but the positive Wassermann test probably due 
 to congenital syphilis and the psychopathic aspect of her quick- 
 tempered, moody disposition were less conspicuous in her case 
 than her unreliable conduct. Legal complications appear from 
 time to time. She seems to be one of those persons who are 
 always on the verge of association with the court. 
 
 When Alice was three years old she was taken by the court 
 from her parents, both of whom were alcoholic and sexually 
 delinquent, and placed in the care of a children's agency. She 
 was boarded in homes of the best sort, and given up by one 
 after another because she was troublesome. When she was 
 about thirteen her parents kidnapped her. They became drunk 
 and quarreled, and the father after having the mother arrested 
 took the child to a shack in the country where he practiced 
 incest. She was rescued by the police and committed to an 
 industrial school as "a wayward child, grov/ing up in circum- 
 stances exposing her to lead an immoral, vicious, and criminal 
 life." At the school she made a fairly good record and was 
 a great help in the sewing room as long as she was allowed 
 to be prominent. She would do almost anything to attract 
 attention. 
 
 In childhood she had fits of temper when she would scream 
 for an hour at a time. She showed such a tendency to vulgarity 
 
 167 
 
1 68 THE KINGDOM OF EVILS 
 
 that she could not be allowed to play with the neighbors' chil- 
 dren in the respectable homes where she was boarded. If 
 crossed she became sullen, refused to eat, threatened to kill her- 
 self, and finally got into a state of nervous excitement that 
 alarmed her friends. A physician who saw her thought that 
 she should be kept under restraint for the public safety. 
 
 When she was allowed to leave the industrial school to do 
 housework in private families she used obscene language and 
 was lewd in her manner with men upon the street. 
 
 Alice was sent to the Psychopathic Hospital because she 
 threatened suicide when a girl whom she had known at the 
 school spread stories about her in the town where she was 
 working. Five months later she was returned after an at- 
 tempt to take poison. On this occasion she had been allowec' 
 to visit her mother, now married a second time to a steady, 
 respectable man, and no longer alcoholic. Her mother accused 
 Alice of being in league with her stepfather to run the house 
 and a quarrel arose that led to Alice's attempt to kill herself. 
 The medical diagnosis the first time was "not psychotic." The 
 girl was distinctly not feeble-minded, according to the psycho- 
 logical examiner. She appeared bright and quick. The second 
 time she was in the hospital the final conclusion of the medical 
 staff was that there was a question of early dementia praecox. 
 The Wassermann reaction was positive and antisyphilitic treat- 
 ment was given. As the mother had syphilis, the presumption 
 was in favor of the opinion that Alice was a case of congenital 
 syphilis. 
 
 The family chart of this girl is very black. Her mother is 
 a high-grade moron ; both parents were alcoholic and sex 
 delinquents. On the father's side the grandfather was criminal- 
 istic, the grandmother hysterical, the great-grandfather a sex 
 delinquent. On her mother's side, the grandfather and great- 
 grandfather were alcoholic, the grandmother was feeble- 
 minded, had tuberculosis and was alcoholic, and sex delinquency 
 appeared among the great-aunts and uncles, a cousin was 
 insane. Ten of the family were confined in institutions of one 
 sort or another. 
 
 When Alice left the hospital the second time, she had become 
 of age and could therefore no longer remain under the authority 
 and care of the industrial school, so she was taken under super- 
 vision by our social service. In the position found for her she 
 
THE KINGDOM OF EVILS 169 
 
 did satisfactory work but was unmanageable because of her 
 pert and independent manner. It was impossible to tell what 
 she did in her leisure time; but she could not live at home 
 because she and her mother could not keep the peace when long 
 together. Soon without warning she announced her marriage 
 to Joseph Nardini, who had been given to drink and the use of 
 morphine, but for a while had been sober and industrious, 
 working as a grocer's clerk. The results of our supervision 
 until a year and a half later, when the family moved to another 
 state where Alice's stepfather had found promising work foi 
 Joseph, are summarized in the social record as follows : — 
 
 May 28, 1914-March II, 1 9 16 
 
 Social: 
 
 After leaving the hospital in June, 1914, a position at the 
 Roxbury General Hospital was secured for her where she 
 remained until October, 1914. She left without serving notice 
 and was married without visitor's knowledge to Joseph Nar- 
 dini, an Italian of good family. Just before this, she was 
 going out with two different men, both of whom she alleges 
 made improper suggestions to her. Boy was born July 24, 191 5. 
 
 With the exception of a month in the fall of 191 5, when 
 the patient lived with her mother in Westbridge while husband 
 was working in Eastboro, they have lived in the South End. 
 Patient's husband has worked in a grocery store, for a roofing 
 company, driving an automobile, cleaning streets, and as porter 
 in a bank, earning from ten to sixteen dollars a week. The 
 family has been in debt most of the time, and while they have 
 made regular payments, one debt would no sooner be paid 
 than another would be contracted. The parents of both patient 
 and husband have regularly supplied them with money and 
 with clothes. Of a bill of thirty dollars at the Maternity Hos- 
 pital, five dollars was obtained through the efforts of Miss 
 Fuller, a visitor to the Nardinis ' from the Charity Organiza- 
 tion Society. When the family went to New York state, 
 March, 1916, they were in debt over one hundred dollars. 
 
 Patient's husband has had periods of drinking, and for over 
 a year before marriage used cocaine and morphine. He and 
 patient quarrel. When husband is intoxicated, he is ugly and 
 will strike patient. But since baby was born, July, 191 5, he 
 has treated patient better. He seems devoted to the baby. 
 
 For a time patient's mother and patient's husband were not 
 on friendly terms, and patient did not dare let her husband 
 
170 
 
 THE KINGDOM OF EVILS 
 
 know when she had seen her mother. Husband's parents have 
 tried to hold up to both patient and husband a high standard 
 of conduct. They have a strong sense of responsibiHty for 
 patient since she has married into the family. 
 
 Physical: 
 
 Patient was given antisyphilitic treatment here the first sum- 
 mer and has been under observation of Dr. Scott since. When 
 the baby was born in the Maternity Hospital patient was given 
 ether. The delivery was normal. Patient had trichaniasis and 
 was in the Roxbury General Hospital twice in fall of _ 1915. 
 She is not living according to the diet prescribed. Patient is 
 looking fairly well, but has lost weight since leaving the hos- 
 pital. Is kept awake at night with the baby. 
 
 Mental: 
 
 She is fond of her husband and craves affection from him, 
 and is devoted to the baby although she does not wish any more 
 children. There has been a gradual change from the high- 
 tempered, self-willed disposition to a more docile and obedient 
 bending to husband's wishes, so that there is less quarreling at 
 home. In February, 1916, threatened to leave husband, but 
 after quarreling one half day and sending for visitor, went back 
 to him. In December, 191 5. had a noisy quarrel with mother 
 at her home. Other less important squabbles occur. 
 
 Patient is a poor housekeeper, but mother says she is im- 
 proving. She depends upon her mother to do a good deal for 
 her. 
 
 When they returned to Boston after two or three months we 
 reopened the case and results during a period of nine months 
 follow : — 
 
 June I, 1915-February 29, 1917 
 Social: 
 
 Familv returned to former address in the South End because 
 they found it impossible to live on husband's wages. Husband 
 has worked more regularly since his return and makes from 
 twelve to sixteen dollars a week. He has straightened out and 
 no longer drinks or abuses patient. Debts are paid except 
 fifteen dollars at the Maternity Hospital. Second boy born 
 December 28, 1916. 
 
 Physical: 
 
 Patient no longer requires antisyphilitic treatment. Two 
 weeks' rest in the country was urged before confinement, but 
 she could not be persuaded to go. 
 
THE KINGDOM OF EVILS I7I 
 
 Mental: 
 
 Patient shows marked improvement in housekeeping and 
 personal appearance. She takes a real pride in her home and 
 has shown marked ability in sewing for the children, even 
 making some dresses for her husband's young sisters. 
 
 She is less impulsive and seldom quarrels. She allows her- 
 self to be ruled by her husband, and seems happy and content 
 with her life. Her voice is subdued and she has poise and 
 dignity of a grown woman. 
 
 She is now stated as not psychotic. She is considered a 
 psychopathic individual who has been compensated socially. 
 
 Alice was much improved and the case was again closed as 
 the supervision of the in-laws seemed adequate. But a friendly 
 call three months later brought to light the fact that Joseph 
 had been sentenced to the house of correction for a year and a 
 half for drawing a revolver upon an officer who interfered in 
 the advances of himself and his companions to some girls upon 
 the street. Apparently Joseph had no malicious intentions, but 
 the law had its way with him. Alice was being supported by 
 public aid and her father-in-law. We joined Mr. Nardini in 
 an effort to bring about the release of Joseph, who after serv- 
 ing six months of his sentence was paroled. By this time the 
 original problem of the training of a somewhat psychopathic 
 girl had been eclipsed by the "family problem" of the Nardinis, 
 and we asked a family agency to take the case. When we 
 heard of the Nardinis recently, Joseph had been drafted into 
 the army. Before he went he had been drinking and taking 
 morphine and had been abusive to his wife. He had gone about 
 openly with a woman whom Alice styles "a regular bum." She 
 is now endeavoring to discover an opportunity for the police 
 to arrest the woman ; and is thinking of going to court for sep- 
 arate maintenance when Joseph comes home. 
 
 The improvement in Alice herself (aside from the condition 
 of the family) during the four years we have known her is a 
 matter of some surprise. Considering her bad heredity, and 
 unfortunate early experiences, and her unstable character, we 
 did not expect as much stability as she has developed. In spite 
 of many handicaps she has shown continued progress. Joseph, 
 while he has had his good spells, has been a difficult husband to 
 manage even with the help of able in-laws. Alice's mother, 
 though kind and helpful for the most part, has an uncertain 
 
1^2 THE KINGDOM OF EVILS 
 
 temper and once at least was intoxicated and "disgraced" her 
 daughter in the eyes of the Nardini family. Alice herself has 
 had a good deal of sickness and the first baby had ear abscesses 
 and the second child was in a hospital at eleven months for 
 feeding troubles. The third child was never well and died 
 at three months. The uncertainty of their income has been 
 another burden upon Alice, for although funds have always 
 been forthcoming, Joseph's irregular habits of work and ten- 
 dency to gamble as well as drink have kept the family most ol 
 the time in debt. 
 
 During the first pregnancy Alice was given antisyphilitic 
 treatment regularly, and the baby was a fine child. Before the 
 birth of the second child she was under medical observation, 
 but treatment was not considered necessary. This baby also is 
 well and sturdy. When we referred Alice to a general hospital 
 for treatment for syphilis, the diagnosis upon our medical 
 record "question of early dementia praecox" proved to be a 
 snag, for the superintendent of the hospital to which we wished 
 to refer her replied that in view of the diagnosis "the patient 
 was directed to return" to our hospital, since if there was "any 
 question of mental disease in her case" he felt she belonged 
 in the care of our hospital. The matter was finally adjusted, 
 with some difficulty, upon a statement from one of our physi- 
 cians that Alice Nardini was "not a mental case." 
 
 Hours spent by IMedical record, 17 pages 
 
 Social record, 31 pages 
 Physician, 5%. Social work : 
 
 Visits, 48 
 Psychologist, i Interviews at hospital, 1 1 
 
 Telephone calls, 6 
 Social worker, 76^4 Letters, 16 
 
 Incompetent young wife quarrels with in-lazvs, then quarrels 
 zvith husband, who deserts. 
 
 Case 32. Although Catherine O'Connor by psychological 
 tests would be classed among high-grade morons (she graded 
 at II. 6 years by the Point Scale and was twenty-three years 
 old when tested), she was bright and teachable, fairly intelli- 
 
THE KINGDOM OF EVILS 173 
 
 gent, and even capable when she exerted herself. She was not 
 mentally different from many women coming to social agencjes 
 whose intelligence is never questioned to the extent of psycho- 
 logical tests. While her case might be regarded as presenting 
 difficulties in the group of morbi, owing to her somewhat defec- 
 tive intelligence, yet the factor of intelligence defect played a 
 relatively small part in her treatment, and the main difficulties 
 to be dealt with lay in the moral and financial fields. After 
 the desertion of her husband the question of support for herself 
 and the children was the pressing consideration. Her moral 
 difficulties were faults of "temper." Up to the time of her 
 marriage she showed an easy-going disposition and had no 
 particular trouble. As a child, however, she was somewhat 
 peculiar, having sullen spells when she would go two and three 
 weeks at a time without speaking to anyone in the house. 
 After the birth of her first child, she quarreled continually with 
 her husband and lost no opportunity to be rude to his family, 
 whom she disliked. She would burn presents that they sent 
 to the baby. At times she had thrown dishes at her husband 
 and refused to cook his meals. She never did justice to her 
 housekeeping, and was slack and untidy. The husband also 
 was of an easy-going disposition and quick temper and bore 
 up his end of the family quarrels. After one particularly violent 
 scene, in which Catherine became very much excited and 
 obsessed with the idea that her sister-in-law intended to take 
 her baby away, a doctor was called, who advised sending her to 
 the Psychopathic Hospital for observation. She said he told 
 her "the hospital would be a good place to rest in" and she was 
 willing to come. 
 
 The story of social treatment during two years and nine 
 months is briefly told in a summary from our record prepared 
 for the Associated Charities in another city to whom the case 
 was referred after Mr. O'Connor had returned and the family 
 had been transplanted to a new neighborhood. We asked that 
 a friendly visitor keep in touch with them. Both Mr. and Mrs. 
 O'Connor had shown marked improvement apart, but it re- 
 mained to see whether they could attain stability in their corn- 
 mon life. A copy of the summary follows : — ■■ 
 
174 THE KINGDOM OF EVILS 
 
 SUMMARY 
 
 Social History: 
 
 Patient is an American born woman, twenty-six years old. 
 of Irish parentage. She is a pretty woman, short and sHght, 
 has pleasing manners and an attractive smile. Patient was 
 married six years ago to Frank O'Connor. For a time they 
 were happy together, but after the birth of the first child, 191 3. 
 there was constant friction. The husband earned fourteen 
 dollars per week, and patient had great difficulty in making 
 both ends meet. Patient also did not get along well with her 
 husband's family. She felt that they were trying to take her 
 child from her. Finally the husband had patient sent to this 
 hospital, June, 191 5. They were advised to separate, but 
 decided not to and apparently were happier. Five months a f tcr 
 birth of second child, January, 191 6, patient's husband deserted 
 her. Patient was sent to Peterboro for a vacation. She en- 
 joyed the place so much that she decided to remain. 
 
 For fourteen months she and her l^aby Marion, now a year 
 and a half old. lived in Peterboro. where the patient worked as 
 stitcher in one of the Fox & Blake shoe factories. Patient 
 earned between seven and ten dollars per week with which, 
 together with the small amount given her by her sister Mary, 
 she supported Marion and herself. Patient was well liked by 
 her employers and made many friends in Peterboro. While 
 there she lived in three different places in each of which there 
 was someone to care for Marion during the time patient was 
 working. Patient's older child, Winifred, four years old, is 
 well cared for Ijy Mrs. Edward O'Connor, 36 Troy Street, 
 Foxbridge, mother-in-law of patient. 
 
 Early in the spring of 191 7, patient heard that her husband 
 had deserted from the army in which he had enlisted under an 
 assumed name. In June he returned to Boston and went to 
 see patient several times. He gave himself up and served a 
 sentence of eight months at Blackport Island. 
 
 In October, 191 7, patient was not able to work more than 
 three or four days a week because of fatigue, due to preg- 
 nancy. November 13, she and Marion went to board at 12 
 Ford Street, where they had an attractive bedroom, a sitting 
 room, opening on an enclosed porch, together with board for 
 nine dollars a week. 
 
 Patient's board was paid by the Red Cross until February 
 9, 19 1 8, at which time the sentence of patient's husband ex- 
 pired, and he returned to Boston. Previously patient's husband 
 
THE KINGDOM OF EVILS I75 
 
 had been an unstable, irresponsible young man, lacking in am- 
 bition. Since his return, however, his entire attitude has 
 changed. He at once sought work and secured a position as 
 meat-cutter at fifteen dollars per week. The second week he 
 was raised to sixteen dollars. He was desirous of leaving this 
 city and making a new start. He chose Lawrence, went to the 
 Y. M. C. A. there, secured employment at seventeen dollars 
 per week in a factory and in addition worked as meat-cutter 
 for Saturday afternoon and evenings. Eighteen dollars was 
 lent him to pay patient's board for two weeks ; of this he has 
 already paid back sixteen dollars. Three dollars additional 
 was given to patient, so husband now owes this hospital five 
 dollars. 
 
 On February 28 patient was confined at the Maternity Hos- 
 pital, where she gave birth to a boy weighing six pounds, four 
 ounces, and where she remained eleven days. She then returned 
 to 12 Ford Street for two weeks, her board being paid by 
 Country Week. Patient and baby then spent a few days with 
 patient's sister Mary, in Arlington. March 30 patient joined 
 her husband in Lawrence. 
 
 During patient's confinement, baby Marion came down with 
 scarlet fever and is now in the Contagious Hospital doing 
 fairly well. 
 
 Physical History: 
 
 Patient had a normal birth and development. Her children's 
 births were normal. While her husband was in, she became 
 pregnant and was confined in February. During early part of 
 last pregnancy patient was examined at Suffolk General Hos- 
 pital and while at 12 Ford Street attended a prenatal clinic. 
 There was nothing unusual during her confinement. 
 
 Mental History: 
 
 Patient went to the seventh grade in school. She is fond 
 of reading and dancing, but had had little recreation since 
 marriage. She is untidy and slack as a housekeeper, but when 
 she tries she keeps herself and her baby neat and clean. 
 
 Patient's psychological examination at this hospital showed 
 that she graded at 11. 6 years. Diagnosis was: Not insane. 
 Since leaving hospital in 191 5, patient has been under the care 
 of the social service. She has done her best to carry out sug- 
 gestions made to her, especially recently, and is always appre- 
 ciative of what is done for her. 
 
 Patient is optimistic about the future and greatly pleased 
 
1/6 THE KINGDOM OF EVILS 
 
 because of the change in her husband's attitude. She is eager 
 to have a happy home and reaHzes that she must do her share 
 to make it so. She also has become more interested in hygiene 
 and in the health of her children. At present she is greatly 
 worried about Marion, to whom she is devoted. She is amen- 
 able to social treatment. 
 
 A year after the family left Boston, one of the social workers 
 who had dealt with them (three social workers had in turn 
 charge of the case) happened to be near their new home and 
 called. She found Mr. O'Connor doing well, and Mrs. O'Con- 
 nor happy in a good, well-kept home. The whole family had 
 been sick with the influenza during the epidemic and Mr. O'Con- 
 nor had nursed them. The oldest child, a beautiful little girl, 
 died. Even under the strain of this grief, Mrs. O'Connor has 
 remained reliable. Mr. O'Connor is still going "up the ladder" 
 as he expresses it, in a letter we quote below : 
 
 "My Dear IMiss Goode: 
 
 "Received your letter last week sometime, but as I am not 
 much of a hand at writing it took me until today to answer 
 it. I hope that you have thoroughly recovered from your ill- 
 ness. I suppose that you will be mad at me for writing to 
 Catherine and having her come up here. I found two nice 
 rooms near my work and I also thought that it would be better 
 for Catherine to be here because she was worrying over Marion. 
 Being up here might take her mind off thinking of her. Now 
 of course I know she will be all right at the hospital under 
 the conditions. As I understand from Catherine I have got to 
 pay for her board and treatment there, also the other expense 
 of two visits of the doctors. I am doing all I can to make 
 good. I have secured a position in a market for Saturday 
 afternoons and evenings. So you can see that I am trying my 
 best to get up the ladder as soon as I can and I hope to con- 
 tinue. I am in hopes that nothing more will come up to 
 greaten the expense any more. I am very thankful for all of 
 the good things you have done for both Catherine and myself. 
 I will never forget them you have been my friend. Now as 
 soon as I can I will try and straighten out all matters with you. 
 I would like very much to see you but it is almost asking too 
 much to call up to see me. I want to keep in touch with both 
 you and the Y. M. C. A. 
 
 "Sincerely, 
 
 "Frank O'Connor." 
 
THE KINGDOM OF EVILS I77 
 
 Hours spent by Medical record, 39 pages 
 
 Social record, 53 pages 
 Physician, 5 Social work : 
 
 Visits, 49 
 Psychologist, i Interviews at hospital, 18 
 
 Telephone calls, 75 
 Social worker, 100 Letters, 45 
 
 Persistent forger and "ne'er-do-well/' 
 
 Case 33. Ignatz Simanski forged a number of worthless 
 checks totaling $176 all within a period of eight days. Siman- 
 ski was an American-born Polish Jew who had gone back o 
 Berlin in his teens, worked with various firms, and was an in- 
 terpreter seven years. Apparently he lived very well in Europe, 
 but never sent money to his mother or sister. He kept mis- 
 tresses in Europe. He did not want to enlist in the war, was 
 ashamed not to, and finally left Europe to keep out of the war. 
 An artist divorcee with whom he became infatuated used up 
 his money. The forging then began. He got out of prison 
 in eleven months, without money or clothes. A friend of 
 Simanski's sister advised him to go to the Psychopathic Hos- 
 pital suspecting that, with his record, he might be a victim of 
 psychopathic personality. He came and was put under a sort 
 of supervision. Assistance was given him — a week's board 
 and shoes. A job was got for him in a munition factory. 
 Three months after there had to be a tonsil operation which 
 was arranged for. Upon emerging from the hospital he was 
 again destitute. That Simanski was in any psychopathic (ex- 
 cept under that extreme view of delinquents which regards 
 them as all in some sense psychopathic) was very doubtful. He 
 was referred to an agency for homeless men and the case was, 
 from the Psychopathic Hospital point of view, closed. It ap- 
 peared from recent advices that Simanski was married and is 
 making good in a small way. Of course, he is not cutting the 
 rather wide figure which apparently he cut in Europe and 
 shortly after his return. Whether, in the long run, he will turn 
 out again a more markedly delinquent, or whether he will be- 
 come obviously psychopathic is a question. Of a psychopathic 
 trend we found no sign. 
 
178 THE KINGDOM OF EVILS 
 
 We have described Ignatz Simanski as a case without pre- 
 dominant or certain medical disorder. Perhaps we should re- 
 gard him as a moral problem and lay stress upon his irrespon- 
 sibility and selfishness, which we ascribe to educational defi- 
 ciency. Superficially viewed, this man has developed sundry 
 vices, but whether he is accessible to moral treatment in the 
 ordinary sense of that treatment is to be doubted. Just as some 
 authorities view crime as a sort of disease, so others view crime 
 as a sort of vice. We do not wish to enter the lists to argue 
 these views. In any event, the problem of Simanski is one 
 of low moral standards combined with economics. 
 
 Hours spent by Medical record, 4 pages 
 
 Social record, 8 pages 
 Physician, 3% Social work : 
 
 Visits, 3 
 Psychologist, o Interviews at hospital, 7 
 
 Telephone calls, 21 
 Social worker, isJ/2 Letters, 20 
 
 Psychoneurotic plumber unable to zvork for six years. 
 Afraid to go out alone. 
 
 Case 34. Daniel Griffin is a case we choose to analyze as 
 one of almost purely medical difficulty. Educationally he was 
 rather unusually without blemish, achieving the highest mental 
 age level consistent with the scales in use and achieving a gen- 
 eral intelligence score of 97. The psychologist noted that 
 Griffin's performance was exceedingly good in the construction 
 puzzles for example, but that he took much longer time on a 
 second trial than on the first, since he became very nervous 
 and feared that the second trial would fall off in excellence, al- 
 though he cooperated well and showed great interest in both 
 tests. He afterward complained of being greatly fatigued as 
 he had not slept at all the night before. 
 
 Thus, although psychological tests are not as a rule extremely 
 good sources of psychiatric data (as we cannot carry over a 
 specific deficiency in given tests, such as one for oversuggesti- 
 bility for instance, to argue a general psychiatric oversuggesti- 
 bility), yet Griffin's behavior during the tests suggested the 
 disease of which we think him the victim. Beyond question 
 
THE KINGDOM OF EVILS 1 79 
 
 he belongs to the psychoneurotic group-. He came voluntarily 
 to the Psychopathic Hospital, complaining of feeling tired. He 
 had had, he averred, a nervous dread for some five years. It 
 was not a particular dread, but there was a feeling that some- 
 thing terrible was going to happen. He was worried because 
 he could not get on his feet and could not make a man of him- 
 self. He himself called his disease "neurasthenia." 
 
 He had been a plumber and said that he had contracted lead 
 poisoning, which was the cause of his disorder. However, at 
 another time he explained the beginning of his disorder in 
 a bout of rivalry over some bit of technique in the plumber's 
 trade with a man who beat him in performance. All this he 
 had taken much to heart. Whenever that particular thing was 
 to be done in plumbing he kept having precisely the same creepy 
 feeling that ran over him the day his fellow workman over- 
 reached him. 
 
 For some six years Griffin had not worked. Mornings he 
 felt shaky and trembly, was without ambition, and could not 
 seem to "get started." He felt a dread that "something might 
 happen" to him if he were alone. Evenings he would feel 
 better and might then take a solitary walk. Day times, how- 
 ever, he could never prevail upon himself to go out. Day 
 times he read or helped his mother about the house. He was 
 interested in lectures, in studying, and in serious conversation. 
 He spurned moving pictures. Whereas he had for a long time 
 been very fond of athletics, he now had no stomach for any- 
 thing except treatment for his nervous trouble. His brothers 
 and sister, he said, had ostracized him. He was angry with 
 one brother, though in point of fact at least a part of his 
 feeling might be attributed to his vexation at not having his 
 doctor's bills paid by the family. There appeared to be no 
 religious or sex concern in Griffin. 
 
 Griffin presented a good general appearance, though his 
 manner was a bit effeminate. He was not sad but anxious in 
 expression and, though for the most part agreeable, became 
 at other times petulant. He had been referred from the out- 
 patient department into the wards of the Psychopathic Hos- 
 pital. As soon as he entered the wards he wanted to know how 
 soon he could go home. Nevertheless, he stayed, being funda- 
 mentally willing enough. His fault-finding would run after 
 this fashion : "This has been a strenuous evening for me," he 
 
l80 THE KINGDOM OF EVILS 
 
 would say. "I just got. through with the lady with the puzzles 
 and it has affected me." 
 
 Nothing psychiatrically other than the above was found 
 in Griffin's rather short stay (six days) in the wards, whence 
 he was discharged (as the clinic slang has it) "to self and to 
 the out-patient department." 
 
 He has been under observation for a good part of a year 
 and is perhaps a bit better. He is now being got to take more 
 interest in housework and repairs about the house, upon which 
 he spends several hours a day. He thinks, or at least states, 
 that his visits to the department are of little avail. He insists 
 that physicians should tell him concretely what will make him 
 well. He would rather like to have his excellent psychological 
 rating on paper to present to friends as evidence that he is men- 
 tally normal. In all the visits that he has made to the out- 
 patient department, he had never yet been able to go alone 
 although he has from time to time made elaborate plans to get 
 to the hospital alone. Evidently the brief trip seems to him a 
 compHcated tour. He protests that he must not come in the 
 car with a social worker because he will "look awkward." The 
 family's attitude to Griffin is altered again to one of affection. 
 
 This case we have picked as one of relatively uncomplicated 
 medical interest. As above noted, he is psychologically on a 
 rather superior level. Morally one might lay up to him as a 
 kind of vice or bad habit the attitude towards work which he 
 has assumed. It is somewhat a question of terminology, 
 whether we shall regard this psychoneurotic attitude as dis- 
 tinctly a kind of vice or bad mental habit. To be sure, the 
 effects of the psychoneurosis are found in the moral sphere 
 and affect both emotions and the will. But probably that ana- 
 lyst would go quite wrong who should feel that, by those moral 
 measures that aid the normal person who falls into moral 
 difficulties, he could restore Daniel Griffin. Naturally the 
 proof of the pudding in this case, as in many others, lies in the 
 eating. 
 
 Nor would we deny that some cases called psychoneurosis 
 have been cured by the usual moral measures at the conmiand of 
 the adult person of common sense who knows something about 
 the world and has a modicum of personality. Of course, too, 
 in some wide sense of the term, these common-sense moral 
 measures might be regarded as a form of psychotherapy. On 
 
THE RiNGDOM OF EVILS ,l8l 
 
 this extremely wide (and we think excessively wide) interpre- 
 tation, even the processes of normal education as well as those 
 of moral training would fall under the caption psychotherapy. 
 But psychotherapy, strictly speaking, is a form of therapy, and 
 the term therapy has come to be used as signifying treatment 
 of disease or defect. No doubt, then, in a case like that of 
 Daniel Griffin, ordinary measures must be used just as ordi- 
 nary devices of education and instruction must be used. But 
 the stock moral measures of the community will not serve 
 and (as Daniel Griffin's five or six years of proper contacts 
 with an excellent family prove) have not served to turn the 
 trick. 
 
 To be sure, our own efforts have not been crowned with 
 complete success — nor may they ever be, despite the uninter- 
 rupted up-curve which we have in the past months noted. 
 What the real cause of psychoneurosis actually is remains to 
 medical minds a question. We do not need here to mention the 
 various psychogenic explanations which have been offered. 
 Griffin was in charge of a competent physician fully cognizant 
 of various modern suggestions as to the mental origin of sun- 
 dry kinds of psychoneurosis. Whether psychogenic causes 
 were absent or whether they simply were not discovered, at all 
 events, no single or removable cause has ever been alleged for 
 Griffin. AH legal and virtually all economic difficulties fail to 
 complicate the case. There was indeed nothing in Griffin's 
 life or history, as so far brought out, which could combine with 
 his psychoneurosis to form a picture like many of those before 
 described. 
 
 Griffin is the first of five cases, in which we are attempting 
 to display comparatively uncomplicated instances of medical 
 (Daniel Griffin), educational (John Henry), moral (Clara 
 Perkins), legal (Nathan Blumberg), and economic (Margaret 
 Dolan) disability. Thus the cases of slightly greater com- 
 plexity with which Griffin's case could readily be compared, 
 are cases 24 to 27. Of these four cases of medical trouble 
 combined with one or other type of non-medical trouble, two 
 (case 24, David Stone, and case 27, Herman Simonson) are 
 also cases of psychoneurosis. The case of David Stone we 
 regarded as a binary combination of medical and educational 
 deficiency, whereas Herman Simonson we regarded as a com- 
 bination of medical and economic trouble. 
 
182 THE KINGDOM OF EViLS 
 
 In passing it may be noted that case 25, Alfred Stevens, was 
 also at first thought to be a case of psychoneurosis. That case 
 of Alfred Stevens was in fact, the striking case in which altera- 
 tion of the physician's estimate from psychoneurosis to cyclo- 
 thymic constitution (constitutional slight melancholia) made so 
 profound a difference to the man's happiness and self-support- 
 ing power. 
 
 Hours spent by Medical record, 19 pages 
 
 Social record, 23 pages 
 Physician, 4^ Social work: 
 
 Visits, 22 
 Psychologist, i Interviews at hospital, 4 
 
 Telephone calls, 20 
 Social worker, 453/^ Letters, 45 
 
 Boy kept a prisoner by insane mother. Enforced seclusion 
 did not prevent 'intellectual development. 
 
 Case 35. John Henry was a nine days' wonder in the 
 newspapers. He was a fifteen-year-old boy who was "rescued" 
 from a dark cellar where his mother had kept him five months. 
 The older medical textbooks used to tell of certain "wolf 
 boys," of whom the celebrated Caspar Hanser was one of the 
 first to bring up the problem whether an absolute lack of normal 
 education would so dull or retard development as to produce 
 in itself insanity or feeble-mindedness. The wolf-boy question 
 hardly admits a general answer. No doubt many of the wild 
 waifs picked up in the woods are actually feeble-minded or 
 victims of dementia praecox. John Henry was not in that 
 sense a wolf boy. He had been kept in his cellar on 1 strange 
 hypothesis. His mother had kept him back in school ; she 
 persuaded the teachers to hold John back on the score of his 
 feeble-mindedness. 
 
 Naturally, after John's somewhat picturesque rescue, he be- 
 came the especial object of the psychologist's attention. Mira- 
 bile dictu, John graded virtually at normal. At a chronological 
 age of fifteen and a half years, his Point Scale level stood at 
 16, and his level on the Stanford scale stood at 15.5. 
 
 This case so well illustrates the peculiar and critical advan- 
 tages of mental tests in certain instances, that we here trans- 
 
THE KINGDOM OF EVILS 183 
 
 cribe a large portion of a special report made by the psycholo- 
 gist at the Psychopathic Hospital, Dr. Josephine Foster.^ This 
 report includes some notes upon John's present situation and 
 progress. 
 
 REPORT OF A CASE IN WHICH ENFORCED SECLUSION DID NOT 
 PREVENT INTELLECTUAL DEVELOPMENT 
 
 The psychologist who gives "mental tests" is frequently met 
 by the statement : "This low mental age means nothing because 
 the child has been sick and has not been a regular attendant 
 at school" or by : "You can't expect a child who has lived on 
 a lonely farm and who has had no playmates to test at age." 
 In vain may the psychologist answer : "I admit that inability 
 to read may lower the mental age with a scale like the Binet 
 or the Point Scale. In other respects, however, school training 
 has little influence on the outcome of psychological examina- 
 tions." Such a reply usually fails to carry conviction to one 
 who is not an experienced examiner. Instead, an objector is 
 likely to depart, thinking that the psychologist is grossly ex- 
 aggerating the importance of the tests, resolving to take mental 
 ages in the future with as large a grain of salt as ever, and 
 continuing to consider the mental age only when it agrees with 
 his personal opinion of the case. 
 
 In our work at this hospital we have come to use the answer : 
 "Let me tell you about a fifteen-year old boy we examined some 
 months ago." The illustration has been so successful that we 
 offer it here to other psychologists for similar use. 
 
 John Henry (this, of course, is not the real name, but it is 
 like it in having the same second name, which the boy spelled 
 Henery) was born in a rather poor district of a New England 
 city on August 13, 1902. Of his remote ancestors we know 
 comparatively little. Presumably his paternal grandparents 
 were natives of Ireland. His maternal grandparents are said 
 by one of our informants to have come from England and 
 Scotland, and by another to have been born in Nova Scotia 
 and Maine. We have one history which says that a maternal 
 uncle died in an insane asylum. Another maternal uncle, who 
 came to the hospital upon request, is reported to have been 
 insane, and appeared to be very unintelligent and was consid- 
 
 1 Foster, Josephine Curtis. A Case in Which Enforced Seclusion Did Not Pre- 
 vent Intellectual Development. In Journal of Applied Psychology, June, 19 19. 
 
184 THE KINGDOM OF EVILS 
 
 ered as "probably untrustworthy in his statements." This uncle 
 denied mental illnesses in the family, but at the same time 
 showed such familiarity with hospitals for the insane as to 
 suggest personal acquaintance. Of the boy's immediate family, 
 the father was born in Ireland, and was probably a horse- 
 trainer. He was heavily alcoholic, abused the children, and 
 some five years ago deserted the family. John's mother was 
 born in New England. She was at this hospital for a time, 
 and is now an inmate of a state hospital for the insane with a 
 diagnosis of dementia praecox, paranoid. Four of John's 
 siblings are said to have died of starvation in the first year. 
 An older half-sister is apparently normal. 
 
 The schooling of John and this half-sister Julia was decidedly 
 meager. They were allowed to attend school occasionally, but 
 although both of them learned to read, they acquired little else. 
 If we could add together all the days John spent in school, they 
 might come to three years. We know that the family moved so 
 frequently (at least eleven times in five years) that he could 
 seldom have spent a full term in any one school. John was 
 last in the fourth grade. He attended school in this grade 
 irregularly for some years. Apparently he was not held from 
 advancement on account of dullness, but because the mother 
 went to the teacher and said : "Don't waste any time over this 
 boy of mine. He is feeble-minded and will never learn, no 
 matter how much effort you expend on him." Apparently, 
 also, the teacher believed the mother who was so candid about 
 the failings of her son, accepted her advice, and spent her 
 energies on the other children. 
 
 As might be expected under the guidance of such a mother, 
 home life was not an aid to John's mental development. Julia 
 says that her earliest remembrances are of squalid surround- 
 ings, a room or two with the poorest of furnishings, which 
 were never anything but filthy. She had very little clothing, 
 and at times such a small amount that she was forced to stay 
 indoors. John says that his mother would buy him new clothes 
 and then lock them up till he had outgrown them. Moreover, 
 there was never enough food, and the children were continually 
 hungry. The mother and stepfather beat Julia and obliged her 
 to chop wood and do all the work. In her presence they also 
 indulged in perverse sexual practices. John was not abused to 
 the same extent, probably because he was the father's own 
 
THE KINGDOM OF EVILS 1 85 
 
 child. However, the only attempt to teach him anything was 
 his father's instruction in obscene verses and songs. 
 
 John and Julia had not even the opportunity to learn from 
 contact with other children. Their mother often kept them in 
 the house, and this happened still more frequently after the 
 father deserted. Even when the mother was away scrubbing 
 in the middle of the day, the children dared not venture out for 
 fear there might be some truth in their mother's statements 
 that "there was a God overhead who would do various things 
 to them, that the policeman would get them and do terrible 
 things, that people would kill them," and later, when Julia 
 was living elsewhere, the mother told John that "they would 
 jatch him in the draft," — a hazy, but horrible fate. 
 
 John's story of his life is of a succession of moves from 
 house after house, with periods of confinement varying from 
 a few days to one that lasted thirteen months. Most of the 
 day time he slept or amused himself by reading the Bible, the 
 few religious books, and the few Indian stories which they 
 owned. When the mother returned from her work, he seems 
 to have been occupied with endeavoring to escape her wrath. 
 He says that she would ask him questions and then answer 
 them herself. H he attempted a reply, she usually slapped his 
 face. She talked continually of the references which the news- 
 papers made to her, and of the pictures the moving-picture men 
 were taking of her. They had no regular meals. The mother 
 probably ate something at the restaurant where she did scrub- 
 bing, but all she brought home to John was bologna sausage, 
 milk, crackers, and bread. When he came to this hospital, the 
 boy had not had a hot meal in months. At night he was often 
 kept awake by his mother's talking, by what he called "mother's 
 lies." 
 
 Things went from bad to worse with John, but they im- 
 proved for Julia in the spring of 191 7. At that time the mother 
 accepted a position as "an experienced cook" and took the 
 children with her. On the third day she was discharged as 
 dirty and hopelessly incompetent. Julia, however, was retained 
 and since that time has had normal surroundings. John and 
 his mother returned to their squalid living, and the boy was 
 confined even more closely until early in 1918, when the police 
 and one of the children's societies found them and brought 
 them both to this hospital. 
 
1 86 THE KINGDOM OF EVILS 
 
 When John was examined here, he was a large, overgrown 
 boy, sallow and anemic. His voice was husky and uncertain. 
 He did not know how to meet strangers, and was shy and 
 reserved. His face was a little sober, but almost expressionless. 
 He smiled slightly and then only after many interviews. He 
 answered all questions as briefly as possible. The most sur- 
 prising thing about his attitude was that he took practically 
 no interest in his surroundings or in what was to happen to him. 
 John's ignorance of the world about him was astounding. He 
 could name the president, the governor, and several recent 
 mayors, but when asked for the capital of Massachusetts he 
 did not understand what was meant. He knew nothing what- 
 ever of geography. With the exception of reading, arithmetic 
 was the only school subject in which his performance was at all 
 creditable. He had never seen a moving picture or a baseball 
 game. 
 
 We have here, then, a boy of fifteen and a half, who has 
 had practically no school training, practically no contact with 
 other children, and no home education save what he may have 
 picked up from the reading of a few religious books, and per- 
 haps a stray copy of a newspaper. 
 
 In spite of this overwhelming lack of information and of 
 training, when given a psychological examination, John re- 
 ceived a mental age of 16.0 (I. O., 104) on the Yerkes- 
 Bridges Point Scale, and a mental age of 15 yr. i mo. (I. Q., 
 .98) on the Stanford Revision of the Binet. There is nothing 
 in the examinations that would be unusual in a normal boy of 
 his age. On the Point Scale the errors he made were in : repe- 
 tition of seven digits, repetition of the longest sentence, failure 
 to give interpretation for two of the pictures, failure to give 
 definitions in terms of classification, acceptance of the line sug- 
 gestion, failure in one of the memory drawings, in one of 
 the definitions of abstract terms, and in one analogy. On the 
 Stanford Scale, he passed all the 9 year tests, failed in designs 
 from memory in year 10, an interpretation of pictures in year 
 12, in the vocabulary in year 14 and the succeeding years, in 
 giving differences between abstract words, in repeating back- 
 wards, and in the code in year 16, and in the repetition of digits 
 forwards and backwards and in giving the thought of a passage 
 in year 18. His arithmetical ability is particularly evident in 
 
THE KINGDOM OF EVILS 187 
 
 the Stanford examination. He did the Healy Construction 
 Puzzle A in seven moves in fifteen seconds and Construction 
 Puzzle B in twelve moves in thirty seconds. His attitude dur- 
 ing the psychological examination was somewhat listless and 
 a bit childish, but he cooperated well and showed occasional 
 interest and pleasure. 
 
 The conclusion must be that, in this case, at least, lack of 
 school education, lack of home training, and lack of normal 
 intercourse with other children have not prevented a normal 
 rating on intelligence scales. 
 
 John's subsequent history, while not of consequence for our 
 purpose, is, nevertheless, interesting. He was discharged from 
 this hospital with the diagnosis "not insane, not feeble-minded." 
 We hoped that it would be possible to give an examination at 
 the expiration of his first year of living in normal surround- 
 ings. This proved inadvisable because the boy is doing good 
 work on a farm, and a trip to the city might encourage his 
 present ambition to work in a store, a job which doubtless 
 would not fit him just now. The society, however, sent us a 
 detailed report of a "visit" made, and we give the substance of 
 that report here : — 
 
 John is living on a farm with a family who understand his 
 case and are anxious to assist him in every way possible. He 
 has gained in weight since last year and he looks physically 
 well. However, he is very slow in his movements, and appears 
 to take no interest in his surroundings. He seemed little af- 
 fected by the fact that the visitor had come from Boston to see 
 him, and the family say that this is his usual attitude. In the 
 year that he has been with them, he has never spoken of his 
 mother and sister, has never asked questions about places to 
 which he has been taken in the automobile, or shown any inter- 
 est in them. The only exception was one trip to the ocean 
 when he asked, "Why can't you see the other side?" He has 
 never spoken of the trip since. His typical day is as follows: 
 Rises at six without being called, feeds the horses without 
 being told, milks three cows, comes into the house for breakfast 
 without being called, eats a hearty breakfast, then, without any. 
 comment, returns to work, waters the cows, and cleans up the 
 barn. He comes back to the house about meal time, gets the 
 mail from a box at the end of the lane without reading any 
 addresses or ever asking if there is a letter for him. After the 
 
1 88 THE KINGDOM OF EVILS 
 
 noon meal he takes care of the hens and does odd jobs. In the 
 summer time he goes for the cows. After supper he reads the 
 jokes in the daily paper and Farm Journal, sometimes smiling 
 a little. He never grumbles while doing anything he is asked, 
 never asks a question, very seldom speaks without being spoken 
 to, goes to bed without being told to at six-thirty and is per- 
 fectly willing to do this day in and day out. In fact, far from 
 disliking routine, he is somewhat disturbed when rain prevents 
 the performance of some of his usual chores. He shows no 
 interest in anything. He is good to the animals but never pets 
 them and the dog and cat never ask him for food. He never 
 notices anything unusual. If. for example, a cow were in great 
 distress and he had not been told to notice whether or not the 
 cow was sick, he would make no comment. Neither is he at 
 all interested in the fact that the farmer is willing to give him 
 fifty dollars if he remains with him a full year. Besides this 
 total indifiference, the farmer and his wife have reported sev- 
 eral facts which are of importance in the prognosis of the case. 
 He has recently been smiling more often, and occasionally 
 laughs heartily when alone at his work. When asked what 
 he was amused at, he insists that he did not laugh. He has 
 never made any attempt to play with a boy who lives in the 
 next house, a quarter of a mile away. It seems likely that the 
 boy may end by having dementia praecox, like his mother. 
 
 From the above account as published by Dr. Foster, it will 
 be seen that our initial idea in presenting John Henry ; namely, 
 that he might be regarded as an instance of purely educational 
 deficiency minus all four other forms of social defect that we 
 classified in this book, medical, moral, legal, and economic, is 
 destined to prove unsound. Perhaps, in short, we did regard 
 John Henry as a combination of psychopathic trend and educa- 
 tional defect. He brings out so purely and picturesquely, how- 
 ever, what lack of education cannot do that we have determined 
 to keep him in his place in the series to portray a singularly 
 simple instance of educational deficiency. 
 
 Hours spent by Medical record, 25 pages 
 
 Social record, pages 
 Physician, 4V2 Social work: 
 
 Visits, 
 Psychologist, 1 Interviews at hospital, o 
 
 Telephone calls, o 
 Social worker, o Letters, o 
 
THE KINGDOM OF EVILS 189 
 
 Girl who fabricated and ran away from home. Mother of 
 two illegitimate children. 
 
 Case 36. Clara Perkins' difficulties are all in the moral 
 sphere. She was an average scholar, graduating from the 
 grammar school at fourteen; and she qualified for entrance to 
 a nurses' training school, where she spent a few months in 
 training. She had had no difficulty in supporting herself ; and 
 her family, although they find it hard to make both ends meet, 
 manage to keep out of debt. With public authorities Clara has 
 had no contact. When she was under observation in the Psy- 
 chopathic Hospital at the age of eighteeen, the diagnosis made 
 was psychopathic personality ; but after she had been under 
 supervision for a year and a half, the opinion of the physician 
 in charge of the out-patient department was that this diagnosis 
 was a mistake. He considered her normal and sufficiently 
 stable to undertake nurse's training. By psychological tests 
 she graded at adult age and did still better in the supplemen- 
 tary tests upon another examination a year after the first. 
 
 The cause of her examination at the Psychopathic Hospital 
 was a series of fabrications that began about a year earlier. 
 The following account is taken from the social record : — 
 
 Since January, 191 5, patient has systematically and success- 
 fully deceived her mother and associates as to the work she has 
 been doing. To her employer and fellow employees she told 
 stories of being engaged, of the abuses of her parents who had 
 "sold her into virtual slavery" at fifteen to a man by whom 
 she had a child. She told of being an illegitimate child herself. 
 To her dentist she told elaborate tales of abuses by her parents 
 and the discovery of her real father. She maintained the 
 family were trying to force her to marry someone she did not 
 want to. To her family and neighborhood friends she gave 
 minute details of her nurse's training course and the visiting 
 nursing among the poor which she was doing. She stayed 
 away from home, ten days at Hotel Cambridge and three or 
 four days at Tremont Street lodging house, on a pretext of 
 being "on cases." She wrote two long letters to her dentist 
 and once sent for him to see her at Hotel Cambridge which he 
 did. To her family and to employers' children she introduced 
 some man by different names. She explains later this was a 
 chauffeur friend of a girl working in neighborhood. No other 
 suggestion or positive history of sex delinquency. 
 
IQO THE KINGDOM OF EVILS 
 
 During this period of lying patient's habits were as regular as 
 before. She left her place of employment to be married she 
 said, and her mother's telephoning there to find out where she 
 was disclosed the truth. Patient went constantly to moving 
 pictures and could remember a film a year back as vividly as 
 though she had just seen it. They affected her so much that 
 she imagined herself as playing some of the parts. 
 
 Clara's father had been alcoholic for a time and her paternal 
 grandfather and great-grandfather were insane. Her mother 
 comes of good stock, but is a delicate "nervous" woman. The 
 other children, three little brothers, are well. A half-sister and 
 a half-brother, who live in the city, are married and successful, 
 and take a good deal of interest in Clara. Except for the 
 narrow limits of the family income (Mr. Perkins earned about 
 fifteen dollars in a garage) Clara's home life should have been 
 on the whole comfortable and happy. They had been in more 
 comfortable circumstances in Nova Scotia, but Mr. Perkins 
 lost his position through drink, and so nine years before they 
 had come to Boston for a new start. Mrs. Perkins had always 
 "kept a girl" and had not been used to the heavy work in the 
 house that she now had to do. Mr. Perkins no longer drank 
 to the point of intoxication, but enough to affect his disposition 
 at home. Clara was very fond of her family but afraid of her 
 father and jealous of his attention to the younger children. 
 She was very affectionate and would sometimes cry if she did 
 not receive the attention she desired. With her mother she 
 often got into little quarrels, as both were quick-tempered, and 
 Clara was apt to feel that her mother did not understand her. 
 She never went out in the evening and had no girl friends ex- 
 cept her half-sister and sister-in-law; and she had never "gone 
 out" with young men. The home was neat and pleasant, but 
 she was ashamed of it, because "the stair carpet had been taken 
 up" and not replaced. 
 
 After leaving school Clara worked in eight different places 
 within four years as bundle girl, laundry worker, and nurse- 
 maid. She was never discharged but changed about from rest- 
 lessness. She had no ambition except a vague desire to become 
 a nurse. 
 
 When she left the hospital she was taken to a general hos- 
 pital for the removal of tonsils and adenoids and after some 
 weeks in a convalescent home was gotten a position in a laun- 
 
THE KINGDOM OF EVILS IQI 
 
 dry. Her eyes were examined for glasses and a fallen arch 
 was strapped at a general dispensary. After a few months she 
 left her position when a raise of wages was refused, and for 
 several days went about the city looking for work and conceal- 
 ing her unemployment. After this she seemed physically tired 
 and could give no clear account of how she had spent the time. 
 This was the only recurrence of her deceptiveness until over 
 three years later, when, a year after the case had been closed, 
 her mother came to us in alarm because Clara had "begun her 
 fabrications" again. She had been telling extravagant false 
 stories about her half-sister with whom she was living, which 
 stopped at once when she heard that her mother had consulted 
 the hospital. 
 
 Work away from home was tried next and a position as 
 maid in a small out-of-town hospital obtained for her. She 
 gave satisfaction in her work and was advanced to greater 
 responsibility. Her conduct was satisfactory also. Two young 
 men whom she met in the town proposed to her and her attitude 
 toward them seemed to be sensible and dignified. To one of 
 them she was about to become engaged when he enlisted and 
 was sent to France. Clara decided not to be formally engaged 
 to him until his return. She wanted very much to enter a train- 
 ing school for nurses and was not opposed. After a few months 
 she was doing so well that we felt we could close the case. We 
 were influenced in this decision by the fact that the social 
 worker who had dealt with Clara's case from the beginning was 
 leaving. Although we felt that another year of supervision 
 would be required before we could feel satisfied that Clara was 
 in a stable condition, between the difficulty of introducing a 
 new social worker to the case and the pressure of new work, 
 we decided to close the case, unwisely as the event showed. 
 We inquired of Mrs. Perkins in December, 1918, and were 
 told that Clara was doing well; that she had given up the 
 nurse's training which proved to be too hard for her, but was 
 working in a mill and living with her half-sister, and that she 
 heard from the young man in France who had asked her "to 
 wait for him." When three months later the family were 
 alarmed at signs of a returning tendency to fabricate and Mrs. 
 Perkins came to us for advice, she told the real reason for 
 Clara's leaving the training school — she had become pregnant. 
 
 When she left the maternity home where she was confined, 
 
192 THE KINGDOM OF EVILS 
 
 she boarded the baby with a friend of her mother and went to 
 live with her half-sister, whose husband was willing to have 
 the baby come, too, when it should be a little older and less 
 care. Clara claimed that she had written the whole story to a 
 soldier in France to whom she was "half engaged" and that he 
 had replied in a fashion that led her to hope he still expected 
 that they would be married. The case was reopened for super- 
 vision of the baby's health (the child was found to be in poor 
 condition), of Clara's health (for she had been having more 
 trouble with the arches of her feet), and to steady Clara during 
 this period, while she was expecting the return of her fiance. 
 
 When the soldier returned, however, he disclaimed an 
 engagement to Clara and married another girl. In the mean- 
 time Clara had become pregnant again. The only account of 
 the parenthood of this child that could be obtained was her 
 story of an assault. The first baby she placed for adoption 
 against our advice, and with the second baby she went to nurse 
 during confinement the wife of the young soldier to whom she 
 had claimed to be engaged. She filled this position with a 
 good deal of ability, and when her services were no longer 
 needed, she went with her baby to keep house for a small 
 family at their summer home in the country. Here she is 
 well liked and is highly commended for her ability in cooking 
 and managing. 
 
 Hours spent by Medical record, 38 pages 
 
 Social record, 54 pages 
 Physician, 7 Social work: 
 
 Visits, 38 
 Psychologist, 2 Interviews at hospital, 53 
 
 Telephone calls, 15 
 Social worker, 69 Letters, 13 
 
 Overfrugal tailor in court for non-support. Attention of 
 legal authorities to social and medical facts. 
 
 Case 37. Perhaps the Psychopathic Hospital should not 
 have handled such a case as Nathan Blumberg, presented as a 
 paradigm of relatively pure legal difficulty. Yet we can readily 
 show a dark reflex of legal trouble upon several other sides of 
 the man's life. In no sense of heroic proportions, just such 
 
THE KINGDOM OF EVILS 193 
 
 gray or drab difficulties form the stock-in-life of a number of 
 "normal enough" persons, whose best aid will probably turn 
 out to be aid from social psychiatry. As in novels of Balzac 
 the characteristic legal troubles not unreadily find a psycho- 
 pathic figure in their midst or at least a figure which has a 
 soitpgon of mental disease about it, so in cases like Blumberg's. 
 Blumberg was even at one time provisionally classified as 
 falling in the group of psychoneurotics, but on the v/hole no 
 satisfactory diagnosis of the sort can be offered, or perhaps 
 any psychiatric diagnosis. 
 
 Amongst the social symptoms in case Blumberg we find such 
 items as the following : arrest, separation from family, partial 
 industrial disability, unemployment, family dissension. In 
 point of fact, Blumberg was never seriously disabled, indus- 
 trially speaking, save as the immediate result of his legal 
 tangles. 
 
 Blumberg was a Russian Jew, one of twelve siblings. There 
 were apparently no psychopathic or especially neurotic features 
 in his family. He had not attended school in Russia and main- 
 tained that there were no schools where he was born. Never- 
 theless, he had in America learned to read English. He had 
 learned tailoring from his father in Russia. He had been in 
 the Russian Army before the Russo-Japanese War and came 
 to America in 1904 to escape service in the army. He had 
 already married at the age of twenty-six a quarrelsome wife, 
 from (as he said) a quarrelsome family. He came to America 
 without his wife. Finally, in the course of eighteen months, 
 he sent for his wife. He had now become a bushelman tailor. 
 Soon, however, the wife's complaints about money and her 
 extravagance began to grate on Blumberg, who himself had 
 an ambition to save every cent. He loaned money to a pros- 
 perous brother-in-law, but when he tried to get the money back 
 a year later, he found that his wife was spending some of it. 
 By the time the whole of the money was returned, Mrs. Blum- 
 berg had bought a fur coat with two hundred dollars of the 
 sum. 
 
 Then came quarrels. Once the Blumbergs came to blows. 
 According to Blumberg, his wife struck him first, as she 
 "would not take him right." Blumberg was forthwith arrested 
 and was triumphantly informed by his wife that "in this coun- 
 try a lady can do as she pleases." The case was filed, but he 
 
194 THE KINGDOM OF EVILS 
 
 moved to another city whither his wife followed him some 
 months later. With Blumberg's money Mrs. Blumberg started 
 to run a shop with one of the boarders that she had been 
 taking. Blumberg became suspicious that his wife was not 
 true to him, but the suspicion was rather of her general loyalty 
 than of any sex delinquency. Now shortly the wife began a 
 suit for separate maintenance, and the newspaper publicity 
 caused him again to remove, this time with two of his children, 
 to a relative's farm. Then came the decree that he pay fifteen 
 dollars a week for the support and care of his children and 
 that meantime all the children should live with the wife, but 
 visit Blumberg with reasonable frequency. 
 
 Blumberg had not of late been working steadily. He finally 
 appeared at the Psychopathic Hospital out-patient department, 
 coming alone and complaining that for the past year he had 
 often been chilly all over, that he had had pains in all his bones 
 and dizziness in his head which was worse on windy days, that 
 he had slept poorly, that he had had bad dreams and was sweat- 
 ing profusely at night. 
 
 Upon investigation it appeared that the cause of the legal 
 entanglements was chiefly financial, due to a conflict between 
 Blumberg's ambition to save and Mrs. Blumberg's contrary 
 ideal. Blumberg could not pay the maintenance allowance. It 
 is somewhat edifying, though not amusing, to find that when 
 Blumberg could not pay the allowance, he was adjudged (after 
 some correspondence) to be under contempt of court and 
 actually was committed to jail until he should pay one hundred 
 dollars. He was bailed out two days later and fled to New 
 York City. He wrote asking what he should do next, was 
 advised to return and try to make it up with the court and 
 did, in fact, come back to Boston; but before he could be seen 
 by the physician with whom he was on friendly terms, he 
 walked out and has not since been heard of. 
 
 It is a question in our minds whether what might be termed 
 the "frightfulness" of the jail order has not tended to sever con- 
 nections completely between Blumberg and his family. Some- 
 times inexperienced courts talk about "these cases" without, so 
 far as we are aware, defining to what group ''these cases" ac- 
 tually belong. We are not ourselves sure that we are dealing 
 fundamentally with a "case," medically speaking. A case with 
 such indefinite mental symptoms or features suggests that pro- 
 
THE KINGDOM OF EVILS I95 
 
 found allowances should be made for errors in handling; much 
 hangs on whether Blumberg is psychoneurotic or is not psycho- 
 neurotic. It seems clear that his legal handling has not been 
 based upon as thorough a knowledge of the everyday facts as 
 lay directly at the hand of the court. 
 
 It is not that the wife's story was particularly appealing in 
 contrast to Blumberg's, for no one has asserted that Mrs. 
 Blumberg's moral attitude was of the most exquisite. Our 
 present point simply reduces to the feeling that proper atten- 
 tion is not always paid by legal authorities to social and medi- 
 cal facts. Nor will it much longer serve for the legal authorities 
 in these modern days to justify themselves by the vague gener- 
 ality that we lawyers understand these things whereas you lay- 
 men exist in the penumbra. We are bound to say that some- 
 times these matters are not attended to in extcnso and in all 
 their profundities by the judges themselves, but rather by the 
 clerks of courts and probation officers, some of whom are not 
 yet educated (even by prolonged "practical" experience) in 
 psychiatric social work. 
 
 Hours spent by Medical record, 6 pages 
 
 Social record, 16 pages 
 Physician, 4Y2 Social work: 
 
 Visits, I 
 Psychologist, o Interviews at hospital, 6 
 
 Telephone calls, i 
 Social worker, 9 Letters, 24 
 
 Poor old woman, zvorried and overworked. 
 
 Case 38. Though Margaret Dolan came to us as a patient, 
 her difficulties were almost entirely financial. The medical 
 opinion after she had been observed for ten days in the hospital 
 was "not psychotic." Her mental condition was the result of 
 well-founded worry. For nine months she had been in con- 
 siderable anxiety about debts, doctors' bills, and even the 
 means of subsistence. She suffered from indigestion, which 
 four doctors in turn had not been able to relieve, and was 
 afraid to eat for fear of increasing her stomach trouble. She 
 was afraid that she would go insane and spoke of feelings of 
 unreality, saying "I feel I am way ofif in some other world." 
 
196 THE KINGDOM OF EVILS 
 
 Educationally Margaret was not lacking, — after graduating 
 from high school, she had studied bookkeeping; and she was 
 far removed from conflict with public authorities. But her 
 financial difficulties loomed large. 
 
 She was fifty-two years old, and her sister Annie, with whom 
 she lived, was fifty-nine. They were two gentle little old ladies, 
 of frail physique and brave hearts. Annie was the more 
 optimistic and had "always looked on the bright side of things" 
 but Margaret always worried a bit. They took two lodgers in 
 their tiny apartment and while Margaret did the housework 
 Annie worked in a shoe factory, getting from seven to twelve 
 dollars a week. In this way they were able to have a more 
 comfortable home than if Margaret, too, had gone to the shoe 
 factory. She had expected to be a bookkeeper, but soon after 
 she took her first position she was called back home to nurse 
 ■her mother through an illness of years, and again after working 
 for a short time went home to nurse her father until his death. 
 ■fifteen years ago. Then she and her sister came to the city 
 to keep house for their brother. He drank heavily and finally 
 eight years before had disappeared. The sisters continued to 
 keep their home and got along comfortably, until Annie was 
 laid ofif during a slack season, one of the lodgers left, and Mar- 
 garet began to have indigestion. For doctors' bills for Mar- 
 garet and living expenses they had gradually borrowed two 
 hundred and fifty dollars and they could barely meet their living 
 expenses. They could not afiford to pay for the refitting of 
 Margaret's artificial teeth, which did not fit properly and 
 caused her difficulty in chewing. 
 
 After reassurance and three weeks' rest in the country, and 
 a new plate for the teeth, Margaret had gained fourteen pounds 
 and felt much better. It was several months before she would 
 venture alone on the street. She held two hundred and fifty 
 dollars life insurance for her brother, whom the sisters 
 believed to be dead. This money was finally secured through 
 a friendly lawyer to pay ofif the debt that was worrying them. 
 Lighter work was to be found for Annie, as army shoes made 
 heavy work for the frail little woman ; but she developed cancer 
 and soon had to be sent to a hospital where she died in a few 
 months. Aid from a relief society was obtained for Margaret, 
 who kept the home and visited her sister every day in the 
 hospital. After Annie's death, she was well enough to take 
 
THE KINGDOM OF EVILS I97 
 
 a position at housework. During her sister's illness many of 
 her old friends renewed their interest in her. She no longer 
 had a sense of unreality or feared to go about alone and seemed 
 quite capable of taking care of herself. 
 
 Hours spent by Medical record, 17 pages 
 
 Social record, 27 pages 
 Physician, 8 Social work: 
 
 Visits, 47 
 Psychologist, o Interviews at hospital, 10 
 
 Telephone calls, 64 
 Social worker, 90J/2 Letters, 25 
 
BOOK III 
 
Oh that my vexation were hut weighed, 
 And all my calamity laid in the balances. 
 
 Job, Chapter 6, Verse 2. 
 
ELEVEN MAJOR GROUPS OF MENTAL DISEASES 
 
 Illustrated in Sixty-two Specimen Cases of 
 Psychiatric Social Work 
 
 I. General paresis, juvenile 
 
 paresis, etc. 
 II. Feeble-mindedness of vari- 
 ous forms. 
 
 III. Epilepsies. 
 
 IV. Alcoholic, drug, and 
 
 poison cases. 
 V. Focal brain lesion cases 
 
 (mental). 
 VI. "Symptomatic" mental 
 cases (bodily origin). 
 VII. Senile, senescent, pre- 
 senile cases (old age 
 group). 
 VIII. Dementia praecox; para- 
 phrenia. 
 IX. Manic-depressive psy- 
 
 choses ; cyclothymic. 
 X. Hysteria, neurasthenia, 
 psychasthenia. 
 XL Dubious and special psy- 
 chopathias. 
 
 Syphilopsychoses 
 
 Hypophrenoses 
 
 Epileptoses 
 Pharmacopsychoses 
 
 Encephalopsychoses 
 
 Somatopsychoses 
 Geriopsychoses 
 
 Schizophrenoses 
 Cyclothymoses 
 Psychoneuroses 
 Psychopathoses 
 
 Note. — This book is intended to give the physician a general view of 
 the social-psychiatric problems in the main mental disease groups. 
 
SECTION I 
 
 SYPHILOPSYCHOSES ( NEUROSYPHILIS) 
 
 Costly delay of diagnosis in a case of general paresis that 
 looked like neurasthenia. Industrial disability for five years. 
 Social work — free treatment and home care. 
 
 Case 39. We begin now to present social cases from the 
 medical point of view. The psychiatric social worker (and 
 eventually the layman too) must learn that insanity is not a 
 unit. There can be no better way of grasping the fact that 
 insanit)', though legally a unit, is not medically a unit, than 
 by considering cases of syphilis of the nervous system (briefly 
 put, neurosyphilis) giving rise to mental symptoms. 
 
 We may begin with the case of Greeley Harrison, a case 
 already presented from the medical point of view in the case 
 history, Neurosyphilis by Southard and Solomon, 191 7 (case 
 9 in that collection). These authorities put Greeley Harrison 
 first in every account of the systematic diagnosis of the main 
 forms of neurosyphilis because they desired to impress the med- 
 ical profession with the costly delay of diagnosis in that form 
 of neurosyphilis known as general paresis. 
 
 ''W^hy was not I told that my disease was syphilis five years 
 ago?" Harrison was wont to say after he had come under medi- 
 cal treatment at the Psychopathic Hospital at the age of forty- 
 six. In point of fact, we found that for a number of years 
 past there had been symptoms which should have attracted 
 medical attention. Five years before he came to our observa- 
 tion, namely, at the age of fort\'-one, Harrison had been ap- 
 parently overcome when working near a stove, and afterwards 
 went upstairs, talking incoherently. However, he recovered 
 shortly, and nothing was thought of the episode. Spells oc- 
 curred almost every month for a time, and later still more 
 frequently. Finally these spells became associated with uncon- 
 sciousness and with loss of memory. 
 
 It is no part of the task of this book to give the details of 
 
 203 
 
204 THE KINGDOM OF EVILS 
 
 medical diagnosis or treatment. From the standpoint of the lay 
 observer, the fact was outstanding that Harrison had for five 
 years been unable to do regular work. What misled the medical 
 inquirer, and this is a lesson for physicians and laymen in all 
 forms of mental disease as well as in the present form, was 
 that Harrison's constant complaining would set him down as a 
 kind of neurasthenic or psychasthenic. It would be stretching 
 a point to say that his ideas were delusions, that is, demonstra- 
 bly false beliefs, but he continually dwelt upon bodily symp- 
 toms, after the manner of the psychoneurotic (under the so- 
 called psychoneuroses the psychiatrist is apt to include neuras- 
 thenia and hysteria). Harrison approached sundry physicians 
 for aid, complaining of nervous indigestion of years' standing, 
 of headache, of insomnia, of nervousness, of failing memory, 
 and of deafness. After one knew that Harrison was a neuro- 
 syphilitic it was, of course, easy to point out that headache and 
 failing memory might well have suggested syphilis. However, 
 a number of physicians told him that he was a neurasthenic, 
 and when he arrived at the Psychopathic Hospital he announced 
 that neurasthenia was the disease from which he was suffering 
 and that he had been treated for this disease by hypophosphites. 
 The so-called six tests (blood serum Wassermann, spinal fluid 
 Wassermann, globulin and albumen reactions of spinal fluid, 
 cell count and gold sol. on spinal fluid) proved positive. The 
 medical diagnosis seemed, beyond much question, to be that 
 of general paresis. 
 
 The medical lessons of this case are: — 
 
 I. Neurosyphilis, even in its paretic form (so-called general 
 paresis or "softening of the brain") may look to the physi- 
 cians like that purely functional disease, neurasthenia. 
 (For an example of pure neurasthenia see below, case 87.) 
 2. Neurosyphilis, in its paretic form, is not necessarily com- 
 pletely intractable to treatment. (This is a most important 
 conception, not yet well established in the medical mind.) 
 And on account of the doubt which prevails concerning 
 general paresis and its inevitable non-responsiveness to 
 treatment, we shall need to look further into the medical 
 history of. case Harrison. 
 
 . Harrison has had a great deal of antisyphilitic treatment 
 including mjections into the ventricles of the brain. He has 
 continued in about the same state mentally : that is, there is a 
 
THE KINGDOM OF EVILS 205 
 
 considerable degree of deterioration and he has occasional 
 seizures. He is in a state hospital where he has charge of the 
 patients' dining-room. Physically he is in rather good condi- 
 tion. His laboratory tests are now quite normal. He seems 
 to have been held stationary for the past four years. 
 
 The social work consisted in getting Harrison free treatment, 
 encouraging his mother, and seeing for how long he could 
 receive suitable care at home. His mother and sister worked 
 and supported him. He had used up considerable savings 
 when he came to us and had nothing of value left except a fur 
 coat. 
 
 Hours spent by Medical record, 55 pages 
 
 Social record, i page 
 Physician, 23^2 Social work: 
 
 Visits, o 
 Psychologist, I Interviews at hospital, 6 
 
 Telephone calls, o 
 Social worker, 3 Letters, 
 
 Widow with syphilis contracted from an abusive husband. 
 Well for fourteen years. Now marked depression. Treatment, 
 rest, employment. 
 
 Case 40. Another case from Southard and Solomon's 
 Neurosyphilis, Greta Meyer, (107 of that collection) is one 
 of neurosyphilis, not of the type of so-called general paresis or 
 "softening of the brain" but of a more diffuse type of disease, 
 or, as commonly termed in medicine, "cerebrospinal syphilis." 
 
 This widow of fifty-one came of her own volition to the 
 Psychopathic Hospital wanting aid from the physicians for a 
 marked depression. It seems that she had lain down one day 
 for a nap and on waking up found that she could move her 
 right arm and leg only with great difficulty. She got much bet- 
 ter in a few days. 
 
 Going back in her history, it appeared that two years before, 
 at forty-nine, a small swelling had appeared on the right side 
 of the forehead near the hair line, a swelling that was firm and 
 not sore. Treatment, evidently antisyphilitic, reduced this 
 swelling but left a hollow space in the bone. 
 
 Going still farther back in her history, it appeared that 
 
206 THE KINGDOM OF EVILS 
 
 some sixteen years before her coming to the Psychopathic 
 Hospital, namely at the age of thirty-five, she had developed 
 some red spots on her hand which she learned at a hospital 
 were due to syphilis. She was treated rather faithfully for 
 these spots for a year's time, whereupon she seemed perfectly 
 well and, in fact, remained perfectly well for fourteen years. 
 Going still farther back in Mrs. Meyer's history, it seems that 
 she was married at sixteen and lived with her husband until 
 twenty-nine, but at this time she left him on account of his 
 being alcoholic and abusing her, and on account of her dis- 
 covering, through his physician, that he was sufifering from a 
 venereal disease. 
 
 As is mentioned more in exfenso in the Neurosyphilis case 
 history book, the diagnosis of a diffuse neurosyphilis, possibly 
 associated with a plugging of arteries, was then made. 
 
 After she had improved under salvarsan treatment, she then 
 became also a problem for social workers in certain respects. 
 She was referred to the social workers for employment and 
 rest. She was accordingly given some three weeks of rest in a 
 convalescent home. Some temporary jobs were then secured. 
 The depression for which she had originally consulted the hos- 
 pital was greatly diminished during this treatment by rest and 
 employment. The case could then, for a period of about a 
 year, be closed by the social workers and then referred to the 
 follow-up division of our department to insure the proper con- 
 tinuance of medical treatment. An incident of her care was 
 that about six months after her original treatment for syphilis 
 she slipped on a wet floor and fell, fracturing the pelvis. (The 
 bones of some syphilitics are well known to be rather more 
 susceptible to fracture than those of normal persons.) 
 
 From the standpoint of social case analysis, the case of 
 Greta Meyer seems then, comparatively simple ; namely, a case 
 of practically pure medical disorder. Not even the economic 
 factor came specially into evidence. 
 
 Hours spent by Medical record, 22 pages 
 
 Social record, 6 pages 
 Physician, 14 Social work: 
 
 Visits, 
 Psychologist, o Interviews at hospital, 5 
 
 Telephone calls, i 
 Social worker, 3j/< Letters, 2 
 
THE KINGDOM OF EVILS 'lQ>'] 
 
 Familial syphilis. Routine examination of "wife and children: 
 positive blood test in all. No other indications of syphilis: 
 source of infection unknown. 
 
 Case 41. We borrow the case of Walter Heinmas from 
 the medical, legal, and social part of the Southard and Solomon 
 book on Neurosyphilis, (in that collection case 97), not because 
 either he or his family ever came to the point of social treat- 
 ment, but because the problem of familial syphilis seems ex- 
 quisitely exemplified in the children. The situation is one 
 which rather astounds even medical men who are not al- 
 ways too well aware of the caprice with which syphilis shows 
 itself. 
 
 Heinmas himself was a case of general paresis of a classical 
 type, with marked feeling of well-being (the so-called euphoria) 
 and characteristic grandiosity. 
 
 It is the routine procedure of the Psychopathic Hospital to 
 look into the families of syphilitic patients. The Heinmas 
 family consisted of the parents and two daughters aged nine 
 and seven respectively. Both the patient himself and his wife 
 denied all knowledge of syphilitic infection, nor was the wife 
 able to support the idea that she had ever had any primary, 
 secondary, or tertiary symptoms; especially there had been no 
 abortions, miscarriages, or stillbirths. Both children had 
 been born at term and had been absolutely healthy. Upon 
 examination, the mother had no physical signs which could be 
 referred to syphilis. Both daughters were well endowed in 
 mind, were of very good physique and showed no stigmata of 
 congenital syphilis, yet the blood tests of all three (the mother 
 and two children) proved positive. These tests were repeated 
 several times with the children (both with and without sal- 
 varsan injections) and their bloods remained consistently 
 positive. 
 
 In the Southard and Solomon series it has been found that 
 about 15 per cent of the marriages wherein one spouse develops 
 paresis result in sterility, in 18 per cent there are abortions, 
 miscarriages, or stillbirths, in 15 per cent there are positive- 
 Wassermann reactions in one or other members of the family. 
 The rather obvious motto can be adopted: "The families of 
 paretics are the families of syphilitics." 
 
20h THE KINGDOM OF EVILS 
 
 Hours spent by , Medical record, 2 pages 
 
 Social record, i page 
 Physician, 3^^ Social work: 
 
 Visits, 5 
 Psychologist, o Interviews at hospital, 3 
 
 . Telephone calls, 13 
 
 Social worker, 9 Letters, 19 
 
GENERAL PARESIS 
 IN A MACHINIST 
 
 October, ipi6 
 
 Disabled for Work 
 
 Inebriety 
 
 Marital Discord 
 
 No Income 
 
 Debts 
 
 No Money for Therapy 
 
 January, ipi/ 
 Employed 
 Sobriety 
 Happiness 
 Adequate Wages 
 Debts Reduced 
 Treatment 
 
Paretic machinist, alcoholic, neglected treatment: on the verge 
 of complete breakdown. Restored in three months to industrial 
 efficiency through combined medical and social treatment. Pro- 
 moted to foreman. 
 
 Case 42. David Collins we present as a good example of 
 social problems in that common form of syphilitic mental dis- 
 ease known as general paresis. 
 
 General paresis is a kind of mental disease long known by 
 psychiatrists and has always been thought to have a fatal prog- 
 nosis in a period ranging say from three to five years from the 
 onset of symptoms. Patients surviving that period for any 
 considerable length of time would ordinarily be regarded as 
 either not cases of general paresis at all or very non-typical 
 ones. Accordingly the psychiatrist and the medical man in 
 general would feel very skeptical as to the value of spending 
 overmuch time or money upon social work designed to bring 
 out earning abilities or develop valuable changes of character in 
 victims of general paresis. No doubt this skepticism is statis- 
 tically rather well founded. Yet modern work seems to show 
 that neither mental and nervous symptoms nor laboratory signs 
 (blood serum, spinal fluid, etc.) alone, nor any combination of 
 these symptoms and signs, will invariably suffice to establish 
 the diagnosis of general paresis in the early months or, let us 
 say, in the first year of its symptoms. 
 
 If a mental disease looking like general paresis is not going 
 to prove to be general paresis, what form of disease is likely 
 to develop? There is another form of syphilis of the nervous 
 system ( for which the abbreviated term neurosyphilis has come 
 into general use) called cerebral syphilis or cerebrospinal syphi- 
 lis or diffuse neurosyphilis, which form has a much more favor- 
 able prognosis with respect to duration and a much more fav- 
 orable prognosis with respect to the self-supporting capacity 
 and manageability of the victim. It may accordingly make a 
 crucial difference to the man and his family whether he is dis- 
 govered eventually to have the paretic form of neurosyphilis 
 
 2.U 
 
212 THE KINGDOM OF EVILS 
 
 (i.e., general paresis) or the diffuse form of neurosyphilis 
 (commonly called cerebrospinal syphilis). The medical man 
 should not, and the medical social worker cannot, neglect the 
 other members of the paretic's family. The children of a 
 paretic, are, of course, the children of a syphilitic (examples 
 of the value of this slogan are given elsewhere in Section I of 
 this book) and accordingly various steps in mental and physical 
 hygiene must be taken. These latter we do not discuss under 
 the case of David Collins, but call attention rather to the value 
 of psychiatric social work for the family. 
 
 Disabled for work in October, 1916, David Collins had, in 
 three months, found work with the firm that had previously 
 employed him. From a condition of inebriety he had, under 
 the social service influence, become sober. A state of serious 
 marital discord had been replaced with domestic happiness. 
 The family which had had no income in October had, by Jan- 
 uary, the advantage of adequate wages. The debts previously 
 incurred had been reduced, and treatment for the man's neuro- 
 syphilis had been arranged for. The case had been an appealing 
 one to the social service, and it proved easy to raise money 
 by newspaper advertising (under "Divers Good Causes") on 
 the ground that he was in dire need of medical treatment and 
 would otherwise lose his mind. It must also be noted that 
 within the first three months of social work the wife had also 
 gone under treatment (blood test of a child proved negative). 
 
 Collins, at forty-five, had had to give up his machine shop 
 work on account of becoming tremulous and sometimes con- 
 fused about his work. He fell down unconscious a number 
 of times. When he arrived at the Psychopathic Hospital out- 
 patient department with his wife, they had nothing but return 
 carfare upon them, and it was found that they had no means 
 of income whatever. 
 
 Already two years of possible treatment had been lost, since 
 the patient had two years before been brought to the hospital 
 by the police who had found him in convulsions on the street. 
 At that time he had refused to return for treatment. Such a 
 refusal is, of course, a matter of great regret to the ardent 
 believer in social work and intensive medical treatment for 
 neurosyphilis. No doubt, in an ideal mental hygiene situation 
 enough force and ingenuity could be brought to bear to bring 
 all such cases, even when like Collins exceedingly recalcitrant, 
 
THE KINGDOM OF EVILS 213 
 
 under medical and social care. He had always been a hard 
 drinker and was still drinking. 
 
 It seems that he had had three jobs in two years which he 
 had been forced to leave, finding each one too hard for him. 
 By arrangement with the social service, the manufacturing 
 firm that had previously employed him allowed him two morn- 
 ings ofif a week to come for his treatment, on condition that 
 he make up the time at night. On this basis he got his full 
 pay, twelve dollars a week. He was influenced to stop drink- 
 ing, the wife becoming immediately reconciled with him again 
 and said it was the best day of her life when she brought him, 
 two years after his first hospital appearance, to the out-patient 
 department. Now, she said, they had become "like sweethearts 
 again." Besides obtaining treatment for the wife, work was 
 found for her by the social service. Ordinarily it vvould be 
 considered rather poor social work to cause the wife to go 
 out to work but in this particular situation it seemed advisable, 
 so that the debts of the family might be paid off. Shortly Col- 
 lins himself obtained a raise of pay. Later on he was promoted 
 to the position of foreman. 
 
 In some ways this case of Collins might seem a schematically 
 simple one. We find in our notes, however, that the investiga- 
 tion entailed inquiries of (i) Mrs. Collins, (2) the priest, (3) 
 previous employers, (4) neighborhood storekeeper, (5) daugh- 
 ter's teacher, (6) the landlord, (7) previous landlady, (8) a 
 neighbor, (9) the social service of a hospital where Collins 
 had once been treated. Valuable data were obtained from prac- 
 tically all of these sources. It is plain that without a consider- 
 able social service staff this kind of work cannot be done and 
 that it is entirely out of the question to suppose that the admin- 
 istrative officer, whether medical or social, who sits at his desk 
 in however well appointed an institution, can obtain these data 
 in such quantity as to permit valuable work. 
 
 Let us remark, too, in passing, upon the tremendous change 
 in the attitude of public and private charitable institutions 
 toward such problems as these. Time was when each institu- 
 tion "passed the buck" to some other institution and hardly 
 any board of trustees would advocate "borrowing trouble" by 
 seeking cases to treat in the community. Yet we believe we 
 are safe in asserting that this modern attitude toward the hid- 
 den sources of disease in the community is the only attitude 
 
214 THE KINGDOM OF EVILS 
 
 which, in the long run, turns the trick of eradicathig either 
 venereal disease or any other form of widespread social 
 disease. 
 
 Yet with all the rather optimistic features present in the 
 early progress of Collins' social care, under pressure of work 
 the case was too early closed and not followed up as it might 
 and should have been. It was again reopened through the 
 vigilance of officers having in mind the tremendous value of 
 this program of social work in neurosyphilis, and Collins went 
 again under treatment. He was particularly difficult on ac- 
 count of his alcoholic tendencies and on account of the usual 
 story on the part of these patients, namely their tendency, as 
 soon as they feel rather well again, to drop treatment and re- 
 fuse to report. This is the story not alone in the social care 
 of neurosyphilis but in that of many other forms of chronic 
 disease. All in all, Collins received regular treatment by sal- 
 varsan for a continuous period of nineteen months and subse- 
 quently for further periods. He is one of the cases under 
 systematic therapeutic investigation by the Massachusetts Com- 
 mission on Mental Diseases. What is to be the outcome of 
 that investigation which began in 19 14 and has under observa- 
 tion several hundred neurosyphilitics can doubtless not be said 
 until the period of a decade has elapsed. 
 
 Here, then, is a sample of mental disease clearly syphilitic 
 in origin, clearly chronic in its course, if not likely to pass 
 rapidly into dementia and death; yet by combined efforts of 
 the medical and social service, a reasonably good front to the 
 disease on the one hand and the world on the other was pro- 
 vided. We now have a history of five years since his first 
 appearance in the hospital after falling into convulsions on 
 the street, and we have a history of three years since the initia- 
 tion of a period of regular treatment. Whatever be the patho- 
 logical fate of David Collins, whether it be early or late, at all 
 events partial or temporary cure by social service must be scored 
 for the Collins family, as well as for its central psychopathic 
 figure. His case is by no means an isolated one in our experi- 
 ence. We feel ourselves entitled to crave most earnestly the 
 concession by medical men that social service energy shall be 
 duly expended even upon these cases of such (statistically 
 founded) unfavorable prognosis. It is, perhaps, also worth 
 while to insist that neither the intensive medical care nor the 
 
THE KINGDOM OF EVILS 215 
 
 elaborate social care undertaken in the case of David Collins 
 would have been vv^arrantable by itself alone. 
 
 Hours spent by Medical record, 11 pages 
 
 Social record, 26 pages 
 Physician, 8 Social work : 
 
 Visits, 2."] 
 Psychologist, o Interviews at hospital, 15 
 
 Telephone calls, 5 
 Social worker, 51 Letters, 9 
 
 General paresis in a soldier; at first thought to be dementia 
 praecox. 
 
 Case 43. Carl Spindler came from a public health hos- 
 pital with the diagnosis of dementia praecox. His case was 
 found to be one of general paresis requiring commitment. He 
 was incoherent, and very talkative, to the efifect that he was 
 going to Washington to take the President's place, that the 
 girls were all crazy about him, and that he had plenty of money. 
 He was a well-built man of thirty-three of German descent. 
 He had worked in packing houses until he enlisted in the army. 
 He had seen service in France, where he had got a number 
 of shrapnel wounds and had been gassed. He was transferred 
 to a state hospital for prolonged care. 
 
 Hours spent by Medical record, 7 pages 
 
 Social record, i page 
 Physician, 314 Social work : 
 
 Visits, o 
 Psychologist, o Interviews at hospital, 2 
 
 Telephone calls, o 
 Social worker, lYz Letters, 2 
 
 Steady young soldier who began to sing, dance, and fight. 
 Taboparesis. Symptoms following his mother's death. 
 
 Case 44. Thomas Scannell was drafted at the age of 
 twenty-one and had been in the army fifteen months (of which 
 seven months' service in France) before he was sent to an 
 A. E. F. hospital. He passed through three hospitals in this 
 country where he was thought in turn to be suffering from (a) 
 
2l6 THE KINGDOM OF EVILS 
 
 dementia praecox, (b) general paresis, and (c) manic-depres- 
 sive psychosis. He was excited and talkative (threatening, 
 e.g., to write to the President for a better room), sang, danced, 
 and fought. In the Psychopathic Hospital he proved definitely 
 a paretic (taboparetic form). Accordingly commitment was 
 recommended. But his sister and her husband, both plainly of 
 low mentality, insisted upon taking him home, saying that they 
 should never feel satisfied if he were not given a chance at 
 home. He is now receiving treatment as an out-patient only. 
 His mother died while he was in France, and he himself at- 
 tributes his illness to nervousness resulting from worry over 
 her death. 
 
 He is the illegitimate child of a hard-working respectable 
 woman married to a worthy man who died when the boy was 
 eight years old. Scannell was a steady young man with a pleas- 
 ant disposition. He "was crazy about his sister's baby." He 
 did not use alcohol and had held one job for five years. 
 
 Hours spent by Medical record, lO pages 
 
 Social record, 2 pages 
 Physician, 2% Social work : 
 
 Visits, o 
 Psychologist, o Interviews at hospital, 3 
 
 Telephone calls, 6 
 Social worker, 31/2 Letters, 6 
 
 Boy with congenital syphilis (juvenile tabes). Dropped 
 behind in school at eleven. Difficulty of getting parents to have 
 treatment for him. 
 
 Case 45. The physician's point in presenting Archibald 
 Sherry, the twelve-year-old victim of congenital locomotor 
 ataxia (juvenile tabes) would be to show special pride in his 
 therapeutic results in a rare disease. The case has been pre- 
 sented briefly from the medical point of view as case 38 in 
 Southard and Solomon's case history collection Neurosyphilis. 
 We may here omit the medical details. The layman would, 
 of course, readily observe the unsteadiness of the boy's gait, 
 and would come upon certain oddities in his teeth (typical 
 Hutchinsonian teeth). The psychiatric social worker, like 
 other lay observers, should bring notes concerning superficial 
 
THE KINGDOM OF EVILS 21/ 
 
 oddities of teeth for the physician's consideration and now 
 and again the worker will be able to throw considerable light 
 upon obscure cases under direct medical observation by retriev- 
 ing sundry dental facts concerning relatives of the patient, 
 superficially examined in the course of taking histories in the 
 patient's home. 
 
 The Sherry boy, after the diagnosis of his syphilis had been 
 thoroughly proved in hospital, was treated and certain pains 
 of his, certain attacks of confusion, and trouble with his speech 
 disappeared upon salvarsan injections, and his gait became 
 steadier. 
 
 From the standpoint of social psychiatry, Sherry's family 
 history was of interest. On the father's side there was nerv- 
 ousness (as well as alcoholism and degeneracy). The number 
 of things which "nervousness" may at bottom be is legion; of 
 course no conclusion as to syphilis in the family could be drawn 
 either from a history of nervousness or of degeneracy. The 
 fact that the maternal grandmother had cancer is, no doubt, of 
 no importance. A sister, four years older than Archibald, was 
 also thought to be "nervous" and unstable. One task of social 
 psychiatry was to have this girl examined for syphilis and 
 especially to have her blood and spinal fluid examined. Both 
 blood and spinal fluid failed to yield signs of syphilis. 
 
 Instructive also is the fact that Archibald, although always 
 a weak and sickly child, did well in school to the end of his 
 eleventh year, when his capacity to keep up with the other chil- 
 dren dropped and he became no longer so amiable and sociable. 
 An odd thing in the case was that the eye-lashes of the boy had 
 turned white during the year. 
 
 It was, of course, also the duty of the social service to se- 
 cure blood reactions of father and mother, who denied syphilis. 
 The reactions of both father and mother proved, in fact, nega- 
 tive, and also, as above noted, that of the older sister. The 
 medical observers remained in doubt as to whether the case 
 was one of syphilitic disease handed down from father or 
 mother, or whether the case was one of a rare or unique con- 
 dition, namely — "acquired" juvenile tabes. (Concerning the 
 true meanings of the terms hereditary, congenital, and ac- 
 quired, the psychiatric social worker should make absolutely 
 sure.) 
 
 Social work in this case proved difficult by reason of lack of 
 
2l8 
 
 THE KINGDOM OF EVILS 
 
 cooperation on the part of Archibald's mother. Treatment 
 could not, in fact, be consistently continued. However, social 
 workers from time to time visited the boy in his home, and he 
 has apparently shown no setback since his initial improvement 
 following a few injections of salvarsan into the blood that were 
 made some six years ago. 
 
 Hours spent by 
 Physician, 5^/3 
 Psychologist, o 
 Social worker, 4254 
 
 Medical record, 9 pages 
 Social record, 18 pages 
 Social work : 
 
 Visits, 24 
 
 Interviews at hospital, 3 
 
 Telephone calls, 18 
 
 Letters, 14 
 
 Industrial disability caused by syphilis. Under treatment 
 returned to work. 
 
 Case 46. The full text of Harold Gordon's social record 
 is given in Appendix A. 
 
SECTION II 
 
 HYPOPHRENOSES ( FEEBLE-MINDEDNESS) 
 
 High-grade moron, daughter of a good family. Stealing, 
 sex irregularity. "Football of environment." Institutional 
 care. Need of psychiatrist, psychologist, and social worker. 
 
 Case 47. Florence Warner, nineteen, brought to the 
 Psychopathic Hospital for observation at the family physi- 
 cian's suggestion, turned out to be a moron, measuring 11.5 
 years by the Point Scale and 10 1/5 years by the Binet Scale. 
 
 It is worth while to premise that these minor differences in. 
 the mental test levels, as is clear from the data of many previous 
 cases in this book, allow no doubt whatever that the girl so 
 tested was a moron, — provided always that the tests were car- 
 ried on under favorable conditions without (a) fatigue on 
 the part of the examiner, or (&) on the part of the patient, 
 without (c) any clouding of consciousness, such as infectious 
 disease, alcohol, drugs or other condition might produce and 
 {d) without any trace of stupor or dullness of mental facul- 
 ties incident to many forms of the frank psychoses. None of 
 these latter phenomena were shown by Florence Warner. She 
 was at the time of examination perfectly clear-headed and 
 capable of a very fair amount of attention to the tests. In fact 
 we find from the report recorded that her comprehension was 
 good and that she had a very excellent power of reasoning in 
 the examples set for her. Her memory, to be sure, was only 
 fair and her anal3^ical power limited. Her loss of points in 
 the mental tests accordingly was a rather general one and the 
 separate items were valued from rather poor to fairly good or 
 even good — being for the most part only fair. 
 
 We may further take occasion at this point to say that the 
 detailed procedures of the mental tests, whether by the various 
 revisions of Binet or by the Point Scale, are entirely within the 
 scope of a social worker to learn and even to use, as (in point 
 of fact) these procedures are within the scope of any well edu- 
 
 219 
 
220 THE KINGDOM OF EVILS 
 
 cated person. But we do not need to exhibit the prejudices of 
 an overspecializing psychologist when we insist that these tests 
 are not to be trifled with, and are not to be valued highly save 
 when performed by an examiner of considerable skill and ex- 
 perience who "has his hand in" and who for the most part is 
 doing little else in life. This is not to say that what Professor 
 James called the Ph.D. octopus need dominate the field of 
 practical mental examination, although for our part we feel 
 that every laboratory executing routine tests in important cases 
 should be managed by an expert psychologist who shall stand 
 sponsor for the results. Those not familiar with the situation 
 in applied psychology may not bear in mind how rapidly the 
 field is changing and how numerous the modifications and im- 
 provements in psychometric tests will be before at last we reach 
 the ideal set of tests. On the other hand, the time is past when 
 anyone can safely doubt the present-day value of the tests we 
 have within ordinary limits of variation and under the special 
 safe-guarding conditions enumerated above. 
 
 The problem in the Warner case was stealing and sex irregu- 
 larity. While we are discussing the psychometric tests it may 
 be worth while to insist that these tests throw little or no light 
 upon the causes of such bad habits or vices. The mental tests, 
 being almost exclusively intcUigcnce tests, throw little light 
 upon either the quality or the level of the emotional or voli- 
 tional sides of the person examined. To be sure Florence War- 
 ner was somewhat "suggestible" to test; but this "suggesti- 
 bility" is a very specific one which does not necessarily argue 
 that the one who shows it steals or enters into irregular sex 
 relations on account of it. Tlie chances are that Florence was 
 the "football of environment" ; but it would require a far more 
 elaborate analysis by psychiatrists (or by persons otherwise 
 expert in the world's ways) to prove that' her irregularities 
 were phenomena of weak will or suggestibility. How, we may 
 ask, shall such analysis of all sides of the mentality be made 
 as will throw the needed light upon the causes of stealing, sex 
 irregularity, and the like? There is no certain answer to this 
 question, although various psychiatrists and psychologists have 
 suggested schemata for analyzing personality under various 
 headings. 
 
 It seems that Florence had been in the habit of stealing from 
 members of her family and from friends ever since she wa.s vj 
 
THE KINGDOM OF EVILS 221 
 
 small child. She could now no longer live in her brother's 
 family unless means were found by which she could support 
 herself. But, as she was given to stealing, she could not be 
 recommended to any employers. To add to the difficulty she 
 had recently begun sex relations with various men. It seems 
 she had gone to a distant state to work as a telephone operator 
 and had there fallen into bad habits — drinking, smoking, and 
 irregular sex living. 
 
 Upon the discovery of her level as a high-grade moron, in- 
 stitutional care was recommended, on the particular grounds 
 that she was a high-grade moron of such a trend that she might 
 benefit by institutional care and would otherwise be in consider- 
 able danger of becoming a source of venereal infection. In 
 point of fact Florence was still negative to test as to venereal 
 disease, but was already being strongly urged by a girl friend 
 to join the prostitute group. 
 
 As is the situation in most of our states in the present phase 
 of mental hygiene, the waiting lists at the schools for feeble- 
 minded were extremely long. However, upon the Psycho- 
 pathic Hospital's representation, Florence was listed amongst 
 the urgent cases. She was in the meantime sent to a small pri- 
 vate institution which agreed to make exception to its general 
 rule not to receive mental cases. The institution must have 
 regretted its step at the end of three months since Florence 
 had plotted to escape with another girl and had a bad influence 
 on the other girls. 
 
 The feeble-minded schools' waiting lists were still long and 
 in the interval Florence was sent to the state infirmary, i.e., 
 the big almshouse hospital of Massachusetts. She promptly 
 took a violent dislike to the women she was there thrown with 
 and was given night work so that she might avoid them. After 
 three almshouse months she was eventually admitted to a state 
 school for feeble-minded. She immediately began to mingle 
 with the older girls and seemed to become perhaps more happy 
 than could be reasonably expected. 
 
 It may be remarked that Florence's family was on rather a 
 high level. It was naturally rather hard to persuade her rela- 
 tives to let her go to a state institution. Of course the general 
 level of mental hygiene in Massachusetts, as in a few other 
 states, is such that we may hope that the general prejudices 
 against all state institutions will at last melt away. 
 
222 THE KINGDOM OF EVILS 
 
 Could such a case be handled by the social worker in com- 
 bination with a competent psychiatrist ■mithout the aid of a 
 psychologist f The psychiatric examination determined her to 
 be not insane. The positive evidence for the moronity in Flor- 
 ence is derived almost wholly from the mental tests. The phys- 
 ical examination was largely negative; still it may be of some 
 importance to the girl that diseased tonsils and a functional 
 heart murmur were found. The medical examination also was 
 of value to her in showing that she was not as yet a "venereal" 
 case. It is especially important to her that the psychiatrist 
 could find no evidence of a definite acquired psychosis. We 
 feel that it is of the greatest importance to exclude psychosis 
 from these cases of feeble-mindedness. We are familiar with 
 numerous cases in which moronity has been confused with ac- 
 quired and progressive psychosis. In short, we hold that the 
 psychiatric examination in these cases has extraordinary nega- 
 tive values. 
 
 While we are comparing the practical values of the psycholo- 
 gist whose data made the positive diagnosis "moronity" and 
 of the psychiatrist whose examination was exclusive of any 
 such disease as dementia praecox, let us inquire whether the 
 psychiatrist and the psychologist combined could have handled 
 this case effectively, without a social worker. It will be noted 
 that the eventual success in getting Florence into the right in- 
 stitution was a matter of very time-consuming and ingenious 
 persuasive work. The more competent the psychologist the 
 more valuable his work in the laboratory and the less likely 
 he or she would be inclined to "hug the telephone" and do the 
 traveling necessary. The same holds for the psychiatrists. 
 Moreover, as those acquainted with social service technique 
 are well aware, neither the psychologist nor the psychiatrist 
 has a knowledge of the institutional equivalents, institutional 
 and other personalities, community and neighborhood habits 
 and peculiarities, and the technical facts which training and 
 experience give to the social worker. Happily we are able to 
 say that, as the years pass, the psychiatrists and psychologists 
 are becoming less willing to say that, just because they under- 
 stand every social service device employed, therefore they can 
 perform the steps effectively in proper sequence and without 
 loss of time. 
 
 With respect to the relations of the general medical social 
 
THE KINGDOM OF EVILS 223 
 
 worker to the general problem of medicine, there is no longer 
 any doubt of the necessity of a medical social worker in any 
 community with high health standards. But if this is true for 
 general medicine and the medical social worker in general, it is 
 one-hundred fold truer still for the complicated relations of 
 the psychiatric social worker. In fact we do not need to argue 
 upon this line for those who have had any practical experience 
 in the field. But we take occasion in discussing this first of 
 our group of feeble-minded cases to insist upon a point which 
 stands out most clearly in a case like that of Florence Warner. 
 Of course we do not know what the eventual outcome in 
 Florence Warner's case may be, granted that the psychometric 
 diagnosis of feeble-mindedness is correct (and there seems to 
 be no doubt of the accuracy of the diagnosis in this case). Pos- 
 sibly it will be in some respects easier to handle a moron who 
 steals and has sex irregularity than to handle a person of per- 
 fectly normal mentality with precisely the same trends; but 
 there is no general rule to this effect. 
 
 Hours spent by Medical record, i8 pages 
 
 Social record, 5 pages 
 Physician, 3^ Social work : 
 
 Visits, 2 
 Psychologist, I Interviews at hospital, 2 
 
 Telephone calls, 4 
 Social worker, 7 Letters, 4 
 
 A psychopathic family. Each member (parents and eight 
 children) an indimdual problem. Syphilitic, feeble-minded 
 father. Distinction between hereditary and congenital. 
 
 Case 48. The family is today, in many social service quar- 
 ters, the unit of interest in social work. We do not deny that 
 the family ought to be the object of social work, yet we feel 
 that the psychiatric viewpoint has gone far to prove that every 
 family should be analyzed in the first instance, not so much 
 from any supposed general family tendency, and not so much 
 from the standpoint of the family income as from that of the 
 social situation presented by each member of the family taken 
 as an individual. We are aware that many social workers will 
 feel that this plan is carrying individualization to an absurd 
 degree. Particularly in the case of the Newman family, whose 
 
224 THE KINGDOM OF EVILS 
 
 plight we hang- upon the individual case of Bessie, but which 
 contained ten members (parents and eight children), it would 
 seem a little preposterous to consider technically every member. 
 But let us consider the situation of each member. 
 
 Bessie, the third child, nineteen years of age as we now 
 write, is a case of feeble-mindedness belonging in the moron 
 group, measuring psychometrically 94/12 years by the Stan- 
 ford-Binet method and 9.7 by the Point Scale. Bessie whom 
 we first observed at the age of fifteen was at once determined 
 to be suitable for a state school for the feeble-minded. The 
 waiting lists were too long, however, and she could not be 
 admitted. She remained at home, finally became pregnant, 
 altered her character somewhat thereafter so that she became 
 something of a runaway and was delivered of a child which 
 became a public charge (because of Bessie's obvious inability 
 to take care of it and because the family otherwise had already 
 too much on its hands). Bessie remains at home a good deal 
 of a problem. There was at one time a question whether 
 Bessie might not be a victim of schizophrenia (dementia 
 praecox) partly on account of the history of her going over 
 to New York to visit a prostitute girl friend and an episode 
 of throwing clothes out of the window. Technically, however, 
 on the whole no convincing proof of schizophrenia could be 
 found. In any event such a process would have been one 
 grafted upon an original feeble-mindedness. 
 
 It was not Bessie, but a sister Rachel, seven years younger, 
 who first came to the hospital's attention. She was sent by 
 her teacher for falling out of her chair, one day as often as 
 three times in an hour. Rachel was found to grade approxi- 
 mately at her age (eight) at the time of examination, although 
 there was the hint of subnormality in her comprehension, 
 emotional control, and power of concentration. No definite 
 psychosis was determined for Rachel ; but a certain hyper- 
 kinetic tendency on her part might look in the direction of 
 some form of psychopathic personality. 
 
 She came under hospital observation two years later, a 
 nail-biter and thumb-sucker, still suffering from the hyper- 
 kinetic tendency which was termed "nervousness" and "insta- 
 bility." Under hospital observation, as is so frequent, the 
 girl showed no sign of the hyperkinesis noted outside but 
 when she returned home she was as bad as ever. 
 
THE KINGDOM OF EVILS 225 
 
 The most important individual problem next in order 
 amongst the children is that of Isaac, the oldest son, now 
 twenty-three. He is definitely feeble-minded, grading 9.7 
 years by Point Scale when observed at the age of eighteen 
 and a half. Icaac's record shows a general leveling down of 
 his mental capacities although his power of attention and his 
 emotional control are more prominently affected than the other 
 faculties (recalling the situation with Rachel). Isaac was 
 unable to read or write but made five dollars a week. He 
 was a domestic nuisance because he, without provocation, ad- 
 ministered heavy blows to the children. At the present time 
 he is working with fair regularity for a relative and gives no 
 trouble, though he "knows it all." He often sits for long 
 periods without talking and cannot eat if the other children 
 are about. 
 
 His next younger sister, Molly, two years older than the 
 third child Bessie, seems to be absolutely normal in every 
 respect, is physically something of an athlete, and was found 
 upon the Psychopathic Hospital observation to be normal in- 
 tellectually. Were it not for the abnormality of all the other 
 members of this family of ten, we should regard Molly's 
 having an illegitimate child as not especially suggestive of 
 psychopathy. Perhaps it is safer not to guess psychopathy 
 even against the heavy atmosphere of the Newman family. 
 Molly has also a so-called "doubtful" Wassermann serum reac- 
 tion of the blood which so often turns positive later on and 
 is always suspicious. (The father of the family was syphilitic 
 to test.) Molly, with the aid of one of the children's agencies, 
 made some effort to take care of her child but eventually had 
 it placed for adoption. She later made what seemed to be 
 a promising marriage. When her husband returned from 
 army service, he failed to support her and became sexually 
 abusive. Now she is back with her own family seeking a 
 divorce. She claims that one of the reasons for her quarrels 
 with her husband is his failure to keep the agreement he made 
 when they married that he would take steps to find and recover 
 her first child. 
 
 Having considered, first Isaac, second Molly, third Bessie, 
 we come now to the fourth, Louis, two years younger than 
 Bessie and five years older than Rachel. He tested, when 
 his actual age was thirteen, ten years by the Binet and 11. 3 
 
226 THE KINGDOM OF EVILS 
 
 by the Point Scale. He was a boy with an uncontrollable 
 temper and hyperkinetic in various ways, making grimaces and 
 jerky movements of the limbs. He is now in a special class 
 at a business school but is doing very unsatisfactory work and 
 will no doubt shortly drop out. 
 
 Daniel two years younger than Louis, is bright in school, 
 a nervous, irritable boy with a positive Wassermann serum 
 test. He seemed to be always in a fight. His brother, two 
 years older (Louis) and his father were especial irritants for 
 him. He was quite uncontrollable by his mother. This boy 
 Daniel graded a few points higher than his actual age, eleven 
 and a half, by both the Point Scale (11.8) and the Binet 
 (11 3/5 ) . He may be regarded as in a general way somewhat 
 precocious and to test was deficient only in his learning ability 
 and in a certain oversuggestibility. 
 
 Of the two remaining children, Leo, now eleven, is a good 
 deal of a problem. He is also, like his brother Daniel, not 
 feeble-minded. He is a restless, quarrelsome, and excitable 
 boy who cannot sit still and (resembling Rachel's falling from 
 her chair at school) often falls down when playing or walking. 
 He has recently developed hysteria and has already had two 
 sufficiently pronounced attacks with paralysis of a leg. This 
 paralysis combined with pain in the back of the knee has at 
 times been cured for the moment through persuasion and 
 command by the psychiatrist. 
 
 Sally, now seven years of age and the youngest, was at 
 three years regarded as a bright little girl and passed most of 
 the four-year-old tests. She even now grades approximately 
 to her actual age. She cries continually, has a violent temper, 
 is given to biting herself when angry, hits herself against the 
 wall and, like Leo and Rachel, has the falling tendency noted 
 for them. 
 
 What kind of parents did these eight children possess? The 
 father Jacob, examined at forty-four, proved to have a mental 
 age of some 9 years. His blood serum showed a suggestively 
 positive reaction for syphilis (three years later a test proved 
 definitely positive). At the earlier age it was thought that 
 some organic mental disease, presumably a form of neuro- 
 syphilis, was developing. Jacob makes many complaints at 
 home, grows easily angry but has not in three years of obser- 
 vation yet developed any progressive mental disease. What- 
 
THE KINGDOM OF EVILS 2.2^ 
 
 ever he may develop, it seems likely that he is feeble-minded. 
 It might be inquired whether Jacob acquired his syphilis or 
 was perhaps the victim of congenital syphilis. He has no 
 marked stigmata to external observation. There is appar- 
 ently some enlargement of the right lobe of the thyroid. A 
 heart examination taken in connection with the positive serum 
 test suggests aortic disease. There was some tendency to 
 clubbing of the finger nails and there was a pronounced 
 cyanosis of both hands. He sometimes complains of attacks, 
 which taken into association with his syphilis, might seem to 
 suggest organic disease of the nervous system. Yet it is pos- 
 sible that many of these phenomena in Jacob are hysterical. 
 
 His wife, Sadie Newman, although a woman of somewhat 
 limited intelligence (not tested but almost certainly not defec- 
 tive; has efficient brothers known to the social service) has 
 some psychoneurotic symptoms (heat flashes, nervous spells 
 with chin quivering and inability to speak, feeling of general 
 weakness). Almost all the other features in Sadie's life are 
 extraordinarily to her advantage. She has naturally had a 
 most difficult life but has brought the afflicted family through 
 more difficulties than a normal mother would like to face. 
 Mrs. Newman has had in all twelve pregnancies. The first 
 was a miscarriage and the second child died young (thought 
 to be feeble-minded). Then came Isaac, the definitely feeble- 
 minded boy. These first three pregnancies form the clinical 
 ascending scale of improvement found in the syphilitic family 
 and the fourth child, athletic Molly, might be regarded as 
 showing that the syphilitic taint had run itself out. However, 
 next came a definitely feeble-minded child, Bessie, an ugly, 
 pugnacious child. After Bessie came the second and last 
 miscarriage. Then came the grimacing, high-tempered Louis, 
 followed by nervous Daniel with his positive serum test ; then 
 came Rachel, Leo, and Sally with their overactivity and falling 
 tendencies, but between Leo and Sally came a boy that died 
 four days after birth. 
 
 We spoke of Molly as possibly terminating the syphilitic 
 taint shown in the first three pregnancies but will remind the 
 reader that this good child (the best in the family) herself 
 had a doubtful Wassermann reaction of the serum. Three 
 members of the family, Molly, Daniel, and the father Jacob, 
 have suggestive or positive Wassermann serum tests. 
 
228 THE KINGDOM OF EVILS 
 
 Of course if we should construct a chart of the mental and 
 nervous diseases and defects in this family we might make 
 out a strong case for so-called "heredity" if we, for the mo- 
 ment, forgot the syphilis in the situation. It is worth while 
 for the social worker to remember that, after all, we must 
 regard many of the phenomena in this family as preventable 
 in view of the fact that most of these phenomena accord very 
 well with our idea of what syphilis can produce. To be sure 
 we do not know why the father Jacob was feeble-minded and 
 it may be that the expert eugenist could trace the separate 
 threads of inherited feeble-minded and syphilitic infection in 
 the Newman group. We do not at all know that the father 
 Jacob was a congenital syphilitic. It may be that he was a 
 feeble-minded person who acquired syphilis. Furthermore we 
 must point out a number of psychoneurotic traits in Mrs. 
 Newman, though it would be almost fair to inquire whether 
 many of these traits were not a rather natural acquisition for 
 a housewife in her plight. At all events, as we have repeat- 
 edly insisted elsewhere in this book, the social worker should 
 not confuse the hereditary with the congenital. What the 
 feeble-minded part of Jacob transmitted may perhaps be hered- 
 itary. What the syphilitic part of Jacob contributed was, no 
 doubt, congenital. We would not bore the reader to under- 
 stand the distinction between hereditary and congenital by this 
 repeated insistence ; however we have heard some relatively 
 expert social workers on the platform using in their propa- 
 ganda terms which signify that for them at least at the mo- 
 ment, tJie distinction between hereditary and congenital did not 
 seem to be a worth-while distinction. It will be observed that 
 this distinction is a very important one psychologically and even 
 from the standpoint of the budget. The philanthropist who 
 wants to stop hereditary mental disease and defect may per- 
 haps best proceed by endowing eugenic researches and propa- 
 gandas. The man who has in mind the prevention of certain 
 preventable forms of mental disease and effect (by well-known 
 public health methods, now being rounded into marked ef- 
 ficiency) would raise money on the venereal disease propa- 
 ganda supported by research. 
 
 Let us briefly sum up the social treatment of the Newman 
 group : I . Financial assistance was got so that household goods 
 might be procured with which more decent standards could 
 
THE KINGDOM OF EVILS 229 
 
 be maintained, with the result that while six years ago the 
 family lived in dirty and dilapidated surroundings (there was 
 not even a bed for one of the sisters) now they live in a fairly 
 well appointed apartment. 
 
 2. Numerous and changing arrangements had to be made 
 from time to time for different children. Three of the chil- 
 dren have been boarded out for periods of some two years 
 each. To be sure these children were neither "dependent" nor 
 "neglected" children in the technical sense of those terms so 
 that the fact that a public agency was got to give them better 
 care must be scored as a triumph of prevention. 
 
 3. Arrangements had to be made for two confinements 
 (illegitimacy in both), and for the care of the illegitimate 
 children. 
 
 4. The father had to be instructed concerning work and his 
 attitude to the family. 
 
 5. Advice and encouragement was given to the mother in 
 regard to the father and in regard to each of her children in 
 turn. 
 
 6. The relatives had to be advised with respect to the 
 mental condition of the family so that their cooperation might 
 be maintained. It was natural that from time to time they 
 should lose patience. 
 
 It may be noted that twenty-six medical and social agencies 
 have been found so far on the records as dealing with the ten 
 surviving members of the Newman family. 
 
 Hours spent by Medical record, 145 pages 
 
 Social record, 99 pages 
 Physician, 491/^ Social work: 
 
 Visits, 95 
 Psychologist, 15 Interviews at hospital, 38 
 
 Telephone calls, 105 
 Social worker, 180 Letters, 98 
 
 Imbecile boy kept at work by frequent changes. Trained 
 in special class. Feeble-minded father gotten a job: sick mother 
 treated. 
 
 Case 49. The Rosenthal family pales into insignificance 
 beside the Newman family. Yet amongst five members three 
 are definitely psychopathic up to date. The boy, Nathan, was 
 
236 THE KINGDOM OF EVILS 
 
 the first to appear under hospital observation. He was sent 
 by a school teacher with a question as to his mental defect 
 and yielded a Binet rating of 6 with an actual age of twelve 
 years. Once later he tested at a rather lower level but at the 
 last examination definitely tested at 6 3/5 by the Binet and 
 5.9 the Point Scale. He is accordingly classified as an im- 
 becile. 
 
 It was plain that he should be sent to a school for the feeble- 
 minded. There was for the moment no vacancy to allow his 
 admission. Concerning the possibility of couunituient it may 
 be noted that the family refused to allow commitment; even 
 had the family entertained the idea of commitment, no doubt 
 the committed child would have been released from the insti- 
 tution forthwith on the ground that there were other case? 
 more suitable for schooling. Nathan had, therefore, to be 
 supervised at home. He was hard to manage, irritable, quar- 
 relsome, and if crossed, disagreeable. He threatened with a 
 toy pistol persons who, he thought, had injured him. He 
 would wait behind a door with this pistol to shoot a boy who 
 had hit him. He attended a special class at school and his 
 conduct improved a little after his teacher obtained for him 
 a newsboy's license. Nathan is now working irregularly; his 
 mother finds fresh jobs for him when he decides to leave one. 
 He is very sensitive to children's taunts and comes home to 
 his mother crying because somebody has teased him. 
 
 Nathan's two siblings, a boy two years younger and a girl 
 three years younger, are regarded as very "smart'' and are 
 in the high school and grammar school respectively in proper 
 grades (tested at the hospital their age levels are well up to 
 normal). 
 
 The social service work in the case of Nathan shortly 
 brought out the fact that his mother Sarah (forty-three) had 
 bad headaches and so-called "rheumatism" with numbness of 
 the arms. She was examined in the out-patient department, 
 took hydrotherapeutic treatment and gradually improved. 
 
 Mrs. Rosenthal had to take care of the family finances 
 because her husband Abram, also examined in the out-patient 
 department, proved to be nine years of mental age (actual 
 age forty-seven). Mr. Rosenthal, a painter, seems to have 
 had a fall upon his head at about the age of twenty-four. He 
 had come from Russia at the age of nineteen. He was still 
 
THE KINGDOM OF EVILS 23 1 
 
 unable to read English. Rosenthal's friends thought that he 
 had not been normal since his fall. He had been getting 
 gradually worse and had begun to suffer from spells of dizzi- 
 ness. He accordingly had to give up his painting. At his 
 first examination in the out-patient department there were 
 some signs of lead poisoning. He was sent to a general 
 hospital for treatment (the same general hospital where he 
 had been treated twenty-three years before for "concussion 
 with question of laceration of the brain," evidently the basis 
 of his traumatic defect-condition). At this general hospital 
 he was operated upon for appendicitis. Aid had to be given 
 to the family in the meanwhile by two charitable agencies. 
 Dental work was arranged for. Upon recovery he was helped 
 to get a city position. His general health had by this time 
 much improved. 
 
 At the present time, what with the father's improvement 
 in general health and the mother's improvement as to head- 
 aches, the general situation is as good as might be expected. 
 Once when out of a job Rosenthal came to the hospital for 
 aid in getting another city job. Of course it is naturally not 
 advisable for any agency, and above all a public agency, to 
 cause patients to lean financially upon it; but a little aid ap- 
 plied at a critical time to help restore physical or mental health 
 does not necessarily encourage a dependent attitude. Our 
 assistance is often sought in finding work when there is no 
 thought of money help. 
 
 Concerning heredity in this family complex, we know noth- 
 ing concerning Rosenthal except that he was one of six chil- 
 dren, one of whom died at twenty-five years but the others 
 of whom lived to more advanced ages. The like holds true 
 for the mother who was one of some nine children, all of 
 whom are said to have lived to a considerable age. Both 
 father and mother are the only ones of their siblings that 
 survive. A niece of the mother has epilepsy. The data, as 
 in the case of many immigrants, are of no particular value 
 from the eugenic side. We do not know of any hereditary or 
 syphilitic features in the family, li Rosenthal is a true case 
 of traumatic defect-condition (that is with mental symptoms 
 due to definite structural lesion of brain tissue caused by the 
 accident) then we should have no reason for thinking that 
 the boy could have inherited his feeble-mindedness from the 
 
232 THE KINGDOM OF EVILS 
 
 father, but of course, we do not know whether Rosenthal 
 graded to normal at the time of his accident. 
 
 Hours spent by Medical record, 39 pages 
 
 Social record, 45 pages 
 Physician, i6j4 Social work: 
 
 Visits, 31 
 Psychologist, 5 Interviews at hospital, 23 
 
 Telephone calls, 20 
 Social worker, 64 Letters, 10 
 
 Street car conductor, steady quiet fellow; moron. Enlisted 
 in the navy. Sex obsessions and delusions. 
 
 Case 50. Bernard Bornstein, a moron, seventeen years 
 old, wanted to enlist in the navy to see the world. His parents 
 refused permission because the father was out of work and 
 the family dependent on the boy's wages (he was earning 
 between fifteen and twenty dollars a week as a street car 
 conductor). So Bernard ran away and enlisted. His first 
 day on shipboard he met another Jewish boy, who became his 
 chum and in the course of time told him that the other sailors 
 intended to make him commit sodomy. Bernard believed this. 
 In the hospital he insisted that there had been about a hundred 
 and fifty of his shipmates who had followed him around so 
 that he could not do anything ; write a letter, or take a bath, or 
 get to sleep. He said he would wrap the blankets about him in 
 his hammock and they would come and tear them off. He had 
 in fact complained to the officers, who sent him to the hospital 
 with a statement that there was no basis in fact for his ideas. 
 
 This boy had attended the public schools in New York until 
 he was fourteen, made there {though a moron) a fair record, 
 and had then worked regularly earning increasingly good 
 wages. He lived with his parents and gave his weekly pay 
 to his mother, to whom he was much attached. He was a quiet 
 fellow who spent his evenings at home and went about very lit- 
 tle with other boys. In this protected environment he was con- 
 tented and useful, until a sudden impulse to see the world car- 
 ried him into a life of responsibilities beyond his capacity. 
 
 Hours spent by Medical record, 29 pages 
 
 Social record, o 
 Physician, 4]4 Social work, 
 
 Visits, 
 Psychologist, i Interviews at hospital, O 
 
 Telephone calls, o 
 Social worker, o Letters, o 
 
THE KINGDOM OF EVILS 233 
 
 Feeble-minded recidivist. Honorable discharge from the 
 army. 
 
 Case 51. Howard Driscoll by psychological tests showed 
 a mental age a little over ten years (twenty-one at the time 
 he was examined). He had enlisted in the artillery at sixteen 
 and had been after three years in camp sent to England for 
 guard duty, and later to France where he was wounded several 
 times and gassed. His army record was sprinkled with 
 A.W.O.L.'s but in the end he got his honorable discharge. He 
 came home but after a short time vanished, turning up only 
 at intervals for a few days. He was even arrested once for 
 vagrancy and served a reformatory sentence. Again, he broke 
 into the house of an aunt and stole jewelry for which he was 
 given three months in jail. 
 
 He now enlisted in the navy and was soon discharged for 
 mental incapacity. Some months later he joined the state 
 guard and was assigned to a machine-gun company. A week 
 later, whilst guarding ammunition, he offered to relieve an- 
 other guard so that the latter could get his dinner. When the 
 other man had been gone for several hours, Driscoll got angry, 
 left his post, and went off for four days. He was then sent 
 to the Psychopathic Hospital for examination, where he was 
 pronounced feeble-minded as above. 
 
 The family gave an account of a change of character at 
 the age of nine when the boy had a fractured skull. After 
 this he lied and stole and fought. He had been twice in a 
 reform school. He never kept at a job for more than a few 
 days or a few weeks, with the exception of a position as 
 moving-picture operator which he held off and on for two 
 years, leaving five separate times because he did not like the 
 "boss" who "called him down." Two months after discharge 
 from hospital, he was again admitted, sent in by the court 
 on a charge of larceny. His mother was distracted, fearing 
 that the boy might do some terrible thing that would bring 
 harm to him and disgrace to the family. During the two 
 months' interval between his admissions to the hospital, he 
 married a girl whom he met on the street after a week's 
 acquaintance and in the full knowledge that she was preg- 
 nant by another man. This girl, as it chanced, had alsO' been 
 at one time a patient at the Psychopathic Hospital, a moron 
 
234 I'HE KINGDOM OF EVILS 
 
 suffering from chorea sent in from a reformatory where she 
 
 had made an attempt at suicide. 
 
 For lack of suitable hospital provision for such defectives 
 
 as Driscoll, the chances are that the rest of his life will be 
 
 spent in intermittent penal sentences. The girl he married 
 
 is a similar problem. 
 
 Hours spent by Medical record, 13 pages 
 
 Social record, i page 
 Physician, 3^ Social work: 
 
 Visits, o 
 Psychologist, i Interviews at hospital, 2 
 
 Telephone calls, o 
 Social worker, i^ Letters, i 
 
 Subnormal psychopathic girl. Illegitimate child that died. 
 Unhappy, quarreling. Family known to twenty-four social 
 agencies. 
 
 Case 52. Beatrice Cellini has never been in the wards of 
 the Psychopathic Hospital. She has been handled as an out- 
 patient and under the social service. She came to us alone, 
 crying and telling about her unhappiness. We found that she 
 had been sent from another out-patient department with the 
 idea that she might be a mental case such as could properly be 
 treated at the Psychopathic Hospital. It proved that she came 
 of a family that had been the subject of attention by no less 
 than twenty-four social agencies in the City of Boston before 
 she came to the Psychopathic Hospital as the twenty-fifth. 
 
 She said her home conditions were poor and that she cried 
 a great deal. It was partly her own fault. A man had been 
 attentive to her whom she wanted to marry, but "how could 
 a girl who has had an illegitimate child marry." She said she 
 had never gotten along with her mother, who had nagged her. 
 Moreover she quarreled with her brother and disliked her step- 
 father, (There were five stepsiblings.) She had worked in 
 candy factories not earning more than eight dollars a week. 
 At sixteen she had run away to another state with a man who, 
 according to her story, assaulted her. This man afterwards 
 went to prison. At the age of twenty, according to her story, 
 she was raped; at all events she became pregnant and the off- 
 spring, turned over to the state, shortly died. It was this 
 past that she had so much upon her mind. A brother was 
 dying of tuberculosis in a hospital. 
 
 Beatrice was given the psychometric tests (non-English) and 
 
THE KINGDOM OF EVILS 235 
 
 was found to grade at 13.4 years. The examination was a 
 so-called regular one. She appeared to be overhasty and 
 thoughtless in answers though she cooperated perfectly well 
 in the tests. No doubt Beatrice is to be regarded as some- 
 what subnormal or perhaps amongst the upper third of the 
 morons. Accordingly only a relative adaptability to the social 
 milieu is to be expected. The expected success was scored. 
 Beatrice was got to canvass for a magazine and this work 
 appealed to her. She went out amongst friends and acquired 
 a more cheerful attitude to the world. Through the counsels 
 of the social service and otherwise she got upon much better 
 terms with her mother. In some way, either through the 
 passage of time or the friendly conversations with visitors, the 
 history of her rapes and of the illegitimacy was either erased 
 from her memory or, as the phrase goes, "rationalized." We are 
 inclined to insist upon the value of what may be called the "psy- 
 chiatric touch" or attitude. One of the general social workers 
 who had come in contact with Beatrice had fired the following 
 adjectives at her; "vain, idle, lazy, selfish, untruthful, immoral." 
 The innermost nature of the psychopathic personality re- 
 mains to be worked out (see Book III, Section XI) and the 
 relation of subnormality and moronity to psychopathic per- 
 sonality is a little unclear (see, for example, comments under 
 the case of Marian Spring, Case 63, and elsewhere). Beatrice 
 varied much in her attitude to the worker. Upon one visit she 
 would be perfectly amiable and compliant, upon another, sullen 
 and disagreeable; even within the space of a single visit her 
 mood might well vary from sullen to amiable. On the whole 
 the variation was almost always polarized towards the more 
 pleasing mood ; that is, she responded well to friendly contact. 
 It was noted above that she disliked her home atmosphere; 
 nevertheless she could not be persuaded of the value of going 
 away from this disagreeable home. Whether these moods 
 correspond with a slight tendency on the part of Beatrice to 
 the so-called cyclothymic constitution (see Book III, Section 
 IX) we may suspect but leave doubtful. 
 
 Hours spent by Medical record, 11 pages 
 
 Social record, 17 pages 
 Physician, 3^ Social work: 
 
 Visits, 6 
 Psychologist, I Interviews at hospital, 3 
 
 Telephone calls, 13 
 Social worker, 15 Letters, 7 
 
SECTION III 
 
 EPILEPTOSES (epilepsies) 
 
 A reliable zuorkman for tivo years past disabled by epileptic 
 seizures. Drinking debauch after mother's death: attack of 
 violence. Doing well at work on relative's farm. 
 
 Case 53. Luigi Silva was brought to the Psychopathic 
 Hospital by the poHce. He had had a fit and become violent 
 and destructive during a heavy drinking debauch. He was 
 still noisy and excited upon his entrance, unclear as to mental 
 processes, and quite inaccessible to the examiner. When seen 
 he was trying to break windows ; looked as though he saw 
 animals and seemed to be trying to pick up some things and 
 avoid others. He would cry out : "Why don't you take that 
 thing off of my shoulder?" or again "It is a lie!" 
 
 Two days later he was perfectly clear. He remembered 
 having hallucinations of hearing and had a proper insight 
 concerning them. He was quite vague as to his time in the 
 hospital. He seemed on the whole rather dull. Psychometri- 
 cally he graded at 9.2 years; the grading was rather irregular, 
 suggestive, that is to say, of an acquired deterioration. He 
 was rather effective with the construction puzzles and fair upon 
 the memory tests. Physically the only positive points of note 
 were moderate impairment in hearing of both ears, slight 
 nystagmus, and slightly excessive reflexes on the left side of 
 the body. 
 
 Silva had been born in Boston of Italian parents, left school 
 at the age of fourteen to go to work, and had sometimes earned 
 (doing heavy nickel and brass work) as much as ten dollars a 
 week. Later he earned as much as twelve to fifteen dollars 
 a week. He had been a reliable workman, not especially 
 alcoholic. At about the age of thirty-one he had had his first 
 attacks of an epileptic nature, coming every three or four 
 weeks. For the past two years he had been unable to work 
 on account of the seizures. Of late he had begun to drink a 
 
 236 
 
THE KINGDOM OF EVILS 237 
 
 good deal of whisky. Two weeks before his arrival at the 
 hospital, his mother died, and after her death he had a very 
 heavy drinking debauch whereupon ensued the violent and 
 destructive attack above mentioned. 
 
 Upon his discharge from the hospital he went to live with 
 a relative on a farm. The plan was to keep Silva away from 
 the temptation of liquor. Now and then he was to come to 
 town to go to the hospital clinic. This plan was carried out. 
 The patient helped about the farm, doing light carpentry, 
 feeding animals, and cutting ice. The cousin brought him to 
 the hospital from time to time. Immediately after his dis- 
 charge the attacks grew for a period more frequent and severe. 
 He is still having attacks which for the time are of milder 
 nature. He is said to be improved mentally, which improve- 
 ment presumably means that there are fewer after-effects of 
 the now somewhat mitigated attacks. 
 
 There are a number of medical problems in the Silva case 
 still unsolved. Like all but a small minority of epileptics he 
 exhibits a number of signs of structural disease of the nervous 
 system. We do not know why the epilepsy began, as it is 
 said to have begun, after the age of thirty. We have so far 
 found no evidence of epilepsy in other members of the family. 
 
 Perhaps we might use our ignorance of certain features in 
 the epileptic Silva to insist upon the importance of the whole 
 problem of the epilepsies. Perhaps nothing is more harmful to 
 the victims than to lump them all under one term "epilepsy." 
 It is just as true that there are numerous forms of epilepsy 
 as that there are various forms of mental disease. The rela- 
 tions of alcohol to epilepsy are particularly intriguing. It 
 seems to have proved that alcohol tends to produce more fre- 
 quent and possibly more severe attacks of epilepsy in con- 
 firmed epileptics. There are also cases to prove that alcohol 
 'Can de novo produce epilepsy in a person without hereditary 
 soil or acquired taint, and that this epilepsy may then persist 
 even without the stimuli of further alcoholism. But these 
 relations between alcohol and epilepsy cannot be said to be 
 thoroughly established in such a way as to offer clear prin- 
 ciples of prognosis. Alcohol is only one cause or complication 
 of the epilepsies. Following, on page 467, is a grouping of the 
 major kinds of epilepsy; without going into their special 
 natures, it can be readily seen that in the field of epileptology, 
 
238 THE KINGDOM OF EVILS 
 
 the social worker, to say nothing of the psychiatrist himself, 
 must step gingerly. 
 
 Hours spent by Medical record, 19 pages 
 
 Social record, 6 pages 
 Physician, 5^ Social work: 
 
 Visits, 10 
 Psychologist, i Interviews at hospital, o 
 
 Telephone calls, 6 
 Social worker, 17^4 Letters, 3 
 
 Epileptic who killed his mother. Convulsions after head 
 injury. 
 
 Case 54. Patrick Donovan, thirty-six, killed his mother 
 and an indictment was found against him for murder in the 
 first degree. Patrick had given himself up to the police, say- 
 ing that the beer he had drunk the night before had been 
 drugged and he did not know what he was doing. His sister 
 thought he had had convulsions the night before the murder. 
 These convulsions were not necessarily "epilepsy." It is im- 
 portant for the social worker not to confuse every fit of con- 
 vulsions with the disease, epilepsy. But these particular fits 
 turned out to be verv^ definitely epilepsy, due to an injury ten 
 years before. 
 
 Patrick had never had any serious illness before the age of 
 twenty-six, although he was said to have been always very 
 quiet, sullen, and quick-tempered — more quick-tempered with 
 members of his family than with strangers. In short even 
 before the fracture of his skull at the age of twenty-six he 
 might be thought to have shown somewhat of an epileptic 
 temperament, at all events a psychopathic temperament. Pat- 
 rick's brothers were all alcoholic ; his paternal great-grand- 
 father had had a mental disease ; his father had become insane 
 at the age of forty. 
 
 The patient was struck on the head by a ledge weighing 
 sixty pounds and was in the hospital for some thirteen weeks. 
 On the day of the accident there were nineteen convulsions. 
 From that time forward convulsions occurred frequently 
 throughout his life, as a rule at night. Patrick drank heavily 
 of water and had a large appetite. He grew very jealous 
 and was unsociable in his family. 
 
THE KINGDOM OF EVILS 239 
 
 There could be hardly any doubt that Patrick's action was 
 epileptic. His mother's body was badly mutilated. Some 
 time before, it now transpired, Patrick had assaulted also his 
 sister, breaking her jawbone. He had at that time also been 
 drinking. 
 
 The psychiatrists found Patrick well oriented as to time, 
 place, and person, nor could much impairment of memory be 
 determined. He told of times when his heart stopped beating 
 for long periods whilst he was lying in bed. He told how he 
 had a queer, shivery sensation in his body. Often he felt he 
 was falling when he was not falling. 
 
 The psychologists found Patrick of the mental level of 
 thirteen years. There were no irregularities in his mental 
 tests (that is to say, no marked examples of his passing tests 
 of high year levels while failing to pass the tests of earlier 
 years). His associative processes proved to be slow, as well as 
 all of his responses, although he cooperated well. His vision 
 had been somewhat diminished since the accident and the 
 psychologists felt that his rating was thereby somewhat 
 lowered. It seemed accordingly that Patrick was not to be 
 regarded as feeble-minded by the mental tests. 
 
 Physically there were signs of the old head injury. There 
 was no marked evidence of heart disease. Neurologically he 
 showed sundry effects of his old fracture in the shape of 
 elimination of the fields of vision of the right side and some 
 visual impairment. The X-ray confirmed the history of the 
 fracture. 
 
 Here is a case in which the sphere of authority was in the 
 sense of our Book I almost purely public — indicted for crime 
 he could almost at once be determined to be irresponsible for 
 an act done at the time of epileptic seizures. He could there- 
 fore promptly be sent to an institution for the criminal insane, 
 where no doubt he will lead a tranquil enough life punctuated 
 by occasional epileptic seizures. In certain epileptic cases there 
 is a possibility of surgical aid. But in this instance the medical 
 details of the examination were such that surgery was not 
 recommended. 
 
 What is the province of the social worker in a case like 
 that of Patrick Donovan? The social worker's task is prac- 
 tically confined to the collection of data of value in the medical 
 and psychiatric judgment of the case. In this case various 
 
240 
 
 THE KINGDOM OF EVILS 
 
 points concerning heredity were obtained. Thirteen agencies, 
 relatives, friends, and employers were consulted by letter, tele- 
 phone, or interview. 
 
 There is no special tendency to epilepsy in the offspring of 
 the injured patient. It is often of value to reassure the rela- 
 tives of traumatic epileptics upon just this point. The theory 
 is that the injury to the brain which brings on cerebral con- 
 vulsions does not injure the germ plasm and accordingly has 
 no effect upon heredity. In this instance there were no epilep- 
 tics in the family tree, but there was mental disease on the 
 father's side and there the patient's brothers were alcoholic. 
 Besides this his somewhat psychopathic temperament must be 
 considered. 
 
 Hours spent by 
 Physician, 5 
 Psychologist, i 
 Social worker, 5 
 
 Medical record, 15 pages 
 Social record, 4 pages 
 Social work : 
 
 Visits, 2 
 
 Interviews at hospital, o 
 
 Telephone calls, 6 
 
 Letters, 6 
 
 Drafted but discharged because of epilepsy. Beginning of 
 symptoms after industrial accident. 
 
 Case 55. Charles Lovell was sent from the National 
 Guard camp with the statement that he was depressed, appre- 
 hensive, and excited. He seemed to be trying to give an im- 
 pression of more mental trouble than existed. He said he 
 "was crazy a year ago," that his "mind gives way under 
 strain." He was twenty-seven years old and had lived with 
 his mother in a small town, where he worked for a florist. 
 In school he went to the sixth grade, leaving at the age of 
 sixteen. By psychological tests he graded irregularly at 11. 8. 
 
 Five years before, it was learned, while at work in a foundry 
 he had been hit on the head, had lain unconscious two hours, 
 and next day became "raving crazy" and attempted suicide. 
 He was in bed several months and according to his mother 
 did not get "right in his head" for a year. Thereafter had 
 had occasional dazed spells and lapses of memory, such as for- 
 getting how he came by money that his mother had lent him. 
 
THE KINGDOM OF EVILS 24I 
 
 The diagnosis was epilepsy (no doubt traumatic). The pa- 
 tient was discharged from the army and returned to his old 
 job. Two months later his mother wrote a frantic letter to 
 the social service to ask advice as Charlie had received another 
 draft paper to fill out. A statement of the examination here 
 was sent her, and a local physician was obtained to take over- 
 sight of the case. 
 
 Hours spent by Medical record, 17 pages 
 
 Social record, i page 
 Physician, 3J4 Social work: 
 
 Visits, 
 Psychologist, i Interviews at hospital, I 
 
 Telephone calls, o 
 Social worker, i34 Letters, 4 
 
 Soldier in whom seizures follozved vaccine inoculation. 
 Always siihnormal, hut a steady lad. 
 
 Case 56. Frank Wayne was helping his father on the 
 farm in a southern state when he enlisted at the age of nine- 
 teen, in the coast artillery, in the spring of 191 7. Ten months 
 later, following several vaccine inoculations, he began to have 
 "fits." These attacks came on at night, while he was asleep. 
 He would run about, without regard to the danger of hurting 
 himself and would sometimes bellow and froth at the mouth. 
 He was discharged from the service after a period in an 
 army hospital and sent home. His seizures now became so 
 frequent (he had as many as eight in ten hours) that his 
 father could not control him, and he was returned tO' the 
 government hospital and then sent here for a period of 
 observation. 
 
 Before enlistment Wayne seems to have been a simple- 
 minded lad of good habits and few interests. He went to 
 school irregularly because of work on the farm and left at 
 seventeen. He was considered by his father to have "good 
 health" and to be "sound mentally." A year and nine months 
 after his first seizure his mental rating was 8 by the Point 
 Scale. There had evidently been some mental deterioration, 
 though he was probably always subnormal in intelligence. He 
 had a speech impedirnent and $eemed dull, but otherwise 
 
242 THE KINGDOM OF EVILS 
 
 showed no peculiarities while in the hospital. After a few 
 weeks in the public health hospital he demanded his discharge 
 and was again sent back home. The diagnosis in both hos- 
 pitals was epilepsy with deterioration. 
 
 Hours spent by Medical record, 12 pages 
 
 Socfal record, i page 
 Physician, 334 Social work: 
 
 Visits, o 
 Psychologist, i Interviews at hospital, 2 
 
 Telephone callSj o 
 Social worker, 2^ Letters, i 
 
 Policeman who enlisted and had night attacks after first 
 typhoid inocidation. Epilepsy or hysteria f 
 
 Case 57. John Bristol had been on the Boston police force 
 before he enlisted, and was taken on again after his discharge 
 from service, but lost his position during the police strike of 
 1919. While in the army he was boxing instructor in a train- 
 ing camp. 
 
 After his first typhoid injection he had a queer attack in 
 the night. These attacks continued to occur nearly every 
 night, always coming during the night, always alike, and num- 
 bering from six to fifteen in a night. He would suddenly turn 
 over in bed, bury his face and head in the pillow until he lost 
 his breath, then lift his head to get air and awake partly 
 conscious. During the attack he knew what was going on 
 about him, but could not control himself. He would jerk 
 about and sometimes hit himself in the face. 
 
 He came into the hospital as a voluntary patient because 
 these nocturnal episodes kept him from feeling up to regular 
 work. He was single and made his home with his family. 
 The father had died in an alcoholic psychosis. His case was 
 left undiagnosed, for although it was felt that the trouble was 
 probably epilepsy, the possibility of hysteria could not be 
 positively excluded. An X-ray showed a slight clouding in 
 the pituitary area, but there was no positive evidence of glan- 
 dular trouble as the cause of the attacks. 
 
 After four months' treatment in the out-patient department, 
 the attacks fell in number to five or six a night, and Bristol 
 
THE KINGDOM OF EVILS 243 
 
 felt encouraged and ready for regular work. He said if he 
 could ever get the attacks down to four a night he should feel 
 that he was completely cured. 
 
 Hours spent by Medical record, 9 pages 
 
 Social record, 8 pages 
 Physician, 3^4 Social work: 
 
 Visits, o 
 Psychologist, o Interviews at hospital, 7 
 
 Telephone calls, 4 
 Social worker, sH Letters, 10 
 
SECTION IV 
 
 PHARMACOPSYCHOSES ( MENTAL DISEASES CAUSED BY ALCOHOL 
 
 AND drugs) 
 
 Expert physicist: invahtablc employee. Drinking spells 
 when violent and abusive. Evidence of character anomaly. 
 His fault mental or moral? 
 
 Case 58. John Logan, thirty-nine, is a very competent 
 advertising man in a business wherein a certain technical 
 knowledge of physics is of importance. Logan was born in 
 Ireland and had an excellent technical education there. He 
 had come to America in his thirty-seventh year, having at that 
 time been married four years and having two children. Within 
 a year of his marriage he l^egan to drink, and he drank con- 
 tinuously for seven months, during which time he was under 
 the care of male attendants. From time to time he had spells 
 of drinking in which he would become abusive and even violent. 
 His wife even left him at one time, but went back with him 
 to his father's house in Ireland, where he recovered. Several 
 more spells of drinking followed. After one very bad attack, 
 his wife again left him, carrying with her the two children,.- 
 and consulted a lawyer. Upon this, Logan sold his house, 
 came to America, got a good position where his technical 
 ability counted, and eventually persuaded his wife to join him 
 once more. 
 
 Work piled up and, in the course of some six months, Logan 
 again began to drink on the ground that he was helped in his 
 work thereby. He again jjecame abusive with his wife, and 
 the landlord gave him notice to quit. He turned upon the 
 landlord, finally said he was going to hire a man to shoot the 
 landlord, and was brought by the police to the Psychopathic 
 Hospital, 
 
 According to Logan's wife, her husband was, as a rule, 
 considerate enough yet objected to her making friends or hav- 
 ing any other associations save with himself and the children 
 
 244 
 
THE KINGDOM OF EVILS 245 
 
 He would not take her out of an evening, being content to 
 stay at home, reading or talking. He had never allov^^ed a 
 door to be unlocked at night, or a window to stand open even 
 in the hottest weather. He was apt to become irritable at 
 any trifling noise or disturbance. If his wife complained, he 
 would threaten to go away and drink. In point of fact, had 
 it not been for the children, Mrs. Logan said she would not 
 live a moment with her husband. 
 
 After two weeks' observation in the hospital, Logan was 
 discharged and went back to his position. He was regarded 
 as "not insane" ; he was thought to have been a victim of acute 
 alcoholism and not of any alcoholic psychosis. The question 
 of his being a delinquent was left unresolved. 
 
 Is it worth while to try to clear up a point or two concern- 
 ing the respective place in diagnosis of "delinquency," "alco- 
 holism," and "alcoholic psychosis"? As we have repeatedly 
 hinted in other parts of this book, it may well be that the 
 psychiatrists and the criminologists of the future will show 
 that all delinquents are in some sense psychopathic ; but so far 
 as we are aware, this proof has not been brought. Even in 
 those instances in which the character anomaly of a delin- 
 quent is so outspoken that the term psychopathic fits pretty 
 well, nevertheless from the legal and even from the moral 
 points of view, this anomalous character may remain per- 
 fectly "responsible." Naturally, it is not here our duty to 
 inquire the meaning of the term "responsible." We leave the 
 issue at this, namely, that delinquency is not a psychiatric 
 diagnosis. The question of psychopathy remains to be deter- 
 mined whenever delinquency of whatever type is asserted. 
 
 Somewhat the same situation holds with respect to "alcohol- 
 ism." Alcoholism is obviously a social diagnosis. It is very 
 possibly a medical diagnosis. Sir Patrick Manson has spoken 
 of alcoholism as a disease due to the toxin developed from 
 yeast ! But assuredly alcoholism is not a psychiatric diagnosis. 
 It is especially important for the psychiatric social worker to 
 bear in mind that acute and chronic alcoholism are two forms 
 of social condition which are not at all necessarily mental 
 diseases. 
 
 Logan was dismissed the first time from the Psychopathic 
 Hospital without a psychiatric diagnosis. That he was a 
 victim of acute alcoholism was obvious. That he might pos- 
 
246 THE KINGDOM OF EVILS 
 
 sibly be a delinquent (from his abusiveness, violence, and 
 threats of homicide) was obvious. That his character was a 
 bit eccentric might also be alleged. But then the "benefit of 
 the doubt'' had also to be extended to Logan. 
 
 Logan's employer had supposed that the man would have 
 to be discharged. The situation was explained to the employer, 
 who remarked that Logan's work was of so much value to 
 the firm that an occasional leave of absence might be granted 
 to him if necessary. The patient readily agreed to do no more 
 overtime work, to give up alcohol, and to take more interest 
 in his wife's happiness and amusement. Logan began to take 
 a great interest in the Men's Club. (For a brief description 
 of this club, see case 6, Alfred Mack.) Logan in fact even 
 undertook to act as its president. However, within four 
 months he began to neglect the club, grew resentful of the 
 hospital's continuing to take an interest in him, even threatened 
 to leave the state, said he could not be dictated to, and began 
 to think that everybody in his office was jealous of him and 
 working against him. He began again to drink heavily and 
 to abuse his wife, and even once threatened to choke her. 
 Upon this his wife notified the social service and Logan was 
 brought back to the Psychopathic Hospital by the police. The 
 next day he said he was rather glad he had come. He said 
 he could not believe that he had been dangerous, and it was 
 with some difficulty that he could be convinced of his change 
 of character. 
 
 He was discharged once more after a period of ten days, 
 again with the diagnosis of acute alcoholism (not a psychi- 
 atric diagnosis), yet the notes show that this man's character 
 anomaly stood out somewhat in relief, so that a suggestion 
 of the diagnosis of paraphrenia was offered by some observers. 
 This condition termed paraphrenia is a disease rather closely 
 similar to the so-called paranoia, a condition with which even 
 the laity has become more or less familiar. It is a disease in 
 which to all external appearances the patient acts quite nor- 
 mally. Neither his will nor his emotions are at all out of 
 keeping with his ideas. It is these ideas which are at fault. 
 Characteristically, the disease runs a course through (i) a 
 somewhat indefinite early phase to (2) a phase of feeling per- 
 secuted. In typical cases, the phase of persecutory delusions 
 passes insensibly over into (3J a phase of grandiose delu- 
 
THE KINGDOM OF EVILS 247 
 
 sions in which the patient feels himself superior to or domi- 
 nant in his family and surroundings. There was in point of 
 fact in Logan's case no very striking sign of any grandiose 
 trend, but his complainings, jealousies, and ideas of persecu- 
 tion by his working associates and his wife seem consistent 
 enough with this diagnosis. On the whole, however, there 
 was no sufficient argument for paraphrenia. Upon discharge, 
 Logan seemed "amiable though rather peculiar." He came a 
 number of times to the Men's Club; then he begged to be 
 excused, disliking, as he said, the hospital associations and 
 feeling that his fellow employees would see him on the way 
 to the hospital. In point of fact, so skillfully had hia hospital 
 stays been guarded from knowledge that only four or five 
 persons amongst his working associates knew at all of his 
 having been treated in hospital for alcoholism. 
 
 Four years followed in which Logan's family life was rea- 
 sonably successful. To be sure, he remained capricious and 
 unreasonable, haggling over every slight expenditure and giv- 
 ing his wife money for food only. However, he drank not 
 at all, enjoyed his work, sent his family on good vacation; 
 when his wife was away himself did some work about the 
 house, and all went well. A third child had been born. The 
 family had moved to pleasant suburbs, where garden work 
 was the center of interest. 
 
 It is to be noted, however, that the prognosis by the medical 
 staff upon his second discharge remained a bit dubious. That 
 he might return some day to the hospital was an opinion that 
 stood for four years in the records without confirmation. 
 Even when the old situation recurred and he was again a fit 
 subject for the Psychopathic Hospital, there was a good deal 
 of doubt whether a man who had never received a psychiatric 
 diagnosis was suitable for reception. Could the Psychopathic 
 Hospital dogmatically advise the family or the police to bring 
 a man like John Logan back under care ? Here lodges a large 
 arid important question in the mental hygiene of the com- 
 munity. We make no doubt that in the end such advice prop- 
 erly supported by medical, psychological, and social data will 
 be proffered in cases far less dangerous than John Logan's. 
 However, we are aware that in vast communities of the United 
 States no such interference with personal liberty and an 
 alcoholic's privilege of the pursuit of happiness would be 
 
248 THE KINGDOM OF EVILS 
 
 tolerated. No doubt sundry representatives of the judiciary, 
 even in our own community, might raise their eyebrows at 
 this kind of reaching out from government to the citizenry. 
 Looked at from another point of view, however, we are sure 
 that progress will be in the line of such "interference."' If it 
 be "interference" to preserve a man from his own anomalies 
 (to say nothing of his wife and children), then one might say. 
 Make the most of it ! The ideal day when psychopathic hos- 
 pitals throughout civilized communities shall be as open to 
 the mental sick as general hospitals are open to the somati- 
 cally sick, will see far milder cases than John Logan's brought 
 to the examining table. No matter what the cake of custom 
 fixates in the minds of uncivilized communities, the Psycho- 
 pathic Hospital movement must and will irresistibly go for- 
 ward, and perchance engulf those very superconservatives that 
 everywhere block progress. 
 
 We wrote the above words before the critical first of July, 
 1919, upon which day national prohibition in our country 
 began. As a matter of history, Logan, it appears, was influ- 
 enced to start drinking again by the suggestion that July i 
 was upon us and that a few last drinks might well be in order. 
 He took these drinks, and during the next fortnight at home 
 drank more and more until he became again in the familiar 
 way excited, noisy, threatening, and abusive. Aside from 
 trembling of his hands and tongue, he was quite normal physi- 
 cally. As always, he was psychometrically on a high level, 
 getting the maximum year level that our tests permitted. 
 Again he received the medical or social diagnosis "alcohol- 
 ism," was regarded as non-psychotic, and was discharged. 
 What is Logan's prognosis? National prohibition may settle 
 his fate. If, however, his spells of excitement and abusive- 
 ness are really not socially alcoholic in their origin but repre- 
 sent some profound wave of emotional change in Logan, then 
 perhaps a new picture will unroll itself. 
 
 What has the social work accomplished in the case of John 
 Logan? Such cases have not been at all frequent. Physi- 
 cians might well be entitled to doubt whether such cases be- 
 longed to the medical, and particularly to the psychiatric, field 
 at all. The question has been raised several times whether 
 John Logan was really a proper subject for the Psychopathic 
 Hospital. Would he not perhaps have been straightened out 
 
THE KINGDOM OF EVILS 249 
 
 as effectively by treatment in some other form of hospital, or 
 even as a delinquent? We are personally, however, strongly 
 of the opinion that the psychiatric point of view is the best 
 available for the elucidation even of such mild character dis- 
 order as we find in Logan. Logan himself, especially after 
 he had been drinking for some time, no doubt felt that the 
 Psychopathic Hospital cast somewhat of a stigma upon him. 
 He was always polite enough to the particular worker set over 
 him; but his behavior was unmistakably that of a somewhat 
 complaining, resentful man. His wife, on the other hand, 
 felt that John Logan's fault was far more mental than moral. 
 Perhaps she was taught by our social workers so to think. 
 In any event, without the aegis of some hospital, and perhaps 
 without the particular aegis of our own in this community, 
 Mrs. Logan would have felt quite at a loss. No one would 
 have picked up the loose ends of the family plight; and we 
 feel that an enormous debacle might well have ensued in this 
 family without the support afforded by social work. 
 
 The only alternative that we can think of to the sort of 
 support afforded by the Psychopathic Hospital social service 
 would be a similar type of support that one might ideally 
 think of as possible under a greatly reformed criminological 
 system. Should it ever be possible for the present system so 
 to develop a fine system of extramural threads running to all 
 parts of the community of delinquents and near-delinquents, 
 then we can ideally conceive that an extension of the proba- 
 tional system along preventive lines might turn the same trick 
 that was turned by the Psychopathic social service in the 
 Logan case. But we may be permitted to point out that, if 
 it remains doubtful whether the Psychopathic Hospital has 
 any right to spread its wings over John Logan, then it is per- 
 haps more doubtful whether a benevolent and reformed prison 
 system could quite so readily spread its wings. Moreover, we 
 think that the wings of the Psychopathic Hospital will always 
 be of whiter hue than the wings of any prison system. 
 
 For the administrator of such a beneficent system, whether 
 it stretches its wings from a commission on mental diseases or 
 from a bureau of prisons, the problem presented by such a 
 man as John Logan is always a bit difficult. Shall he or shall 
 he not be admitted as virtually a psychopath when much doubt 
 rules whether he is demonstrably a psychopath? Whatever 
 
250 THE KINGDOM OF EVILS 
 
 the system, all depends, as is ever the case, upon the operator 
 of the system. Imagine a stickler upon fine technical obstacles 
 and you will imagine an operator who will fail whatever the 
 general virtues of the system. Wherever possible the com- 
 munity should be given the benefit of the doubt, and in our 
 experience, giving the community that benefit incidentally 
 inures to the good of the central figure in the tragedy. 
 
 Hours spent by Medical record, 11 pages 
 
 Social record, 22 pages 
 Physician, 4 Social work: 
 
 Visits, 12 
 Psychologist, i Interviews at hospital, 8 
 
 Telephone calls, 16 
 Social worker, 29 Letters, 16 
 
 First attack of delirium tremens. Drank to excess while 
 wife was in hospital. 
 
 Case 59. Patrick Nolan, forty, is presented as a case of 
 delirium tremens, that most frequent of the alcoholic psychoses. 
 (In the discussion of the next case, John Sullivan, we make 
 some note of the differences between delirium tremens and 
 alcoholic hallucinosis so far as these are of importance to the 
 social worker.) This man was, according to the mental tests 
 made by the psychological examiners, of a very high rating, 
 namely 15.5 years of mental age (close to the limit of age that 
 can be tested by present-day psychometric tests) and scored 
 in other ways his intelligence was high. This test was made 
 November 19 and the patient cooperated well though he was 
 at that time impatient to get to his family waiting upstairs. 
 He had been admitted to the hospital four days before, namely 
 on November 15. 
 
 Nolan was an Irishman, alcoholic from the age of twenty- 
 two years. He had been drinking to great excess for some 
 days and had l^ecome very nervous and tremulous. Two 
 nights before admission, that is on the night of November 12, 
 Patrick waked up a family that lived near him and asked the 
 head of the house to come to the Nolan home and stay with 
 him as he was nervous and afraid he would die. His wife was 
 in hospital for a slight operation and he had resorted to whisky 
 for companionship. He himself said that while he and whisky 
 had always been good friends before that, after his wife had 
 
THE KINGDOM OF EVILS 25 1 
 
 gone to the hospital he and whisky had become inseparable. 
 His friend, Mr. Doherty, stayed with Patrick all night. Pat- 
 rick slept not at all but wandered from room to room. He 
 seemed a little better next day but in the afternoon talked 
 about seeing his dead brother. Accordingly a physician was 
 called who found all the lights in the house lighted and the 
 doors locked. Patrick refused to see the doctor ; the police 
 came ; Patrick then opened the door and went with them talk- 
 ing about devils who were getting him. So far as his friends 
 knew or at least would say, Patrick had never had a similar 
 state before. 
 
 For two nights in the hospital he continued to see devils 
 under his bed. He was "somewhat depressed" but the line 
 between depression and a proper sadness is naturally hard to 
 draw. When he told his story he had become humorous. All 
 are familiar with the humor of the Irish but it would appear 
 from medical observations in alcoholic psychoses that the so- 
 called "humorism" is not merely an Irish trend but is found 
 as a somewhat differential effect of alcoholism in a variety of 
 races. 
 
 Patrick Nolan failed to see the "animals" which one is sup- 
 posed to see if a victim of delirium tremens. Perhaps "devils" 
 will serve in their place. It is just as well, however, that the 
 case we here choose to illustrate delirium tremens is a case 
 without the so-called zoopsia or hallucinations of animals. 
 
 Physically Patrick was a muscular, gray-haired, ruddy-faced 
 man having the somewhat characteristic weather-beaten alco- 
 holic facies. Aside from a flushed face and widely dilated 
 pupils, there was nothing of note in the physical examination 
 save very active knee jerks. The victim of delirium tremens 
 is rather apt to look more "sick," that is, physically sick, than 
 the victim of alcoholic hallucinosis (to be considered in the 
 next case, John Sullivan). The facial flush, the tremulous- 
 ness, the dilated pupils, the look of a certain confusion and 
 perhaps fear combine to give this impression of a delirium 
 tremens victim as looking "sick." "Nervousness" is a term 
 the layman is apt to use about this state ; but the term is used 
 for so many other states that it is of little or no value from 
 a standpoint of diagnosis. He was discharged recovered on 
 the seventh day and his frank psychosis had thus lasted appar- 
 ently some nine or ten days in all. 
 
252 THE KINGDOM OF EVILS 
 
 Patrick was now referred to the social service. He was a 
 married man without children who lived on the top floor of 
 a three family house. He was an unskilled laborer earning 
 fifteen dollars a week. Both he and his wife were church 
 members. In Ireland he had had schooling until his thirteenth 
 year and had worked on a farm until he was twenty- four. A 
 brother had died at forty of cirrhosis of the liver, a condition 
 which many books describe as of alcoholic origin, and which, 
 no doubt, is often alcoholic in origin though other factors must 
 probably enter. Another brother had died at the same age, 
 forty, of heart disease. Still another had died of tuberculosis 
 at thirty-six, and the fifth of the five brothers had been a vic- 
 tim of delirium tremens at one time at the Psychopathic 
 Hospital. 
 
 An arrangement was made for the patient to come to the 
 Men's Club but this proved not feasible. However, without 
 this aid, through the very light supervision necessary, the 
 patient ceased to drink and it was possible to close the case 
 two months and a half after he first came under observation. 
 It may be queried whether this case was not closed too early 
 and this must be admitted, though no doubt with the experi- 
 ence in hand any renewed resort to alcohol on Patrick's part 
 would have been quickly called to the hospital's attention on 
 account of the relations established with the wife. 
 
 Hours spent by Medical record, 13 pages 
 
 Social record, 2 pages 
 Physician, 3J/2 Social work: 
 
 Visits, 2 
 Psychologist, i Interviews at hospital, i 
 
 Telephone calls, 
 Social worker, 5 Letters, i 
 
 Alcoholic hallucinosis in discharged real estate agent. Other 
 forms of alcoholic psychoses. Temporary care law. 
 
 Case 60. John Sullivan, forty-seven, was a victim of a 
 so-called alcoholic hallucinosis, a condition which somewhat 
 resembles the condition well known to the laity under the 
 name delirium tremens and not always easily told from de- 
 lirium tremens on the one hand and from various other forms 
 of alcoholic mental disease on the other hand. Before the 
 
THE KINGDOM OF EVILS 253 
 
 era of national prohibition both alcoholic hallucinosis and 
 delirium tremens formed so important a group of diseases that 
 no social worker could fail to take an intimate interest in their 
 nature, especially touching their prognosis. 
 
 It is worth while stressing the fact that the alcoholic mental 
 diseases do not vary in severity in proportion with the alco- 
 holism which is indispensable to their production. Whether 
 there are not some other more essential factors that lie at the 
 basis of alcoholic mental disease in its various forms is, at 
 present, unknown. By the administration of alcohol one 
 coidd not promise the production of an alcoholic psychosis. 
 To be sure there are some pseudonormal forms of alcoholic 
 mental disease that seem somewhat closely allied to drunken- 
 ness, a condition which is not ordinarily, or perhaps properly, 
 termed a mental disease. The periodic form of uncontrolled 
 drinking called dipsomania and the rare disease known as 
 pathological intoxication are two conditions which require the 
 most thorough observation and expert judgment to diagnosti- 
 cate. The victim of genuine dipsomania is, no doubt, as a 
 rule, a psychopath on some broader and deeper basis than the 
 mere alcoholic habit. . The basis of the strange disease, patho- 
 logic intoxication, is perfectly obscure, though the condition 
 may suggest, in its suddenness and relation with perfectly in- 
 significant intakes of alcohol, some peculiar condition of sensi- 
 tization that may finally be explained when all such matters 
 as shellfish poisoning, strawberry skin eruptions and the like 
 are explained. We insist rather upon these points because 
 there is an almost irresistible tendency for the lay worker and 
 for the inexperienced physician to regard the alcoholic psy- 
 choses as, after all, probably somehow based on the intake of 
 greater and greater amounts of alcohol. While upon the gen- 
 eral topic we may add that despite sundry assumptions to 
 the contrary, it is doubtful whether particular kinds of alco- 
 holic beverages have very especial outcomes in relation to 
 mental disease. (The experimental absinthe convulsions form 
 an important exception.) 
 
 But the great bulk of the alcoholic mental diseases with 
 which the social worker or the court officer comes in contact 
 is, no doubt, composed of the disease delirium tremens, an 
 example of which is the case of Patrick Nolan given above. 
 Some authors even deny that a differentiation can be made 
 
254 THE KINGDOM OF EVILS 
 
 between the two conditions, delirium tremens and alcoholic 
 hallucinosis, and they can point out numerous transitional and 
 intergrading forms of alcoholic mental disease. Some cases 
 looking like delirium tremens may run along for several weeks 
 after the manner of alcoholic hallucinosis. Some cases of 
 delirium tremens, instead of presenting the hallucinations of 
 vision that are typical thereof, present hallucinations of hear- 
 ing such as we may ordinarily find in alcoholic hallucinosis. 
 On the other hand, alcoholic hallucinosis, though it is less 
 likely to run the brief course of less than a fortnight which 
 delirium tremens runs, may not seldom show hallucinations 
 of sight like those of delirium tremens. It is easy to see 
 that the lay mind would here run too readily upon diagnostic 
 rocks. To illustrate this fact we may point out that owing to 
 certain details in the Massachusetts law, the Psychopathic Hos- 
 pital was not expected to take cases of delirium tremens any 
 more than it was expected to care for cases of real drunken- 
 ness. Nevertheless, every year scores of cases of delirium 
 tremens were admitted to the hospital under the false assump- 
 tion that they were cases of alcohohc hallucinosis. To be sure 
 humanity entered here to cloud the issue. No other institution 
 in Boston was so well equipped materially or diagnostically 
 to handle the alcoholic psychoses as was the Psychopathic Hos- 
 pital. (It is to this day a sad commentary on the progress of 
 the so-called general hospitals that they have not equipped 
 themselves with baths, isolation rooms, corps of skilled at- 
 tendants, and proper diagnostic specialists to meet the com- 
 plications of alcoholism, with the result that the jails have 
 had to serve as hospitals in states not properly equipped with 
 psychopathic units.) Accordingly we were in the habit of re- 
 ceiving, on the ground of humanity, sundry cases that seemed 
 to be in extremis but which turned out to be cases of delirium 
 tremens. When all is said and done, the differential diagnosis, 
 even in this group of mental diseases which the layman is apt 
 to think he understands fairly well, is not easy. 
 
 The prognosis of these cases is particularly hard, not to 
 say often impossible to lay down, and some cases of a disease, 
 ordinarily fairly acute, turn inexplicably into chronic cases 
 requiring institutional care or its equivalent, and persisting 
 with a batch of hallucinations and delusions like those with 
 which the disease began, or else subsiding into a deterioration 
 
THE KINGDOM OF EVILS ^55 
 
 or dementia in the midst of which any very definite alcoholic 
 features are hard to descry. 
 
 Before dismissing this topic of the alcoholic psychoses in 
 general, we may mention the existence of a third group of 
 alcoholic psychoses of an insidious onset and a chronic course, 
 cases that do not necessarily begin with any acute form of 
 mental disease (though they may do so) but do not charac- 
 teristically "hallucinate" (a slang phrase of the clinic having 
 reference to the process of having hallucinations ; that is, false 
 perceptions in some field of sense, notably in the alcoholic 
 psychoses in the spheres of vision and hearing). We offer a 
 case of this third group in that of Michael Piso, a case of 
 jealousy psychosis. 
 
 John Sullivan was a real estate sales agent. He said his 
 business had been going wrong for some time, that he had 
 gone up to Canada one day and returned on the next train, 
 having the idea that a detective was following him; in fact 
 he said he saw someone following him and that he heard some 
 men on the train talking about him. Even after entering the 
 hospital he said he heard people remarking about how he 
 was using other people's money. 
 
 Technically the fact that Sullivan had an idea that a detec- 
 tive was following him would be regarded as a delusion or 
 false belief. If, however, he actually saw real men and, not- 
 ing their whispers, conceived that they were talking about him, 
 then his status would be technically regarded as one of the 
 so-called delusions or ideas "of reference." 
 
 Whether Sullivan actually had hallucinations is a matter of 
 some doubt, though he admitted hearing voices of no visible 
 source, but he heard them rather vaguely. The victim of a 
 typical alcoholic hallucinosis should, perhaps, have heard voices 
 much more definitely than did Sullivan. The theoretical line 
 of separation between ideas "of reference" and hallucinations 
 is sharp enough, seeing that the latter must be definite false 
 perceptions, whereas the former are a kind of erroneous idea ; 
 yet the practical claim of separation between these two symp- 
 toms wavers tremendously. 
 
 He had had a history of several weeks of such delusions, 
 believing that the police were after him because he had held 
 back his rent, that people had scoffed at him, that he was 
 ruined (he had actually lost money in recent sales). He said 
 
256 THE KINGDOM OF EVILS 
 
 that his mind had become rather confused of late and that he 
 could not think. In fact, he "must have been insane." He 
 had once even gone so far as to threaten suicide. 
 
 With all this it may seem strange that Sullivan had actually 
 come to the hospital as a voluntary patient. When it came 
 to signing the application for his admission he, however, be- 
 came suspicious and refused to sign. He was accordingly 
 admitted under the Temporary Care Law (see Appendix C for 
 discussion of the Massachusetts Temporary Care Law, one of 
 the measures without which extensive state work with non- 
 committable psychopaths is impossible). As he admitted hav- 
 ing hallucinations or other symptoms of a frankly psychopathic 
 nature, it was perfectly proper to have a medical officer (not 
 upon the stafif of the hospital) make application for his ad- 
 mission. Upon these preliminaries, Sullivan went to the ward 
 without protest. This was on May 23 and by June 29 it was 
 possible for him to be discharged, as recovered, to the outt 
 patient department. He had had seven days of so-called "tem- 
 porary care," that is, of care under the law which did not carry 
 him to the probate court, but upon the seventh day, that is, 
 May 29, he was actually "committed," that is, his case was 
 carried to the probate court upon the evidence of two expert 
 physicians not connected with the Psychopathic Hospital. 
 
 He was then carried upon the books until December 29. 
 Already by May 29 he had improved a great deal so that the 
 commitment to the hospital was really a measure on the pa- 
 tient's behalf, to the end that he could have hospital care until 
 his disease was over. He was under hospital care, therefore, 
 for a period of about five weeks. At some time in the third 
 week he got good insight into his past condition. At this 
 point the social service took control, although the term "con- 
 trol" might seem a rather heavy one for this particular case. 
 Sullivan was a very amiable sort of man with what may be 
 termed a rather high empathic index. ^ The technique of 
 this social care consisted in utilizing the Men's Club for hos- 
 pital and human contacts and in counsel and encouragement. 
 
 John's mother had been for two months at a hospital for 
 the insane some years before, also the victim of alcoholic men- 
 tal disease. One of three brothers was also a very heavy 
 
 * Southard, E. E., M.D. : "The Empathic Index in the Diagnosis of Mental Dis- 
 eases," Journal of Abnormal Psychology, October, 1918. 
 
THE KINGDOM OF EVILS 257 
 
 drinker though all three brothers and four sisters were physi- 
 cally well. John's father had died of accident. John had 
 had little schooling but had educated himself. Though he 
 had been a gardener in England he had become a real estate 
 agent in America. His business had been good until it had 
 gone downhill during the last year, obviously the result of his 
 alcoholism. So far as the history was frank, it would seem 
 that before that time he had been drinking more moderately 
 though all through the twenties and early thirties he had been 
 a very heavy drinker, apparently without any mental effects 
 of a nature to interfere with self-support. 
 
 Physically he proved entirely normal save his thinness, and 
 psychiatrically there were no abnormalities save those men- 
 tioned. He explained that he had taken the trip to Canada with 
 a vague idea that he was going to start anew there. 
 
 We find medical notes of reports in July, August, Septem- 
 ber, November, February, March, May. These notes show 
 that there was no return of symptoms and that Sullivan was 
 making a good deal of headway with his debts and with his 
 business. Pari passu with these medical notes we find social 
 service notes in February, March, April, and May of the year 
 following his attack and, in fact, in May the case was closed 
 by the social service. The social-service notes had told of 
 visits at Sullivan's home and of advice concerning his coming 
 to the Men's Club. The economic problem was not in the 
 foreground, as the wife kept a lodging house. 
 
 Hours spent by Medical record, lo pages 
 
 Social record, i page 
 Physician, 7% Social work: 
 
 Visits, 3 
 Psychologist, o Interviews at hospital, 2 
 
 Telephone calls, I 
 Social worker, 5^/^ Letters^ 4 
 
 Root of family dissension may be disease /)f one member. 
 Acute alcoholic hallucinosis; chronic inebriety; morbid temper- 
 ament. 
 
 Case 61. If we examine a social case card-catalogue, we 
 shall find case after case of so-called family dissension. We 
 say "so-called" not because the term is meaningless, but be- 
 cause cases left with the designation family dissension are, 
 
258 THE KINGDOM OF EVILS 
 
 we believe, cases not properly analyzed as to the form of evil 
 at work. That form of evil may as readily be disease in one 
 or other member of the family as any other of our major 
 groups of evil. Thus Margaret Murray, a Scotch woman of 
 thirty-nine, was living in New Hampshire with her six-year- 
 old daughter Pearl, apart from her very reputable husband, 
 an iron-worker earning some thirty dollars a week. The 
 "symptom'' catalogue stood as follows : 
 
 Social symptoms: 
 
 Inebriety (chronic) 
 
 (?) Insane commitment 
 
 ( ?) Neglect of child 
 
 (?) Immoral influence on child 
 
 Marital discord 
 
 Arrest 
 Social diagnosis: 
 
 Family dissension 
 Medical diagnosis: 
 
 Acute alcoholic hallucinosis 
 
 We hold that the medical diagnosis in this case is the social 
 diagnosis and that family dissension, though a perfectly cor- 
 rect term for the social conditions found, is not the caption 
 most helpful in determining social treatment. Chronic in- 
 ebriety is set down as one of the social factors : a fortiori, 
 acute alcoholic hallucinosis is another and even more command- 
 ing factor, since (a) this disease brought Mrs. Murray to the 
 Psychopathic Hospital and (b) its prognosis and treatment 
 (whether by costing confinement in a state hospital or not) 
 will influence every social step taken. In short we would pre- 
 fer to place this case among the Morbi rather than among the 
 Vitia where family dissension would tend to leave it. Let the 
 morbid factor be removed, and the moral factor can remain — 
 i.e., Mrs. Murray would then have her chronic inebriety to 
 face (provided that in her case the habit is not itself a disease). 
 Let the inebriety be removed, and there might still be a basis 
 in morbid temperament or bad habits for family discord. 
 
 Let us examine enough of the facts to demonstrate the 
 issue. Mrs. Murray had drunk to excess and had been twice 
 arrested for drunkenness (chronic inebriety). She came to 
 Boston and, whilst working in an institution, developed the 
 symptoms that brought her to the Psychopathic Hospital. 
 
THE KINGDOM OF EVILS 259 
 
 There she had hallucinations of hearing and told (delusional) 
 stories of her husband's abuse of her. There was even raised 
 the question of commitment. The husband was by now dis- 
 heartened and antagonized and had begun to regard his wife 
 as irresponsible. There was discord over the question whether 
 she should live with husband and daughter, should take the 
 daughter with her, or leave the daughter with her father. 
 Mr. Murray felt that daughter Pearl might suffer immoral 
 influences from her drunken mother. Upon study of the case 
 it appeared to the social workers that the child could hardly 
 be unaware of her mother's drunkenness. It was on this 
 account that the list of social symptoms contained the two 
 questions "neglect of child?" and "immoral influence on 
 child?" 
 
 The efforts of the social service were summed up as fol- 
 lows : — 
 
 1. In arranging for temporary care for patient and child 
 upon the former's discharge from the hospital until the hus- 
 band could be located and until employment was found for her. 
 
 2. In making an investigation of the family situation to 
 understand the facts. 
 
 3. To give advice and cooperation to both the patient and 
 her husband as they are working out their readjustment. 
 
 If we take the phrase "working out their readjustment" 
 upon the simple basis of family dissension, we should hardly 
 avoid being influenced by the phrase itself. Family dissen- 
 sion clearly points to moral difficulties within the sphere of 
 what we have in this book termed Vitia. Family dissension 
 does not at all necessarily point to disease (Morbi). The man 
 in the street and the social worker can hardly help feeling that 
 family dissension is a matter of ingrained temperament dif- 
 ficult to train by moral methods, difficult or impossible to 
 reeducate by the intellectual route alone and, even if psycho- 
 pathic, by the same token harder than ever to meet. In short, 
 the social worker, should she content herself with the social 
 diagnosis family dissension, might believe that she was doing 
 the charitable thing by her patient. Family dissension as a 
 moral matter sounds less heinous than family dissension as 
 a matter of disease. 
 
 But let us look into the facts. As a matter of the actual 
 situation and its outcome, the social condition family dissen- 
 
26o THE KINGDOM OF EVILS 
 
 sion proved to be almost entirely, if not quite, fear of a rather 
 acute mental disease or the so-called hallucinosis. That there 
 was any deep underlying psychopathic trend of temperament 
 is extremely doubtful. Even if Mrs. Murray became alco- 
 holic through some deep trend of her nature, there is no proof, 
 theoretical or practical, that this temperamental trend would, 
 in and by itself, lead to family dissension. Accordingly, we 
 hold that our proof is positive, that the social diagnosis in 
 the case of Mrs. Margaret Murray should be alcoholic mental 
 disease, in particular acute alcoholic hallucinosis. We hold 
 that the social prognosis depends upon the medical diagnosis 
 and prognosis. We hold that family dissension is an effect 
 rather than a cause and is probably removable. We hold that 
 the questions raised concerning neglect of child and immoral 
 influence upon the child by her mother are questions which 
 would be removed by a solution of the mother's alcoholic 
 problem. Likewise we hold that the arrest and the question 
 of commitment of Mrs. Murray to a chronic institution (a 
 question raised during her temporary care whilst she was 
 recovering from the acute effects of her alcoholic psychosis) 
 are likewise purely secondary products of the situation. 
 
 We should also like to call attention to the fact that the 
 phrase "chronic inebriety'' which stands at the head of the 
 list of social symptoms in this case is likewise somewhat mis- 
 leading. To be sure the acute mental disease known as alco- 
 holic hallucinosis was, in this case, incidental to a chronic in- 
 ebriety. It is also true, no doubt, that alcoholic hallucinosis 
 is, as a rule, incidental to a chronic inebriety, but it is not at 
 all clear that chronic inebriety must necessarily or in any 
 large proportion of cases lead to alcoholic hallucinosis. • As 
 one author rather paradoxically said, "The causes of delirium 
 tremens are still obscure." The same holds for the allied 
 disease, alcoholic hallucinosis, the causes of which are per- 
 haps still more obscure than those of delirium tremens itself. 
 Neither of these diseases is at all proportional to the amount 
 of alcohol consumed by the victims nor to the duration of 
 the habits of inebriety. Nor can we say that the prognosis 
 of cases of delirium tremens or of alcoholic hallucinosis at 
 all varies with the duration or severity of the alcoholic bad 
 habit. We may be permitted to add that chronic inebriety 
 shares with family dissension the pretty distinct intimation 
 
THE KINGDOM OF EVILS 26 1 
 
 that we are dealing with bad habits and vices rather than with 
 deficiencies in the patient's education or psychopathic tempera- 
 mental tendencies. 
 
 The general social worker must bear in mind these intima- 
 tions of the social phrase. The psychiatric social worker 
 quickly learns the more obvious pitfalls of phraseology, but 
 each type of social worker and the physician himself must 
 guard against throwing all cases of family dissension and oil 
 cases of chronic inebriety over into the disease group. It 
 must be plain from the general drift of our contentions in 
 this book that disease must be considered as a primary hy- 
 pothesis and not necessarily as a statistical probability. De- 
 ficiencies in education leading to family dissension or to chronic 
 inebriety are even less statistically probable as a matter of 
 actual fact — still, we must consider the hypothesis of faulty 
 education. Nevertheless, if we are entitled to give over the 
 psychopathic hypothesis and the maleducational hypothesis, 
 then we shall be reduced to the hypothesis of moral deficiency 
 or perversion. If we are reduced to this hypothesis, we shall 
 find, far more trouble in the process of readjustment for every- 
 body, — as some might say nine parts of internal readjustment 
 to one part of external and merely social readaptation. Family 
 dissension might conceivably be an almost purely legal diffi- 
 culty owing to perfectly logical disagreements on the part 
 of different members of the family concerning (let us say) 
 financial arrangements ; but of that rare possibility there was 
 no question in the Murray case. Nor \yas there any question 
 of a purely economic basis for the dissension in this family. 
 
 The social analysis of the Murray case leads us, in the end, 
 to placing an acute and curable alcoholic mental disease sharply 
 in the foreground. The social prognosis becomes extraordi- 
 narily brighter than it would be if we took family dissension 
 prima facie as the root difficulty. We are dealing with an- 
 other sample of the well-known, though somewhat paradoxical, 
 plight, the situation that it is rather better to be sick than 
 to be vicious. 
 
 Hours spent by Medical record, 6 pages 
 
 Social record, 7 pages 
 Physician, 3^ Social work: 
 
 Visits, o 
 Psychologist, o Interviews at hospital, 2 
 
 Telephone calls, 22 
 Social worker, 7 Letters, 15 
 
262 THE KINGDOM OF EVILS 
 
 Feeble-minded teamster ten years married to a good wife, 
 suffers from alcoholic "jealousy-psychosis." Violent, abusive. 
 Improvement. Family difficulties: poverty, sickness. 
 
 Case 62. There are hardly more intriguing cases than 
 those of jealousy in alcoholics. Psychiatrists recognize a pe- 
 culiar alcoholic "jealousy psychosis," sometimes conceiving 
 that the onset of sexual impotence on the part of the alcoholic 
 leads up by somewhat natural steps to the belief that the spouse 
 is in love with a rival. Now there is, perhaps, especially in 
 alcoholic families, always a possibility that there is some ac- 
 tual fire under the delusional smoke. The psychiatrist, and 
 even the social worker who comes in close contact with family 
 conditions, may be for a long time in doubt as to the actual 
 facts. In alcoholic communities the psychiatrist often feels 
 himself entitled to suspect alcohol in any case of delusions of 
 jealousy. Yet the psychiatrist has constantly in the back of 
 his mind sundry exceptional instances in which jealousy delu- 
 sions appear in wo;2-alcoholic persons, for example in victims 
 of schizophrenia (dementia praecox). The social worker's 
 data become of prime importance in making exactly this deci- 
 sion between alcoholic jealousy-psychosis and dementia prae- 
 cox with sex ideas. 
 
 Michael Piso had been jealous of his wife, according to 
 his history, ever since their marriage. As a jealous husband 
 he questioned her about everything — at one time accusing her 
 of immorality with a lad of nineteen years. They had been 
 married for ten years, and his wife was in point of fact an 
 exceptionally good woman. There were three living children. 
 Michael had been alcoholic for some fifteen years. He always 
 made excessive sex demands upon his wife and twice tried to 
 choke her when these demands were not met. He was a team- 
 ster and worked in one place throughout his married life. At 
 one time he developed an abscess in the right ear and com- 
 plained of severe headaches. The psychiatrist brought up a 
 question, upon his arrival at the hospital, of organic brain 
 disease but was even then convinced (by such portion of the 
 story as was available) that he was probably a case of alco- 
 holic psychosis and was at the same time feeble-minded. This 
 combination of diagnoses proved in fact the final one, and 
 he was discharged as a high-grade moron with alcoholic 
 psychosis. 
 
THE KINGDOM OF EVILS 263 
 
 Just before entering the hospital he threatened to buy a 
 pistol and attacked his wife. He had left work about a week 
 before entering the hospital and had grown increasingly jeal- 
 ous of his wife and imperious as to sex. A year before he 
 had had a severe headache which had thrown him out of work 
 for ten days, and at that time he vomited and had blurring of 
 the eyes. As to heredity, one of his children had had convul- 
 sions and a cousin died insane in a state hospital. 
 
 The psychologist could find no marked irregularity in 
 Michael's reactions; and, finding his mental age according to 
 the Point Scale to stand at 11.6 (Binet 103/5) years, made 
 the diagnosis of feeble-mindedness. It might be inquired 
 whether this feeble-mindedness was more apparent than real. 
 Seeing that Michael had been heavily alcoholic for fifteen 
 years, we might regard him as a victim of alcoholic deteriora- 
 tion. Some victims of alcoholic deterioration do give a low 
 test of this sort, even without marked irregularities ; on the 
 whole, however, a victim of acquired psychosis is very likely 
 to show some traces of inability to pass tests of the earlier 
 years of the scale {e.g., seven-year-old tests) at the same time 
 that he passes the tests of the higher scale years {e.g., eleven- 
 year-old tests). Michael was a teamster, and his work no 
 doubt did not as a rule require behavior more complicated than 
 that of the mental age level of 1 1.6. 
 
 The psychiatrists could upon physical examination find no 
 sign of brain tumor, nor, with the exception of pyorrhea, was 
 there any marked condition of disease in the body. 
 
 There was considerable doubt whether he had ever had 
 hallucinations, although there was a possibility of auditory 
 ones. The delusion of infidelity on the part of his wife he 
 now very well concealed. After some three weeks in the hos- 
 .pital he grew quieter, remarked that he had one night heard 
 a voice about his wife, saying, "Do not trust her" — a voice 
 which he knew to be imaginary, — and now claimed he had 
 never suspected his wife of anything and that he trusted her 
 absolutely. Upon his discharge he seemed to be quite normal 
 except for slight sidewise movements of both eyes (nystag- 
 mus), which were however held very quietly when looking at 
 some definite point. He was now discharged to the social 
 service, which had to face family conditions of some compli- 
 cation. The picture of the results obtained may be got from 
 
264 THE KINGDOM OF EVILS 
 
 the following transcript (names, as always, changed). See 
 below for general comment on these results. 
 
 July 8-October 8, 1916 
 
 Social: 
 
 Patient has been steadily at work earning thirteen dollars a 
 week. Expected to go to Men's Club, but did not come to 
 September or October meetings. 
 
 Physical: 
 
 Patient has only once had headache of late. Has worn 
 glasses for four years and will have eyes reexamined. 
 
 Mental: 
 
 Patient has not been drinking except once. Wife still com- 
 plains of sexual demands but commends him in every other 
 way. 
 
 October 8, 1916-January 8, 191 7 
 
 Social: 
 
 Family visited five times. Mrs. Piso pregnant and without 
 clothes to get outdoors in. Children's shoes worn out and no 
 warm clothes. Clothes taken and arrangements made to send 
 wife to Boston Lying-in Hospital as free patient with permission 
 of own doctor. Dr. McDonald. Patient could not be per- 
 suaded to let wife go, so visitor arranged to have district nurse 
 give prenatal care. Patient is working steadily and brings 
 home wages every -w^eek, and comes in every night at six 
 o'clock. Patient has walked to Boston two evenings with wife 
 and about Charlestown once or twice. Wife is anxious to have 
 everything in good order around the house before confinement. 
 There is nothing abnormal in wife's condition and she feels 
 well. Children are well now and have had no colds since they 
 have been able to go outdoors. Dr. McDonald to take confine- 
 ment case. 
 
 Physical: 
 
 Patient is well. 
 
 Mental: 
 
 Patient, is not drinking now, at least wife sees no signs of it. 
 He was very firm about not letting wife go to hospital. 
 
THE KINGDOM OF EVILS 265 
 
 January 8-April 8, 191 7 
 Social: 
 
 A baby girl was born January 23 and baby and mother did 
 well in care of Dr. McDonald and the district nurse. Patient 
 has worked steadily and brought money home. Patient has 
 had no recreation except to visit his father who is ill. He 
 spends his leisure at home with the children of whom he is 
 very fond. Wife took cold in her breast and had to stop nurs- 
 ing the baby for a few days, but recovered satisfactorily. Is 
 having teeth treated. The baby has some stomach trouble 
 and has not gained very fast, but dispensary doctor says she is 
 all right. 
 
 Physical: 
 
 Patient has been well except for trouble with hemorrhoids 
 which lasted about two weeks in March, 
 
 Mental: 
 
 Patient drank about a week after birth of baby but stopped 
 because it was so hard on family. He is very agreeable and 
 helpful at home. He came once to Men's Club meeting and 
 would have come two other months but his wife was ill and 
 the distance great. 
 
 April 8, 1917-July 8, 1917 
 
 Social: 
 
 Patient worked steadily and was kind and devoted to the 
 family during April and the early part of May, Patient's 
 father died May 12, and he drank steadily for a month. For 
 the last four weeks he has drunk nothing. Wife and children 
 are rather tired and run down and have been registered at the 
 Country Week for a two weeks' vacation. The baby has been 
 under dispensary care and is doing well. 
 
 Physical: 
 
 Patient's work has tired him and he has suffered from head- 
 ache occasionally but has not been induced to have his eyes 
 examined. He has not worn his first glasses faithfully. 
 
 Mental- 
 While patient was drinking he became exceedingly jealous 
 and irritable. His sexual demands were excessive. When not 
 drinking he has been agreeable and helpful at home. At- 
 tended the Men's Club. 
 
266 THE KINGDOM OF EVILS 
 
 July 8, 1917-October 8, 1 91 7 
 Social: 
 
 Patient has been working steadily in spite of heavy work 
 and long hours. His pay has been raised to seventeen dollars 
 per week. He has not been drinking for four months. After 
 Mary recovered from diphtheria, patient's wife and children 
 had a Country Week vacation for two weeks, which was very 
 beneficial to them all. Mrs. Martin kept house for patient 
 while they were gone. Patient and his wife go to Boston 
 together Saturday nights to do their shopping now, instead of 
 patient's going alone and getting drunk. Patient and all the 
 family are in need of warm clothes. 
 
 Physical: 
 
 Nothing of note. 
 
 Mental: 
 
 Patient has been very kind to and considerate of his wife. 
 He missed the family greatly while they were away on their 
 vacation, and met them at the station with his express team 
 when they returned. He is very fond of the children, and says 
 that he prefers to spend all he earns for his wife and them, 
 "instead of wasting it for drink." 
 
 Thus, medically the health of the wife and children was 
 supervised and a vacation procured for them. It proved pos- 
 sible also to improve the housekeeping by concrete advice as 
 to procedure. The wife was told "to be nice" to her husband, 
 to "dress up" Saturdays for the purpose of taking her hus- 
 band shopping. She let him buy a derby hat, saying, "You 
 have to let them have something when they work so hard." 
 
 On the economic side she was discouraged from working to 
 supplement the family income, so that Michael should not be 
 dissuaded from trying to get a better paying job. Economi- 
 cally also the family was helped out by means of clothing, be- 
 cause after all Michael's wages were too small for the familv 
 needs. This case showed all the forms of evil discussed in 
 this book except the legal. No doubt the mental issue was 
 the dominant one and the economic probably stood next; but 
 in the family adjustment the social worker employed means 
 quite beyond the merely psychiatric and economic range, to 
 teach the housewife much of value to the family specifically 
 and to improve the moral situation between the spouses. 
 
THE KINGDOM OF EVILS 267 
 
 Hours spent by Medical record, 36 pages 
 
 Social record, 33 pages 
 Physician, 6j4 Social work: 
 
 Visits, 46 
 Psychologist, i Interviews at hospital, 8 
 
 Telephone calls, 17 
 Social worker, 78 Letters, 27 
 
 Morphinism and alcoholism in a woman of psychopathic 
 personality. Fantastic story of a murder. A social service 
 failure. 
 
 Case 63. Marian Spring we present to illustrate morphin- 
 ism, though there is hardly any doubt that she is an example 
 of a so-called psychopathic personality (see Book III, Section 
 XI for other examples). 
 
 Marian had been brought up in her middle-class family and 
 upon leaving school at fourteen had spent two years in a con- 
 vent. Then after living some years at home, at nineteen she 
 began to work in mills. While she was a mill operative, she 
 began, in her twenty-first or twenty-second year, to drink with 
 another girl, and apparently this drinking began after the 
 death of her mother. Finally she got to drinking hard enough 
 to interfere with her work, and at last began to make her rather 
 checkered round of institutions, spending two years in an in- 
 sane hospital from the beginning of her twenty-fifth year, and 
 then being confined in three reformatories up to a period of 
 four months before her admission to the Psychopathic Hos- 
 pital. In the brief intervals between these institutional deten- 
 tions she worked at housework which she did very capably 
 and nicely. Marian, however, had few friends and apparently 
 had chosen her associates from amongst the most undesirable 
 of the mill workers. These associates were so undesirable that 
 they were not allowed at home and the family had become 
 quite discouraged with Marian. 
 
 She was a well-developed and nourished woman with rather 
 prominent eyes and a certain asymmetry of face. She was 
 physically energetic and sturdy, but said she was somewhat 
 unusually susceptible to pain. She had always been healthy, 
 she said, with the exception of having every year a sore throat. 
 
 According to her story and various inquiries she was capable 
 enough in all places that she undertook to fill but lost them 
 
268 THE KINGDOM OF EVILS 
 
 through alcohoHsm and the morphine habit which she had 
 acquired very shortly after beginning to drink. She was a 
 rather winning sort of person and very successful in getting 
 help for herself by various subterfuges. Thus she had the 
 usual skill in getting morphine by surreptitious routes and 
 she could, on occasion, obtain help in getting out of hospitals 
 or institutions. At one of these institutions she had been 
 destructive and quite unmanageable. She told at the hospital 
 a very striking story about seeing a girl friend murdered by 
 a certain doctor who, as she said, had great influence over her 
 own life and with whom she had had sex relations. This story 
 remains quite unverified and is, no doubt, an example of the 
 fantastic lying which not only morphine patients are apt to 
 indulge in but which is likely to be shown by sundry psycho- 
 pathic personalities without the influence of morphine. 
 
 She came to the hospital technically "left by herself" but 
 was, as a matter of fact, brought in in a disheveled state by a 
 man and a woman. The man had found her somewhere drunk 
 and had brought her in an automobile to the hospital, where 
 she had told the man she wished to come. She was quite inco- 
 ordinated, excited, and restive and apparently was hallucinat- 
 ing. (She said: "Oh, how it stares me in the face. If he had 
 only killed me instead of her.") It remains, we suppose, a 
 question whether she was actually a victim of false perceptions 
 or whether she was embroidering after the manner of the 
 morphinist or psychopathic liar. 
 
 The diagnostic question at once arises whether Marian was 
 not feeble-minded. The term feeble-mindedness can, as has 
 been constantly shown above, be used in various ways and 
 some authors speak of a pure defect of will and emotions (the 
 so-called amoralia of authors in which intelligence is entirely 
 preserved or at a normal level) as feeble-mindedness. This 
 use of the term feeble-mindedness would, then, have reference 
 to social rather than demonstrable psychical defect. The im- 
 pression of certain psychiatrists who saw her when she first 
 went to the hospital for the insane was that she was a feeble- 
 minded person but at that time no special tests were made. 
 When these tests were performed she was found to be some- 
 what deteriorated, but the detail of the tests seemed to indicate 
 that she was really not fundamentally feeble-minded. As we 
 insist elsewhere, the things Marian did that brought her to 
 
THE KINGDOM OF EVILS 269 
 
 social attention would not be explained by a low intelligence 
 rating even had she shown such demonstrable defect outside 
 the zone of will and emotion. Put briefly, the psychopathic 
 personality may be feeble-minded to test or may test out not 
 at all feeble-minded ; the psychotic trends remain somewhat in- 
 dependent of the intellectual level, though no doubt the patient's 
 degree of responsibility must hang somewhat upon her intel- 
 lectual powers of judgment. 
 
 This case might be counted as a social-service failure. No 
 doubt the social worker will, until the end of time, have cer- 
 tain failures to score. Supervision has failed to reform Marian 
 despite her capabilities in the line of work and despite a high 
 "empathic index" or attractiveness which means that she will, 
 no doubt, always have friends. Unfortunately she makes 
 friends amongst other psychopaths. The well-known gregari- 
 ousness of morphinists may play a part here and this 
 gregariousness of drug addicts has always to be borne in the 
 social worker's mind. How much this gregariousness is a 
 matter of morphinism or heroinism and how much it is a mat- 
 ter of a certain mild integrating psychopathic trend must be 
 left to the future to decide. 
 
 Marian Spring will be what the English call an "in and out" 
 for many years. Such forces as national prohibition and an 
 effective Harrison law and other devices for the successful 
 removal of alcohol and drugs from her habitat will, perhaps, in 
 the end, leave her a not very socially dangerous character. 
 
 Hours spent by Medical record, ^,2 pages 
 
 Social record, 16 pages 
 Physician, 6^2 Social work: 
 
 Visits, 9 
 Psychologist, o Interviews at hospital, 3 
 
 Telephone calls, 7 
 Social worker, 20^ Letters, 18 
 
SECTION V 
 
 ENCEPHALOPSYCHOSES ( BRAIN DISEASE) 
 
 Psychoses of old age. Prognosis in arteriosclerosis. Sales- 
 man with moments when he "lost himself." State hospital care 
 or private measures? 
 
 Case 64. A psychiatric social worker always has to con- 
 tend with the feeling on the part of many physicians, many 
 fellow social workers, and the majority of laymen that mental 
 disease is incurable. Even if something by experience has 
 been done to diminish this feeling for sundry types of mental 
 disease, the feeling of poor prognosis and of probable incura- 
 bility still hangs about most patients developing mental symp- 
 toms in the fifties, sixties, or seventies. We give two instances 
 later in this book, those of Catherine Cudahy (case 69 and 
 Jeanette Burroughs, case 68), in which psychoses developing 
 in old age were still not inconsistent with remarkable ameliora- 
 tion and easy accessibility to social-service measures. 
 
 A very firmly fixed medical prejudice is that "one is as old 
 as his arteries." Accordingly a victim of the hardening of the 
 arteries (arteriosclerosis) is assumed to be by the same token 
 a victim of old age or its equivalent. Since old age has uni- 
 versally so poor a prognosis, then hardening of the arteries is 
 dropped into the same basket of poor prognoses. Now, in 
 point of fact, there are various kinds of arteriosclerosis, only 
 some of which characterize old age, and many forms of arterio- 
 sclerosis are not in any respect characteristically senile. One 
 of the greatest surprises of the youthful physician is to see 
 cases of severe arteriosclerosis, looking to be at the point of 
 death, come around in the course of weeks or months to a 
 phase of comparative normality and even capacity of self- 
 support. 
 
 Thomas Warren, sixty-four, received the diagnosis of 
 arteriosclerotic dementia at the Psychopathic Hospital, whence 
 
 270 
 
THE KINGDOM OP EVILS 2.^1 
 
 he could be discharged somewhat improved after about three 
 weeks' observation, for the most part as a voluntary patient. 
 The term "dementia" has almost invariably, to a physician as 
 well as to a layman, the suggestion of permanence and in- 
 curability, although there is nothing about the prefix de in this 
 word dementia which necessarily signifies that the deterioration 
 is either permanent or temporary (in fact some of the older 
 psychiatric textbooks talk of certain acute dementias which 
 often led to complete recovery). Sometimes the term "deterio- 
 ration" is used for milder degrees of "dementia." Perhaps it 
 would have been safer to call the case of Thomas Warren 
 (with some of the physicians) a case of arteriosclerotic 
 "psychosis," thereby dodging the suggestion of permanence 
 that now sticks to the term "dementia." At all events, as above 
 stated, Thomas Warren was discharged somewhat improved. 
 
 Little is known of Warren's early history. His father had 
 died of a shock. Warren himself had worked as a salesman 
 and buyer from youth up and had never had any symptoms of 
 nervous disease until some six or seven months before admis- 
 sion, when a hemorrhage of the eye had occurred and he had 
 found some difficulty in working. He kept at work, but began 
 to lose his memory. At times during this period of six months 
 he completely lost himself for a few minutes at a time. He 
 made mistakes in his work and knew that he had to be watched 
 on this account. 
 
 These spells of losing oneself are amongst the most sug- 
 gestive features of arteriosclerosis in men of his age, especially 
 so when associated with gradual loss of memory and other 
 signs of deterioration. (The layman should not, however, 
 feel too great assurance as to the nature of such spells, since 
 epileptic and epileptoid conditions might likewise bring them 
 about.) It is worth while to insist that these "seizures" are 
 not signs of senile dementia, but are signs of either arterio- 
 sclerosis or some other form of disease not necessarily senile. 
 The important point we here try to make is that they do not 
 necessarily argue an invariably down-grade process on the 
 part of the patient. They may very well correspond with ex- 
 ceedingly slight destructive processes, due to blood-vessel dis- 
 ease, in the brain and may very well go alongside an almost 
 complete normality of the whole brain mechanism. Moreover, 
 the progress of these cases is not seldom highly irregular. 
 
272 THE KINGDOM OF EVILS 
 
 Persons with very definite and severe apoplectic seizures, in- 
 volving the paralysis of an entire side, may not only recover 
 to a large extent the functions lost at the time of the so-called 
 "stroke," but may live to perform important functions in life 
 and even to carry on complex business affairs. In short, let us 
 insist that no very definite prognosis, either of regular or 
 irregular down grade or of improvement should be offered. 
 Nevertheless, it will be in the interest of the patient from the 
 social standpoint to give him the benefit of the doubt with 
 respect to his outcome. Not rarely will the worker be rewarded 
 by a very fair compensation in the patient's life as a result of 
 the execution of right social measures. 
 
 Warren was still a rather well-developed and nourished man, 
 with a slightly increased blood pressure. His gait was un- 
 steady and rather stiff. There was a certain incoordination 
 also in the movements of his arms, and with eyes closed he 
 would fall to the ground. Both fingers and toes were tremu- 
 lous at the time of his hospital observation. He had been rather 
 depressed before coming to the hospital. It would, of course, 
 seem natural to the normal observer for a man thus affected 
 to be depressed, and it might seem that the depression was a 
 perfectly normal sadness; yet depression and emotionality with 
 a tendency to rather disproportionate weeping have been ob- 
 served to be symptoms in arteriosclerotic brain disease. The 
 depression is often much more a symptom due to sundry stimuli 
 working directly in the tissues or from the juices of the body 
 than a rational effect of deliberate thinking about one's des- 
 perate situation. 
 
 It became a question whether Warren should not be sent to 
 a state hospital for permanent care, partly on account of his 
 dementia, which might be better cared for at a hospital than 
 at home, and partly on account of the low state of his savings. 
 It becomes a delicate question of some practical difficulty 
 whether to advise that such rather gradually deteriorating per- 
 sons shall remain in the community or be committed to a state 
 hospital. On the whole, in most communities of a proper de- 
 gree of civilization, the state hospital will prove to offer better 
 facilities at a less total cost to all concerned than private meas- 
 ures can readily equal. It is of course possible with these cases, 
 as with almost all others, to construct an "institutional equiva- 
 lent" by turning some home into a hospital. Some years ago 
 
THE KINGDOM OF EVILS 2/3 
 
 public authorities upon the insane used to bring up the question 
 whether the state might not soon be asked to take care of many 
 persons who could as readily exist outside the institutions. If 
 we look at the subject from the standpoint of the total cost to 
 the community, regardless of its exact and temporary source, 
 we shall probably be compelled to agree that on the whole the 
 modern trend toward state hospital care of persons hard to 
 manage outside is the right trend and one to encourage. On 
 the whole, there is an invisible, but none the less actual, insur- 
 ance in the community, through the processes of state care, 
 over against all manner of friction, wasted time, energy, and 
 money spent by inexpert relatives of mentally sick persons. As 
 the almshouse stigma disappears from state hospitals, as the 
 insanity stigma diminishes to a hardly visible point, the trend 
 toward state care of unfortunates of this group will no doubt 
 become stronger still. Sentiment will turn into sentiment for, 
 instead of sentiment against, state care. 
 
 Hours spent by Medical record, 19 pages 
 
 Social record, 11 pages 
 Physician, 8^ Social work: 
 
 Visits, 10 
 Psychologist, o Interviews at hospital, 8 
 
 Telephone calls, 14 
 Social worker, 23 Letters, 4 
 
 Chordc girl with illegitimate child. Outbursts of temper; 
 lying. Improvement in maternity home. Persistent social 
 problem. 
 
 Case 65. Though from the psychiatric side Helen Fitz- 
 patrick gave somewhat the effect of a psychopathic personality, 
 she was a victim of chorea. Her mental symptoms accordingly 
 gave rise to the question whether she was not what psychiat- 
 rists call a "symptomatic" psychosis. These "symptomatic" 
 mental diseases appear incidentally in the midst of other well- 
 recognized diseases of a somatic nature, for example, typhoid 
 fever or pneumonia. Chorea, in the form in which Helen 
 Fitzpatrick showed it, is itself probably an infectious disease, 
 
274 THE KINGDOM OF EVILS 
 
 Looking at the Fitzpatrick girl from the side of social 
 factors, we find the following list: — 
 
 Stealing 
 Lying 
 
 Sex delinquency 
 Outbursts of temper 
 Industrial disability 
 Family discord 
 Separation from family 
 Lack of early training 
 Insufficient income 
 
 The major social diagnosis was set down as delinquency. 
 
 Upon her admission to the Psychopathic Hospital Helen re- 
 marked, "We are all a high-strung bunch, the whole of us at 
 home, and that is all the trouble. We get on each other's 
 nerves." It seems that, a fortnight before, a probation officer 
 was called in by Helen's father, because she had cut up her 
 sister's hair ribbon and thrown flatirons about. Her choreic 
 movements were very marked while she was in the receiving 
 ward. She explained she was untidy in dress because she had 
 been taken from her house at five o'clock in the morning. In 
 point of fact she had refused to dress at all. 
 
 Physically she was found to have, besides choreic movements, 
 slight heart trouble (often found in choreics). All the re- 
 flexes were very active. Mentally she was quite inaccessible 
 to the examiner, although she was plainly oriented in every 
 way and very emotional. Later she grew more accessible and 
 rated by psychological tests pretty evenly at fifteen (she rated 
 at good or very good in the supplementary tests, except in those 
 for motor coordination wherein she was fair and in those for 
 voluntary attention where she was poor). While in the hos- 
 pital she grew quieter and the chorea was even somewhat 
 lessened. 
 
 The court, on representation that supervision for Helen 
 should be undertaken, readily accepted the offer of supervision 
 for Helen by our social service. After a few weeks in a con- 
 valescent home, where it was determined that she had become 
 pregnant, she was sent to a maternity home and remained until 
 after the birth of her baby three months later. She Improved 
 in health and recovered from the chorea. Her mental attitude 
 improved and she took a mature and sensible view of her situa- 
 
THE KINGDOM OF EVILS 275 
 
 tion. She was brighter than most girls in the home. She 
 showed no conduct irregularities or signs of bad temper while 
 there. 
 
 Her marriage with the child's father, a boy, Thomas Lynch, 
 was seriously considered. In the beginning her father insisted 
 that they should be married, but, as the shiftlessness of Lynch 
 and the rather low standard of his family came to light, Helen's 
 parents became persuaded that the marriage would be an addi- 
 tional misfortune. Lynch was willing to marry, but left the 
 decision to his mother. Mrs. Lynch objected to having her son 
 "tied for life to a girl like Helen." As the boy was under age, 
 his mother's consent was necessary, and in the end she flatly 
 refused to give it, although she did agree that Thomas should 
 support the baby. The final conclusion of all concerned was 
 that a marriage between the two would lead only to further 
 unhappiness. The priest cooperated by advising against the 
 marriage. 
 
 When Helen was ready to leave the maternity home, she 
 was referred to a children's agency with the understanding 
 that she and her baby should be boarded in a family where 
 Helen might be trained in the care of the child. She was fond 
 of the baby and proud of her. Her attitude in general was 
 so much improved that she was allowed instead to go home, 
 but, though she took good care of her baby, she shirked all 
 other responsibilities and got on so poorly at home that she 
 was sent to board with the baby in a country home. The baby 
 after being weaned was boarded separately, and Helen was 
 placed in another family to do housework. This she did not at 
 all like, and she proved unsatisfactory to her employer because 
 she was untruthful and untidy. After three months she was 
 allowed to go to a relative, who conducted a small sanatorium 
 and who undertook to be responsible for her. Mrs. Fitzpatrick 
 took the baby home. 
 
 Here then is a case which promises to be a persistent and 
 year-long problem. 
 
 Hours spent by Medical record, 21 pages 
 
 Social record, 20 pages 
 Physician, 3^ Social work: 
 
 Visits, 2.2 
 Psychologist, l Interviews at hospital, 6 
 
 Telephone calls, 10 
 Social worker, 34 Letters, 18 
 
SECTION VI 
 
 SOMATOPSYCHOSES ( BODILY DISEASE) 
 
 Mother of illegitimate child, with dubious mild psychosis. 
 
 Case 66. Ethel Murphy, twenty-seven, had been somewhat 
 depressed, or at all events sad, since having an illegitimate child 
 two months before admission. Her eyes were somewhat promi- 
 nent, her thyroid gland was enlarged, her pulse was rapid. 
 She thus presented many of the features of a Graves' disease 
 which was, however, of mild degree. She had never expressed 
 any suicidal ideas. It was suspected that at one time she had 
 had auditory hallucinations. 
 
 The social worker at the hospital where she was confined 
 brought her to the Psychopathic Hospital on the ground that 
 as the baby was to be adopted it was important to have the 
 mother examined for her mentality, so as to reassure the foster 
 mother. 
 
 The psychologists found that Ethel graded very irregularly 
 at II. 3 years. She cooperated very well but she made several 
 illogical errors in the picture puzzle test. The irregularity 
 (see discussion under case 19) presumably signifies an ac- 
 quired psychosis rather than an original subnormality, but 
 there is really no evidence of a definite psychosis unless we 
 are to think of her as a victim of a slight or minor psychosis 
 due to hyperthyroidism. Various diagnoses suggested were 
 subnormality of mind, hyperthyroidism, epilepsy, and exhaus- 
 tion, but the psychological examination appears to dispose of 
 the subnormality of mind, at least as a fundamental and origi- 
 nal state. There was no good evidence of epilepsy. The re- 
 maining suggestions of hyperthyroidism and exhaustion place 
 her in an undefined group of mental diseases due to bodily dis- 
 ease. (See remarks under the case of Helen Fitzpatrick, case 
 65.) The child was, at the suggestion of the physician, placed 
 under state care and separated from the mother, 
 
 27O 
 
THE KINGDOM OF EVILS 277 
 
 The case was followed by the social service and Ethel is 
 
 now at work in a contented frame of mind. That the social 
 service had positively something to do with this result cannot 
 be contended; although only the usual technique of counsel and 
 assurance was followed. The earlier difficulties of technique 
 had centered about getting this girl, who was (in her own 
 judgment) only slightly ill to take the step of going into the 
 wards of the Psychopathic Hospital from the out-patient de- 
 partment from which she had been first referred. Xo doubt 
 the advance of psychiatry in the far future will bring more 
 and more of these exceedingly dubious and (from the ordinary 
 medical viewpoint) extremely mild cases under early suitable 
 observation. 
 
 Hours spent by ^.ledical record, 25 pages 
 
 Social record, 9 pages 
 Physician, 5 Social work: 
 
 Visits, 20 
 Psychologist, i Interviews at hospital, 4 
 
 Telephone calls, 9 
 Social worker, 34V2 Letters, 16 
 
 Attack of mental disease follozi'ing influenza. 
 
 Case 67. Joseph O'Brien is an example of influenza psy- 
 chosis incidental to the influenza epidemic in Boston in 191 8. 
 He was a case of toxic delirium. His mental symptoms de- 
 veloped in the period of defervescence, in fact seven days after 
 the temperature fell. It seems that his mind became affected 
 immediately thereafter. He wanted to wander about, thought 
 he was on board ship, did not recognize his family and had 
 to be restrained by his relatives, would fall down, once set 
 fire to a bureau. He himself said that he had been taking a 
 good deal of alcohol but this was denied by his relatives. 
 
 Upon admission he seemed to be confused and was probably 
 hallucinated as he reached out his hands to grasp imaginary 
 objects, apparently looked at the object, and then began pick- 
 ing at the mattress. His hands were tremulous. He remained 
 in the hospital four days short of two months and was dis- 
 charged in greatly improved physical condition. His periods 
 of confusion kept recurring for three weeks after admission 
 
278 THE KINGDOM OF EVILS 
 
 and he developed from time to time a temperature which 
 reached 103 degrees on the fourth and fifth days after admis- 
 sion. For the rest, the physical examination proved negative. 
 The task of the social service is here simple. It is a ques- 
 tion of follow-iip. The return of symptoms in influenza psy- 
 chosis is naturally a matter of research at the present time. 
 Letters are from time to time received from O'Brien showing 
 that he is getting on well and, in fact, "could not be any better." 
 
 Hours spent by Medical record, 11 pages 
 
 Social record, o 
 Physician, 5^ Social work: 
 
 Visits, o 
 Psychologist, o Interviews at hospital, I 
 
 Telephone calls, o 
 Social worker, i Letters, 4 
 
SECTION VII 
 
 GERIOPSYCHOSES (OLD AGE) 
 
 Senile psychosis. Widow sazv her son zvho had been dead 
 forty years. Improvement: proper care arranged. 
 
 Case 68. Jeanette Burroughs, a widow of seventy-two, 
 was found getting her meals on a gas heater and doing needle- 
 work for an art society, with her son paying the board bill. 
 She went to church and to the movies and called upon her 
 friends from time to time. She entered the wards of the 
 Psychopathic Hospital from the out-patient department. She 
 had had dizzy spells for two or three years, though she had 
 never fallen down. Sometimes she had a peculiar feeling in 
 her head like rushing water. She was in many respects very 
 well preserved, looking younger than her age. She had at one 
 time been treated for diabetes. Just before coming to the out- 
 patient department, she had imagined that a son, now forty 
 years dead, had sat beside her and talked to her. A man in 
 black had walked up and down in front of her house. She 
 felt, she said, prostrated with grief, and her sleep had become 
 disturbed and fitful. She was a voluntary patient at the hos- 
 pital, but there could be no doubt that she was legally com- 
 mittable on the score of the clear hallucinations and delusions. 
 
 Physically she was well developed and nourished. There 
 were no obvious lesions of the heart and lungs, and there was 
 no special disturbance of blood pressure. There were no evi- 
 dences in the neuromuscular examination that there had ever 
 been any degree of destructive brain disease. A certain emo- 
 tionality and a feeling of loss of memory were the most out- 
 standing mental symptoms, except the ideas revolving about 
 the resurrection of her dead son. 
 
 Admitted April i6, 191 7, it was not until June i that she 
 gave up her delusions, admitting at that time that, though the 
 ideas still did "come up at times," she was now "able after 
 struggling always to put them down." She said she was less 
 
 279 
 
28o THE KINGDOM OF EVILS 
 
 collected in the evening than in the morning and night, perhaps 
 better be spoken to earher rather than later in the day. 
 
 The only point concerning the discharge of Mrs. Burroughs 
 now lay in the question whether she would have proper care 
 on leaving the hospital. This became the province of the social 
 service to accomplish. During the period of a year the social 
 service was able to keep her properly boarded out (with some 
 aid from charitable organizations) and saw to it that she was 
 visited by friends from time to time. She resumed her habit 
 of attending church and the movies. She fell and injured her 
 hip one winter's day — an accident which in an old person is 
 ordinarily very dangerous. The hip trouble proved to be merely 
 a contusion, and Mrs. Burroughs recovered. At the end of 
 this time the case could be closed so far as the Psychopathic 
 Hospital social service was concerned. She was left under the 
 care of a non-psychiatric social agency. She has throughout 
 continued to make a little money by needlework but so far as 
 can be seen must remain for the rest of her life somewhat of a 
 charge. 
 
 Is Mrs. Burroughs mentally normal? She is at all events 
 now not a victim of any acute delusional psychosis, whether 
 senile in causation or of any other origin. Nevertheless from 
 time to time it appears that she still sees her dead son, and it 
 is probable that she still bears inside some traces of the former 
 psychosis. However, if she had never shown more psychop- 
 athy than she now shows, no doubt, she would never have 
 appeared on the records of an institution for mental diseases. 
 
 Hours spent by Medical record, 28 pages 
 
 Social record, 10 pages 
 Physician, 8 Social work: 
 
 Visits, 16 
 Psychologist, o Interviews at hospital, 
 
 Telephone calls, 12 
 Social worker, 21^ Letters, 2 
 
PRESENILE PSYCHOSIS 
 
 WOMAN, 55 
 
 February June 
 
 Unoccupied Occupied 
 
 No Pleasures Friends Call 
 
 Outbursts of Temper Husband Told Why 
 
Presenile psychosis. Scolded by the clock. Home life al- 
 tered: improvement. 
 
 Case 69. Catherine Cudahy, fifty-five, kept hearing the 
 big clock on the mantelpiece ticking at her vindictively. She 
 had become violently enraged by this ticking at least twice in 
 a period of two months. At last her husband had to send her 
 to the Psychopathic Hospital. She thought a Holy Father 
 was on the roof. 
 
 Her case was put by the psychiatrists in the presenile group 
 and was called involutional psychosis. They found her a vic- 
 tim of hallucinations of hearing, but found that her delusion 
 about the Holy Father was not very definite or fixed. She 
 finally admitted that the ticking of the clock at her was only 
 imaginary. She had not heard the clock ticking after the ar- 
 rival at the hospital. Her memory seemed to be poor for 
 details both of recent and remote events, but she could remem- 
 ber excellently the main events in her life. She was physically 
 rather obese and, since an operation two years before, had 
 not been able to go to church. She had begun to feel tired all 
 the time and had been hearing the clock talking for about five 
 months. Mrs. Cudahy did not use alcohol (an important nega- 
 tive fact for the psychiatrists). 
 
 The problem for the social worker came upon her discharge 
 "improved." She was somehow to alter her home life; she 
 was not to be left alone so much or spend so much time unem- 
 ployed. These suggestions were carried out and she was made 
 to take daily exercise outdoors. The relatives were persuaded 
 to cooperate. They visited her and kept her busy. She re- 
 ported regularly at the out-patient department every fortnight, 
 and the clock went definitively out of her life. 
 
 Hours spent by Medical record, 11 pages 
 
 Social record, 3 pages 
 Physician, '7 Social work: 
 
 Visits, 3 
 Psychologist, o ■ Interviews at hospital, 6 
 
 .. .., r« w . Telephone calls, i 
 
 S6cial worker, 7% Letters, 5 
 
 283 
 
SECTION VIII 
 
 SCHIZOPHRENOSES (DEMENTIA PRAECOX) 
 
 Cose of dementia simplex self-supporting in the community. 
 May look like feehle-mindedness. Training. Simple environ- 
 ment provided. 
 
 Case 70. There is a form of schizophrenia (dementia 
 praecox) to which the adjective simplex is added. In this form 
 of the disease there is a certain deterioration and dulHng of 
 the emotional hfe which fails to be accompanied by the vari- 
 ous so-called catatonic ( formerly termed cataleptic) symptoms 
 or by the delusions which are so frequent in most cases of 
 schizophrenia. Moreover, in these so-called simplex cases the 
 emotional deterioration may itself be slight, and it is commonly 
 thought by psychiatrists that a great number of these cases 
 of dementia simplex are found in the community at large, per- 
 haps self-supporting or nearly self-supporting, with a history 
 of having sustained a slight regression in their mental capacity 
 insufficient to warrant or to suggest their internment in any 
 hospital for the insane. It is, perhaps, a little difficult for the 
 layman and even for some of the old-time physicians to think 
 of cases of schizophrenia (dementia praecox) as "not insane." 
 Until the concept of mental disease tJiat is not (medico-legal) 
 insanity becomes deeply imbedded in the lay mind, as well as 
 in the minds of medical men and social workers, we shall not 
 come through with a proper program of community mental 
 hygiene. 
 
 Dana Scott, an unmarried man of thirty-seven, was brought 
 to the Psychopathic Hospital for observation. The woman 
 with whom he boarded told of violent fits of temper on Scott's 
 part, during which clothing was torn and furniture knocked 
 to pieces. As a matter of fact, the landlady greatly overdrew 
 the story about Scott, as investigation failed to substantiate 
 any destructive tendencies, nor was the landlady herself a good 
 sort of person to live with. Nevertheless, with all the smoke 
 
 284 
 
THE KINGDOM OF EVILS 285 
 
 there was some fire. It was generally agreed that Scott lacked 
 ambition and initiative and might perhaps be the victim of some 
 sort of mental defect. Had it not been for the landlady's char- 
 acter (an angel from heaven, it was said, could not live peace- 
 ably with her), Scott might have remained in the community 
 even to this day without being noted by any expert to be psycho- 
 pathic. He had been a rather queer child. It was told of 
 him that he took books to the attic and stayed all day with them, 
 omitting meals. The country neighbors who saw him daily did 
 not consider him at all harmful. A nurse who brought him 
 to the hospital said that he was one of the most willing and 
 obedient patients she had ever had. 
 
 Here then was a man who was plainly in some sense a psycho- 
 path. Perhaps by straining a point he could have been com- 
 mitted to an institution. He was in charge of a guardian and 
 had some little property, so that board could be paid for him. 
 A place in the country was found in the family of a widow 
 and her daughter. Here Scott could help with chores and 
 might perhaps obtain some work in the neighborhood. Shortly 
 letters were received from Scott telling how much he liked his 
 new home. The family were well satisfied with him and 
 pleased at having a permanent boarder who was so helpful. 
 
 It may be permissible to point out that with the old system, 
 under which the public or private charitable institution "bor- 
 rowed no trouble," the hospital work might have ceased with 
 the diagnosis. In point of fact the social service was at first 
 merely requested to secure a history. Yet, when such history 
 was secured, perfectly obvious and valuable social-service meas- 
 ures stood revealed as the proper procedure. In institutions 
 where psychiatric social work is carried out effectually this is 
 no infrequent event, namely, that the social worker, sent out 
 to secure a few facts, comes back with a series of rational 
 measures. 
 
 Victims of the so-called simplex form of schizophrenia are. 
 often looked upon, even by physicians, as feeble-minded, nor 
 is it at all possible in routine examinations always to determine 
 medically with which condition one is dealing. The psycho- 
 metric tests, executed by a properly grounded mental examiner, 
 are sometimes of service ; for instance, in the case of Scott, the 
 Binet record stood at 12 1/5 years, and he was set down as 
 beyond question not feeble-minded. His deterioration was 
 
286 THE KINGDOM OF EVILS 
 
 not intellectual. The mental impairment was, as it characteris- 
 tically is in all cases of schizophrenia, in the field of the emo- 
 tions. There was a marked dulling of them. He was, from 
 some points of view, not at all unintellectual ; was. for example, 
 a great reader of books on science and art, and conversed very 
 fairly on current topics. Although psychopathic in this par- 
 ticular way, he had no savor of feeble-mindedness and would 
 have been quite above the level of the majority of the teach- 
 ings, which are so skillfully carried out for the feeble-mmded 
 in the schools appropriate for that group of defectives. There 
 can be no doubt that his life with the widow and her daughter 
 upon a farm was exactly the right fate for him. As with the 
 psychological examination, so the physical and mental exami- 
 nation by psychiatrists at the hospital failed to show any strik- 
 ing deviations from normal, and the psychiatric impression 
 of the case, based upon the medical and social history, was 
 accordingly left at the diagnosis schizophrenia (dementia prae- 
 cox) of the simplex form. 
 
 Of course many cases of schizophrenia, particularly of the 
 catatonic group above mentioned, are not unlikely to become 
 suddenly excited or violent; nor can it be absolutely excluded 
 from the range of possibility that Scott may turn catatonic 
 through some sudden access of the structural or functional dis- 
 ease which underlies his symptoms. 
 
 The layman, as well as the physician, must have forced upon 
 his attention a certain sexuality in the symptoms of the ma- 
 jority of cases of schizophrenia (dementia praecox) ; but it 
 would be an injustice to many examples of the disease to think 
 of the sexuality as socially dangerous. Whatever bad habits 
 in the sexual field and whatever bad table manners and other 
 impolitenesses Scott might have been guilty of, probably all of 
 these matters may never fall within the social danger zone. 
 No doubt many of these psychopathically bad manners and cus- 
 toms can be, to a great degree, trained out of patients of this 
 order by proper methods. Just as it is possible to train or tame 
 certain animals without the employment of the methods open 
 to a Socrates or a Plato, so it is possible to get sundry effects 
 sometimes termed recducative in cases of the schizophrenic 
 group. Whether the training is in all cases a genuine rationali- 
 zation with the Socratic or Platonic echo may be doubted. 
 However this may be, the well-managed hospital for the chronic 
 
THE KINGDOM OF EVILS 287 
 
 insane, harboring as it does so many victims of this disease, 
 shortly becomes a very effective school for schisophrenics. In 
 some governmental units, colonies for such schizophrenics have 
 been developed, whose star patients are not those who, like 
 Scott, are very easy to deal with from the outset, but patients 
 who have passed through most violent and dangerous phases 
 or phases of extreme apathy and utter economic worthless- 
 ness, only in the end to be schooled into a very fair efficiency. 
 With respect to Dana Scott, then, we may perhaps regard 
 the non-angelic landlady as really something of an angel in 
 disguise. 
 
 Hours spent by Medical record, 38 pages 
 
 Social record, 4 pages 
 Physician, 4^^ Social work: 
 
 Visits, 2 
 Psychologist, i Interviews at hospital, I 
 
 Telephone calls, 9 
 Social worker, 5 Letters, 2 
 
DEMENTIA PRAECOX 
 IN A MACHINIST 
 
 January, ipi6 January, igiy 
 
 Industrial Disability Good Health 
 
 Unemployment Regular Work 
 
 Debts Out of Debt 
 
 Suicidal Attempts Cheerful 
 
Vagrant: irregular worker: alcoholic: attempted suicide. 
 Men's Club. Peculiarities indulged at home. Steady, reliable 
 zvorkman: a compensated schisophrenic. Economy of social 
 care. 
 
 Case 71. Ralph Johnson left home at thirty-one and was 
 not heard of for the next seven years. In point of fact he was 
 roaming over the country on foot, jumping freights and work- 
 ing ofif and on in railroad gangs. Wanderlust over, Ralph got 
 back to Boston and worked as an automobile repairer for the 
 next nine years in six different places. He then ceased to work 
 altogether for a number of months. It seems that he had had 
 an infection in his hand for some three months. He felt "run 
 down and weak," one night grew suddenly talkative, said he 
 saw dead people, friends of his, and cut an artery in his wrist 
 with a razor. He had been drinking, and a diagnosis of alco- 
 holic mental disease was made. There were no sexual contents 
 or ideas of jealousy in Johnson, but he did show delusions of 
 persecution (people were going to kill him) and ideas of refer- 
 ence (the people that he saw outside of his house seemed to 
 him to be "laying for him"). There were no genuine halluci- 
 nations (false perceptions) in any sensory field. 
 
 Johnson was now referred to the out-patient department and 
 when jogged by letter reported from time to time. He ceased 
 to take any alcohol and for the most part felt "fine, though 
 somewhat unsettled in my mind with thoughts constantly 
 changing." After a few months he came in one day agitated 
 and weeping, maintaining that "his left side was dead" and 
 that he had "done terrible wrongs to several people" — could 
 he not be chloroformed or have his head cut off? Nobody 
 would hire such a man as he was and consequently he would 
 not ask for a job. 
 
 However in the course of a few weeks he came in again much 
 more clear-headed and alert, laughing about the death of his 
 left side, etc. Again he complained of "lack of concentration 
 of his thoughts" and talked somewhat ramblingly. He was 
 fading away, having lost he said, fifty pounds. From time to 
 
 291 
 
292 THE KINGDOM OF EVILS 
 
 time he reported rather regularly for the Men's Club and after 
 a time became one of the most regular attendants at this Club 
 which he found his only recreation. However, finally he 
 stopped coming and, upon being visited, assumed a hostile 
 attitude and feigned indifference to the hospital, its staff and 
 its attendants. He said he had other things to do than to 
 attend a men's club. 
 
 The entire history, since his first appearance at the hospital, 
 has occupied five years. There was, however, a second appear- 
 ance in the wards of the Psychopathic Hospital some eleven 
 months after the first admission. Some days before entrance 
 to the hospital he had begun to cry out aloud at night. He 
 said his mother was calling him. For several days he cried out, 
 talking rather desperately at times yet laughing at other times, 
 and told of a feeling of electric currents over him. He was a 
 readily committable case, telling the committing physician that 
 he had heard God's voice and could hear it in the hospital as 
 well as at home. 
 
 The diagnosis upon his discharge from this second admis- 
 sion stood at a question of dementia praecox, where the diag- 
 nosis should, perhaps, still stand. There is no longer any ques- 
 tion of alcoholic mental disease, despite the rather certain view 
 of the psychiatrist at his first admission that he was a case of 
 alcoholic paranoia. Concerning the very existence of any such 
 disease as alcoholic paranoia psychiatrists have registered 
 doubts, and it can readily be seen that a commixture of schizo- 
 phrenic symptoms and alcoholic traits can easily confuse the 
 issue; many psychiatrists hold that the only true form of men- 
 tal disease of delusional nature produced by alcohol is the so- 
 called jealousy-psychosis, an example of which, from the social 
 point of view, is given in this book under the case of Michael 
 Piso (case 62). 
 
 Johnson remained in the hospital four months after this 
 second admission. On his discharge he went to work once 
 again in an automobile repair shop. They said he was a good, 
 handy man at this work, although he worked somewhat slowly 
 and if at all hurried got nervous and tired. He had to be laid 
 off once when work was slack. He readily got another position 
 at eighteen dollars. They said he was a very steady and reli- 
 able workman. Once he had a petty argument with his fore- 
 man and lost his job. Immediately he secured another job, this 
 
THE KINGDOM OF EVILS 293 
 
 time at twenty-five dollars a week. Johnson's home was on 
 a fairly high economic level. He lived with his sister. She 
 had to be instructed concerning the indulgence of eccentricities 
 on Johnson's part. She learned not to irritate him overmuch 
 and was got to manage him with exceeding intelligence. 
 
 Is this a case of schizophrenia (dementia praecox) ? It is, 
 at all events, a case with definite psychopathic phases and prob- 
 ably belongs somewhere in the general group of the schizo- 
 phrenics. Yet we may think of Johnson as in some sense a 
 compensated schizophrenic. Perhaps no one would regard 
 him as entirely normal, though it would certainly stump the 
 ordinary observer to pick anything psychopathic out of his 
 behavior for days and weeks at a time. There seems to be no 
 question whatever that the social service here aided and abetted 
 the process of character compensation. Again, we may not 
 unduly insist that the ordinary method of letting such cases 
 go adrift in the community without supervision and follow-up 
 is, in the long run, a much more expensive process to the com- 
 munity than the cost of proper medical and social care and 
 supervision (to say nothing of the effects of a non-compen- 
 sated schizophrenic in the matter of possible violence, and 
 disturbance of the peace). There was also to consider the alco- 
 holism, to which this wanderer had fallen victim when he first 
 came to observation at the age of forty-eight. How many 
 of the wanderers on the countryside and persons found jump- 
 ing freights may really be schizophrenic is a statistical ques- 
 tion whose answer might vary in different communities and 
 countries. Whether the tally reaches fifty per cent may be 
 questioned. A good many epileptics, manic-depressive psy- 
 chotics, and psychoneurotics may also be found amongst the 
 hoboes to say nothing of queer characters whose abnormalities 
 are of a milder and not easily classified form. (There is even 
 a group of so-called victims of poriomania that seem to repre- 
 sent a specially developed instinct of wandering.) 
 
 Hours spent by Medical record, 11 pages 
 
 Social record, 18 pages 
 Physician, 7^ Social work: 
 
 Visits, 7 
 Psychologist, o Interviews at hospital, 12 
 
 Telephone calls, 7 
 Social worker, 27 Letters, 5 
 
294 THE KINGDOM OF EVILS 
 
 Litigious vagrant: counterfeiter. Case of paraphrenia sys- 
 tematica. 
 
 Case 72. Manual Rizzo is, no doubt, a victim of so-called 
 paraphrenia systematica, a new name now rather frequently 
 used for the so-called delire chronique a evolution systematiqiie 
 of the French psychiatrist Magnan. Although the task of the 
 social service here was more contributory to diagnosis than 
 to treatment or care, the Rizzo case is presented because the 
 social worker ought to have in mind some general picture of 
 this condition. 
 
 Born in the Azores, Rizzo had come to this country at seven- 
 teen and was now sixty years of age. For some seven years 
 he had been a vagrant. He was of a rather villainous appear- 
 ance on account of a turning out of his reddened eyelids. He 
 was in general docile and affable but would now and then flare 
 up. In the admission ofifice he said he thought the officer who 
 arrested him had it in for him. In fact that same officer had 
 arrested him seven years before. He was very circumstantial 
 in his talk and gave the impression that he felt he was a rather 
 important personage. He said he was quite able to supp9rt 
 himself. He told circumstantially about his trip from the 
 Azores and the various jobs which he had held. According 
 to his own story his trouble had begun in his forty-eighth year 
 over some trade dollars which he exchanged for legal dollars. 
 He said that ever since he had had a lawsuit over these dollars 
 with the United States Government. He had studied law and 
 was now able to handle his cases perfectly well. He said he 
 was a strong temperance man and gave a long harangue on 
 temperance. He explained his not working for seven years 
 on the ground that he had been too busy looking after his affairs 
 in court. He said he did a little work now and then and lived 
 on it. However, he did not live very well for he was alive with 
 vermin. Upon inquiry at the courthouse it was found that 
 there were actually docket entries of nine cases. He had lost 
 all of these cases except one. It appeared that he came to 
 court daily when not in jail and went to file a suit against some- 
 one every time he had the necessary three hundred dollars. 
 As for the jail, it was found that he had been sent to jail at 
 least twelve times for vagrancy. Apparently he had once had a 
 small tailor shop and a man was found who had known him 
 
THE KINGDOM OF EVILS 295 
 
 for some twenty-five years and knew him as "queer but harm- 
 less." It appears that in those early days he had been very 
 religious. He had gone to church daily, sometimes had gone 
 up to the altar and followed the priest about imitating every- 
 thing he did toward the celebration of the mass. He bored 
 holes in silver coins and plugged the holes with other material. 
 Of recent years he had been seen getting food from garbage 
 pails. He was also much of a collector, keeping pieces of 
 paper and other objects that he happened to find in ash cans. 
 He had served three prison sentences for counterfeiting. 
 
 The emotions and the will in the paraphrenic are theoretically 
 supposed to be normal or to suit the nature of the ideas enter- 
 tained. Rizzo would grow irritable at times, particularly when 
 telling of his troubles, but this irritability was a very super- 
 ficial one and soon disappeared. He assumed rather an ora- 
 torical attitude when speech-making but here again the action 
 suited the idea and there could be no question of a primary 
 disorder of the will. The imitation of the priest at mass may 
 very possibly be so regarded ; yet on the whole, we are better 
 entitled to regard this old habit as a sign of his belief, even 
 at that time, in his being a good deal of a personage. 
 
 Hours spent by Medical record, 14 pages 
 
 Social record, 3 pages 
 Physician, 5^ Social work: 
 
 Visits, 3 
 Psychologist, Interviews at hospital, o 
 
 Telephone calls, i 
 Social worker, 4 Letters, o 
 
 Diagnosis between schizophrenia and cyclothymia. Skilled 
 salesman who lost his position through peculiar behavior. Re- 
 covered: remained steady: works regularly. 
 
 Case 73. It is an open secret that it is not an easy psy- 
 chiatric distinction to draw in every case between schizophrenia 
 (dementia praecox) and cyclothymia (manic-depressive psy- 
 chosis). The two diseases are paired in the psychiatrist's mind 
 as sister diseases, the former rather more frequent than the 
 latter, both in the number of first cases developing and in the 
 number remaining in state hospitals under observation. When 
 
296 THE KINGDOM OF EVILS 
 
 the diagnosis lies between schizophrenia and cyclothymia, ap- 
 parently the psychiatrist is statistically somewhat more likely 
 to be right if he decides upon schizophrenia. It should be in- 
 sisted that psychiatrists chiefly familiar with chronic institu- 
 tional material are somewhat more likely to take a pessimistic 
 view of the prognosis of mental disease in general than are the 
 consulting neurologists of out-patient departments or of special 
 practice or the specialists in charge of sanatoriums. In the ten- 
 day period of observation which the law tends to procure for 
 the majority of cases at the Psychopathic Hospital in Boston, 
 there will, perhaps, be an error in diagnosis between these two 
 diseases of something like fifteen or twenty per cent ; sometimes 
 the error will be upon one side, sometimes upon the other. 
 
 The present case of Paul Ernst is not the first in this book 
 in which doubt has reigned concerning the diagnosis schizo- 
 phrenia as against some other form of mental disease. At 
 least three diagnoses, psychiatrically speaking, have been offered 
 for Paul Ernst : namely, alcoholic hallucinosis, dementia prae- 
 cox, and manic-depressive psychosis. 
 
 Ernst has been a patient twice at the Psychopathic Hospital, 
 once in 191 3 and again in 1914-15. At the first admission there 
 seemed no doubt at all of the diagnosis of dementia praecox. 
 He had run about his house nude, broken up furniture, and 
 attacked members of the household. He refused to talk and 
 became very sullen and obstinate. Just before this he had 
 begun to worry over business matters and had grown morbidly 
 depressed when an advance in salary was refused. One Satur- 
 day night he had been quite broken up and discouraged and 
 unable to sleep. Sunday he had been normal, but Monday 
 grew wildly excited. His excitement had lasted twenty-four 
 hours. 
 
 In the hospital he became very violent, at times requiring 
 seven or eight attendants to put him in the wet pack. He 
 shouted, screamed, swore, and cried out, talking either sarcas- 
 tically or very angrily about his treatment. During inactive 
 periods he assumed a disagreeably sullen manner. He remained 
 for the most part quiet, inaccessible to the examiners, but 
 evincing some flight of ideas in his talk. 
 
 He was committed to the Boston State Hospital where he 
 remained a month but was discharged with the diagnosis manic- 
 depressive psychosis. He became entirely clear in his mind 
 
THE KINGDOM OF EVILS 297 
 
 before discharge. He now went back to his work as a sales- 
 man of a special kind of goods. He had never been alcoholic, 
 so that the initial suggestion of alcoholic hallucinosis was 
 unfounded. 
 
 After a time he began again to worry about finances. One 
 day at the department store where he worked, he began to act 
 peculiarly and left for home. There he smashed windows and 
 brought down a chandelier. He was again brought to the 
 Psychopathic Hospital and was there acutely maniacal for 
 some three days, but after this interval a physical examination 
 became possible, and he was found to be practically negative 
 in all respects. Mentally he was suspicious, rather facetious, 
 and non-cooperative upon admission but obviously perfectly 
 oriented for time and place. He tore blankets and night shirt, 
 was profane, obscene, and noisy and was treated by the pro- 
 longed baths and by packs. He either was not, or assumed not 
 to be, interested in his surroundings, kept his eyes staring 
 wide open, and winked constantly. He lay in bed in a rather 
 strained position. For a while on the first day he stood in 
 front of a window, talking, but there was a large question 
 whether the behavior was in response to hallucinations. The 
 psychiatric reader will note how difficult a diagnosis must be 
 with such phenomena between schizophrenia and cyclothymia. 
 
 On about the seventh day there was a change of phase : he 
 now appeared confused, was quiet but restive, and threw him- 
 self from the bed a number of times. He would burst into 
 noises now and then, but was at other times apparently quite 
 rational. Things going on about him he took in quickly and 
 was rather mischievous in his remarks and actions. He began 
 to speak of his wife and family and talked about wanting to 
 go home. At the end of three weeks from his admission, it 
 was possible to send him home in a clear state of mind. He 
 thought that he really had heard false voices just after admis- 
 sion, but conceived that they might possibly be the talking of 
 the attendants misinterpreted by him. He had however once 
 thought that his brother was there talking. He tried to read 
 The Three Guardsmen, but could not keep his mind on the 
 book. He was discharged with the diagnosis dementia praecox, 
 unimproved, despite the fact that his general status was for 
 the moment markedly improved. 
 
 The social service now took charge of him, and for a period 
 
298 THE KINGDOM OF EVILS 
 
 of some two years there is a running record which gives no 
 sign of deterioration whatever. To be sure his former em- 
 ployers refused to take him back, though he had been formerly 
 six years employed by the firm in a rather difficult job. He 
 now had to take temporary jobs as salesman, acting from time 
 to time as an extra. Amongst the measures of the social serv- 
 ice were help to the family in the matter of clothes, more or 
 less continuous reassurance of the wife as to the nature of her 
 husband's situation and prognosis, advice concerning work on 
 his part and the securing of vacations for the children. 
 
 Then came the death of the wife, upon learning which it 
 was thought best to reopen the case from the social service 
 point of view. However, despite the strain of the situation 
 the family succeeded in adjusting itself, with the oldest daugh- 
 ter, a capable girl of seventeen, keeping the house. Meantime 
 Ernst had remained steady, was working regularly, did not 
 drink and showed no sign of deterioration. The success of 
 the family adjustment is the more remarkable when it is con- 
 sidered that there are nine children (one of whom is choreic). 
 
 Is or is not this a case of schizophrenia? Perhaps the shrewd 
 psychiatrist might say that time only would tell. Others might 
 say that it was a case of dementia praecox that had gotten well 
 or had made a compensation practically equivalent to recovery. 
 Others might insist that the case was one of cyclothymia. For 
 our part we may content ourselves with insisting that, which- 
 ever of these diagnoses is rendered, there is a certain statistical 
 likelihood of error in diagnosis with our present knowledge 
 (especially perhaps in the war group of cases). There may 
 be noticed many instances of cases looking even more like 
 schizophrenia than the present case of Ernst and yet turning 
 out to be curable or capable of decided remission. Also it is 
 worth while stressing the fact that the term "dementia" in the 
 phrase dementia praecox should not be allowed to dominate 
 anybody's conception of the disease schizophrenia. The so- 
 called "dementia" is from the standpoint of all clear-cut cases 
 a matter of deterioration of the emotions and not at all neces- 
 sarily or characteristically of the intellect. The layman, social 
 worker, or psychiatrist makes a grave error who carries over 
 any ideas that he may possess concerning dementia and dements 
 of the old age group into the so-called dementia of dementia 
 praecox. Perhaps no more unfortunate term than dementia 
 
THE KINGDOM OF EVILS 299 
 
 praecox has yet been devised for an important group of psycho- 
 pathic patients. 
 
 Hours spent by Medical record, 9 pages 
 
 Social record, 4 pages 
 Physician, 7^ Social work: 
 
 Visits, 2 
 Psychologist, o Interviews at hospital, 3 
 
 Telephone calls, o 
 Social worker, 2 Letters, i 
 
 Spoiled child. Suicidal attempts: state hospital: dementia 
 praecox? Marriage to soldier after birth of child: deserted. 
 
 Case 74. Nora McCarthy was rather a spoiled child 
 coming from a not too intelligent, quarrelsome, and alcoholic 
 family. She could not finish high school because she got "tired 
 out" and "nervous." It seems that she got depressed rather 
 often and several times tried suicide, once being taken to a 
 state hospital for a month after a suicidal attempt and therein 
 receiving the diagnosis of psychopathic personality from which, 
 perhaps, there should be no dissent. 
 
 For some two years she had been at home doing nothing 
 whatever. Then she became engaged to a very excellent young 
 man whom she had known a year and who was about to enlist. 
 They wanted to marry. Nora's mother refused, whereat Nora 
 cried continually for a month, refused to eat with the family, 
 was sent to the Psychopathic Hospital for observation and was 
 there thought to have schizophrenia (dementia praecox). 
 
 It was now discovered that she was pregnant. The fiance 
 was unable to get a furlough for marriage. There were even 
 preparations for an eleventh-hour marriage as he was en route 
 for overseas. In point of fact the detachment had been hur- 
 ried from train to ship and there was not even time to wire. 
 An attempt at a proxy marriage was made but there was 
 some doubt of its legality. Her fiance wrote regularly and 
 sent her money. 
 
 At the hospital she was given mental tests and was 
 found to grade at I4j^ years on the Stanford-Binet Scale. 
 Her failure lay not so much in intellectuality but in im- 
 pulsive and hasty answers. She was physically quite normal, 
 
300 THE KINGDOM OF EVILS 
 
 psychiatrically some of her talk about her family might give 
 ground to the suspicion of her being paranoidal, but on the 
 whole her statements seemed to be accurate or merely exag- 
 gerated. Emotionally she was somewhat depressed and at 
 times gave the appearance of apathy. It was, no doubt, upon 
 this latter ground that the idea of dementia praecox obtained. 
 In retrospect it would seem that a good deal of this abnormal 
 emotional appearance was really due to her feelings about her 
 pregnancy. 
 
 She remained for a time as a voluntary patient under ob- 
 servation and then went home, where she at first did nothing. 
 Gradually she became interested (in part under the visitor's 
 stimulation) in making baby clothes. The baby was born be- 
 fore its father returned from overseas. She worried about the 
 supposed nervousness of "the poor little thing." She gradually 
 became interested in housework and grew interested m taking 
 care of the baby even to the point of absorption. A proper 
 marriage had been celebrated. 
 
 At this point the social service closed the case. It appears 
 from the record that this decision was influenced by Mrs. Mc- 
 Carthy's statement that Nora was "very happy and well and 
 not at all depressed, taking an interest in her baby and in the 
 household." The closing note reads : "Case closed since pa- 
 tient is doing well and further visits would simply antagonize 
 her and her mother. Her mother is keen enough to recognize 
 new mental symptoms quickly and to insist upon patient's re- 
 porting to the doctor." Perhaps the fact that the McCarthys 
 lived at some distance from the hospital and on top of a steep 
 hill may have influenced the decision to close the case. Pos- 
 sibly the fact that several times the visitor climbed the hill only 
 to be told that Nora was out had also played its part. At any 
 rate, it was judged that her husband could not take care of 
 Nora; and it was left to Mrs. McCarthy to explain her con- 
 dition to him. The young couple were to live with the 
 McCarthys. 
 
 Five months later the social worker received a letter from 
 Nora saying that her mother would not allow her to talk with 
 the social worker in the past but that she must see someone 
 now as she was in great trouble. Her husband had gone to 
 make a visit to his father several months before and had not 
 
THE KINGDOM OF EVILS 3OI 
 
 returned. He had communicated with her several times, but 
 without letting her know his address. The explanation of this 
 unexpected conduct in a man of excellent reputation has not 
 yet been found. She was advised to take legal action to trace 
 him. Meanwhile she is working as cashier in a department 
 store, and living at home. She still complains of her family 
 but manages to get on with them. 
 
 Hours spent by Medical record, 36 pages 
 
 Social record, 28 pages 
 Physician, 5^ Social work: 
 
 Visits, 53 
 Psychologist, i Interviews at hospital, 3 
 
 Telephone calls, 10 
 Social worker, 81 Letters, 18 
 
 Girl committed after three years' observation. Intensive so- 
 cial treatment. Diagnosis altered from psychoneurosis to 
 schizophrenia. 
 
 Case 75. We cannot regret the kind or the degree of social 
 work carried out in the case of Clara Goldberg; yet in the 
 sequel it might be thought that a good deal of someone's time 
 was, for Clara Goldberg at least, wasted. 
 
 We choose the Goldberg case as one of dementia praecox. 
 In the end, over three years after our original observation, the 
 girl was duly committed to a state hospital, with the usual 
 prognosis of cases of dementia praecox, that is, with the great 
 likelihood of a persistent deterioration. 
 
 We noted above in the case of Alfred Stevens (case 25) an 
 instance wherein the change of medical diagnosis proved of 
 the utmost importance. The alteration of the diagnosis from 
 psychasthenia to cyclothymia (manic-depressive psychosis) in 
 the case of Stevens worked out tremendously to his benefit; 
 for his stay in the state institution led to the smoothing out 
 of his depression and his rehabilitation. Clara Goldberg is an 
 instance of alteration of diagnosis from the psychoneurotic 
 group to the schizophrenic (dementia praecox) group. The 
 commitment of Clara Goldberg to an institution for chronic 
 cases no doubt makes it somewhat easier for the girl herself 
 and straightens out many family problems. In the present 
 
302 THE KINGDOM OF EVILS 
 
 phase of medical science this will no doubt be the issue in the 
 majority of cases of schizophrenia (dementia praecox). 
 
 Let us first consider her appearance and behavior at the 
 time of her final commitment as a case of dementia praecox. 
 She was then twenty-two years of age and had just entered the 
 hospital with a record of not having eaten anything for several 
 days. She volunteered the statement that she was a bad girl 
 and a flirt and did not deserve to eat. Direct questions she 
 answered correctly, but often wore a silly expression, hiding 
 her face. For the most part she refused to talk. When asked 
 a question she sometimes appeared as if about to say some- 
 thing but her words failed to come; she was "blocked." She 
 was constantly seen sitting in a chair with her head inclined 
 forward and the saliva running from her mouth. Now and 
 then her hands and arms would shake violently. Her pupils 
 were dilated. For the rest the physical examination was not 
 remarkable. 
 
 A psychological examination would have been at this time 
 impossible. Clara had, however, been under out-patient de- 
 partment observation for three years and had twice had a 
 psychological examination. The second time, about a year 
 before her appearance in the above described characteristically 
 schizophrenic state, she made by the Point Scale a level of 13.5 
 years, grading, in fact, somewhat higher than she had graded 
 on the previous examination a year before. She did, however, 
 show on the second examination much poorer planning ability 
 than she had at first shown. 
 
 Looking back upon her history, it is now easy to see schizo- 
 phrenic traits. She is described as having had many manner- 
 isms from the early teens, such as touching her face and teeth 
 constantly and continually moving the muscles of her face. 
 Efforts to curb these mannerisms — she felt that her expression 
 was silly and even made definite efforts to change her expres- 
 sion — resulted in movements worse than ever. 
 
 In the later teens it appears that she became untidy in her 
 person. It was wasteful, she thought, to have money spent 
 on clothes. She would eat dry bread between meals so that 
 the bread might not be wasted. A habit of masturbation had 
 begun at thirteen. It is not even impossible that her deteriora- 
 tion had begun at school days (for instance, she spent three 
 years in the seventh grade). 
 
THE KINGDOM OF EVILS 303 
 
 Clara's mother had had two attacks of manic-depressive psy- 
 chosis, and Clara had a sister known to be excitable. 
 
 A year before the conditions described above, Clara Gold- 
 berg was the object of considerable attention. The social 
 workers described themselves as at the end of their particular 
 rope. They wanted to know what to do. The impression of 
 this earlier phase was different. Notes, for example, ran at 
 a staff meeting : The patient came in shrinking, with eyes red- 
 dened from weeping. She sat herself down and kept twisting 
 in her chair with her head downcast. She was apparently 
 laboring under great emotion. She answered haltingly and 
 in a low voice. In response to questions she said that her 
 conscience did not work, that she was not the right sort of 
 person, that she had caused a certain social worker to leave 
 the hospital, and finally she burst out weeping loudly. 
 
 After the interview and a presentation of all available facts, 
 there was a remarkable split in the opinions of the staff, some 
 of the more mature and experienced physicians lining them- 
 selves on both sides of the question, psychoneurosis versus 
 schizophrenia. The purposefulness and emotionality of her 
 reactions suggested psychoneurosis to several competent 
 workers. Still it was noteworthy that when the "pragmatic 
 rule" was applied and the question was asked zvhether the pa- 
 tient was committable or not, eight persons out of eleven felt 
 that she was at that time committable and but three felt that 
 she was not committable. Now, inasmuch as on the whole 
 psychoneuroses are probably best treated outside of state in- 
 stitutions, whereas on the whole schizophrenics are best treated 
 in state institutions, this opinion on the part of the staff is 
 noteworthy. Observers who saw a large psychoneurotic ele- 
 ment in Clara Goldberg were nevertheless inclined to think 
 she would do best in a state institution. 
 
 It sometimes appears that the application of this "pragmatic 
 rule," What would you do for the case? is technically superior 
 to asking the question. What particular disease is this patient 
 suffering from? To be sure, great authorities agree that one 
 cannot make the generic diagnosis of mental disease safely 
 without specifying the particular kind of mental disease that 
 the patient is assumed to have. No general statement that a 
 patient is "insane," "unbalanced," "deranged," is quite safe to 
 accept. When the particular type of mental disease cannot 
 
304 THE KINGDOM OF EVILS 
 
 be agreed upon by a large and active medical staff, it appears 
 to be good technique to ask the pragmatic question as indicated 
 above. 
 
 With respect to social treatment, some recommendations 
 early made were as follows : 
 
 1. Mother's attitude should be changed to one of encourage- 
 ment instead of fussy concern over Clara. 
 
 2. Occupation should be secured for the patient, an occupa- 
 tion interesting to her; if possible, with small remuneration. 
 
 3. The girl should be educated by being placed, if possible, 
 in a domestic-science class. 
 
 4. She was to be influenced to mix more with girls of her 
 own age. 
 
 5. She was to report regularly to the out-patient depart- 
 ment for medical observation and treatment, and she was to 
 attend a gymnasium for her physical development. 
 
 The results of treatment cannot be very briefly stated. While 
 (a) living at home she failed to show improvement. She went 
 from one relative's home to (b) another, thence to (c) a con- 
 valescent home and thence to (d) a working girls' home. 
 Finally money was raised to send her to (c) a small summer 
 camp for girls, whence she went back to (/) the home. 
 Arrangements were made for (g) medical treatment through 
 payments by her sister. She was engaged (//) to tell stories to 
 children at a settlement playground and she was even somewhat 
 successful in this. She was got to go to (/) a cooking class and 
 then to (/) a pottery class. She was taught (k) to knit and 
 kept persistently at the task of knitting a muffler, though the 
 winter was over before the muffler was finished. She learned 
 (/) to do simple office work in a fortnight at a public stenog- 
 rapher's office and then did (m) voluntary work for some 
 weeks in the office of a civic organization. Then she served 
 (n) as an errand girl in a dressmaking shop. All these em- 
 ployers reported that she was useful and willing. She received 
 no pay for this work -which was regarded as educational. At 
 the summer camp she entered into all sports and games such as 
 basketball, archery, and swimming. Physically she was greatly 
 improved by her stay at the camp, (o) Her teeth were filled. 
 
 Whereas at home she had made no physical improvement, 
 she improved steadily after her first stay at the convalescent 
 home. The mannerisms that she had had since the early teens 
 
THE KINGDOM OF EVILS 305 
 
 became less noticeable. She became able to meet and talk with 
 other persons without much embarrassment. She looked rather 
 pretty and appealing and dressed attractively. She spontane- 
 ously bought Christmas presents for social workers. 
 
 About ten months before she fell into the utter dilapidation 
 described at the outset of this description, Clara began to fall 
 off in her working capacity. She obtained work in a biscuit 
 company but had no confidence in her ability to do the work 
 and shortly gave it up. She became slower in all her processes. 
 She began to accuse herself and said she was not earning her 
 board. Her employers in the biscuit factory liked her well 
 enough but found her in the end "impossible." Her statements 
 and phrases became peculiar. She said, "I have burned my 
 sister inside of me." She told the forewoman to discharge 
 her, saying that she (Clara) was silly-looking and no good and 
 that she had turned the hair of two of the doctors gray. She 
 was reticent, seclusive, and very forgetful at the mill. At lunch 
 time she would disappear with her package very mysteriously 
 and return in time for work. H addressed by the forewoman 
 she would tremble and shake and be unable to work. 
 
 Here then was a fairly promising case, as cases go, of de- 
 mentia praecox. Here was a case with a good deal of emotion- 
 ality and apparent insight with considerable ambition. It was 
 always possible up to the last to exert the kind of influence 
 upon her which occupational therapeutists desire to use. Her 
 mannerisms had developed very early and appeared to have 
 but a superficial relation to the main currents of her emotions 
 and will. Was or was not the progress of the schizophrenic 
 process in Clara Goldberg postponed or slowed down by the 
 social work, rest, treatment, and occupational therapy ? 
 
 Aside from the obvious physical improvements above noted, 
 can we safely allege that her psychosis was slowed up? The 
 only concrete point we can make is based upon the two special 
 psychological examinations at a year's interval, the second about 
 a year before her commitment (at which time a psychometric 
 estimate would have been impossible). These two psychologi- 
 cal examinations, so far as they go, give the impression that, 
 up until about a year before the final slump, Clara Goldberg's 
 deterioration was not actively in process. This conclusion is 
 in accord with the maintenance of her general social status and 
 working capacity up to and beyond the time of the second 
 
306 THE KINGDOM OF EVILS 
 
 psychometric examination. Clara, it is worth noting, found 
 her own jobs for the most part during the years of our treat- 
 ment. The last one in which she failed was no doubt too hard 
 for her. 
 
 Can it be that with superior light and power over what we 
 have at command, a simpler job without the disturbing ele- 
 ments of exact and monotonous mill work and without the 
 presence of great numbers of fellow workmen would have 
 saved her from immediate deterioration? The question, some 
 might say, is of little importance, since in the long run a patient 
 like Clara Goldberg is bound to decline. This, some would 
 say, is the almost universal history in true cases of schizo- 
 phrenia (dementia praecox). Even concede this unhappy trend 
 to be the rule, it is nevertheless of the utmost importance to 
 pursue more intensive studies of just this sort, punctuated by 
 occasional psychometric examinations, so that we may get 
 some further light upon the interior of the schizophrenia 
 problem. 
 
 No doubt, under the conditions favoring occupational ther- 
 apy of modern state institutions, the Goldberg girl will become 
 a sufficiently effective hospital worker, though of no great 
 industrial value. Accordingly, although we probably should 
 not have carried out quite such extensive therapeutic measures 
 in Clara Goldberg unless she had shown many psychoneurotic 
 features over and above schizophrenic traits in the early period 
 of her medical observation, we cannot be sorry that so much 
 work was done. 
 
 Hours spent by Medical record, 44 pages 
 
 Social record, 42 pages 
 Physician, 20^4 Social work: 
 
 Visits, 45 
 Psychologist, 2 Interviews at hospital, 33 
 
 Telephone calls, 32 
 Social worker, 90 Letters, 116 
 
 Negro soldier cited for bravery. Dangerous paranoid con- 
 dition after discharge. 
 
 Case 76. George Stone, a negro soldier, who enlisted early 
 in 1918, made an honorable record overseas. His discharge 
 papers stated that he was in several battles, received a citation 
 
THE KINGDOM OF EVILS 3P7 
 
 for bravery in escorting an officer through shell-fire, and was 
 cited for the croix de guerre. He was gassed and in conse- 
 quence was declared eligible for compensation on the ground 
 of "pain in the region of the heart and lung defects." He was 
 first sent in as a voluntary patient by the Red Cross, four 
 months after his discharge from the army. 
 
 He had married immediately upon his discharge a widow 
 about his own age (he was thirty-seven), who had shortly 
 after joined a religious sect that absorbed a good deal of her 
 time. Stone began coming to the Red Cross office nearly every 
 day complaining that his wife stayed out all night and read 
 the Bible all day in bed, would not cook for him, and did not 
 care for him "since she got that religion." He talked inces- 
 santly and laughed a good deal in a silly manner. As he thought 
 the pains around his heart were being made worse by his 
 troubles, it was easy to get him to go to the hospital. He was 
 very jealous of his wife and thought she was trying to injure 
 him. He told her if she bowed to a man on the street he 
 would kill him. 
 
 The case was diagnosed as a "paranoid condition" and com- 
 mitment was advised. But as Stone was not considered dan- 
 gerous he was allowed to go home. Within a month he was 
 brought back by the police, to whom his wife had turned for 
 protection. Meanwhile he had gone to Washington for a 
 physical examination, in order, he said, to prove to his wife 
 that he was not well, as she said he was. Now he accused his 
 wife of infidelity and believed she was trying to get rid of him 
 in order to obtain his pension money. He wrote letters to 
 prominent officials complaining and asking protection from his 
 wife. He believed that he had two hundred thousand dollars 
 invested. He said he felt wonderfully healthy and was happy 
 because God was in his soul. This time he v*^as committed but 
 escaped from the hospital and started to his old home in the 
 South. Through Red Cross channels he was steered into a 
 hospital in Washington and returned here. 
 
 Hours spent by Medical record, 37 pages 
 
 Social record, 2 pages 
 Physician, 7^ Social work: 
 
 Visits, o 
 Psychologist, i Interviews at hospital, 2 
 
 Telephone calls, 
 Social worker, 2^ Letters, 6 
 
308 THE KINGDOM OF EVILS 
 
 Left a state hospital and enlisted. 
 
 Case 77. George Mullen was a single man of twenty-five, 
 who was born in Canada but had spent most of his life in a 
 New England state where his family live. In 191 5 he was in 
 this hospital suffering from dementia praecox. He was com- 
 mitted to a state hospital for mental diseases and discharged 
 after five months. He immediately sailed for England and 
 enlisted in the British Army. He fought in France, was 
 wounded, and returned home. He seemed indifferent to his 
 family, was excitable, talked continually about money. After 
 a week at home he attempted to cash a check that he had signed 
 with the name of a prominent financier, whose partner he 
 claimed to be. After observation at this hospital he was again 
 committed to a state insane hospital with the diagnosis of 
 dementia praecox confirmed. 
 
 Hours spent by Medical record, 13 pages 
 
 Social record, i page 
 Physician, 3^ Social work : 
 
 Visits, o 
 Psychologist, Interviews at hospital, I 
 
 Telephone calls, o 
 Social worker, i Letters, 2 
 
 Discharged from the National Guard as a case of dementia 
 praecox. Drafted: again discharged. Claimed to be faking 
 mental disease. 
 
 Case 78. Paul Dawson was first admitted to the Psycho- 
 pathic Hospital two years ago. At that time he was twenty- 
 three and had recently married a girl of seventeen. He had 
 always been a great liar, had never worked long at a time, and 
 had loafed a good deal between jobs. A year before he had 
 joined the National Guard and been sent to the border. He 
 claimed that he had "faked mental disorder" while there with 
 his regiment and that he knew the symptoms since he had 
 worked at times as attendant in state hospitals. He was dis- 
 charged from the service with the diagnosis dementia praecox 
 (the diagnosis of the Psychopathic Hospital physicians also). 
 
 He was sent home from the border to his father under guard. 
 He and his wife then went to live with her family, but Dawson 
 
THE KINGDOM OF EVILS 309 
 
 got into a quarrel with the in-laws and they were put out. 
 They were taken in by his family, but when Dawson made no 
 attempt to get work, his father refused to keep his wife, now 
 pregnant. She returned alone to her own home, where she 
 received a somewhat cold welcome. Dawson continued to loaf 
 and drink, insisting that his wife return to him, but making 
 no attempt to support her. Although several positions were 
 suggested to him, he failed to go to work. His wife insisted 
 that she would not "give him up," but finally she settled down 
 to the necessity of making her home indefinitely with her fam- 
 ily. When later her husband was drafted, she received an 
 allotment. After the birth of a fine boy, her attitude was that 
 she would return to him if he would "make a man of himself." 
 
 When war was declared Dawson at first decided to enlist, 
 saying it would be better to do that than be drafted, but then 
 he came to the conclusion that he would wait for the draft. He 
 was taken into the army in the spring of 1918 and four months 
 later was sent to the Psychopathic Hospital from camp with 
 the following statement on the admission blank : 
 
 "Insomnia, weakness, pains, and poor appetite. Feared 
 return of old mental trouble. Hears voices and sees people 
 about his bed; has delusions that he has put electric wires 
 about his bed to keep enemies away; believes wife trying to 
 poison him and wants to do his own cooking. Will not speak 
 to any patient or be spoken to." 
 
 He claimed again that his mental disorder was "faked." He 
 had written his family from camp that he meant "to put up a 
 game," because he did not want "to go across" and that he 
 would "give the doctors a run for their money." The physi- 
 cians believed that he had delusions, which he denied and tried 
 to conceal, and made the diagnosis of unclassified paranoid 
 psychosis. He worked for four months at a state institution 
 and then joined the merchant marine where he became chief 
 petty officer on a ship sailing for China. 
 
 Hours spent by Medical record, 23 pages 
 
 Social record, 17 pages 
 Physician, 6^ Social work: 
 
 Visits, 22 
 Psychologist, i Interviews at hospital, 5 
 
 Telephone calls, 35 
 Social worker, 41 J4 Letters, 4 
 
310 THE KINGDOM OF EVILS 
 
 Corporal who developed dementia praecox in camp. 
 
 Case 79. Howard Lancaster when drafted was doing ex- 
 ceptionally well in a bonding house. He worked hard and 
 efficiently and spent his leisure time studying law. He had 
 always been inclined to be seclusive and a little suspicious, and 
 he had times of being depressed, when he thought he was not 
 doing his work well and that his associates were talking about 
 his falling-off. He tried to enlist and was rejected because of 
 a defective eye; but later he was drafted. After two or three 
 weeks in camp, he was promoted to corporal. After two 
 months he became ill, acting and talking in a silly manner, say- 
 ing that he heard voices forbidding him to perform his duties. 
 The diagnosis was dementia praecox. He was committed to a 
 hospital, but in a month had improved enough to be discharged 
 "on visit" to his family. 
 
 Hours spent by Medical record, 34 pages 
 
 Social record, 2 pages 
 Physician, 4V2 Social work: 
 
 Visits, I 
 Psychologist, i Interviews at hospital, i 
 
 Telephone calls, 
 Social worker, 2 Letters, 2 
 
 Army captain zvith dual personality. Arrest for forgery. 
 
 Case 80. Major Dobson (who proved to be Captain 
 James Hill) was sent for examination by federal authorities 
 after arrest on the charge of having forged a check for one 
 thousand dollars under the name of Major Mark S. Dobson. 
 He claimed a dual personality but could not explain it. He 
 said that he used two names, because he had two fathers, one 
 of whom was dead, the name of the living one being Hill. He 
 believed that he had the rank of major and that the check he 
 tried to cash was his pay check. He thought that Captain 
 Hill had been discharged but that Major Dobson was still in 
 the service. Although he had lived all his life in Florida, he 
 claimed that part of him had been educated in Europe. His 
 conduct had been peculiar for several months, — in France he 
 had wandered about for a month (he said he knew what he 
 was doing but could not control it). He had been hearing 
 
THE KINGDOM OF EVILS 3II 
 
 people say such things as, "Kill him." He was worried about 
 himself and anxious for help in solving his problem. The 
 newspapers had his story under the headline, "Afflicted by 
 Shell-Shock." 
 
 Captain Hill had seen several terms of army life. He enlisted 
 in 1912 and purchased release in 1913; reenlisted in 1914 and 
 again purchased release in 191 5. In 1916 he went to an offi- 
 cers' training camp and was commissioned. He served eighteen 
 months in France and was once wounded. While overseas he 
 cabled a proposal of marriage to a girl he had known for two 
 years, a dancer in a comic opera company. They were married 
 on his return and the week that Hill was taken into custody, his 
 wife went on tour. The court charge of forgery was dropped 
 when the hospital physicians submitted the diagnosis dementia 
 praecox and the captain was sent to his family for hospital care. 
 
 Hours spent by Medical record, 19 pages 
 
 Social record, 8 pages 
 Physician, 4^4 Social work : 
 
 Visits, I 
 Psychologist, o Interviews at hospital, 3 
 
 Telephone calls, 11 
 Social worker, 5^2 Letters, 4 
 
SECTION IX 
 
 CYCLOTHYMOSES ( MANIC-DEPRESSIVE PSYCHOSES) 
 
 Young woman with spells of wandering and eroticism. 
 Three diagnoses rendered — psychoneurosis, dementia praecox, 
 manic-depressive psychosis. Importance of diagnosis in 
 treatment. 
 
 Case 8i. We find stretched on the records in the case of 
 Winifred Reed three different psychiatric diagnoses; namely, 
 psychoneurosis, dementia praecox, and manic-depressive psy- 
 chosis. 
 
 Of all the diagnoses in the whole of psychiatry no doubt 
 these three offer the maximum of difficulty. To be sure, 'we 
 place in an eleventh or miscellaneous group of psychoses sundry 
 conditions of still greater obscurity, both as to their nature 
 and frequently as to their diagnosis. Yet these eleventh group 
 cases of psychopathia are indeed so obscure that they prac- 
 tically defy analysis, but the three diagnoses that come in ques- 
 tion with Winifred Reed fall into groups which in our Psycho- 
 pathic Hospital experience we place just ahead of the eleventh 
 group. The schizophrenic group (dementia praecox) we have 
 placed eighth in our list; the cyclothymic (manic-depressive) 
 stands ninth ; and the psychoneurotic group stands tenth. In 
 short, after we have swept aside the major diagnostic groups 
 of a more definite character, we find ourselves confronting 
 groups of cases of great diagnostic difficulty and very doubtful 
 genesis. It will be the task of the psychiatry of the future to 
 unravel the cause or causes of the schizophrenic, cyclothymic, 
 and psychoneurotic disorders. Nor can we undertake in this 
 book to expound at any length the psychiatric nature of these 
 or any other conditions. Let us insist that whatever doubt 
 may at bottom prevail concerning the nature and causes of 
 these types of disease, nevertheless their treatment, once a par- 
 ticular diagnosis is rendered, is almost always specifically indi- 
 cated. Let us insist with all emphasis that it makes every dif- 
 
 ^12 
 
THE KINGDOM OF EVILS 3I3 
 
 ference to the medical and social treatment of a case of mental 
 disease whether it receives the diagnosis schizophrenia (demen- 
 tia praecox), cyclothymia (manic-depressive psychosis) , or 
 psychoneiirosis. Moreover, let us insist that it makes a differ- 
 ence to the patient even when the diagnosis is incorrect. We 
 have above considered the interesting case of Alfred Stevens 
 (case 25) to whose fate the matter of a psychiatric diagnosis 
 was of extreme importance. It will be remembered that Alfred 
 Stevens was erroneously classified as a psychoneurotic, was 
 amply treated therefor, failed to make progress, and was 
 promptly put on the right road again when the correct diagnosis 
 (manic-depressive) was rendered. It will be recalled that as 
 soon as Stevens was called a manic-depressive he was forthwith 
 prevailed upon to enter a state hospital, wherein all his troubles 
 quite smoothed out. 
 
 Winifred Reed was not very long seriously considered a 
 psychoneurotic; nor was psychotherapy of the sort indicated in 
 psychoneurosis used upon her. (In this instance, as every- 
 where when we speak of psychotherapy and its applicability or 
 non-applicability to a case, we are obviously not talking about 
 such advice and counsel as are properly given to every normal 
 person ; we are talking about psychotherapy deliberately chosen 
 and planned to affect the particular rationalization of a particu- 
 lar difficulty.) The vital issue lay between the diagnoses of 
 dementia praecox and manic-depressive psychosis. In the end, 
 Winifred Reed proved, we believe, to be a victim of manic- 
 depressive psychosis, but still she was for a long time regarded 
 as a victim of dementia praecox. Omitting consideration of the 
 medical data for and against these diagnoses, what are the 
 prognostic features that bear upon social treatment? The 
 psychiatric social worker must, of course, rely upon the medi- 
 cal diagnosis (erroneous though it may be in fifteen or twenty 
 per cent of cases amongst these dubious groups) and must pro- 
 ceed on the hypotheses that underly these respective diagnoses. 
 
 We ordinarily think of dementia praecox as a progressive 
 mental disease without characteristic tendency to recovery. 
 Per contra we ordinarily think of manic-depressive psychosis 
 as a disease with a strong tendency to recovery and to recur- 
 rence. If these ideas are taken boldly at their face value, then 
 the logician might conclude that this victim of dementia prae- 
 cox tending to an incurable dementia might as well forthwith 
 
314 THE KINGDOM OF EVILS 
 
 proceed to his finish in some receptacle for the chronic insane. 
 Per contra the logician might conceive that this victim of manic- 
 depressive psychosis being likely to get well at least of this 
 particular attack, might well be tided over his attack at home. 
 But these conclusions of the logician taking the classical prog- 
 noses on their face value would land us in many a quagmire. 
 The fact is that the schizophrenic, flattened out and leveled 
 down as he may to a greater or less extent become, can often 
 find a suitable nidus in his own home or somewhere in the 
 community outside hospital walls. Contrariwise, the manic- 
 depressive can be tided over his attack at a home only with 
 extremes of difficulty which are quite unwarranted. You may 
 perhaps at any time set up an institutional equivalent in a 
 private home, with day nurses and night nurses and constant 
 medical care, but ten to one you have not helped the patient's 
 own attitude to his disorder in the slightest and there has been 
 a very trifling gain in the avoidance of whatever stigma now 
 remains for the mental case in the modern community. Far 
 better is it that the tiding over shall be more effective and safely 
 accomplished within the walls of a hospital. Moreover, if we 
 attach to the benefits of the hospital stay the value of precise 
 records for comparison with the data of future attacks and the 
 potential virtues of social work in family adjustment, then we 
 feel that there can be no doubt medically or socially of the 
 propriety of sending these particular curables to hospitals. We 
 again arrive at an apparent absurdity; namely, that curables 
 should he forthwith hospitalized and that incurables shall he 
 kept in the cotnrminity. Obvious though this conclusion is, it 
 nevertheless proves difficult to make the world understand it. 
 
 Winifred Reed was first admitted to the Psychopathic Hos- 
 pital when twenty-four years of age. The physician who sug- 
 gested that she ought to be observed said that she had been 
 much depressed and thought she was "crazy." There was a 
 history of her having wandered for two days and a night in 
 the late autumn, hoping to die from starvation and exposure. 
 Again, in the dead of winter, she had walked off knee-deep in 
 snow, to the point of freezing her feet, again with the idea of 
 dying from exposure. Upon examination there was little 
 psychiatrically to find; she had a considerable insight into her 
 situation. Aside from depression and over-active reflexes, 
 she seemed mentally and physically normal enough. After 
 
THE KINGDOM OF EVILS 315 
 
 elaborate discussion at staff meeting, the staff felt inclined to 
 make the diagnosis dementia praecox, though psychoneurosis 
 was also considered. 
 
 She was then dismissed to the social service, who fell into 
 sundry difficulties with her. Her father was alcoholic. Her 
 mother was a Christian Scientist. It seems that the father had 
 become intemperate when Winifred was about ten years old, 
 and had steadily become more and more of a drunkard (ap- 
 pearing at one time in a state hospital). The girl had been a 
 stenographer without special responsibilities. It is not quite 
 certain what the first mental symptoms were and when they 
 occurred. It appears that she lost her job through an odd bit 
 of behavior which has never been explained (she charged a 
 fellow employee with stealing another's hat). She then lost 
 another job after some three weeks and then tried to act as a 
 salesman for her father. It appears that Winifred talked 
 rather boldly about being "sporty." Some employers thought 
 that she was "man crazy." It was difficult to decipher the 
 course of her conduct because of the unreasonable character 
 of the father. At one time the girl was kept in the back part 
 of her father's shop, and customers were assured that the 
 girl was kept there because she was going crazy. Just before 
 coming to the hospital, Winifred had become careless and 
 indifferent, though previously energetic and bright. In fact, 
 Winifred had obtained unusually good grades at the high school 
 from which she had graduated. 
 
 It is difficult or impossible to unravel some of the features 
 of her history. There is no doubt that she was, in the stock 
 phrase of the employers, "man crazy" from time to time. She 
 herself dated her excess of erotic passion from the age of 
 twenty-one, when, according to her story, she had sex inter- 
 course for the first time. According to the girl, she had tried 
 to fight against her intensity of passion but was not able to 
 control it. In the same (twenty-first) year, there was also a 
 period of depression which lasted about three months. Nothing 
 connects this depression directly with the initial sex intercourse. 
 These periods of depression have come on from time to time 
 every year since, and in fact have increased in frequency as 
 well as in duration. 
 
 If one read the history as we have just reviewed it there 
 might seem to be little doubt of the patient's being a victim 
 
3l6 THE KINGDOM OF EVILS 
 
 of manic-depressive psychosis. Her general excitability of 
 temper, her attacks of depression, and her erotic episodes and 
 trend would be entirely consistent with the diagnosis. If we 
 look back, however, at the picture which she presented upon her 
 first admission to the hospital after her fugue-like wanderings 
 into the woods and snow, and if we bear in mind her change 
 of character and indifference, to say nothing of the oddities of 
 her behavior, then we shall readily see how the diagnosis of a 
 mild dementia praecox could have been set up. 
 
 At all events, such is the general opinion of Winifred Reed. 
 The best line appeared to be to manage her in the community 
 with such moral support of the girl herself and of the family 
 as might keep her on a fair level of social efificiency. Despite 
 the fact that the prognosis of dementia praecox would run to a 
 certain impairment of personal and social efficiency, yet from 
 our social endeavors with the girl and with her associates much 
 might be hoped. An endeavor was made to separate her from 
 her alcoholic father and socially inadequate mother and to put 
 her at suitable employment. The first step consisted in sending 
 her to a convalescent home. From this house she forthwith 
 escaped and repaired to her own home. Twice afterward she 
 was also placed in convalescent homes, but whether from a con- 
 valescent home or from good conditions in some job that was 
 got for her, Winifred Reed never failed to leave; she would 
 repair to her home and there keep in hiding for a time, eventu- 
 ally telephoning to the hospital for help. Her eroticism and 
 her odd behavior did not abolish the fidelity of a patient ad- 
 mirer who stood by her throughout, and though practically 
 engaged to the girl, never married her. 
 
 Eventually, after some seventeen months, the overt act 
 which so often supervenes with psychopaths occurred. Ap- 
 parently she had a fresh outburst of eroticism (which is medi- 
 cally to be regarded as a form of attack in her disease). She 
 was arrested for cohabitation and again brought to the hospital. 
 The diagnosis seemed now to be much plainer than in the be- 
 ginning. Instead of community care, with the securing of 
 jobs for which she was not ready, and difficult supervision, 
 she was accorded hospital treatment. In two months she could 
 be discharged to probation. Her attack of slight mania had 
 subsided. The further steps in this case, in which similar 
 attacks are only to be expected, are part of a rather clear 
 
THE KINGDOM OF EVILS 31/ 
 
 program. With this diagnosis in hand, it seems as if Winifred 
 Reed could in future be managed with considerable if not with 
 absolute success. 
 
 Hours spent by Medical record, 64 pages 
 
 Social record, 50 pages 
 Physician, 13 Social work: 
 
 Visits, 23 
 Psychologist, 2 Interviews at hospital, 13 
 
 Telephone calls, 122 
 Social worker, 81 Letters, 16 
 
 Cyclothymic waiter came to the out-patient department 
 because he lacked initiative. 
 
 Case 82. William Donahue, thirty-six, came of his own 
 volition to the Psychopathic Hospital, out-patient department, 
 saying he had had depressed spells from a boy up. He said he 
 was confident enough of his ability to work, but "lacked initia- 
 tive." He said too that he had considerable trouble in getting 
 on with other people, being regarded as a "grouch." It ap- 
 peared upon conversation that he had had short periods of 
 exhilaration. The diagnosis of manic-depressive psychosis 
 was soon made by the psychiatrist, and Donahue was referred 
 to the social service for employment. This was procured at 
 a department store. He worked there for a number of months, 
 but reported from time to time that he had not quite got back 
 to his best form. 
 
 Donahue was never referred to the wards of the hospital, 
 but was handled from the out-patient department and the social 
 service. It seems he had worked always rather irregularly, usu- 
 ally as a waiter. His head had been split open when he was 
 knocked down by a runaway horse at the age of eight. Dona- 
 hue had never been very strong, had never taken much part in 
 games with other boys, and had been out of school a great deal 
 owing to sickness. His father was a heavy drinker. No spe- 
 cial mental tests were made upon Donahue. He often left his 
 jobs, which rarely lasted over a few months, for no reason 
 whatever. He always wanted to work on his own responsibility. 
 He wanted to be let alone and, if he was not let alone, he did 
 not want to stay. He was self-supporting except between jobs, 
 
3l8 THE KINGDOM OF EVILS 
 
 when he was dependent upon relatives. He was now in debt 
 to relatives and to the dentist. 
 
 Amongst the measures of treatment given the patient, it was 
 suggested that he attend the Men's Club. He became a most 
 regular attendant thereat. One important measure was the 
 explanation to his employers of his exact condition and reports 
 to them of his improvement as it grew. Social treatment in- 
 cluded such items as follows : — 
 
 Interview to discuss possibility of advancement at his depart- 
 ment store ; 
 
 To persuade patient of the necessity of more aggressiveness 
 on his part for the purpose of getting promoted ; 
 
 To increase his self-confidence and to widen his interests and 
 increase his acquaintance. 
 
 A letter would occasionally be sent to express the visitors' 
 regret at not seeing him at the Men's Club. 
 
 The situation was explained to the secretary of a voluntary 
 association in which he took out membership. 
 
 As a result Donahue did greatly improve although he re- 
 mained supersensitive and somewhat lacking in confidence and 
 aggressiveness. He became more interested in reading and cur- 
 rent events. His aggressiveness w^ore off. He felt he was now 
 doing a man's work and was filled with the idea of getting ahead 
 in the world. 
 
 This is an example of the handling of what may be termed a 
 cyclothymic constitution (mild manic-depressive psychosis). 
 The more we look the more examples of such mild or severe 
 cyclothymic constitutions are found in all corners of the world. 
 Precisely these patients make rather good workmen, indeed 
 sometimes extraordinarily good workmen if their psychopathic 
 sides are understood and proper adjustments made. Of course 
 neither the psychiatrist nor the social worker should attach too 
 much significance to improvement in cyclothymic cases, at least 
 from the point of view of claiming such improvement as the 
 result of treatment. 
 
 As demonstrated elsewhere in this book, there have been 
 numerous cases where such patients have improved over periods 
 of months and years under influences beyond our knowledge. 
 Still there can be no doubt that direct effects are obtained upon 
 
THE KINGDOM OF EVILS 319 
 
 the under and over activities of some of these cyclothymic 
 patients by counsel, encouragement, and direction of interests. 
 
 Hours spent by Medical record, i page 
 
 Social record, 19 pages 
 Physician, iy'2 Social work: 
 
 Visits, 6 
 Psychologist, o Interviews at hospital, 14 
 
 Telephone calls, 18 
 Social worker, 32 Letters, 19 
 
 Governess with attacks of excitement and depression, requir- 
 ing hospital care. 
 
 Case 83. Marie Dubois, forty, was a bookkeeper, very 
 competent and well educated, of French-Canadian origin. She 
 had a spell of depression at about thirty years of age, where- 
 upon she came across the line and worked variously as a gov- 
 erness and a bookkeeper, holding her positions for long periods 
 except during the year preceding her arrival at the hospital. 
 We surmise that her succession of jobs during her fortieth 
 year was due to the gradual appearance of the second depres- 
 sive phase. Yet there was a more striking occasion for the 
 eventual necessity of hospital care, — her mother died and two 
 days later her cousin. This cousin she had been living with as 
 his wife but without legal sanction, since her religion frowned 
 upon a cousin marriage. She then fell into a depression. She 
 was profoundly in love with this cousin. She wrote in her 
 diary of how he died of a Sunday and how every Sunday fol- 
 lowing she grew sad. 
 
 It was some six months after the paramour's death that she 
 got into a rather small difficulty which brought her to the 
 hospital. She appeared at a place where she had formerly 
 worked and was well liked and wanted to sell some tickets for 
 a charity. She was allowed to set up her booth. She set this 
 booth up rather inconveniently to the shop but claimed that 
 God told her just how to do so and that the Cardinal had 
 blessed her sales. She got very angry when requested to move 
 the booth. During her depression she had been rather religious. 
 She tells in her diary of having gone eighteen times to see, 
 understand, and enjoy Billy Sunday's pantomime remarking 
 
320 THE KINGDOM OF EVILS 
 
 that "it was a splendid derivatif from my recent sorrow" and 
 that she "admired his perfect subtlety and his complete under- 
 standing of the masses of people." 
 
 While in hospital she narrates in her diary how "in my soul 
 then I did see at first a beautiful grave of white marble, the 
 top stone covering herself slowly with a small quantity of 
 tulle (material for both dresses and veils) . It was a young lady 
 in the grave. I was helping the lover. It was growing and 
 growing in my very presence until it was a beauty. Then ap- 
 peared under this soft mass some wonderful stems of white 
 lilies. I have never seen anything so beautiful in a funeral 
 marble yet. This stayed with me all night, but in the meantime 
 something was going on to prepare a wonderful Caliban that 
 the committee has never heard of. (Too bad it is only in my 
 imagination.)" 
 
 The first attack, as noted, had been one of depression and 
 her mood after the death of her mother and her lover had 
 been chiefly a depressive one. The episode of the ticket-selling 
 was a sample, however, of excitement and the diagnosis ren- 
 dered at the hospital was that of manic-depressive psychosis- 
 manic phase. Miss Dubois was very restless and irritated at 
 the time she was examined. She could not concentrate her 
 attention. She grew restless and required packs and baths. 
 She would sing and play about the room dramatically. She 
 remained nude a part of the time but seemed not so much 
 erotic as to have lost for the time being her delicacy. (In point 
 of fact her diary records a considerable delicacy with respect 
 to her early handling by the nurses.) Now and again she 
 would seem to react to hallucinations of vision and hearing 
 and above has been given an example of the sort of visual hal- 
 lucination, if it be one, which she had. The imagery was more 
 of that fixed and solid sort which psychologists have recently 
 discussed, than of the fleeting, cinema-like sort which we are 
 accustomed to find in the psychoses. She assumed no fixed 
 attitudes at any time, took her nourishment willingly, and ap- 
 parently had a rather good insight into her abnormality of 
 mind. Physically she was almost normal, though her eyes were 
 a bit prominent. 
 
 Upon discharge she reported from time to time to the out- 
 patient department and the notes indicate that she remained 
 
THE KINGDOM OF EVILS 321 
 
 exhilarated for some six months further. After a year it 
 seemed to the out-patient medical staff that she need report no 
 longer as a patient. To be sure she was a little overemphatic in 
 her speech but perhaps not more so than a French-Canadian 
 woman should be. 
 
 Hours spent by Medical record, 22 pages 
 
 Social record, 15 pages 
 Physician, 9^ Social work : 
 
 Visits, 20 
 Psychologist, o Interviews at hospital, 2 
 
 Telephone calls, 8 
 Social worker, 35 Letters, 6 
 
 Hyponmnic hoy on probation: ran away. A "had actor" in 
 school. 
 
 Case 84. Joe Marino, fifteen years old when he was 
 first referred to the hospital from a juvenile court, is a kind of 
 adolescent delinquent that psychiatrists feel belongs pretty cer- 
 tainly in one of the more definite groups of mental diseases, 
 namely the so-called manic-depressive or cyclothymic group. 
 He yielded the impression of the so-called "hypomanic" man- 
 ner of mild overexcitement when he first came to the hospital 
 and his entire history seems consistent with his being funda- 
 mentally a cyclothymic. 
 
 He was a short, stocky Italian boy with rather an old-looking 
 face. He was very talkative and noisy, easy enough to control 
 but apt to get into mischief when not under immediate super- 
 vision. It seems that he had had an idea, perhaps an obsession, 
 about going to California. He was opposed in this idea at 
 home and became abusive and rather violent there. He boarded 
 a train and got as far as Providence, when he was picked up by 
 the police. He was brought back to the juvenile court where 
 he had twice before been and from which he was even at that 
 time on probation. Employers had always found him way- 
 ward and impertinent, and he had never stuck to a job longer 
 than five weeks, for the most part leaving a job after only a 
 few days. He had been arrested for breaking and entering, 
 had ripped off plastering in unoccupied houses, and was re- 
 
322 THE KINGDOM OF EVILS 
 
 garded as a "bad actor" in school, where he had shouted and 
 broken windows. 
 
 He was one of seven American-born children in an Italian 
 family that lived in cramped and rather squalid quarters. His 
 father got rather irregular employment but was somewhat in- 
 telligent and well disposed. The mother was an ignorant and 
 excitable woman suspicious of interference and unreliable. 
 The other six children were lively, jolly children and not espe- 
 cially troublesome. The family regarded Joe's visits to the hos- 
 pital as rather a joke. They regarded his activity and pug- 
 naciousness as due to his being "a kid and full of fun." Joe 
 was under hospital observation in all for about seven weeks at 
 two different times. His associations and his replies to ques- 
 tions were very rapid. He showed very well the symptom 
 called distractability. picking up all the features of his immedi- 
 ate environment and weaving them into the conversation. 
 Upon staff rounds, for example, he talked as if he were in a 
 courtroom, affixing comments to the bystanders, calling one a 
 lawyer, another a witness, another a stool pigeon, and the like. 
 He was at times so active that the treatment of prolonged 
 baths was executed ; and the hypomania so verged upon a true 
 mania that the committing physicians felt themselves entitled 
 to take the extreme step of actually committing him to hospital 
 by procedures of the probate court. 
 
 After his discharge from the hospital he remained "on visit" ; 
 that is, on the books subject to recall for a year. He got his 
 picture in the newspapers at one time by desiring to enlist in 
 the marines as a water boy who had had plenty of experience. 
 He said that as his name was Marino he ought easily to get 
 into the marines. (Of course the name Marino is fictitious 
 and the very characteristic maniacal pun which the boy made 
 was actually a good deal more complex than the form we offer.) 
 
 The case was closed by the social service some eight months 
 after his first appearance at the hospital although, as above 
 stated, his name was carried on the books of the hospital for a 
 year. At the expiration of the eight months it would seem that 
 the great wave of overexcitement which had been punctuated 
 by the various adventures mentioned was now, for the time 
 at least, well over. Perhaps Joe will appear again in another 
 phase of mania or possibly even of depression if our diagnosis 
 of cyclothymia is a correct one. No doubt previous experi- 
 
THE KINGDOM OF EVILS 323 
 
 ence with Joe will allow for rapid and accurate decisions con- 
 cerning him should he become once more a "bad actor." 
 
 Hours spent by Medical record. 14 pages 
 
 Social record, 17 pages 
 Physician, 8j^ Social work : 
 
 Visits, 13 
 Psychologist, Interviews at hospital, I 
 
 Telephone calls, 8 
 Social worker, 25 Letters, 5 
 
 Sailor who became overactive. Had been given to ''excited 
 actions." 
 
 Case 85. The following is Robert MacPherson's story as 
 recorded by the social worker, when she interviewed him on 
 the wards : — 
 
 "The patient is a nice-looking boy with a very pleasant 
 manner, which, however, seems to become rather suspicious at 
 times. He is twenty-three years old. He was born in Phila- 
 delphia. The family came to Boston when he was a baby. 
 When he was three years old, his mother was taken to a state 
 hospital, and he and his younger sister were placed in some 
 sort of institution at that time. His sister developed pneumonia 
 and died. Patient's father took him at that time, and patient 
 has lived with him since then until a year ago. Patient says 
 his father has never worked very steadily, that he is a drinking 
 man and so was his father before him. His father is now 
 about sixty years of age. He is not a man of much education 
 and patient thinks maybe he was jealous of him because he 
 got so far ahead of him. He thinks his mother was quite 
 educated. He does not know how old she is, as she will 
 never tell him. She is now in a state hospital where he goes 
 to see her. She seems all right but at times if she becomes 
 discontented or something happens to upset her, she is liable 
 to create quite a disturbance. 
 
 "Patient went to grammar school, then to a high school of 
 commerce where he graduated, and also graduated from an 
 evening high school. Then he went to a commercial college 
 for two or three years but he did not finish, as he did not 
 like the course. While he was still going to school he worked 
 with Weston Brothers as a clerk (his father works there as a 
 packer). He also worked at the Plymouth Publishing Com- 
 
324 THE KINGDOM OF EVILS 
 
 pany and ushered at the Lexington Theater. At clerking he 
 would make about three dollars a week a^d at ushering he 
 earned fifty cents a performance; however, he thinks the latter 
 is 'a poor way to earn money.' When patient started work 
 regularly, he started in at the National Sugar Company where 
 he earned nine dollars a week. Then he worked at the 
 American Electrical Company, earning fourteen dollars a week ; 
 later he worked for the Standard Insurance Company 'at 
 eighteen dollars a week. He was two years there and he says 
 he knows enough about insurance not to want to take it out. 
 
 "When war was declared he enlisted in the naval reserve; he 
 was never called and so secured his discharge August 21, 191 7> 
 but reenlisted in the United States coast guards. He was on a 
 revenue-cutter. About July, 19 18, he was sent to a naval hos- 
 pital where he stayed a month. He was circumcised there. 
 He was discharged in August, 1918. It was about this time 
 that his mental trouble began. He became more ambitious, 
 attempted things he had never done before and led 'sort of a 
 wild life.' He had saved up about seven hundred and fifty 
 dollars and he purchased a Big Six Buick. He says that is 
 enough to show he was 'out of his mind.' He would invite 
 everybody to ride and would 'kick them out' just as quickly. 
 He sold the magazine, The Puritan, and because he was in uni- 
 form he made quite a lot of money and he spent it just as 
 quickly. His father 'kicked him out.' After his discharge he 
 became a four-minute man and it was while he was speaking 
 in dififerent theaters that he was advised to go to the Fenway 
 School of Oratory. There he met a Mrs. Reed. They oflfered 
 to give him lessons and after a time Mrs. Green (who was 
 also connected with the school), Mrs. Reed, and Mr. Reed 
 (who was a tea salesman) all 'vamped' him, so that he went to 
 live with them. He says he will do anything that they tell him 
 to do. Patient later went to work with the United Importa- 
 tion Company. At first he was a checker. Later he started the 
 follow-up system and soon established a department of adver- 
 tising. When he started he was the only one in the department, 
 but now there are six and he is the head of the department. 
 His salary is only twenty dollars a week ; but he made more 
 on the side in business deals in connection with the firm. He 
 says he has made as much as ten thousand dollars at one time, 
 but he does not often make these sales. Patient wants to get 
 into the foreign department and wants to get down to South 
 America. He speaks some Spanish which he studied in high 
 school and has made arrangements to study Portuguese with 
 the son of a former ambassador. 
 
THE KINGDOM OF EVILS 325 
 
 "Patient says that he has recently become interested in pur- 
 chasing automobiles again, and he thinks that maybe it is 
 because he has been doing these things that they got him into 
 the hospital, but he intends to sue whoever was responsible for 
 having him 'shanghaied' here. Patient already has four motor 
 cycles, a motor boat, a sail boat, a deer skin, and a bear skin, 
 which he purchased through the company and which he intends 
 to have made into gloves and a coat. He doesn't know how 
 much he has in the bank. He has been looking up Buick 
 roadsters and on Saturday he repeated 'the same sort of stunt' 
 that he had done before, just after he was discharged from 
 the navy. 
 
 "At that time he took two girls out riding in his car, drove 
 them out a mile and then stopped his car in front of a garage 
 and made them all walk home. On Saturday he asked the 
 same girl to go out with him in the roadster, which he was 
 trying out; he drove her over to the garage, where he made 
 a deposit on the car; he left the car there and took her home 
 in a jitney, Saturday night Mrs. Reed asked him to lend her 
 four hundred dollars. He thought this was very queer as she 
 had never made such a request before. The more he thought 
 the matter over the queerer it seemed, so he took a suitcase and 
 decided to go back to his father to stay with him for a while. 
 He promised to let them know when he got to his father's, so 
 he telephoned them and they asked him to come out. He and 
 his father went. He says that while they were there, he noticed 
 that they kept a pretty close watch on him. A Dr. and Mrs. 
 Foster arrived, who were evidently friends of the Reeds. Dr. 
 Foster started talking to him and seemed to draw him out, but 
 he was perfectly willing, so he talked ahead. The doctor said 
 that he had a car to sell, and invited him to come riding with 
 him, so they went and he was brought here to the Psychopathic 
 Hospital. Patient says that 'the same stunt was pulled' on his 
 mother twenty years ago and it is no wonder that she is still 
 in a state hospital. He knows that there is something wrong 
 with her now, but his father has never told him what happened 
 twenty years ago. He would like to know about it as he thinks 
 there may have been 'some crooked work.' " 
 
 This somewhat highly colored story if taken with a grain of 
 salt gives a fairly accurate account of Robert's experiences 
 between the time of his discharge from the navy, in the sum- 
 mer of 1 91 8, and his stay in this hospital, in the fall of 19 19. 
 He was very talkative and active, getting into difficulty with the 
 other patients. He had no marked outbursts of excitement but 
 
326 THE KINGDOM OF EVILS 
 
 was continually restless. His hypomanic condition made in- 
 definite hospital care necessary and he was transferred to the 
 same state hospital where his mother was a patient. 
 
 Before enlistment Robert had worked in an insurance office 
 and lived with his father, who helped out with his expenses, 
 so that he had been able to save about seven hundred dollars. 
 He had shown average ability in school but had been more 
 interested in athletics than in studies. At one time he was 
 engaged to a girl who broke the engagement on account of 
 Robert's "excited actions." He did not show any great or 
 deep regret over the affair. He was always full of energy; in 
 the habit of having his own way and rather self -centered. He 
 was neat in his personal habits and did not show peculiarities of 
 conduct up to the time he left the navy. His attack of excite- 
 ment began about a month before his discharge. 
 
 Hours spent by Medical record, 14 pages 
 
 Social record, 5 pages 
 Physician, 3^ Social work: 
 
 Visits, o 
 Psychologist, o Interviews at hospital, 2 
 
 Telephone calls, 5 
 Social worker, 41/2 Letters, 5 
 
 Enlisted; gassed; discharged. Became restless, talkative, 
 moralistic. Voluntary patient. 
 
 Case 86. Clarence Adams was gassed fourteen months 
 after his enlistment and, after passing through several hospitals 
 in France, was discharged four months later in the neighbor- 
 hood of Boston. He took a few months' vacation and then 
 during the hot weather of early summer held a clerical position 
 in a large mill. One day he fainted on the job and gave it up. 
 He held several other positions for short periods but was over- 
 active and could not concentrate. His family then sent him to 
 the woods, by a doctor's advice, in company with a man com- 
 panion. After some weeks his companion felt that he was 
 not improving and brought him back to Boston. When he was 
 admitted to the Psychopathic Hospital he was restless and talk- 
 ative. He took pleasure in reading the Bible and instructing 
 the patients from it. 
 
THE KINGDOM OF EVILS 327 
 
 Adams was now twenty-six years old. He had had several 
 attacks previously, the first four years before, when he became 
 absorbed in the stock market and speculated recklessly. At this 
 time he became "moralistic," according to his brother, and made 
 efforts to bring together his parents who had been separated. 
 After he had been in this condition a year the family sent him 
 to a private hospital for mental diseases, where after five 
 months he recovered. Once or twice after this he resorted to 
 the same hospital for short periods. Adams had made a 
 rather brilliant record in school and after entering college he 
 had done well for a year. During the second year he became 
 "dissipated," contracting gonorrhea. He was in the second 
 month of the senior year when he went into the army ; and he 
 returned to college and got his degree. During his term of 
 army service he did very well, so far as can be learned. 
 
 From the Psychopathic Hospital (where he was a voluntary 
 patient) he went of his own accord to a near-by hospital, as a 
 further period of hospital care was advised. 
 
 Hours spent by Medical record. 14 pages 
 
 Social record, 6 pages 
 Physician, 3^ Social work: 
 
 Visits, o 
 Psychologist, o Interviews at hospital, I 
 
 Telephone calls, 3 
 Social worker, 334 Letters, 10 
 
SECTION X 
 
 PSYCHONEUROSES 
 
 Cigar-maker with psychonetirosis. Financial worries: dis- 
 like for his trade. Family adjustments. Different forms of 
 psychotherapy. Individualization. 
 
 Case 87. In one of the great Atlantic seaboard hospitals 
 (which shall be nameless) there used to be an out-patient de- 
 partment diagnosis Judaism, although the diagnosis Judaism 
 was probably a sly Caucasian hit at the frequenters of the clinic. 
 There is some basis for the idea of a preponderance of psycho- 
 neurotics amongst Jews. But, inasmuch as the Jews have the 
 excellent habit (from the mental hygiene point of view) of 
 very speedily resorting to physicians for their ills, the statistical 
 preponderance of Jews in many Atlantic seaboard clinics is 
 perhaps deceptive. There may be as many Caucasians of dif- 
 ferent varieties that fall victim to psychoneurosis as there are 
 Jews. It would be difficult to point out anything really differ- 
 ential in the psychology of the Jew. 
 
 Maurice Eastman was a Russian Jewish immigrant, forty 
 years of age. He came on his own initiative to the Psycho- 
 pathic Hospital complaining of indigestion, stomach trouble, 
 constipation, frequent urination for months at a time, year- 
 long headaches, and what he summed up as nervousness. In 
 point of fact various doctors told him he was a victim of 
 nervous instability, nervous prostration. He had evidently 
 been coached by physicians to know that "it was all foolish- 
 ness." He said he was always worrying, always afraid (that 
 the children would be killed, that there would be accidents while 
 he was asleep). He was unable to control his thoughts. 
 He had what would almost amount to a symptom in itself; 
 namely, an intense and analytic interest in his case. He slept 
 well, in fact he always felt sleepy and tired, but even more tired 
 on rising. He knew that he ought to "cheer up as there was 
 nothing the matter," but he could not. He had read an ac- 
 
 328 
 
THE KINGDOM OF EVILS 329 
 
 count of the Psychopathic Hospital work in the Sunday news- 
 paper. Later interviews showed that he was worried over his 
 physical condition, over family finances, over increase in the 
 number of children (there were now five ranging from twelve 
 to two years), over his domestic relations and over practice of 
 self -abuse which he thought had affected his health. 
 
 Here is a sufficiently characteristic picture of a psychoneu- 
 rotic with many features suggestive of the obsessive or psy- 
 chasthenic. We omit further medical details, insisting merely, 
 by the way, that the above picture, although characteristic, can 
 be found in a variety of other mental diseases than the psycho- 
 neurotic group. (Particular cases of that sort may actually 
 prove to be syphilitic and greatly improve by antisyphilitic 
 treatment. ) 
 
 Eastman was forthwith placed for some time under the care 
 of a student in psychology who had made a special study of the 
 methods of psychotherapeutic suggestion. (This sort of tech- 
 nique can still well be studied in Bernheim's excellent old work, 
 Suggestive Therapeutics, as well as in sundry newer works of 
 Bernheim that carry out the early ideas of Liebault. The 
 patient acknowledged great improvement by the suggestions 
 offered, in periods of one-half to three-quarter hours, and ap- 
 parently was genuinely much improved for a time. Besides the 
 "talking cure," he was made to read popular works on psycho- 
 therapy. The patient thought he was better because he had 
 learned to check his thoughts. He got to reading many books 
 on psychology and on suggestion. He practiced abstinence 
 from sex intercourse for eight months at one time so that the 
 family should not increase too rapidly. 
 
 However, he continued to have troublesome symptoms and 
 feared he would become insane. He had obsessions of several 
 sorts (when he saw a knife he wanted to stab somebody with 
 it; upon looking from a window he wanted to jump out). 
 While these psychotherapeutic efforts at persuasion were going 
 on, occasional hospital visits (at the same time patient was tak- 
 ing hydrotherapeutic treatments there), the domestic adjust- 
 ment had to be made. The mother was an unusually intelligent, 
 thrifty woman, adept at cooking and sewing. Eastman him- 
 self, although he had gone to work at the age of eleven in 
 Russia, had picked up a fairly good education, knew several 
 languages, and read some philosophy. He hated his cigar- 
 
7^0 THE KINGDOM OF EVILS 
 
 making trade although he earned good wages thereat. The 
 family income was just enough to meet current expenses, left 
 no margin for clothes, and allowed only tenement-house life on 
 a shabby street, overcrowded with very poor neighbors. It is 
 clear that several of these domestic, economic, and social fea- 
 tures cannot easily be met by psychotherapy, either of the sim- 
 ple "Cheer up" or "Forget it" kind or the more elaborate and 
 subtle practice by the student of psychology in Eastman's case. 
 There was a social (family) problem as well as the individual 
 one. Possibly it is the social problem both superadded to and 
 lying deeply underneath the individual problem that has caused 
 physicians to fail in the past to effect cures in many psycho- 
 neuroses, despite the fact that a very perfect individual psycho- 
 therapeutic technique was being thoroughly carried out. It is 
 an error of the psychiatrist and the psychologist to rest pro- 
 found faith in arm-chair methods of psychotherapy. It is 
 great merit of the medical social worker in general and the psy- 
 chiatric social worker in particular to have shown the faults 
 of this arm-chair method taken by itself. Meantime the social 
 worker must not fail to acknowledge the extraordinary results 
 of some therapy in camera, such as the amazing results of 
 hypnotism in selected cases and the equally amazing results by 
 psychoanalytic treatment of patients reporting from time to 
 time in the consulting room of the psychiatrist. Our tiresome 
 old formula. Circumstances alter cases, is the only true formula 
 to apply to the whole field of psychiatric social work. 
 
 If there is anything which this book stands for it is plainly 
 the individualization of the diagnosis and treatment of psychiat- 
 ric cases. The adherents to one or other method of psycho- 
 therapy (such as hypnotism, psychoanalysis) are rather apt to 
 overdraw their statistical values in any psychiatry. The social 
 worker has to steer her way very carefully betwixt these vari- 
 ous statistical prejudices of the enthusiastic adherent of some 
 method that is a perfect success in some cases. It is as requi- 
 site for the psychiatric social worker not to cry up the wares of 
 a particular kind of psychotherapeutist, as it is for the psychiat- 
 rist himself to bear in mind that there is more than one way 
 to "kill a cat." Of course, when one is in Rome, one must do 
 as the Romans do. In a large part of France during the war, 
 hypnotism was officially forbidden as a method of treatment for 
 those psychoneuroses familiarly termed "shell-shock." Never- 
 
THE KINGDOM OF EVILS 33 1 
 
 theless, elsewhere in France and in other belligerent countries, 
 hypnotism was being employed in some selected cases with 
 positive and even startling results. The modern formulations 
 of psychotherapy are not so many decades old that they will not 
 be greatly molded and revamped before the last word is said. 
 When all is said on the matter, however, the doctrine of the 
 treatment of the individual as such remains the common pos- 
 session of all forms of psychotherapy. 
 
 After all the psychiatric social worker does not by virtue of 
 contacts with psychopathy become a psychiatrist. The fact that 
 she may know more about individual details and technique of 
 family adjustment than the psychiatrist, does not cause her to 
 have sound ideas concerning the central psychopathic figure in 
 the family under adjustment. In the same sense the student in 
 psychology employed in the case of Maurice Eastman might 
 have been wasting his own and everybody's time by perfectly 
 correct technical endeavors in treating a man with many of 
 the same symptoms which Eastman possessed who should 
 happen to be not psychoneurotic at all. One of our Psycho- 
 pathic Hospital patients who had been regarded for five years 
 as psychoneurotic is described in Neurosyphilis; he was actually 
 syphilitic and the patient plaintively inquired why it had taken 
 so long to establish a diagnosis. Neither the social worker nor 
 the psychologist can be expected to avoid pitfalls such as that 
 case presented. On the other hand, it is just as certain that 
 the psychiatrist has neither training nor time to execute the 
 family adjustments undertaken by the psychiatric social 
 worker. Nor has a psychiatrist often the time and perhaps the 
 temperament to execute persuasive therapy in its best form. 
 Indeed, we are sometimes tempted to think that different types 
 of psychotherapeutist will eventually prove necessary for differ- 
 ent types of psychopathy, just as different sorts of automobiles 
 suit different temperaments. All of which is another example 
 of our constant insistence ; that is, that psychiatrists as psychiat- 
 rists are not social workers or psychologists, and that neither 
 of these other types of workers is likely by training or tem- 
 perament to be able to swap places with the other or make 
 more than snap diagnoses in the psychiatric field. 
 
 The medical measures adopted in Eastman's case (persua- 
 sive psychotherapy) ceased after a time, as all the internal ad- 
 justment that could be made in this way had apparently been 
 
332 THE KINGDOM OF EVILS 
 
 accomplished. The man was apt to be irritable and unreason- 
 able at home. He would complain of the children's noise which 
 prevented him from reading; he complained that his lot was 
 harder than that of other men in like circumstances, as he was 
 more intelligent (this was true) than the average man. He 
 had the advantage of having no bad habits to interfere with 
 his being a good steady workman. The treatment carried out 
 for a period of some six years now finds him much better 
 adjusted to his lot in life. No other form of work could be 
 found for Eastman that would bring him as high wages as 
 cigar-making. As the family was after all not destitute it 
 proved impossible to get supplementary relief by means of 
 loans, such as might have been put into effect for certain 
 indigent families. The wife and children were getting an 
 annual vacation through the settlement house and a vacation 
 was now arranged for Eastman himself. He had not had a 
 vacation in all of his adult life. He helped with the work of 
 the Men's Club, and from time to time pieces of work were 
 secured for the wife who was a clever needle woman to sup- 
 plement the family income. Eastman still hates his work. 
 
 Hours spent by Medical record, 2 pages 
 
 Social record, 35 pages 
 Physician, 4 Social work : 
 
 Visits, 20 
 Psychologist, 6 Interviews at hospital, 
 
 Telephone calls, 19 
 Social worker, 70 Letters, 18 
 
GIRL OF 15 YEARS 
 
 SOCIAL CONDITION 
 
 Hard Work 
 No Recreation 
 No Training 
 Insufficient Income 
 Feeble-minded and Inebriate 
 
 Father 
 Family Discord 
 
 19^5 
 
 SOCIAL CONDITION 
 
 Light Work 
 Recreation 
 Trade Training 
 Adequate Income 
 Home with Sister 
 
 Separation from Family 
 
 MENTAL CONDITION 
 
 Hysterical Convulsions 
 (2 in one month) 
 
 MENTAL CONDITION 
 
 Hysterical Convulsions 
 (3 in past year) 
 
Girl with hysterical convulsions. Father feeble-minded and 
 alcoholic. Psychoanalysis. Social investigation. Prolonged 
 social treatment. Cure or alleviation. 
 
 Case 88. Sadie Strauss was a seventeen-year-old Russian 
 Jewish girl, a case of hysteria whose cure or alleviation could 
 be variously claimed at different times by psychiatrists or social 
 workers. Perhaps neither the psychiatrist nor the social worker 
 should claim too much, since the hysterical trend may be 
 ingrained and persist for years. For some years, however, 
 there have been no clear or striking hysterical outbursts, and 
 only traces of that excessive fear reaction which some of her 
 human sisters often seem a little proud of — that is, fright at a 
 mouse. As it takes more than one swallow to make a summer, 
 so it takes more than one case to break the general medical 
 conception or prejudice: once a hysteric always a hysteric. In 
 passing we make remark that it would seem that the war experi- 
 ences with shell-shock will probably serve to break down this 
 old conception. 
 
 There is still another older conception of hysteria as an 
 ''aristocrat" amongst the functional diseases, that is as markedly 
 hereditary. Concerning heredity in Sadie Strauss, we can find 
 only that the father is perhaps somewhat feeble-minded; pos- 
 sibly his low mental level is really acquired, i.e., alcoholic. 
 Sadie herself was determined by the psychological examiner 
 to be normal. She was deft with her fingers, but did not prove 
 very resourceful in the tests for planning and analysis. She 
 was very "suggestible," but got easily discouraged and seemed 
 more than normally fatigable. Her measurement by the Binet 
 Scale was ii 4/5 and by the Point Scale 11 7/10. 
 
 Menstruation began at twelve. Sadie went to work as soon 
 as the fourteen-year law allowed and was working on piece 
 work in a mill earning from six to seven dollars a week for 
 fifty-four hours' work. After a painful menstruation she one 
 day collapsed, feeling a lump or stone in the stomach. She 
 was taken to the hospital, then home again and back to the 
 hospital, where there was a seizure of pain, screams, laughter, 
 
 335 
 
33^ THE KINGDOM OF EVILS 
 
 and unconsciousness. She was then brought to the Psycho- 
 pathic Hospital. It appeared that she had fainted two or three 
 times in the last few years. 
 
 The psychiatrists could find no abnormal sign upon physical 
 examination either on the motor or the sensory side. In an 
 attack she rolled from side to side on the couch, held an arm 
 or leg in the air, was sometimes stiff, sometimes quite relaxed, 
 but always apparently somewhat conscious, occasionally assum- 
 ing a silly expression, sometimes attitudinizing, sometimes 
 pointing as if hallucinated and quite mute. She did not bite 
 her tongue or void urine. This particular attack was slight 
 and took place during an interview for the purpose of psycho- 
 analysis. 
 
 Psychoanalytic conversations finally turned up news of an 
 early childhood episode. The child had been terribly frightened 
 by having to undress, one night when alone, her drunken father. 
 This episode may have developed sex-consciousness prematurely 
 or it may have provided "buried" memories that could operate 
 after the manner of the Freudian mechanisms. In conversa- 
 tion it developed that the girl dreamed of a dark man in a white 
 garment who chased her. The man's hands were her father's, 
 but his face was like the face of a man who was the first dead 
 person she had even seen. This psychoanalytic discovery 
 might have been supposed to work, as such discoveries some- 
 times work, by the so-called method of psychical "catharsis" 
 to effect an immediate cure. That is to say, if there was a 
 "buried memory" of this infantile sex experience, then (ac- 
 cording to the theory) talking it out will relieve the effects of 
 the repression. It is not entirely sure that the memory in 
 question was buried in Sadie's mind. At all events she had 
 some eight attacks of pronounced hysterical nature after the 
 supposed catharsis. 
 
 Perhaps it will not do to quarrel with the psychoanalyst con- 
 cerning his therapeutic results, and no doubt a large share of 
 the effect in Sadie Strauss' case is to be awarded to the psycho- 
 analyst. Nevertheless it is to be pointed out that a routine 
 social investigation would bring out very promptly informa- 
 tion concerning the Saturday night debauches of the father. 
 A good deal more was found out by such investigation than 
 the psychiatrist or psychologist could discover from the arm- 
 chair. The father was in point of fact brought to the clinic and 
 
THE KINGDOM OF EVILS 337 
 
 proved to be feeble-minded. Supervision of his life yielded 
 definite improvement in the family condition, although he 
 fell from grace and once got into the house of correction. 
 There were many more than merely the medical and tempera- 
 mental problems in the Strauss situation. Clothes were pro- 
 vided for Sadie, so that she could go to the trade school for a 
 year. The family needed Sadie's wages and could not clothe 
 her. They were too proud at first to accept such help but were 
 eventually persuaded. The patient then made her home with 
 her sister ; vacations and recreation were arranged for ; more 
 or less regular reporting to the out-patient department was 
 made a habit, and medical encouragement was there doled out 
 to her. 
 
 Two and one-half years after her initial appearance at the 
 hospital Sadie was married. She had matured visibly and was 
 now capable of much better self-control. Attacks had long 
 since stopped. Her husband was a man of a very good sort, 
 and the case could appropriately be closed. Her husband said 
 that he gave his wife pretty things and let her have her own 
 way in household matters. Outside of hospital time, some of 
 the social workers attended the wedding. 
 
 Hours spent by Medical record, i8 pages 
 
 Social record, 40 pages 
 Physician, 17^ Social work : 
 
 Visits, 44 
 Psychologist, i Interviews at hospital, 24 
 
 Telephone calls, 37 
 Social worker, 107 Letters, 11 
 
 Voluntary patient in state hospitals from time to time. 
 Cyclothymia: sex obsession. Industrial adaptation. 
 
 Case 89. Joseph Fangillo, forty, has been three times a 
 voluntary patient at the Psychopathic Hospital and has also 
 spent some time at the hospital's suggestion at one of the state 
 hospitals also as a voluntary patient. His history shows that 
 he had also, at the age of thirty-four, been a patient at one of 
 the state hospitals. 
 
 He has received a number of diagnoses but he is probably 
 best classified as a psychasthenic. He had recently gone into 
 
338 THE KINGDOM OF EVILS 
 
 the liquor business and rightly or wrongly felt that his affairs 
 had been going downhill ever since. Besides there had been 
 the Billy Sunday campaign and there was the national pro- 
 hibition movement. In addition to ideas touching money, he 
 had some obsessions about sex. He thought that he had an 
 uncontrollable sexual desire and interest and felt that he would 
 be tremendously excited if he saw the pictures of women or if 
 he came at all in contact with them. He complained, too, of his 
 eyes although there was no objective evidence of eye disorder. 
 
 If we regard the diagnosis of psychasthenia as correct then 
 it is plain that the medical and social contacts with Joseph 
 Fangillo will mean much. His five different hospital experi- 
 ences have all been as a voluntary patient. In fact, the last 
 four hospital stays have been part and parcel of a single psy- 
 chasthenic phase out of which he appears now to have passed, 
 aided by the direct influence of counsel and family adjustment 
 between himself and his wife effected by the social service. 
 The wife is intelligent and devoted but needed a great deal of 
 encouragement since she was living upon the family savings. 
 
 If our present diagnosis is incorrect and he is actually in 
 some sense a cyclothymic patient, then so far as we are now 
 aware the thing which will bring him out of a given phase is 
 rather the curative power of nature than any medical or social 
 efforts of any description. However, it is clear that if Fan- 
 gillo is a cyclothymic and the course of his disease is, as the 
 phrase is "self-limited," nevertheless the social service contact 
 with the wife and the counsel to her with respect to her adjust- 
 ment to her husband's psychopathy would mean a great deal. 
 
 This case has not been intensively handled by physicians 
 at any time upon any specific line of psychotherapy such as 
 psychoanalysis. The sexual obsessions above mentioned may 
 date from a specific occurrence which conversation might at 
 last unfold. The psychoanalyst and, for that matter, all kinds 
 of therapeutists, would hope from all cases of psychoneurosis 
 for a fundamental cure by the process of so-called reeducation 
 or rationalization. Without entering the debatable confines of 
 the psychoanalytic question, it is plain that where the diagnosis 
 is so in doubt as in this instance, proceeding to elaborate 
 reeducation upon sex lines or upon other lines of character 
 development would be very time-consuming from the stand- 
 point of the patient himself. If the patient is a cyclothymic, 
 
THE KINGDOM OF EVILS 339 
 
 then he is likely to emerge with absolute normality after a time 
 in any event. If he is a psychasthenic, at all events he has the 
 record of having emerged with perfect normality from the 
 previous attack and his psychasthenia may itself be of periodic 
 or cyclic nature. (It is well for the lay as well as the medical 
 observer to bear constantly in mind that cyclothymia is not the 
 only mental disease which is cyclic.) Accordingly, for better 
 or worse, no special psychotherapy has been undertaken other 
 than that involved in the routine social service contacts by com- 
 petent and intelligent social workers, familiar with psychopaths 
 of various sorts. 
 
 Fifteen months after we first knew him Fangillo was able 
 to take a position in the stock room of a large firm with which 
 he is offered a good prospect of advancement. He made the 
 choice of this position rather than a better paying position of- 
 fered by a former employer because he felt that the larger firm 
 promised a more stable future. Now, a year later, he is still 
 working for this firm and beginning to realize his expectations. 
 
 As a detail of social service technique, it may be remarked 
 that Fangillo was gotten a temporary job with a certain firm 
 through the efforts of a worker who was doing special work 
 on the industrial problem of the psychopathic employee. The 
 employer said that he liked to get workers from social agencies 
 because a good deal more was known about such workers than 
 about the ordinary run of applicants for employment. 
 
 (See also Appendix A for the social record of this case.) 
 
 Hours spent by ]\Iedical record, 26 pages 
 
 Social record, 21 pages 
 Physician, 7J/2 Social work : 
 
 Visits, II 
 Psychologist, i Interviews at hospital, 13 
 
 Telephone calls, 13 
 Social worker, 23J/2 Letters, 6 
 
 Industrial accident. Traumatic hysteria. Compensation 
 qiiestions. 
 
 Case 90. Dennis O'Donnell was sent to the hospital by 
 the Industrial Accident Board. He had gotten a number of 
 fractures, especially of the arms. X-ray examination failed 
 to show that he had any fracture of the skull. After his fall 
 
340 THE KINGDOM OF EVILS 
 
 he was treated for a time in the company hospital, went home 
 at his own request, and in the space of three months began to 
 do some work again, though he was not very successful at any 
 kind of job. He left for a distant state but did not work 
 there for some eighteen months. His left hand was weak. 
 Heat and noise disturbed him greatly in various factories 
 where he tried to work. The family had accumulated many 
 debts and he was much worried about these. His memory had 
 been very poor since the accident. He was a very quiet and 
 contemplative sort of man. He said that his hand felt weak 
 and this was verified by test, but besides this it was found that 
 he had a complete anesthesia of the left side of the body with 
 deafness in the left ear and even some visual disturbance in the 
 left eye. Yet at the same time the reflexes were not different 
 upon the anesthetic side from their condition on the right side 
 of the body. The arm muscles were not atrophic. On the 
 whole there seemed to be no evidence of any organic lesion to 
 account for the weakness or the anesthesia. 
 
 The diagnosis was one of tramnatic hysteria which, to quote 
 from the hospital report, is "a very real disease and so far as 
 we can see would justify compensation." 
 
 O'Donnell had been paid after his accident nine dollars a 
 week for four months and later for six months at the rate of 
 ten dollars a week. This compensation was discontinued by 
 the Accident Board which felt that the man's condition was 
 due more to alcohol and syphiHs than to the accident. After 
 seven months' delay O'Donnell was admitted to the Psycho- 
 pathic Hospital upon the representation of liis lawyer. The 
 lawyer was unaware tliat the patient was working all this time. 
 Four months later O'Donnell was offered a sum of five hundred 
 dollars as a lump settlement to cover unemployment. This sum 
 O'Donnell is not willing to take but says he has not the funds 
 to contest the case. In war times he earned about thirty-four 
 dollars a week but after being a patient at the Psychopathic 
 Hospital he could not get this thirty- four-dollar-a-week job and 
 is now working at fifteen and eighteen dollars a week in a 
 factory. 
 
 Perhaps this case will serve as well as any to indicate the 
 very doubtful question of social-service technique that arises 
 in industrial accidents. Probably the question of syphilis 
 raised by the board is to be answered in the negative; at all 
 
THE KINGDOM OF EVILS 34I 
 
 events there seems to be no evidence of syphilis of the nervous 
 system as a cause for the symptoms shown. Nor had there been 
 any history of alcohoHsm for a period of some fifteen years, 
 ahhough before that time O'Donnell had been alcohohc. It 
 would seem wise for O'Donnell to report from time to time 
 to the out-patient department. There is always a question 
 whether the advantage of counsel afforded by the hospital is 
 countervailed by the loss of self-reliance which some men might 
 feel through having to resort to a hospital. 
 
 Hours spent by Medical record, 21 pages 
 
 Social record, 15 pages 
 Physician, 5 Social work: 
 
 Visits, I 
 Psychologist, I Interviews at hospital, 7 
 
 Telephone calls, 15 
 Social worker, g^ Letters, 18 
 
 Machinist in aviation suffers from traumatic hysteria after 
 blow on the head. 
 
 Case 91. Walter Nelson enlisted at twenty in the naval 
 reserve, during the spring of 191 7, and in the fall was as- 
 signed as a first-class machinist in aviation. While he was 
 vvorking on a plane in a tent hangar during a windstorm, the 
 tent blew down and he was hit by a pole across the back and 
 head. He was unconscious for half an hour and in the hos- 
 pital three days with weakness and backache. There were no 
 other symptoms at that time. Two weeks later he was among 
 volunteers accepted for foreign service, but the party was not 
 sent at the expected time and Nelson was very much disap- 
 pointed. After this he became shaky and excited and was sent 
 back to hospital. He went home for a Christmas furlough 
 and was not well enough to return to duty at the end of his 
 time. He seemed to his family to be "far-off, hazy, in a 
 trance" and "had to be cared for like a child." He worried 
 for fear people would call him "a slacker." 
 
 After a month in the naval hospital, he went back to duty 
 but was still somewhat dazed and confused. He wrote his 
 family that he was afraid of being court-martialed for having 
 done some of his work wrong and asked them to send him 
 poison to take. In the spring he was discharged for physical 
 disability. On his return home he was advised to come to our 
 
342 THE KINGDOM OF EVILS 
 
 out-patient department. He said that he felt "dopey" and 
 changed since the accident, that he had very Httle interest in 
 anything. Reluctantly he told of having a fear after the acci- 
 dent that he had been cursed by a young woman with whom he 
 had had sex relations for a short time, (he had a friend who 
 had been cursed by a young woman), and said he dwelt on 
 this thought constantly. His condition was diagnosed as 
 traumatic hysteria. 
 
 In a month he had improved slightly and in another month 
 was much better. In six months under the influence of treat- 
 ment, including massage, hydrotherapy, suggestion, tonic, and 
 light work, he was much more cheerful and animated and able 
 to work three-quarters time. He had given up the obsessive 
 idea of the young woman's curse and was showing steady 
 improvement. 
 
 Hours spent by Medical record, 5 pages 
 
 Social record, i page 
 Physician, 4^4 Social work : 
 
 Visits, o 
 Psychologist, o Interviews at hospital, 3 
 
 Telephone calls, 
 Social worker, 1J/2 Letters, 
 
 Feeble-minded soldier discharged for hysteria. Marfied a 
 prostitute to refonii her. 
 
 Case 92. Martin O'Hara was sent to the hospital by the 
 court charged with indecent assault upon a six-year-old boy 
 in the hotel where he was working as janitor. He denied the 
 charge, the child admitted previous knowledge of perverted sex 
 practices, and it was never determined whether O'Hara was 
 guilty. 
 
 He was twenty-nine years old and his mental rating by the 
 Point Scale was 11.8. At the age of twelve he had run away 
 to sea and spent a few weeks on a fishing boat. His father 
 would not let him go again to sea so he started to work and 
 held countless odd jobs in theaters, amusement parks, and 
 circuses. He never liked to loaf and when work was not to 
 be found he would go up to the Maine woods. After war was 
 declared he tried to enlist and was rejected because of bad teeth. 
 A year later he was drafted and became sick in camp during 
 the trial gas attacks. He was sent home for a rest and soon 
 
THE KINGDOM OF EVILS 343 
 
 after discharged from the service with the diagnosis hysteria. 
 He was suffering then with gastric pain and vomiting and a 
 sHght tremor of the head. These symptoms disappeared after 
 a while. 
 
 He went to work and in a few weeks married a girl whom 
 he had known for several years. He said that he had known 
 she was sexually promiscuous, but that he had always treated 
 her with the greatest respect and loved her devotedly. They 
 were married in a pool-room where he worked, by a justice 
 of the peace. That same night he returned to work and con- 
 tinued to work until midnight so that he might get double 
 pay. The girl went to stay with her parents that night. The 
 following day he discovered she had a six-months-old baby, 
 and after inquiry he was forced to the conclusion that the 
 father of the child was actually unknown. He forgave the 
 girl for the deception and wished to live with her, "to reform 
 her," but she left him and continued to live as a prostitute. 
 Both she and the baby were syphilitic. He had never lived 
 with his wife since the marriage. 
 
 Under the excitement of these events the tremor had re- 
 turned. When he left the hospital after nine days he still had 
 it, although at times it disappeared entirely, especially when 
 he was interested and intent upon what he was doing. Later 
 when he came to the out-patient department he would some- 
 times tremble violently but at other times would appear quite 
 composed. He went to live with his parents and made up 
 his mind to secure a divorce from his wife. After some months 
 he felt able to work and got a job. 
 
 He is beginning to feel strong and cheerful again and the 
 tremor is less marked and comes less frequently. He says that 
 although he knew a good deal about his wife, before he married 
 her, he did not know "half of it" and he is no longer in love 
 with her. He has worried a good deal over being dependent 
 upon his parents, who have no surplus income, but now he 
 feels fit to maintain himself. 
 
 Hours spent by Medical record, 25 pages 
 
 Social record, 12 pages 
 Physician, 4^ Social work: 
 
 Visits, 2 
 Psychologist, i Interviews at hospital, 3 
 
 Telephone calls, 23 
 Social worker, 51^ Letters, 
 
344 THE KINGDOM OF EVILS 
 
 Drafted soldier discharged for physical incapacity. Psy- 
 chasthenia. Improvement. 
 
 Case 93. Joseph Levenson was drafted in the fall of 191 7 
 (twenty-five years old) and discharged in three months for 
 physical incapacity. When he came to the out-patient depart- 
 ment six months later he was complaining of insomnia, lack 
 of appetite, and pains in his head and back. He claimed that 
 discipline and the rigorous winter had caused him a physical 
 collapse. 
 
 On the theory of a possible developing of acromegalia, an 
 X-ray picture of his head was taken; but it showed nothing 
 abnormal. The diagnosis was psychasthenia. In four months 
 he had made definite improvement and was planning part time 
 work. 
 
 At first a marked increase of symptoms occurred when he 
 was told that he ought to get to work. He was living with a 
 devoted family in a good home. He undertook a course in 
 salesmanship, and at first he was unable to sit through the 
 classes on account of his pains. He would stand it as long 
 as he could (for about two hours) and then stretch out on a 
 table or chairs until he felt able to go on again. After a time 
 he could sit through the seven hours of the school day by 
 relaxing for a few minutes now and then. At this time, even 
 after three months of treatment, he could not walk much. He 
 said once he thought he could never "bear it and live" but now 
 he knew he "had it in him" and could "look forward happily 
 to the future." Later on he had a plan for starting a provision 
 store of his own if the Red Cross would make him a loan; but 
 this was decided to be an insecure investment. Levenson then 
 got a position as salesman in a meat market. He works full 
 time and is improving, though he still suffers from pain and 
 weakness. 
 
 Hours spent by Medical record, 5 pages 
 
 Social record, 5 pages 
 Physician, 4 Social work : 
 
 Visits, 3 
 Psychologist, o Interviews at hospital, 3 
 
 Telephone calls, 12 
 Social worker, 3J/2 Letters, o 
 
PSYCHOPATHIC PERSONALITY 
 
 IN A WOMAN TYPESETTER, 28 
 
 1915 
 Inebriety 
 
 Insufficient Income 
 Non-support of Mother 
 Family Discord 
 Friendlessness 
 Lying 
 Fabrication 
 Suicidal Attempt 
 
 ic)i6 
 No Alcohol 
 Adequate Wages 
 Contributions to Mother 
 Away from Home 
 Companionship 
 No Lying 
 Slight Fabrication 
 Cheerfulness 
 
SECTION XI 
 
 PSYCHOPATHOSES (DUBIOUS AND SPECIAL PSYCHOPAtHlAS) 
 
 Psychopathic personality. Typesetter, sickly, unhappy, un^ 
 popular, discouraged, attempted suicide. Trained to be self- 
 sustaining. Psychiatric social work. Many workers on the 
 case. 
 
 Case 94. There is much discussion as to the meaning of 
 the term "psychopathic personaHty." Whereas in one sense 
 every victim of mental disease shows effects in his personality, 
 the effects by the same token require psychiatric social atten- 
 tion even if the victim have brain tumor. The term has come 
 to be used for many forms of usually rather slighter mental dis- 
 eases than those which receive more definite designations as 
 belonging to well-defined disease entities. Possibly the term 
 being briefer and smoother is theoretically better than the term 
 "constitutional psychopathic inferiority." But the latter term 
 has been worked into sundry official documents, and it is to 
 be feared we shall have it with us for some decades and until 
 a greater definition of the whole topic of psychopathic per- 
 sonalities shall occur. According to one group of thinkers 
 every psychopath, and especially every victim of psychopathic 
 personality, is practically sui generis; that is to say, has a most 
 highly individualized and specialized make-up of soil and taint. 
 Nor does it do any harm to insist upon this ultra-individualism 
 in diagnosis and treatment, as it practically comes up in the 
 clinic. According to other authors there threaten to break out in 
 the group of the psychopathic personalities sundry subgroups. 
 One of these formulations was made a special study of by the 
 former Chief of Staff, Dr. H. M. Adler, at the Psychopathic 
 Hospital. It is mentioned in greater detail in the summary. 
 Perhaps as valuable a statement as any general statement can 
 now be concerning these personalities runs to the effect that 
 the victims are to some extent infantilistic. Some of the per- 
 
 347 
 
348 THE KINGDOM OF EVILS 
 
 sonalities are a little infantile along the line of their emotions. 
 These are likely to belong to a group with hysterical trend. 
 Others show more or less childlike obstinacy and episodic over- 
 reactions to ordinary stimuli, recalling effects in certain chil- 
 dren. Some cases seem to represent enormous exaggerations 
 of particular instincts and are given to wandering, to special 
 types of sex activity and the like. Possibly some alcoholics 
 may be regarded as weak of will in the direction of psycho- 
 pathic personality, so that alcoholic mental diseases cannot 
 be set down as directly and proportionately due to their 
 alcoholism. 
 
 Harriet Farmer was not at all feeble-minded ; in fact tests 
 at intervals of two years showed that she was making a proper 
 improvement to test. Let us take occasion to insist, however, 
 that not seldom the selfsame psychopathic traits do occur in 
 morons or other subnormal persons. We did not have to face 
 in the Farmer case the lack of judgment characteristic of a 
 moron. 
 
 Harriet was certainly an average scholar and indeed read 
 much good classical literature. Twenty-eight upon her first 
 contact with the hospital, she had been for two years very alco- 
 holic, not infrequently drinking alone. She had also been un- 
 truthful and unreliable; she told scandals about a priest; told 
 of mistreatment by her family; and made up stories about the 
 attentions of men to her. Harriet was rather talkative and 
 aggressive with people with whom she came in contact. Church 
 club members did not want to see her at the club. At home 
 she was lazy, slovenly, and thoughtless. She lay in bed late and 
 expected her mother and sister to sew and wash for her. 
 
 It was discovered that her father died of general paresis ; 
 her mother was also treated for many years for syphilis which 
 she had contracted from Flarriet's father. The girl herself was 
 short, slight, pale — the so-called wiry type, rather unattractive, 
 possibly anemic, and with bad teeth. She came to the hospital 
 after an attempt at suicide, which attempt was made a day 
 when nothing at all unusual had been noticed in her behavior. 
 She had been at times depressed at menstrual periods, but there 
 had at this time been no depression. She had lunched with 
 her mother, who a few hours later was notified that paris green 
 had been taken by Harriet. Harriet said she had originally 
 bought the paris green for plant insects. She had taken it 
 
THE KINGDOM OF EVILS 349 
 
 feeling discouraged with her Hfe and with the poor physical 
 condition of her mother. 
 
 The psychiatrists found her practically negative in every 
 respect. Even anemia was found to be not present. Psychiat- 
 rically nothing abnormal could be found beyond the provisional 
 diagnosis "manic depressive" suggested by some observations. 
 She clearly was not committable. As for a motive for suicide, 
 a somewhat curious history transpired. She had put her name 
 and address in a candy box and had gotten up a correspond- 
 ence — "object matrimony" — with a man who turned out to 
 be sixty-five years of age and otherwise ineligible. This episode 
 appears to have helped her to think that there was nothing left 
 for her in life. There had, of course, been considerable 
 pecuniary trouble in the family. The two brothers had mar- 
 ried and were no longer able to help the family. The parents 
 had been separated when Harriet was eight years of age. 
 
 After a month's observation the determined diagnosis was 
 "not insane, not feeble-minded — psychopathic personality." 
 Harriet has now for some years been under pretty continuous 
 observation by the social service. After a period of some two 
 and one-half years she was so compensated or adapted to life 
 as to require little aid. During this period of two and one- 
 half years a rather intensive type of social work, supported by 
 medical consultations, was carried out. The psychiatrist's 
 general recommendation was that a good deal more variety in 
 life was necessary. It was the task of the social worker to 
 secure such variety and to make changes in her living and 
 working arrangements before she should get stale. It was ar- 
 ranged that she should live away from home, and in the house 
 where she lived she now began to make girl friends after a 
 fashion which had been quite unknown to her before. The 
 other girls liked her. Exercise, diet, and bathing became sys- 
 tematic. Menstrual difficulties were discussed with women 
 physicians at the hospital. She stopped drinking and ceased 
 to mention suicide. She no longer told out-and-out lies and 
 the tendency was represented for the most part by exaggera- 
 tions or slight perversions of the facts. 
 
 From time to time she became discouraged and made vari- 
 ous complaints, apparently fearing she was "to be put away." 
 But these spells of bitterness were transient and left her with, 
 her usual friendliness. She began to have a number of dif- 
 
350 THE KINGDOM OF EVILS 
 
 ferent suitors and went walking with them and took meals at 
 hotels and dairy lunches with them. Harriet very gladly ap- 
 peared at the clinic for social workers and told her story in an 
 approximately correct and engaging fashion. The experienced 
 social worker is apt to say, "Why this sort of thing is just what 
 every social worker has to deal with !" We are far from deny- 
 ing that such is the case. We hold that statistics of medical 
 social workers will probably show that practically one case in 
 two of all intensively studied medical social cases will turn out 
 to be in some important way psychiatric. If such commentary 
 means to argue that psychiatric social work is unnecessary as a 
 specialty, just because psychiatric social cases are so frequent 
 that every social worker has met them, then we should be com- 
 pelled to decline to follow the argument. One of two conclu- 
 sions, and we hold that both conclusions, can be drawn from 
 this state of afifairs, namely : First, that instruction in social 
 psychiatry should be given to every medical social worker; 
 second, that there should be specialized training to develop 
 specialized psychiatric social workers. 
 
 It seems to us that the amount of personality study required 
 for the diagnosis of Harriet Farmer and the amount of per- 
 sonal adjustment required would mean that there must be in 
 the world a gro.up of specializing psychiatric social workers. 
 Many medical social workers are by temperament unfit for 
 psychiatric social work, or at all events not as well fitted as 
 are others. It is also, we believe, going to be held that all social 
 workers whether medical or non-medical ought to be given 
 psychiatric training of some sort. It would be hard to show 
 convincingly the extraordinary change in Harriet Farmer from 
 the unsociable, pallid, unattractive girl, with rather a bitter out- 
 look on life, to the competent, self-supporting, physically much 
 improved, rather pleasing cooperative girl with a normal set 
 of outlets along all of the main social lines. 
 
 Too much and too little can be made of the so-called per- 
 sonal relation between some one individual therapeutist and 
 the patient. The slogan "individualization" is often taken to 
 mean that there should be in the ideal a one-to-one correspond- 
 ence between the social agent and the social patient. It is true 
 that many effects, especially in the field of alcoholism, are 
 gained in this manner. But individualized treatment is not 
 necessarily, or as a rule even possibly, the treatment of one in- 
 
THE KINGDOM OF EVILS 35 1 
 
 dividual by one individual. We do not need to paraphrase Lin- 
 coln by saying social treatment is treatment of an individual, 
 by an individual, and for an individual. Treatment is as often, 
 and perhaps always should be, the treatment of all the indi- 
 viduals in a given family — each individual taken as such. The 
 individualization of treatment does not refer to carrying all 
 of the measures up to one head. There is a certain democracy 
 in social treatment, the advantages of which have not been 
 sufficiently preached. In the case of Harriet Farmer, for in- 
 stance, although two social workers not trained in psychiatry 
 had failed to make proper contacts with her personality, yet 
 after the Psychopathic Hospital contact was made the social 
 treatment of Harriet was carried out by not less than six social 
 •workers of various temperaments, who nevertheless all suc- 
 ceeded in aiding the development of Harriet's character with 
 its consequent stoppage of drinking and bitterness. There 
 were also four physicians more or less intimately concerned 
 with the case. 
 
 Of course what Harriet did was in some sense to personify 
 the entire Psychopathic Hospital and to consider herself under 
 its auspices. This relation is by no means uncommon, nay, 
 perhaps, is the usual one. The hospital with its medical and 
 social officers becomes a sort of religion with the patient. No 
 hospital run under what we are sometimes tempted to term 
 "regular-army" regulations can become a religion with such 
 patients. H the social workers were suddenly removed from 
 the institutions, the chances are that a patient of this type 
 would not return to the hospital more than once. 
 
 There is a certain uniqueness about this psychopathic hos- 
 pital relation with its patients which stands out in sharp relief 
 against the "borrow-no-trouble" attitude of the old-style in- 
 stitutions for the committable insane. 
 
 (See also Appendix A for the social record of this case.) 
 
 Hours spent by Medical record, 41 pages 
 
 Social record, 55 pages 
 Physician, 5^ Social work : 
 
 Visits, 76 
 Psychologist, 2 Interviews at hospital, 16 
 
 Telephone calls, 50 
 Social worker, 150 Letters, 14 
 
35^ THE KINGDOM OF EVILS 
 
 Son of an educated Belgian family. Wanderer and irregular 
 worker. 
 
 Case 95. Louis Sand, the son of a Belgian professional 
 man, was twenty-eight "^years of age, an immigrant, upon a 
 rather irregular allowance from his father. He had spent time 
 in twelve different states during five years, working here and 
 there for a few weeks or months at factory or farm work. In 
 fact he had made eighteen changes from one place to another 
 and had borrowed small sums of money here and there. He 
 spent much of his time looking for work and reading. He 
 had the ambition to take courses in engineering and had had 
 some college work in Belgium. There was no language diffi- 
 culty since he spoke and wrote English fluently. It was thought 
 he was a victim of Meniere's disease — one ear was growing 
 deaf and he was dizzy. 
 
 Sand never became a house case at the Psychopathic Hos- 
 pital but was immediately left to the social service after his 
 coming on his own initiative to the out-patient department. 
 Some loans were made to him which he came back from time 
 to time to pay. Nine months after the first observation he was 
 found a position with an engineering firm which he held for 
 some four months and was taking a correspondence course 
 in the general topic. The case was accordingly closed. How- 
 ever, Sand began to feel restless, wrote appealing letters to 
 the social service telling about lack of will power — his desire 
 to get back to Belgium. The case was accordingly reopened 
 by the social service and work was secured for him in new 
 places. He gave the visitor a sum of money which was put 
 in the bank for him, a nasal operation was performed, and 
 new lenses for his glasses were gotten for him. He then left 
 for a distant state. 
 
 Sand, although he desired to return to Belgium, was ashamed 
 to go until he had made good in America. He had no friends 
 or associates with persons of his own educational level. He 
 talked a good deal of his interest in books and in music, but 
 these interests proved to be superficial. He had not rationalized 
 his relations with women, affecting refinement and chivalry on 
 the one hand, on the other hand resorting to masturbation. 
 He had a shell of ambition with apparently little power behind 
 it. Perhaps he is to be classed as a sort of constitutional in- 
 
THE KINGDOM OF EVILS 353 
 
 ferior, inasmuch as the disorder or defect is particularly one 
 of will. If we were asked for a single phrase for him, it would 
 be hypobulic. Hypobulics no doubt require the social worker 
 and the physician to act more as mental splints than in any 
 other definable way. 
 
 Our Belgian correspondence concerning Sand shows that he 
 had been as unsuccessful there and weak of will as he was here. 
 What is to be the outcome of his Meniere's disease, if that be 
 the correct diagnosis? No one can say, but Sand is going 
 to keep in touch with the Life Extension Institute, whose 
 examiners will no doubt trace the further effects if any of the 
 aural condition. 
 
 Hours spent by Medical record, 13 pages 
 
 Social record, 25 pages 
 Physician, s% Social work : 
 
 Visits, II 
 Psychologist, o Interviews at hospital, 27 
 
 Telephone calls, 30 
 Social worker, 43^ Letters, 30 
 
 Child of a thief and a prostitute; brought up by charity. 
 Psychopathia sexualis. 
 
 Case 96. An interest was taken in Theresa Beauvais by a 
 lady who had lived in the town where Theresa was born. 
 Theresa's father was a professional thief and her mother had 
 been a prostitute. Theresa herself had already entered upon 
 this life and was in the poor house when her townswoman 
 found her. When Theresa at fourteen had learned the dangers 
 of pregnancy, she had stopped promiscuous intercourse and 
 begun mxasturbation. Theresa never tried to conceal her life 
 or habits and a psychoanalyst who saw her said that as there 
 was nothing repressed, psychoanalysis was superficial. Be- 
 sides, she was rather unintelligent or at all events looked so. 
 (She later tested at I5>4 years by Stanford-Binet and by Point 
 Scale as 17.5, accordingly probably not at all feeble-minded.) 
 Although unintelligent-looking she made a very good general 
 impression and was well liked. She had studied in an academy 
 for some years but had not finished her work. 
 
 She was observed at the Psychopathic Hospital and finally 
 
354 THE KINGDOM OF EVILS 
 
 regarded as a case of psychopathic personaHty, though a ques- 
 tion of psychoneurosis and a question of dementia praecox 
 had also been raised. She was found to be abnormally senti- 
 mental and somewhat dramatic in her attitude toward her 
 delinquency. She seemed rather to enjoy making an impres- 
 sion upon the maids and nurses with details of how bad she 
 had been and the things she had undergone. She was, how- 
 ever, on the whole, fairly truthful. She said that she could 
 not control herself with respect to sex relations. (There was 
 a history of absolute promiscuity for a period of some three 
 months before admission to the hospital.) Amongst the psycho- 
 pathic personalities there are, no doubt, a number of cases of 
 psychopathia sexualis and amongst these a form called satyriasis 
 to which Theresa may belong, but of course that designation 
 does not afford much information as to prognosis or treatment. 
 
 She had, ten months before admission, started learning to 
 be a nurse and after her discharge from the hospital she was 
 placed as a ward maid in a hospital where she stayed three 
 months. She there had sex relations with an employee who 
 talked of marrying her but had trachoma and was in general 
 unreliable. The marriage was accordingly discouraged. She 
 then got work in mills for short periods, refusing to room in 
 a girls' boarding house, disappeared from view for a fort- 
 night, and then telephoned that she had become a maid in a 
 questionable lodging house. Then she was brought by the 
 police to the hospital again. This was six and a half months 
 after her discharge from the hospital. It transpired that she 
 had been living with a sailor who had forsaken her. She had 
 shown odd conduct, going out two days in succession with her 
 hair down, moccasins on her feet, and a coat over her shoulder, 
 returning exhausted and (by her own story) confused. There 
 was also a spell of screaming and she was picked up by the 
 police sitting on a doorstep. The diagnosis of psychopathic 
 personality was again made. 
 
 After discharge she was put to work in a mill and made to 
 live in a very good boarding house for working girls. She 
 talked about taking a fresh start, yet within two months she 
 was found to be pregnant and was sent to a maternity home 
 where there was a miscarriage. She now went to work. in a 
 professional man's family near by and actually took full re- 
 sponsibility for his house during his wife's illness. She stayed 
 
THE KINGDOM OF EVILS 355 
 
 there eight months. She had been found to have a positive 
 Wassermann test with the serum and was receiving treatments 
 weekly. After a trip to the hospital for such treatment she 
 failed to return to her working place. About six weeks later 
 an officer of her maternity home met her on the street. She 
 said that she had been living as a street-walker and resorting 
 to masturbation constantly. Sent to another hospital for 
 syphilitic treatment she ran away six weeks later, was found 
 again and returned in a few days and again discharged. After 
 further hospital treatment in another hospital she, two months 
 later, took another job in a mill and a pleasant room in a good 
 lodging house was arranged for her. She was interested in 
 her work but was slow in learning the trade. She was easily 
 discouraged. She kept in close touch with the social worker 
 but had spells of being inaccessible and almost antagonistic. 
 She grew tired of her factory work and a position was found 
 for her as nursemaid to care for a semi-paralyzed woman. 
 She was pleased with her new position and was very hopeful 
 about her future. 
 
 Very soon she entered into sexual relations with a man living 
 in the same apartment house, whom she had met in the hall- 
 way. She left her position in a few months and made plans 
 to go to New York with another patient, Bertha Greenwood 
 (case lo). Bertha, however, weakened and telephoned anony- 
 mously to the social worker about the proposed trip; so that 
 Theresa was intercepted and persuaded not to go. She was 
 found to be in need of hospital treatment for gonorrhea. In 
 the end an operation was necessary. While she was in a con- 
 valescent home, she expressed gratitude and afifection toward 
 the social workers for the care she had received from them',, 
 but insisted that she wanted "complete independence.."' Iiii 
 spite of her desire to work in a factory and live i-n a lodgings 
 house, she was persuaded to take a more sheltered position in^ 
 housework. 
 
 Such hypersexuals as Theresa are pathetic figures. Aside 
 from the hypersexuality, a girl like Theresa may make an 
 excellent impression and we have letters about her ambitious 
 although not brilliant school work, her interest in church affairs 
 and the general esteem in which she would be held for months 
 at a time. We must remember in particular the skill and 
 fidelity which she showed in the professional man's family as. 
 
356 THE KINGDOM OF EVILS 
 
 above noted. The sex instinct must be thought of as some- 
 how standing out in relief against a pretty normal background 
 of the other instincts. It is, perhaps, a considerable achieve- 
 ment that these cases are now considered examples of Morbi 
 rather than of Vitia. The entire attitude of the world to 
 morbid hypersexuals must be naturally different from the atti- 
 tude toward the sexually immoral. Sometimes it seems that 
 these frequent social diagnoses, "immorality/' ought to be re- 
 placed with some other diagnosis, since from time to time im- 
 morality is made to cover some psychopathic hypersexuals like 
 Theresa. Yet the psychiatrist would feel a great deal more 
 comforted could he advocate a special treatment of hyper- 
 sexualis. An artificial menopause by X-ray often seems a bit 
 over vehement, at least as routine treatment. 
 
 Hours spent by Medical record, 47 pages 
 
 Social record, 51 pages 
 Physician, 9 Social work : 
 
 Visits, 46 
 Psychologist, 2 Interviews at hospital, 13 
 
 Telephone calls, 86 
 Social worker, 84 Letters, 24 
 
 Family known to thirteen social agencies. Mixed marriage: 
 marital discord. Oittljursts of temper: assault: arrest: proba- 
 tion. Border-line psyclwpatJi. 
 
 Case 97. The showing of social "symptoms" (factors and 
 phenomena) in Leon Blumer was by the card-catalogue . as 
 
 follows : — 
 
 Social syrnptoms: 
 Outbursts of temper 
 Assault 
 
 Marital discord 
 Arrest 
 Probation 
 Insufficient income 
 
 Social diagnosis: 
 Family dissension 
 
THE KINGDOM OF EVILS 357 
 
 Analyzing by forms of evil shown we find provisionally: 
 
 Medical — nothing; possibly family discord, outbursts of 
 temper, and assault on wife mean something psychopathic. 
 
 Educational — nothing; insufficient income possibly due to 
 language difficulty? 
 
 Moral — family discord, outbursts of temper and assault (if 
 not fundamentally psychopathic). 
 
 Legal — arrest ; probation. 
 
 Economic — insufficient income (language difficulty?). 
 
 We can easily dispose of the language question. Blumer 
 speaks English, rates 14 years psychometrically, and gives the 
 impression of being fairly intelligent. Blumer had married at 
 twenty a Nova Scotian Protestant girl. This marriage may 
 have been due to bad judgment, but there are perhaps no 
 eugenic principles well established enough to speak against a 
 Caucasian-Semitic crossing. 
 
 A Malthusian argument is possible. There were nine preg- 
 nancies in ten years. Blumer was a salesman earning from 
 twenty to thirty dollars a week. The family income was in- 
 sufficient. Advocates of birth-control might use such a situa- 
 tion to point a Malthusian moral. But insufficient income 
 would never by itself have led to assault and arrest, nor would 
 Blumer on the basis of insufficient income alone ever have 
 appeared at the Psychopathic Hospital. 
 
 Yet, mirabile dicfu, the family was known to thirteen chari- 
 table agencies. Quarrels began soon after marriage. Children 
 had been placed out for years. The wife broke up the home 
 repeatedly. As a rule the different agencies were consulted 
 on account of the marital difficulties (sometimes for children's 
 health, once for financial relief). 
 
 There the situation stood. Even our own social service let 
 the social diagnosis stand at family dissension. Our orderly 
 analysis by forms of evil clarifies the issue, if it does not solve 
 it. The issue is moral versus medical at bottom. Racial mis- 
 cegenation is not yet to be conceded an error. The legal diffi- 
 culties are plainly secondary to whatever underlies the out- 
 bursts of temper. The economic straits of the family might 
 have been material for dissension, not its adequate cause. 
 
 Let us examine the medical situation. To the offhand ob^ 
 server Blumer had himself well under control. He readily 
 admitted his quarreling, but said he did not know whether 
 
358 THE KINGDOM OF EVILS 
 
 his wife or the general situation at home irritated him most. 
 He was rather emaciated and proved to have a pulmonary 
 tubercle on one side (he now was thirty years of age). 
 
 It was further found that he had had gonorrhea at seventeen 
 and had at some time acquired syphilis (positive serum test first 
 at twenty-eight). 
 
 The wife appeared normal and enlisted general sympathy 
 amongst the agencies. Her husband was sent to the Psycho- 
 pathic Hospital by one of these agencies in the fourth year 
 of the marriage to see whether there was a psychopathic basis 
 for the marital discord. But neither feeble-mindedness nor 
 frank mental disease nor a milder psychopathy could at that 
 time be determined. 
 
 It is the same today : tests and observations fail to prove 
 mental disease or defect, though they do give a definite medical, 
 though non-psychiatric, background for the increasing temper- 
 amental difficulty. Discounting early sex irregularity, mixed 
 marriage, and a possibly fundamental overirritableness as not 
 proving psychopathia either alone or together, we can still see 
 the value to the court of thinking about Blumer as a medical 
 case. If his difficulty is essentially moral, nevertheless there 
 will inevitably be something medical to do. 
 
 But what is a moral case? By classifying a major group of 
 evils as Vifia, we do not explain the nature of Vitia. The 
 medical urge is to make Morbi of all Vitia forthwith. That 
 decision would lead to nothing practical. There is a certain 
 proportionality between Blumer's bad conduct and the compli- 
 cation and duration of his domestic difficulties. Disease does 
 not so nicely proportion causes and results. There is no doubt 
 a strong moral element in Blumer's plight, whence we may 
 probably infer an improvement by training and by guidance 
 in the future. 
 
 Thus we must leave Blumer himself scientifically unresolved. 
 But it is plain that much of value to his family has been brought 
 out. The family syphilis question must be answered. The 
 tuberculosis yields some indications. Next time Blumer ap- 
 pears in the Psychopathic Hospital, further progress may be 
 made in the deep-lying temperament matter. We cannot rid 
 ourselves of the suspicion that we deal with a border-line 
 psychopath. 
 
THE KINGDOM OF EVILS 359 
 
 Hours spent by Medical record, 35 pages 
 
 Social record, 2 pages 
 Physician, 4I/2 Social work: 
 
 Visits, I 
 Psychologist, i Interviews at hospital, I 
 
 Telephone calls, 2 
 Social worker, 3^ Letters, 7 
 
 Psychopathic boy enlisted in the navy: discharged after 
 pneumonia. Sick and ''nervous." 
 
 Case 98. Word came from a neighbor in Francis Cor- 
 coran's home town : "The less said about him the better. If 
 he would go to work as the other boys in town have done, he 
 might be a help to his mother." The mother is a neurotic, 
 hard-working woman, who is taking boarders to support the 
 family through the father's illness. The severity of our corre- 
 spondent's judgment of this nineteen-year-old lad might be 
 moderated if she knew that the physicians at the Psychopathic 
 Hospital found him to be a person of constitutional psycho- 
 pathic inferiority suffering from nephritis and possibly from 
 pulm,onary tuberculosis. 
 
 He was sent from a public health hospital, where he had 
 been under treatment for his physical condition, because he was 
 "nervous." had "attacks of depression," and "could not keep 
 from telling lies." He told many yarns about himself, among 
 them the story that he was a student at the Harvard Medical 
 School. He explained that he wanted to get in to see the 
 operations at the hospital and thought he would be admitted 
 if he were a medical student. After telling the doctor in the 
 public health hospital a number of contradictory fanciful tales, 
 he later came to him to admit the falsehoods, saying that he 
 had just "realized" what he had been doing. He said that he 
 felt a force that compelled him to tell extravagant stories and 
 to do things that he did not mean to do, such as walking the 
 streets until one o'clock in the morning. 
 
 Corcoran was disabled, nine months after his enlistment in 
 the navy, through exposure on transport duty and sent to a 
 hospital with lobar pneumonia. He was discharged after 
 fifteen months in the service. He went home for a while, and 
 
360 THE KINGDOM OF EVILS 
 
 then came to Boston to enter a business school. He had done 
 rather poorly in school. He had entered high school at fifteen 
 but had left almost immediately. After a few weeks' study in 
 Boston, he got nervous and discouraged and resorted to the 
 pubHc health hospital. He was advised to return there for 
 further physical building-up. 
 
 Hours spent by Medical record, 14 pages 
 
 Social record, i page 
 Physician, 3^4 Social work : 
 
 Visits, o 
 Psychologist, i Interviews at hospital, 3 
 
 Telephone calls, 3 
 Social worker, 3 Letters, 
 
 Orchestra-player drafted. Sergeant in the band. Gave out 
 in camp. 
 
 Case 99. From flute-player in a symphony orchestra to 
 band sergeant in a military camp proved a change too severe 
 for the endurance of Manuel Giordani. As a boy in Italy he 
 had been allowed to stay at home instead of being apprenticed 
 to a tailor, doing odd jobs and studying the flute. When 
 he was seventeen he came to America, and by playing at sum- 
 mer resorts earned enough to study music during the winter, 
 until he had attained a position in a first-rate orchestra. He 
 was drafted when he was thirty and was quickly made sergeant. 
 The life was rather hard o him because he was not used to 
 active physical exercise, but he liked it. 
 
 Sometimes he would have to play almost continuously from 
 morning to night. One day after the band had been away from 
 camp playing nearly all day, the sergeant remembers that he 
 was tired and had a feeling of uneasiness and timidity. He 
 went past his station and started to walk back along the high- 
 road until an officer in a motor picked him up. He did not 
 sleep well that night and the next day after a cross-country 
 race felt exhausted in the evening. He could not sleep and in 
 the morning got up and went to his old barracks where he 
 thought it would be quieter, so that he might get some sleep. 
 He was found in a confused state lying on a bed spring, and 
 sent by a physician to the base hospital. He was afraid some- 
 
THE KINGDOM OF EVILS 361 
 
 thing was going to happen to him, and was excited and very 
 talkative. 
 
 In this hospital he was normal in behavior, but very worried 
 because he feared he would lose his standing if it were known 
 that he was discharged from the army because he was "crazy." 
 It was the opinion of the medical staff that his mental disturb- 
 ance was not of the nature of a psychosis, though they were 
 not able to determine exactly what type of disorder he had 
 suffered from. Four months later Giordani was playing in a 
 summer hotel, and wrote that he was quite well. 
 
 Hours spent by Medical record, 27 pages 
 
 Social record, i page 
 Physician, 4^/^ Social work : 
 
 Visits, 
 Psychologist, I Interviews at hospital, 3 
 
 Telephone calls, o 
 Social worker, ij4 Letters, 2 
 
 Draftsman who thought people laughed at him. Given work 
 alone, his earnings doubled. 
 
 Case 100, Henry Allen made a very high mental test, 
 being especially good in construction puzzles. He had come 
 to the hospital as a voluntary patient in a depressed frame of 
 mind, feeling unable to do his work. He had been sleeping 
 poorly. He was fifty years of age and was physically quite 
 negative except for tremors of the tongue and fingers. He 
 complained of headache, aches in the bones, shortness of 
 breath, and general weakness, but there was no physical basis 
 determined for these particular complaints. He said that peo- 
 ple laughed at him and said things about him in the office where 
 he worked and that they had been doing this for years. In fact, 
 he had really for years been worrying about this attitude of his 
 fellow workers but had kept on in the ofifice up to a fortnight 
 since. 
 
 We found Allen a most instructive case from a certain in- 
 dustrial, vocational aspect. He despised the constructional de- 
 tails in his work and rather wanted to do designing. Of course 
 the details in designing would, no doubt, have been as elaborate 
 as the details of the constructive work; apparently it was the 
 
362 THE KINGDOM OF EVILS 
 
 matter of an attitude adopted by Allen to the general nature 
 of his work rather than to his mechanical capacity in it. It 
 was as if he wanted to be more of a figure in the whole office 
 by doing designing rather than constructive detail. As the 
 other workmen so constantly talked about him (as he thought) 
 he did not want to work in a large office with many looking on. 
 He felt he had worked only up to about twenty-five per cent 
 of his efficiency because he had not been rightly placed in the 
 office. 
 
 The hospital diagnosis remains at psychopathic personality 
 but very possibly we should regard this patient as tending 
 towards the cyclothymic (manic-depressive) constitution where 
 he belongs in the depressive group. According to his own 
 story he has been somewhat blue all his life. The self -accusa- 
 tory trend is a characteristic of such cyclothymics. Very pos- 
 sibly his idea that he was being persecuted by fellow workers 
 would transform itself upon analysis into a form of self- 
 accusation nor does the story of the whole case suggest any- 
 thing paranoid, that is, looking in the direction of the persecu- 
 tory delusions of a schizophrenic. 
 
 Allen's case came up for particular consideration at a meet- 
 ing of employment managers at the Psychopathic Hospital. 
 It was at that time suggested that he ought to work for a firm 
 large enough to employ a number of designers so that he might 
 be given the work he liked, rather" than merely constructive 
 detail. It was also suggested that he should work alone in an 
 office. These suggestions have, in a measure, been met by ar- 
 rangement with an employer who has given him greater and 
 greater responsibility in his work. Short notices and pressure 
 upon him for rapid work are avoided. He is earning now 
 twice as much as before. One of Allen's letters to the social 
 worker will tell the story. 
 
 "My Dear Miss Hall: 
 
 "Your inquiry with enclosure from my sister has only just 
 reached me, owing to an error made in forwarding at the post 
 office. 
 
 "My conscience has reproached me many times of late for 
 my apparent discourtesy in neither reporting or calling at the 
 Psychopathic and letting you know what had become of me. 
 Owing to the exigencies of Mr. Anderson's work, in part, and 
 more perhaps because I knew you were on your vacation, I 
 
THE KINGDOM OF EVILS 363 
 
 waited at first to get myself adjusted, and lately have had so 
 much given me to do it has taken all my time and energy to 
 accomplish what was expected of me. I am working very 
 smoothly and getting a good deal done, but only by close appli- 
 cation. I am not just ready yet to form an opinion as to how 
 it will work out for me. Expect to get together with Mr. 
 Anderson on his return from the South in a few days and see 
 if I cannot get things adjusted more satisfactorily. 
 
 "The conditions the work demands are speed, efifectiveness, 
 and thought. The two latter I can supply but not the former, 
 so my problem with myself and with him is to reach a compro- 
 mise which I hope in fact must work out. One cannot work 
 for Mr. Anderson without being put on their mettle, even 
 when, as is certainly true, he is one of the kindest and in inten- 
 tion considerate of employees, and always interesting. 
 
 "For reasons best known to himself he has established me in 
 my own office or work room at considerable present expense 
 to himself. His work would be considered by a designer or 
 landscape man as of a very choice and charming character. 
 It is, or should be, all beautiful. Just how I shall measure up 
 to the opportunity we will have to wait and see. 
 
 "Personally I feel that I have benefited by my stay at the 
 Psychopathic and the difficulty of concentration which I once 
 mentioned to you seems no longer to exist in my work. Will 
 you please remember me very kindly to Dr. Reed, Dr. Patter- 
 son, Miss Dean, and the others? 
 
 "In closing I can only say that I am not sure yet for reasons 
 more readily said than written, whether or not the work, as it 
 is coming to me, will prove the work that I should wisely en- 
 deavor to hold. I am trying it out in the most matter-of-fact 
 and sensible way I can and am reserving my final opinion. 
 
 "When it has developed a little farther, I may want, if I may 
 do so without imposing unduly on your time, to talk over condi- 
 tions as they develop. For no matter how ideal the nature of 
 the work may be I am by no means sure that ultimately to be 
 pinned down as closely to a drawing board as I have been will 
 become impossible — physically I am waiting to see. 
 
 "I trust that your vacation has been very beneficial to you 
 and that you have returned to your profession refreshed for 
 the work which I am sure is as exacting and trying on the social 
 workers in some ways as it is helpful and beneficial to the 
 people you help. 
 
 "Trusting you will pardon the length of my letter and my 
 delay in writing, I am "Very sincerely, 
 
 "Henry Allen." 
 
364 THE KINGDOM OF EVILS 
 
 "p.s. It has occurred to me that what I have written of 
 my work may suggest to you that I am being unduly confined. 
 It is true for the time being, but I think I shall remedy it 
 without difficulty ; and add this lest you should think it wise to 
 write Mr. Anderson on the subject, for I know it is part of 
 your profession to look after the patients when they need it. 
 In this case there is nothing but will adjust itself. And it is 
 all incidental to getting started, so while I have written to you 
 frankly I shall be quite as frank with Mr. Anderson and can 
 instantly make it right, and I do not know how he would take 
 a suggestion from the stafif while I am certain he will from me. 
 Probably you wouldn't think of it in any case. But I have such 
 a warm regard for the intelligent work you are doing at the 
 . Psychopathic I am sure you would do it unless you knew there 
 was no need ! 
 
 "If there is any further information I can send you at any 
 time, I shall be only too happy to do so. 
 
 "H. A." 
 
 It is a question whether it would not have been wiser to have 
 Allen overcome his fear of working in a large office. Possibly 
 if we had regarded his condition as cyclothymic or an obses- 
 sional cme, it might have been wiser to try to break up the 
 obsession by counsel and the initiation of new habits. Where 
 we are dealing, however, not with besetting ideas so much as 
 w^ith a habitual and self -accusatory gloom, it is not likely that 
 "rationalizing," or idea upsetting, psychotherapy would be 
 much in point. Here again, as in the case of Arthur Morton, 
 the differential diagnosis between the depression of psycho- 
 neurosis and the depression of a constitutional cyclothymia be- 
 comes a matter of extremest importance to the victim of the 
 depression which is aided by rationalization on the one hand, 
 and no doubt by abstention from psychotherapy of the argu- 
 mentative or persuasive sort on the other. 
 
 Hours spent by Medical record, 18 pages 
 
 Social record, 38 pages 
 Physician, 4^ Social work : 
 
 Visits, 2 
 Psychologist, I Interviews at hospital, 20 
 
 Telephone calls, 10 
 Social worker. Letters, 19 
 
BOOK IV 
 
What is man, that Thou shouldest magnify him, 
 And that Thou shoiddest set Thy mind upon him, 
 And that Thou shoiddest visit him every morning, 
 And try him every moment? 
 
 Job, Chapter 7, Verses 17, 18. 
 
EPICRISIS 
 
 The descriptive task of this volume is complete. The body 
 of the text presents a set of social cases chosen from psy- 
 chiatric material to illustrate the theory and practice of 
 social work. The first three books present the practice of 
 social work inductively, to the end that the student may almost 
 unconsciously gain an insight into the underlying principles of 
 diagnosis and treatment in social cases. To be sure the reader 
 will find scattered amongst the case-descriptions in all three 
 of these books numerous theoretical remarks. But in Book 
 IV these scattered remarks concerning theory are to be united 
 into a body of principles. At the outset of Book IV we shall 
 offer statements of an exceedingly general nature, designed to 
 align this work with others bearing on the various arts and 
 sciences that have come to be termed sociological. 
 
 RELATIONS OF SOCIAL WORK TO SOCIOLOGY AND PSYCHIATRY 
 
 There is not much in books on sociology, ancient or modern, 
 that touches even the theory of social work. Works on so- 
 ciology since the establishment of the theory of evolution 
 have treated mainly the relation of the family taken as a 
 group to the community also taken as a group. That both 
 the family group and the community group are sets of individ- 
 uals, no sociologist ever denies. Indeed some sociologists pro- 
 claim that the unit of sociology is and must be the human 
 individual. But we believe it is fair to say that modern soci- 
 ology is in the main a theory of the relation of human groups 
 to one another rather than of the relation of the individual 
 "soul" to its fellow or fellows in daily life. 
 
 Certain it is that the sociology books rarely present any case 
 material after the manner of the present work. Yet there is 
 much to be said for building up a new sociology from the bot- 
 tom. If we are to build thus from the bottom, we must cer- 
 tainly begin with the relations of man to man, woman to 
 woman, and man to woman, whether those relations are by 
 
 367 
 
368 . THE KINGDOM OF EVILS 
 
 blood, by marriage, or otherwise. What has been done by 
 jurists upon domestic and personal relations is not only meager 
 but in part doubtless quite false, being founded on the very 
 partial insights obtainable by Bench and Bar. Many of the sit- 
 uations that we have described above will suggest dire need of 
 logical analysis of personal relations with a deeper insight and 
 a less general point of view than the juristic one. This new 
 point of view and insight we can only in this work faintly 
 indicate. We conceive that social work will some day pass, in 
 the form of more or less definite principles, into a great body 
 of sociological theory. The new sociology will in our opinion 
 be, not merely a theory of human "groupism," but a theory of 
 the relation of individuals to each other. Though the student 
 of social work can today find little or nothing to his purpose 
 in sociology books, he should not despair. He is himself 
 recording facts that will go to make up new sociological text- 
 books of the future and give the theory of human group rela- 
 tions its proper fundament in a theory of human individual 
 relations. 
 
 In one sense this volume is a collection of cases of social 
 maladjustment. The whole of life, according to Herbert 
 Spencer, is an adjustment — a continuous adjustment of 
 inner to outer relations. Roughly speaking, we look to the 
 psychologists for a study of the innermost of life's inner rela- 
 tions. Perhaps it is not astonishing that we should find the 
 sociologists beginning with the outermost of life's relations, 
 namely the group relations of the family to the community. 
 But the history of the mental sciences in recent years shows 
 that the psychologists are beginning to study man's inner rela- 
 tions as they touch society (witness books like McDougall's 
 Social Psychology) and that the sociologists are beginning to 
 write books that endeavor to carry society back to certain 
 springs of action in the individual mind. In short we can see 
 signs that the mental sciences are beginning to study not merely 
 life's inner relations as such and life's outer relations as such, 
 but also the adjustments of interrelations of the two. Now 
 the social worker stands in the practical center of these adjust- 
 ments, so far as they concern the relations of man to man. 
 The contributions of the psychologists and of the sociologists 
 are still as separately visible to the readers of books on so-called 
 social psychology as the separate flows of the Missouri and 
 
THE KINGDOM OF EVILS 369 
 
 the Mississippi for a long time after their junction. We are 
 now inductively building up the facts for a true social psy- 
 chology (or shall we say psycho-sociology f) , which is to be 
 something new in which the contributions of psychologists and 
 of sociologists will no longer be separately recognizable as such. 
 Adaptation is the key word of much of the psychology, 
 sociology, economics, and political science of the nineteenth 
 century. Adaptation and maladaptation are the key words of 
 our own branch of practical or applied sociology called social 
 work. The hurnan mind is no doubt the most exquisite of the 
 adjustments of which the nineteenth century talked so much. 
 But the supreme organization of man's mind has its penalty. 
 That penalty is the ease of its maladjustment and maladapta- 
 tion. Man builds up outer relations quite as complex as his 
 own inner ones. There are frequent flaws both in the psychic 
 interior of man and in his environment. These flaws, whether 
 in the shape of initial lacks, or of acquired losses, or of mere 
 twists without lack or loss of constituent elements, can hardly 
 be made good without extraordinary effort, conscious and un- 
 conscious, on the part of man. These efforts we term efforts 
 at reform, reconstruction, rehabilitation, readjustment, readap- 
 tation. 
 
 The fitness of the environment to life has been affirmed 
 with great strength and skill by the modern sciences of chem- 
 istry and physics (witness such works as those of L. J. Hen- 
 derson on the Fitness of the Enznromnent and the Order of 
 Nature). Yet the fitness of man in his environment, or the 
 fitness of the environment to man, is a very general and loose 
 adaptation rather than a special and precise one. Whether it 
 is the generality of the laws of environmental fitness or whether 
 there is some other reason, we have no point to bring in this 
 work ; but it is obvious enough that human maladjustments do 
 occur precisely on the plane in which life's inner relations meet 
 the outer ones. Man perhaps shows the defect of his virtue. 
 He has high sensibility and a delicate responsiveness to his 
 environment. He finds most ingenious ways of shunning ob- 
 stacles. But he finds equally ingenious ways of contriving 
 new obstacles, along with the devising of new ideas, practical 
 and theoretical. To use a homely figure, man is often in the 
 plight of an adventurous cat, which has climbed a tall tree 
 with admirable audacity, but finds herself quite unable or 
 
370 THE KINGDOM OF EVILS 
 
 unwilling to climb down. The order of events is (a) the 
 existence of a perfectly good general adjustment of life's rela- 
 tions, (b) the development of specific maladjustments between 
 those relations, and (c) the social necessity of readjustment 
 amongst the relations. The social worker cannot be respon- 
 sible, as social worker, for the integrity or the interior perfec- 
 tion of the minds of the human beings dealt with. Again the 
 social worker cannot be responsible for the status of all the 
 outer relations which are indispensable to life. 
 
 The duty of the social worker lies in the plane of adjust- 
 ment and of readjustment between the human mind and 
 society. Modern social work undertakes consciously to effect 
 readjustment, so far as possible, in all concrete human cases 
 in which the vital relations, inner and outer, have become mu- 
 tually disorganized. Society has come to regard itself as more 
 and more responsible for the cure and the prevention of all 
 human maladjustments. The man who takes a serious view 
 of human life and human society on the one hand may seek 
 to promote man's "welfare" or on the other hand he may pre- 
 fer to think in terms of man's increased "efficiency." In either 
 event the serious student of social adjustments is looking 
 towards concrete betterment. In a practical age, and with the 
 inevitable memories of the Great War, the student of sociology 
 grows weary of abstractions, generalizations, and universal 
 formulae, such as dogged the world's footsteps before and up 
 to the year 1914. Modern social work finds the prevailing 
 after-war spirit identical with its own familiar spirit of recon- 
 struction. For decades, doubtless, the world will be in a frame 
 of mind to repair and restore rather than to build uncertain 
 novelties upon shifting foundations. Social work has in fine 
 come into a perfectly congenial atmosphere. Social work can 
 be at the same time as charitable as it likes and as efficient as 
 it likes. 
 
 Just as man is more complex and less stable than other 
 forms of life, so inside man himself is man's mind more com- 
 plex and less stable than all else he possesses. Man's mind 
 is at the center and crossing of all those inner relations which 
 Spencer defined as requiring adjustment to the outer world. 
 If modern social work demands readjustment of man to his 
 environment, not to say of the environment to man, then it is 
 clear that the specialist in social adjustment must find his chief 
 
THE KINGDOM OF EVILS 37I 
 
 aid and mainstay, but also the greatest bugbear and stumbling- 
 block, in this selfsame highly sensitive, highly unstable mind. 
 Inside the developing specialty of social work there is now 
 unfolding with great speed and surprising precision a new 
 type of social work called psychiatric. 
 
 Psychopathology and psychiatry are respectively the 
 science of the mind diseased and the art of mental healing. 
 Psychiatric facts and observations are what constitute that 
 practical specialty of medicine known as psychiatry. Psychia- 
 try is a practical branch of medicine. Sometimes its theoretical 
 side is given the name psychopathology. Psychopathologists 
 are theorists that describe and explain what we scientifically 
 know or think we know concerning mental diseases. For 
 example, William James, besides being a psychologist (that is 
 a theorist dealing with the normal and general aspects of the 
 mind) was a psychopathologist (that is a theorist dealing with 
 morbid aspects of mind) ; and the interested reader will still 
 find in James's larger Psychology, published in 1890, a ma- 
 jority of the important facts concerning the general theory of 
 mind and concerning its morbid aspects. Indeed, the general 
 reader is perhaps safer in the reading of that older work than 
 in the somewhat precarious plunges he might readily make in 
 the current magazine literature. But, although James was a 
 psychologist of the first rank and a psychopathologist amongst 
 the most competent, he would not have claimed to be a psychia- 
 trist. To be sure James bore the M.D. degree; but he was 
 not a practitioner of medicine and therefore not in the fullest 
 sense a psychiatrist. The interested layman must never con- 
 found theory with practice, chemistry with dietetics, physics 
 with bridge-building, psychopathology with psychiatry, the 
 theory of mental disorder with the practice of the cure and 
 prevention of mental disease. 
 
 The layman is drawn by a mysterious yet perfectly legiti- 
 mate attraction into the field of what used to be called in- 
 sanity, but which we now like to spread out into the field of 
 mental diseases and defects. Time was when insanity was 
 somehow in the same breath attractive and repellent. On the 
 whole the mind diseased was a forbidding topic. Nowadays 
 the situation is altered. To be sure, there are in various recep- 
 tacles contrived by the philanthropic and self -insuring state 
 governments a certain number of legally insane persons, a 
 
372 THE KINGDOM OF EVILS 
 
 great many more in the urbanized states of Massachusetts and 
 New York than in rural and unorganized states. Of course 
 what the civihzed state is here doing for the chronic insane is 
 in itself a kind of social work which makes for betterment in 
 the state. But the benefits for the state at large are rather 
 negative than positive, and only in states of an advanced civ- 
 ilization is there much coordinated effort, by special treatment, 
 by medical and social teaching, and by well-conceived re- 
 searches, to the end of directly helping the victims inside asy- 
 lums and their families at home. Which means to say that 
 the highest type of social work, both general and psychiatric, 
 is seldom found upon the planet. Still, in the most urban por- 
 tions both of our Atlantic seaboard and in parts of the interior, 
 where the need is most urgent, successful social work, both 
 general and psychiatric, is being carried on. The phrase "ex- 
 perimental stage" can no longer be properly hurled at this work. 
 The blue-prints of it have, so to speak, been manifolded. Com- 
 mittees like the National Committee for Mental Hygiene are 
 forwarding the work throughout this country. But for years 
 to come the work of such committees in many states and com- 
 munities must be limited perforce to that perfectly crystallized 
 form of social work frequently known as "state care of the 
 insane." 
 
 In the first part of this work we have called attention to 
 the distinction between public endeavor and social endeavor, 
 contrasting the public and social spheres of influence with 
 the more personal and individual sphere. Practically we no 
 longer term social work that special portion of the community's 
 task which has been taken over by organized government and 
 reduced more or less to thumb rules, which are perfectly good 
 rules unless interfered with by the exigencies of the public 
 treasury, real or imaginary. There is a good deal in the public 
 (that is organized governmental) service which the social 
 worker, operating from voluntary agencies, cannot touch or 
 modify. The social worker then has to operate, as the military 
 men say, "through channels." Nevertheless, the voluntary 
 agency is often able to flick the wheel of officialdom. The fit 
 of government and law is, we are almost inclined to thank 
 Heaven, not a close fit. The legal order and the administrative 
 order are general rather than individual in their application,. 
 
THE KINGDOM OF EVILS 373 
 
 There is a wavy line separating the pubhc from the private 
 (where we mean by "private" either social or personal consid- 
 erations, not yet reduced to rigid rules and regulations). 
 There is also a wavy line between social considerations on the 
 one hand and personal ones on the other. 
 
 The successes of public health and preventive medicine 
 it is no part of the present work to restate. Public service is 
 one of the most successful things, so far as it goes, that man 
 has accomplished. The theory of sanitation passed smoothly 
 and efficiently from a set of considerations bearing on such 
 matters as sewage and other sanitary concerns to another far 
 more delicate set of considerations bearing on infection and 
 bacteriology. The public health movement is now passing into 
 a phase in which personal hygiene is coming into sharp focus. 
 The mental hygiene movement is about to fuse with the rest 
 of the doctrines of public health. An important part of mental 
 hygiene is a public affair. In the same state governments that 
 were developing departments of health, another movement was 
 quietly going forward for the so-called "state care of the 
 insane." This program is well-nigh complete, so far as the 
 legally insane are concerned. The models for state care have 
 been laid down. In several parts of the world public service 
 has done practically all that our knowledge now allows for 
 the group of unfortunates known as the chronic insane. 
 
 But the chronic insane form a comparatively small group 
 of unfortunates. Psychiatry, as almiost any case in this book 
 will prove, is luckily no longer limited to the classification, care, 
 and treatment of the legally insane. For every insane person 
 now confined in a state receptacle, it may be suspected that there 
 is another almost or quite equally insane person outside brick 
 walls who might very appropriately be interned at once for his 
 own sake and for the state's sake. Laws for the temporary 
 reception and care of such suspects have been placed on the 
 statute books of a few of the most civilized states. In some 
 of these states special psychopathic hospitals have been built 
 and equipped for their care and specialized treatment, study 
 and investigation. The data of this book intend to bring to the 
 layman and to the social worker special information concern- 
 ing mild, incipient, and dubious cases of mental disease, which 
 we shall come to know either as mild instances of various well- 
 
3/4 THE KINGDOM OF EVILS 
 
 known mental diseases or else merely as psychopaths (i.e., not 
 subject to diseases of a well-known and definite character — 
 as it were unspecified cases). 
 
 But the aim of modern mental hygiene is much more ambi- 
 tious. How can the tasks of modern mental hygiene be de- 
 fined? It is plain that, if our analysis of "spheres of influence" 
 in Book I is correct, mental hygiene might well deal with (a) 
 the establishment, maintenance, and improvement of various 
 public, legal, and administrative institutions and relations, (b) 
 the encouragement and improvement of various voluntary and 
 private agencies for the betterment of social relations and the 
 molding of society's opinion on these matters, and (c) the es- 
 tablishment of new facts and devices for improving man's in- 
 dividual relations, particularly the very interior relations of the 
 man to himself. 
 
 The mental hygienist of the present day, whether he be a 
 psychological theorist, a specialist in mental tests, a psycho- 
 pathologist with theoretical interest paramount, a practical psy- 
 chiatrist, or an educationalist specially concerned with high or 
 exceptional talents or with the "ungraded," wants to spread a 
 gospel about mind much wider than the crystallized doctrines 
 of medico-legal insanity, the newer knowledge about the "tem- 
 porary care" (psychopathic hospital) group and the out-patient 
 group of mental diseases and effects of a more or less mild 
 nature. The ambition of modern mental hygiene is to spread 
 its point of view over the entire field of the mental sciences 
 and arts, wherein sociology and economics look especially ac- 
 cessible. Not only the insane, not only the psychopaths, but 
 also the eccentrics and the very slightly subnormal are topics 
 for modern mental hygiene. Nor, as above hinted, would 
 mental hygiene object to considering the supernormal person 
 and the person with specialized capacities as within the range 
 of its point of view. We may mention again the work of 
 William James, this time pointing out how in his Varieties of 
 Religious Experience, published in 1903, he utilized his vast 
 psychological and psychopathological equipment in the study 
 of what he sometimes termed the religious "geniuses." It is 
 worth while insisting that the psychiatric approach does not 
 mean calling everybody crazy or even a little bit crazy ! James 
 himself went to extraordinary lengths in his chapter on "Re- 
 ligion and Neurology" to refute this idea. James's acid test 
 
THE KINGDOM OF EVILS 375 
 
 of psychopathology did not destroy the golden geniuses of 
 religion. When, therefore, we say we want to apply the psy- 
 chiatric insight to practically the entire human world, we are 
 not at all asserting or suspecting that the majority of human 
 beings are in any sense psychopathic. We believe that more of 
 the psychiatric point of view will be of great service to the 
 world, as well in domestic as in political life. Just as James 
 gave new viewpoints concerning the religious ecstasy, and just 
 as Hippocrates and Galen before him were physicians who 
 made the most extraordinary contribution to our knowledge of 
 temperament, so we hope by the spread of the mental-hygienic 
 point of view and the point of view of psychiatric social work 
 to aid the common man and woman to deeper, practical insights 
 into everyday questions. 
 
 METHOD OF APPROACH 
 
 We shall now try to describe in a few sentences and in the 
 most general way the somewhat novel method of approach 
 adopted in this book. 
 
 There has heretofore been no special treatise upon psychiat- 
 ric social work. There is in fact no comprehensive treatise 
 upon social work in general. Accordingly this book has per- 
 force to include much that may seem entirely non-psychiatric. 
 We do not seek to describe comprehensively the technique of 
 social diagnosis or the technique of social treatment. The gen- 
 eral features of the technique of social diagnosis have been 
 ably catalogued by Miss Mary E. Richmond in her work on 
 Social Diagnosis. Comprehensive studies upon Social Treat- 
 ment are rumored to be in preparation, and the experiences of 
 decades, from the first philanthropic endeavors up to the more 
 scientific procedures of present-day social treatment, may then 
 become available for the growing group of general social 
 workers. It is not our design to anticipate future formulation 
 of the methods of social treatment or to repeat the systematic 
 chapters of Richmond, so far as they deal with mental hygiene 
 and psychiatry. We have carefully reviewed Richmond's 
 work and found to our surprise that fully half of the social 
 cases presented by her are cases with a strong mental hygienic 
 or psychiatric flavor. What this signifies can be discerned if 
 we remember that Richmond's selection of cases was a purely 
 
376 THE KINGDOM OF EVILS 
 
 random selection, made for the purpose of illustrating differ- 
 ent forms of technique of social diagnosis. The collection was 
 in no sense designed to display the importance of psychiatry 
 in social work. Reading between the lines we can reasonably 
 conclude that a much higher proportion of the Richmond case 
 collection would turn out upon closer study to be cases involv- 
 ing mental hygiene in its broadest sense — cases, that is to say, 
 that illustrate the importance of considering mild character 
 defects and perversions, mild feut important temperamental 
 distinctions, and the like. Rising from this sort of analysis 
 (and any case collection of social work, so far seen by us, will 
 point the same moral), we are tempted to inquire whether after 
 all psychiatric social work is not merely social work in general 
 with special emphasis upon its mental hygienic features. 
 
 We conclude that the present case collection is perhaps com- 
 prehensive enough to amount to a case collection demonstrating 
 in the rough the main principles of all medical social work. 
 We bear in mind that the great medical inspirer of the develop- 
 ment of medical social work, Dr. Richard C. Cabot, has for 
 years insisted that the supreme values of medical social work 
 lodge in the diagnosis of human character and the care and 
 treatment of social patients in the light of our knowledge of 
 their character. A chief aim of medical social work must 
 always have been recognized, more or less vaguely, as a sort 
 of character-building, a labor with "sick souls" as well as with 
 sick bodies, a labor inevitably interrupted by all sorts of tem- 
 peramental handicaps. Even where no such handicaps stood 
 out in silhouette form upon the history of the patient, still even 
 the more positive forms of character-building would need to 
 take account of fundamental, temperamental, and character 
 traits. This insistence by Dr. Cabot upon the centrality of 
 character-building in social work took the right line. But in 
 those days the modern psychiatric point of view had not ar- 
 rived to deal with the subtle differences amongst men as to their 
 temperamental deviations and slight eccentricities of character. 
 The tendency of eighteenth-century individualism had been to 
 the thought of general ethical principles common to all men. 
 When the eighteenth-century individualism died away to be 
 replaced by the statistical average man of Ouetelet, and when 
 Quetelet's Physique Sociale was supplanted or made over by 
 the evolutionary ideas of man as a species, there was outstand- 
 
THE KINGDOM OF EVILS 377 
 
 Ing a certain overgenerality of view, a certain opinion as to 
 desirable conformities of human beings, old and young, male 
 and female, married and unmarried, white and black, to some 
 norm or model. 
 
 Nowadays we are beginning to look more at differences than 
 at resemblances of human beings. Individualization is the war 
 cry. But the warp and woof of the argument for individual- 
 ization depends on actual case material. This case material 
 can, we think, be supplied nowhere so well as in the wards and 
 out-patient departments of psychopathic hospitals. To the end 
 of making character ultimately better, we now proximately look 
 at the mild psychopaths, eccentrics, and "deviates" of psychi- 
 atric clinics. We are often eloquently reminded to become 
 "masters of our fate" by the utilization of our very handicaps 
 themselves. Grail-hunters, according to available legends, had 
 sundry dragons to slay by the way. The strength of Sir 
 Galahad was as the strength of ten, not merely because his 
 heart was pure, but because of his righteous exercise of soul 
 and body in the leaping of obstacles and the destruction of 
 evils. In point of fact, social work did not lose in moral fer- 
 vor by taking on the more scientific form of seeking social 
 justice rather than a more or less refined alms-giving. But 
 whether with the philanthropist you are giving gifts, or 
 whether with the social worker you are paying society's debts, 
 — in either event you are a dealer in morals. Even the bare 
 aim of efficiency, which causes our legislatures year by year 
 to appropriate more and more money from the tax levy, has a 
 moral motive. The watchdogs of the state treasury, with 
 whom we are so familiar, have their ears to the ground of 
 morality, of social justice, and of such altruism as the com- 
 munity may afford. Yet withal, it must be insisted that the 
 ideas of character-building, of masterhood of fate, of the 
 utilization of one's handicaps, of old-time philanthropy, and 
 of modern social justice are moral ideas derived from the gen- 
 eral stock of such ideas to be found in everyone. Up to recent 
 years the leaders in. social work, like their predecessors who 
 called themselves philanthropists, took their ideas of morals 
 and of moral development from the general stock rather 
 than from any special studies of the moral status and out- 
 look of their patients, taken as "persons," "individuals," 
 or separate and distinct "souls." 
 
378 THE KINGDOM OF EVILS 
 
 We are entitled to claim for psycniatric social work that it 
 employs not only the general stock of human ideas about char- 
 acter, but seeks with some success to employ the new point of 
 view of mental hygiene. Possibly that point of view can best 
 be intimated in a single word by the term individualization. 
 It was the reproach of older medicine, as it was of the educa- 
 tional, legal, and economic orders of our own day, that the 
 human unit was not treated as a whole. 
 
 The late Professor James Jackson Putnam was one of the 
 earliest physicians to point out the necessity of treating the 
 whole man rather than parts of man, such as heart, liver, or 
 kidneys taken as separately subject to disorder. Man seemed to 
 the analytical pathologist of the last century a heap of viscera, 
 in which systems such as digestive, muscular, nervous, respira- 
 tory, and excretory were to be found. Especially in the last 
 decade of the nineteenth century, the "skin and its contents" 
 (as the slang medical phrase runs) began to be tied together 
 once more through the central nervous system, composed, as 
 was discovered, of countless enormously long interconnecting 
 strands, the so-called "neurones." Then followed in the first 
 decade of the twentieth century another process of tying organs 
 together. These new ties were chemical ties ; that is, the so- 
 called ''chemical messengers" or "hormones," which flowed 
 through blood and tissues from the glands which made them to 
 the organs they were designed to stimulate and control. Thus, 
 by the second decade of the twentieth century, even the analyt- 
 ical pathologists were ready to see in disease and health com- 
 binations where they formerly had seen separations, syntheses 
 where they had formerly seen sundering, and all sorts of remote 
 effects which had formerly lain quite unsuspected. 
 
 It was as if a traveler had suddenly by the break of day 
 become aware of great numbers of telegraph lines, great quan- 
 tities of railway trackage, in a landscape which had in semi- 
 darkness seemed to him quite barren and wild, and had become 
 aware of a vast transportation system of highly artificial prod- 
 ucts capable of entirely altering the scene. The men of science 
 had in short by their own endeavors come to see new unities of 
 body and mind and were once more able to work conscien- 
 tiously with their colleagues in social tasks. Analytical men 
 of science are thus now able to work again with the rest of the 
 world on the platform of individualization. What may be 
 
THE KINGDOM OF EVILS 379 
 
 called the neurone set-up of man, that is, his nervous frame- 
 work in the finest sense, is clearly a very individual affair, and 
 the hormone set-up, that is, the special and intimate construc- 
 tion of man in certain vital chemical ways, must needs be also 
 a very individual matter. The individualization of man, as 
 we now look at him in the second decade of the twentieth cen- 
 tury, is individualization to the second power, or to the cube, 
 of what it could possibly seem in the third decade preceding 
 ours, the decade in which so many extraordinary discoveries 
 in bacteriology were made. If it were worth while to drag 
 the argument out 'at greater length, we could point out the 
 obvious increase in individualization in the processes of educa- 
 tion and even somewhat in those of law and economics. That 
 ihe time is ripe for individualization of morals can hardly be 
 doubted. That the technique by which the world shall achieve 
 this individualization of morals is mental hygienic technique, 
 we that write this book are persuaded. The resulting distinc- 
 tions are not medical distinctions, but purely and simply moral 
 ones. In the field of education it is a matter of familiar his- 
 tory that Madame Montessori derived her special ideas for the 
 education of normal persons from the study of the methods 
 used for the feeble-minded. So it is with the new insight into 
 morality which the study of the mild mental disorders is begin- 
 ning to afford. The resulting ethics will be ethics for the 
 normal individual. The dynamite of disease may serve to 
 split out building stones. The acid tests of medical study may 
 display the true moral structure of normal human beings. 
 Psychiatric social work can establish and is now estab- 
 lishing new principles for social work in general. 
 
 The time may come when medicine can be forgotten and 
 hygiene alone maintained. Then would be the golden age of 
 keeping well rather than of getting well. Likewise psychiatric 
 social work may (theoretically) disappear and leave the every- 
 day problems of financial relief, of legal aid, of standardized 
 moral training and of perfectly systematic education. But, 
 even if such a golden age without disease is ever to develop, 
 the chances are good that the study of medicine in its broadest 
 sense would be an indispensable factor in the gilding process. 
 Individualization is very properly the war cry of today. Path- 
 ological method will have much to do- in establishing the prin- 
 ciples of that individualization upon a sound basis. That por- 
 
380 THE KINGDOM OF EVILS 
 
 . tion of pathological method which deals with the diseases and 
 defects of the mind, especially the mildest psychopathies and 
 the faintest eccentricities, will carry the banner of individu- 
 alization to the farthest point now visible ; namely, the con- 
 fines of the mind of man. We have already begun to study 
 with delight and profit the nature of geniuses and of excep- 
 tional persons with special abilities. The varieties of moral 
 and religious experience are being levied upon in the literature. 
 
 Even the legal order, which has been so terribly general 
 in its plan for securing the interests of man, has begun to raise 
 the cry of individualization ; witness not only various theoreti- 
 cal assertions of this trend, but witness the jurists themselves 
 and also the pleasing vogue of a book like that of Dr. William 
 Healy upon the Individual Delinquent — a book founded upon 
 case descriptions. 
 
 Lastly, even in the field of economics, a book like that of 
 Taussig on Inventors and Money Makers serves to show how 
 far the idea of individualization may penetrate a field devoted 
 for decades, or practically since its initial survey, to the "aver- 
 age man." Social work, as plainly shown in the case descrip- 
 tions of this book, touches all these fields of education, morals, 
 law, and economics, and must naturally share the effects of 
 that increase in individualization which all of these great de- 
 partments of knowledge and practice are showing. 
 
 If we concentrate attention upon the medical division of 
 the field of social work we cannot fail to see that the individu- 
 alizing trend must be greatly strengthened by modern develop- 
 ments in medicine, upon which the analyses of medical social 
 workers must depend. If we further concentrate our attention 
 upon the psychiatric division of the field of social work, we 
 cannot escape the conclusion that here at last we find the very 
 pitch and apex of individualization. Landscapes and habitats 
 extraordinarily differ. Races and people differ still more 
 extraordinarily. Human bodies show differences obvious to 
 the casual eye, and their contents such as livers, kidneys, and 
 other glands, must show even greater differences than the 
 environments of their owners. When we take into account 
 the interconnecting filaments of the nervous system and the 
 special qualities of the various chemical messengers uniting 
 the different parts in the body with one another, we perceive 
 that the resulting unities are capable of still greater differentia- 
 
THE KINGDOM OF EVILS 381 
 
 tion. Leibnitz pointed out that no two grass blades were alike. 
 He called his discovery by the extraordinarily obscure name of 
 the law of the identity of indiscernibles. Well! if two grass 
 blades must perforce be different, two brains interpenetrated 
 by the highly specialized bloods and juices must be capable of 
 still greater differences than mere grass blades could display. 
 From this line of argument our main claim will stand out; 
 namely, that progress in the psychiatric division of social 
 work will inevitably bring progress in medical social work 
 las a whole. This progress in medical social work as a 
 whole must react upon the more general non-medical 
 parts of social work. 
 
 What are the relations between psychiatric social work and 
 other fields of social case work? Logically, all portions of 
 the field of social case work are intimately connected. Prac- 
 tically, there are at least three divisions of social case work, if by 
 "practical" we mean divisions defined by the existence of a 
 corps of special workers limited by training, experience, and 
 interest to each special division. On this practical ground we 
 may thus distinguish (a) a field of general social case work, 
 (&) a field of medical social case work, and (c) a field of psy- 
 chiatric social work. We here limit consideration to social 
 case work as distinguished from the broader fields of com- 
 munity work. We speak merely of that total field of social 
 work that deals in one way or other with the individual, either 
 in his public or social or personal relations. 
 
 The point of view of (a) the general social case worker 
 derives historically from the older philanthropic point of view 
 and is still largely founded upon the necessity and desirability 
 of the so-called "poor relief" and the economic establishment or 
 reestablishment of the family. (We must insist that every 
 social case worker, whether general, medical, or psychiatric, 
 has the family point of view ingrained in her training and im- 
 bedded in her practice; the point in the text refers to the pre- 
 dominance of the economic point of view in general social 
 work, pivoting, as it so often must, upon the total wage intake 
 of the family and its proper distribution or supplementing.) 
 
 The point of view of (&) the medical social worker derives, 
 not so much from the older philanthropic point of view as from 
 modern developments in medicine. The medical social worker 
 has her economic interests indispensably, for she also pivots 
 
382 THE KINGDOM OF EVILS 
 
 her work upon the family. But essentially the medical social 
 worker has in mind the restoration of the health of the family 
 and of its individual components. Some of the pioneers in 
 medical social work have been general social workers who had 
 become convinced that medicine must be their particular target. 
 But other leading medical social workers, even at the outset of 
 its development (see Ida M. Cannon, Social Work in Hos~ 
 pitals), were persons theretofore quite untrained in the eco- 
 nomic aspects of social work, who became medical social 
 workers de novo. There was, to be sure, a fortunate union 
 and mutual adaptation of economic and social interests from 
 the beginning of the development of medical social work ; and 
 there are signs of an equally happy reaction running both ways 
 between general and medical social work. 
 
 The point of view of (c) the psychiatric social worker de- 
 rives from the modern developments in mental hygiene. Else- 
 where in this book we have sufficiently insisted that psychiatry 
 (that is, the art of mental healing) is in one very definite sense 
 a branch of the practice of medicine but we have pointed out 
 with equal emphasis that psychiatry has far broader contacts 
 with the world than with medicine alone. We have pointed 
 out that mental hygiene is in some ways a much broader topic 
 than medicine, touching education, ethics, the legal order, and 
 economics, to say nothing of science, art, political science, re- 
 ligion, and philosophy. Practically, moreover, the field of 
 psychiatric social work would never have been developed in its 
 present form, had it not been for the labors of the mental 
 hygienists, amongst whom we must count not psychiatrists 
 only but also psychologists. Psychiatric social work is accord- 
 ingly not alone a logically separate division of social work but 
 also practically a separate division, as defined by the existence 
 of a type of specially trained worker and as defined by the 
 history of the movement itself. 
 
 It is plain that the field of (a) general social case work 
 stands logically somewhat farther apart from (&) medical 
 social work and (c) psychiatric social work than {h) and (c) 
 stand apart from each other. Indeed, it might be claimed that 
 psychiatric social work is nothing but an important subdivision 
 of medical social work akin to such subdivisions as the tuber- 
 culous, orthopedic, lieart, syphilis, and pediatric subdivisions. 
 In fact, this claim has been made by some workers, though 
 
THE KINGDOM OF EVILS 383 
 
 nowhere supported by a thorough logical and historical argu- 
 ment. The observer must bear in mind, however, that, if we 
 are talking logic alone, the public-health movement ought to 
 carry in its front lines the banner of mental hygiene. Public 
 health officers and specialists in preventive medicine ought to 
 have developed mental hygiene divisions as logically and as 
 practically as they have developed their work in sanitation, 
 bacteriology, and in later days personal hygiene. But the pub- 
 lic health movement has never taken the "person" on so broad 
 a basis as the individual "person" of mental hygiene. What- 
 ever the public health movement ought to have been or ought 
 to have become in relation to mental hygiene, the facts are 
 against anyone who should claim that mental hygiene is his- 
 torically an outgrowth of public health. So it is with the move- 
 ment for psychiatric social work. The movement is derived 
 from psychiatric clinics, psychopathic hospitals, out-patient 
 clinics for mental and nervous diseases, mental hygiene so- 
 cieties, and kindred mental hygiene units of the community. 
 Perhaps it has been better so. The man interested in sanita- 
 tion, bacteriology, and the simpler devices of so-called personal 
 hygiene is not apt to be a person profoundly interested in social 
 relationships and their adjustment and readjustment. The per- 
 son interested in economic relief and primarily in the solution 
 of the comparatively simple problems of the tuberculous, the 
 orthopedic, the "heart cripple," and even of the sick child, is 
 not a person who is apt to give due weight to educational, ethi- 
 cal, and legal sides of her problem, having in mind adjustments 
 which transcend the wage intake and the bodily health and 
 comfort of the sick person. 
 
 Now it is perfectly true that to solve the problems of the 
 lame, the halt, and the blind, or of the tuberculous, or of the 
 child sick-of-body, the bigger and more complex social adjust- 
 ments are more and more coming to be regarded as indispen- 
 sable. In the terms of the future history of social case work, 
 we may safely predict that the psychiatric point of view will 
 react upon the general medical point of view in case work. 
 The very same thing is happening in the field of medicine re- 
 garded from the standpoint of the physician. The general 
 practitioner of medicine in every parish is inevitably busy with 
 psychiatric problems, though he may not think of them as such. 
 Psychiatry is a branch of medicine every whit as general in 
 
384 THE KINGDOM OF EVILS 
 
 one sense as is the general practice of medicine itself. The 
 nervous system penetrates every part of the body and the mind 
 influences every diagnosis, every prognosis, and every thera- 
 peutic procedure in medicine. Nevertheless, it will be a num- 
 ber of years before the general practitioners become equipped 
 with the psychiatry they need. So it is with psychiatric social 
 work. Psychiatric social work is bound to influence medical 
 social work, and, in fact, all forms of social case work. Just 
 as the general practitioner of medicine would greatly benefit 
 by getting into his head the main facts about psychiatry, so 
 the medical social worker will equally benefit by absorbing the 
 new principles of psychiatric social work. Logically the two 
 fields of medical social work and psychiatric social work pre- 
 sent aspects of resemblance and aspects of difference. His- 
 torically the two fields present separate lines of development. 
 Practically, even at the present day we must insist that psychi- 
 atric social work is by no means a specialty coordinated with 
 pediatric or orthopedic social work, but presents a body of 
 principles applicable alike to all the subdivisions of medical 
 social work. 
 
 The new theories of social work or practice must soon effect 
 changes even in sociolog}^ as a whole. Sociology as a whole 
 has run perhaps too much to a schematic and general account 
 of supposed evolutionary laws of the nature, structure, and 
 development of society. In this general account of society's 
 evolution commonly called sociology, the individual is very 
 likely to get named on page one but not to figure extensively 
 in the table of contents. We claim then that, by beginning 
 with a study of the individual in his finest and most delicate 
 deviations from the normal, we are starting an inductive study 
 which if carried through sedulously will react upon sociology 
 itself and therefore upon political science, economics, ethics, 
 and the rest of human interest. Let no reader say that this is 
 an elaboration of the obvious. The inductive method has been 
 on the cards since the Novum Organon of Francis Bacon, but 
 inductive progress toward a completer sociology has not begun 
 with the individual and especially not with the individual as 
 delicately dissected out in mental disease. 
 
 We have arranged the case studies of this work in a certain 
 formal way. For the most part, however, we have presented 
 them so that each stands upon its own feet. Nor do we think 
 
THE KINGDOM OF EVILS 385 
 
 that the data have been essentially modified by the process of 
 analysis to which they have been subjected. The narratives 
 are chiefly drawn from "intensive" cases in our hospital files 
 rather than from cases of so-called "slight service." The data 
 presented are condensed to even far less than one-tenth of their 
 original extent, with the omission, however, of no important 
 link in the narrative, taken as a narrative. The book might 
 thus be read purely at random and each case regarded as a 
 source of texts. We have constructed the index to the book 
 in such manner that many of these texts or special maxims can 
 be studied in particular cases, even where no attempt has been 
 made in the summary to unite the cases to demonstrate par- 
 ticular precepts. 
 
 The object of dividing the case descriptions of the book 
 into three main parts was a purely practical one. In Book I 
 we sought to show the main spheres of influence which are 
 brought to bear upon social cases in civilized communities 
 where (a) government and (b) systematic voluntary social 
 agencies and (c) special methods of handling the individual 
 are highly organized. Book II is devoted to a much more 
 individual analysis of the social cases from the standpoint of 
 the various troubles, difficulties, maladjustments, or evils that 
 they present. The analysis of Book III is a medical analysis 
 and gives some slight idea of the varieties of social diagnosis 
 and treatment of cases falling in the more generally recog- 
 nized groups of mental disease and defect. 
 
 THE METHOD OF BOOK I : SPHERES OF INFLUENCE 
 
 The principle upon which the seven cases of Book I are pre- 
 sented may seem a novelty in social work. The triple division 
 of the spheres of influence under which social cases fall, viz., 
 public, social, and individual, corresponds with categories of 
 the legal order as developed by Dean Roscoe Pound. Dean 
 Roscoe Pound's forthcoming work on Sociological Jurispru- 
 dence will soon unfold a logical view of the bases of this triple 
 division. We may be pardoned for remarking more super- 
 ficially upon the division in these pages. The usual distinction 
 between "public" and "private" is still of practical value, de- 
 spite the unclear line which may separate public from private 
 duties and responsibilities. The term "public," as we under- 
 
386 THE KINGDOM OF EVILS 
 
 stand Dean Pound, might well be restricted to the operations 
 of organized government, which is, of course, a part of society- 
 taken in its broadest sense ; but the operations of society taken 
 as a whole are essentially non-governmental, not yet organized 
 into state affairs. In short, there are a great many of the 
 most important concerns of society w^hich are not acknowledged 
 to be public in the sense of governmental affairs. They re- 
 main "private," although they affect social groups. In default 
 of a better term for the non-governmental operations of social 
 groups. Dean Pound, as we understand him, proposes to use 
 the term "social." Social operations in their widest sense 
 would then include governmental operations as well as numer- 
 ous others. Whenever we are talking about governmental op- 
 erations, however, we shall almost inevitably want to dis- 
 tinguish them as such, and we may appropriately use the term 
 "public" for these more fixed, solid, and rigid products (fos- 
 sils) of the social development of bygone days. Dean Pound 
 developed these distinctions in a discussion of the interests of 
 personality derived from a reinvestigation of the so-called 
 "natural rights" of man. Into that deep discussion we do not 
 care to penetrate. We simply adopt this suggested nomencla- 
 ture for the agencies and other spheres of influence that come 
 in contact with our cases. From a practical point of view the 
 social worker must soon concede the influence of public agencies 
 in this special sense of organized governmental agencies. The 
 fixity, solidity, and rigidity of the public service may be a 
 virtue or a fault as the case may be, but in any event nobody 
 is more clearly aware than the social worker of the ex- 
 istence of these obstacles or leverage points of the public 
 service. 
 
 But we also distinguish between the "individual" and the 
 "group." We have come to see that individualization is a 
 leading trend, not only of modern social work, but of most 
 departments of human knowledge. The old distinction be- 
 tween "public" and "private" is accordingly no longer able to 
 serve our best purposes. We need to build up the idea of the 
 private into the idea of privacy as opposed to public or gov- 
 ernmental responsibility — privacy in the sense of what James 
 called "the warmth and intimacy" of the individual man. 
 
 Thus an ancient distinction was : public 7's. private. Another 
 very plain distinction is : group z's. individual. We now have 
 
THE KINGDOM OF EVILS 387 
 
 to combine logically these two distinctions and the results are 
 as follows : 
 
 ^ /Public 
 
 G^o"P {social 1 p^.^^^^^ 
 Individual/ 
 
 For practical purposes we can then distinguish the interests of 
 our cases as public, social, and individual. We shall never 
 forget that in the present state of advanced civilization in the 
 communities where social work flourishes, no individual and 
 no social agency can fail to be affected by the public service in 
 some fashion. But public servants can and do forget that 
 their responsibilities, although strictly limited by law, organi- 
 zation, and regulation, are surrounded by conditions in which 
 the responsibilities of social groups are numerous and also in 
 some respects paramount. Neither the public officer nor the 
 social worker should forget his duties to the individual as such. 
 
 The social worker, standing as she does midway between 
 public service on the one hand and the ideal of individual 
 service on the other, must not remain aloof from both. She 
 can often imagine a procedure far superior to any now afforded 
 by the public service for the forcible handling of a given case, 
 yet she finds the public sphere of influence paramount. 
 She must bow to the public service. Her recourse is so to 
 stimulate social opinion that it shall become public regulation. 
 
 Looking in the other direction, the social worker may often 
 find a situation in which she feels that some family group or 
 neighborhood group would be greatly benefited by a particular 
 invasion of individual rights and a particular interpretation of 
 the interests of this individual running counter to his desires. 
 Persuasion rather than compulsion must here be her aim. This 
 persuasion may not be hers to attempt or to carry through ; 
 that persuasion may be the duty of some physician or other 
 adviser. The middle ground occupied by the social worker 
 between public service and individual desires and rights is a 
 position of danger. She stands in that middle ground, untram- 
 meled by the laws and regulations of the public service and 
 beyond the control in essential ways of the physician. So far 
 as law and medicine are concerned, she is on rather neutral 
 ground. In critical and limited phases of her work she is, to 
 be sure, governed and guided by judge and physician, but she 
 has every chance to push on to crises and limits that may not 
 
388 THE KINGDOM OF EVILS 
 
 be necessary and may not represent the "one best way." She 
 is, as has been remarked, a sort of professional or intensive 
 layman. It may be that a judge or physician would do no 
 better in her place amongst these non-legal and non-medical 
 problems; but, if she pushes her non-legal and non-medical 
 problems into the legal or medical zone, she is likely to be 
 charged with causing difficulties when she has merely shaped 
 their course toward the only available beacons. Can there be 
 any doubt of the importance of securing men and women of 
 the highest grade for social work? Is it not clear that they 
 must understand the main principles of the interrelation be- 
 tween medicine, education, morals, law, and economics ? There 
 used to be much discussion as to what might be given if we 
 could turn the problem around. Define what constitutes a 
 psychiatric social worker — the "points" of such a worker 
 would then correspond with those of the so-called "educated" 
 man. Elsewhere we give a summary of such "points" as prac- 
 tical experience seems to agree upon. 
 
 So much then for the raisoii d'etre of Book I. It will be 
 noted that there are seven cases in Book I. When three terms, 
 such as public, social, and individual, are combined in eight 
 ways, the eighth combination (logically speaking) is that situ- 
 ation in which all three are absent. Accordingly we find that 
 to illustrate all existent combinations, public, social, and indi- 
 vidual, we need but seven cases. Book I also serves as a sort 
 of general introduction to the whole topic, and we have placed 
 in the discussions of the seven cases of Book I a few general 
 remarks that apply to the remainder of the volume as well. 
 But what we especially hope to drive in by the contentions of 
 Book I is a wholesome respect on the part of the social worker 
 for the problems of the individual as such and for the problems 
 of public service as such. If she does not like all aspects of the 
 public service of the present day and if she is dissatisfied with 
 the medical and other knowledge of the psychic interiors of 
 her patients, she must not kick against the prick of judge and 
 administrator in public matters or act as a substitute for the 
 physician or other adviser upon matters depending upon medi- 
 cal diagnosis. There are certain interests of personality to be 
 secured by the legal order and by the public administrator. 
 There are certain aspects of personality which are to be han- 
 dled, so far as they can be handled, by the best expert advisers 
 
THE KINGDOM OF EVILS 389 
 
 obtainable. The task of the social worker, and especially of 
 the psychiatric social worker, remains a morally heavy task — 
 the task of utilizing the fixities and fulcra of public service and 
 at the same time the delicate and elastic values of the expert 
 in personality. Couched in these terms one might think the 
 psychiatric social worker or any social worker must be some- 
 thing celestial. We can only point to the relative successes and 
 instructive failures of the cases presented in this book to show 
 that there is no celestial claim but only a purely practical and 
 human claim made for these workers. If all expert work in 
 the adjustment of personality seems to be rather atmospheric 
 and if the public service seems to some of us at times to have 
 become a solid immovable mass then we must thank the social 
 worker. She remains liquid. She is the ideal being, a uni- 
 versal solvent. She proves herself to be a useful intermediary 
 in whatever field her path finally arrives. 
 
 Whereas the considerations of Book I seem more novel than 
 they actually are, the arrangement of data in Book II is actu- 
 ally the most novel feature of our work. How far the divi- 
 sion of the troubles, difficulties, maladjustments, and evils of 
 society into five groups is a sound, enduring division, it is hard 
 to say. This is not a textbook of sociology. We claim a 
 purely practical applicability for our subdivisions. The data 
 of these cases were not secured under the headings so presented. 
 Since the collection of these data and the completion of this 
 work the divisions of the so-called Kingdom of Evils have begun 
 to be practically used in social work by many workers connected 
 with the state institutions for mental diseases in the Common- 
 wealth of Massachusetts. Practical lectures upon these classi- 
 fications have been given, and the active workers have brought 
 their data to the conferences for discussion. The divisions 
 seem to work out in practice. Surely some division of data 
 is better than no division. 
 
 Heretofore social case records have often proved to be 
 nothing more than ill-digested narratives, with vast accretions 
 of facts hardly analyzable by any person save the original col- 
 lector of the data. The case worker familiar with her case 
 might in the end be able to give a fairly competent account in 
 narrative form of her case. Of course the self-consistent nar- 
 rative may actually miss the point. We have frequently seen 
 maladjustments set down to the score of ignorance which were 
 
390 THE KINGDOM OF EVILS 
 
 actually due to f eeble-mindedness ; sometimes (though seldom) 
 feeble-mindedness has been erroneously suspected. To call a 
 purely moral defect psychopathic is a slant which psychiatric 
 social workers early in their practical work may fall into. To 
 call clearly psychopathic phenomena immorality is a prevalent 
 fault amongst laymen, many physicians, and very many public 
 servants. To charge any or all of these difficulties up to the 
 account of poverty is perhaps the commonest flaw in social 
 analysis in the world at large. Just as the "economic factor 
 in history" was so greatly the rage some decades since, so the 
 economic factor in personal life has been greatly overdone. To 
 be sure it does not take the data of mental hygiene to demon- 
 strate that poverty is not the main cause of social trouble. 
 Social work, before it had attained the psychiatric range, had 
 long ago proved to its own satisfaction that much more was 
 wrong than mere economics. In fact progress from philan- 
 thropy to social work was no doubt largely due to the growing 
 appreciation of the fact that giving alms or financial relief did 
 not go far to solve social problems. 
 
 THE METHOD OF BOOK II : KINGDOM OF EVILS 
 
 The method of Book II is no less practical than that of Book 
 I. Book I treating spheres of influence over social cases pre- 
 sented the cases in their social matrix, as confronted by the 
 social worker looking for practical results in a workaday world 
 full of necessary and unnecessary obstacles. The compulsions 
 of government, the suggestions of the voluntary social agencies, 
 and the intimate lines of attack upon personality were reviewed 
 in the seven possible forms of their combination. Book I thus 
 endeavored to teach the social worker that no layman can set 
 himself up against the power of government and law with any 
 hope of success in the concrete instance. On the other hand, 
 we perceived that it was the social worker's duty, if she found 
 her patient's trouble intimate, individual, and personal in its 
 nature, to swing the whole policy of treatment at once to the 
 physician, to the teacher, to the spiritual guide, or (often the 
 best plan of all) to the man himself. But how is the social 
 worker to pull apart all the concrete particular and special 
 facts and surmises about the patient, to the end of judging 
 whether the patient is best given over to physician, teacher, 
 
THE KINGDOM OF EVILS 39I 
 
 moralist, or back to himself? It is the province of Book II to 
 try in a somewhat novel manner to give the social worker a 
 practical method of analyzing the facts available. 
 
 It has been found possible to present this method of analysis 
 in Book II in the form of thirty-one cases. We pointed out 
 that the three spheres of influence discussed in Book I could 
 mathematically be combined in eight ways, or practically in 
 but seven ways, since the eighth was the null class in which 
 all three elements were absent. The five great groups of what 
 we term the Kingdom of Evils must likewise mathematically 
 combine in a limited number of ways, namely in thirty-two; 
 but again the thirty-second combination would be that com- 
 bination in which all five groups of evil would be absent. Thus, 
 after we had sufficiently described thirty-one instances of evil, 
 (that is, in the combination in their various ways of five forms 
 of evil), we might reserve the thirty-second compartment for 
 some absolutely normal person, if there be such, who had never 
 undergone any form of evil whatever ! It is very convenient 
 to work with five forms of social difficulty rather than with 
 four, with six, or with seven. Had we been dealing with four 
 major groups of social trouble, we should have been able to 
 get on with but fifteen combinations, that is, with the mathe- 
 matically possible sixteen combinations minus one. If we had 
 practically found in our social case analyses six forms of evil 
 we should have been compelled to describe in Book II no less 
 than sixty-three cases, for the purpose of illustrating all pos- 
 sible combinations (sixty- four minus one). And if the world 
 had been still more complex and had yielded up seven kinds of 
 trouble, our exposition in Book II would have had to contain 
 no less than one hundred and twenty-seven cases (the one 
 hundred and twenty-eight mathematically possible combina- 
 tions minus the null case in which all seven kinds of trouble 
 were by hypothesis non-existent!). 
 
 We must eternally insist that such analyses as we make in 
 this volume, and particularly the analyses of Book II, must be 
 made after all the facts are in hand. By no means do we 
 lay down any principle to the effect that the practical social 
 worker shall practically collect the case data in the order in 
 which these data are later to be analyzed. It might be signally 
 unwise to fly at the situation with questions concerning health, 
 educational status, moral trends, legal entanglements, before 
 
392 THE KINGDOM OF EVILS 
 
 the worker had got in hand the main facts about the economic 
 level of the case or of the family. There must be a proper 
 technique of approach for every case as to the collection of the 
 data. Some points and categories in this connection are of- 
 fered in Richmond's Social Diagnosis. We offer in this book 
 no especially new points as to the technique of the collection 
 of social data. Especially with psychopathic cases the appli- 
 cation of any rigidly set method for the collection of the facts 
 might prove injurious, not necessarily to the patient himself, 
 but to the accuracy and speed with which the data are collected. 
 There are some facts which only the extraordinary authority 
 of the courtroom is likely to extract. There are other facts 
 which a judge, however learned, can never hope to unearth by 
 the tools at his disposal. Again it is most obvious that there 
 are many facts that only physician or pastor in consulting room 
 or vestry can obtain. Experience also abundantly proves that 
 there are many facts that physicians and pastors, or even both 
 together, cannot by any means secure. Some of these facts 
 the social worker, especially the woman worker, can elicit by 
 methods which cannot, or at least in this place cannot, be de- 
 scribed. And we are quite ready to admit that some facts can- 
 not be dragged out of some patients by wild horses. That 
 experience with mental cases, stretching over a period of sev- 
 eral months or years, gives the professional social worker far 
 more insight into the technique of quickly securing the intimate 
 facts most useful for the patient's successful treatment, cannot 
 be denied. It is on this account that we elsewhere in this sum- 
 mary insist on the importance of placing in the practical por- 
 tion of every social worker's training a certain amount of ex- 
 perience with mental cases. We shall also point out that to give 
 the proper basis and background for the interpretation of such 
 experience with mental cases, the ideal curriculum of every 
 social worker {zvhether or not the worker is going practically 
 into the field of psychiatric social work) ought to contain a 
 strong didactic part dealing with mental diseases and defects 
 and including the mild psychopathies, eccentricities, and devia- 
 tions from the normal. Dr. G. L. Walton some years ago en- 
 deavored with more or less success to get the term degenerate 
 replaced with the term deviate. Not only was Walton's new 
 standpoint theoretically well based, but there was nmch prac- 
 tical wisdom in these suggestions by the genial author of Why 
 
THE KINGDOM OF EVILS 393 
 
 Worry. For it is much easier to persuade or convince an 
 everyday person that he is perhaps a Httle deviate than to show 
 him that he is a httle degenerate ! In short not only v^ould the 
 mental hygiene of the social worker be improved by a study 
 of mental cases as they practically occur in everyday life, but 
 so also would benefit accrue to the mental hygiene of every- 
 body else. 
 
 Let us picture the social worker returning from the day's 
 work in a reflective state of mind. Let us suppose that the 
 social worker is thinking over all that is now known as the 
 result of, say, twenty-five hours of contact first and last with 
 the case and its surroundings. In describing the method of 
 Book II in a practical way to elementary workers at the outset 
 of their training, we have sometimes recommended to them 
 the following simple device. Let the worker count off upon 
 the fingers of the left hand (the hand conveniently for our 
 present purpose called sinister) the facts as conceived. Upon 
 the thumb let there hang the diseases and defects of the patient 
 and of related members of the family, in fact all more or less 
 non-hygienic features of the situation, including very particu- 
 larly even the slightest mental disorder or defect. Secondly, 
 Tipon the index finger let there be suspended all the forms of 
 ignorance which the patient and the persons around him ex- 
 hibit, so far as these afifect the situation; and let these data 
 include, not merely lack of education, language difficulties and 
 the like, but also all positive misinformations and errors of 
 point of view, so far as these are of intellectual origin. Upon 
 the longest or middle finger let there be strung whatever there 
 is of moral defect (of course not psychopathic and not merely 
 a matter of ignofance), including all sorts of vices and bad 
 habits and many of the so-called sins of theology and common 
 sense. Upon the ring finger there may be placed all sorts of 
 legal entanglements, whether in the nature of crimes and de- 
 linquencies on the part of the patient or on the part of his 
 associates, whether actually subject to court review or poten- 
 tially so subject. There remains the little finger upon which 
 to dispose all such matters as pauperism, poverty, and other 
 forms of resourcelessness. It is the province of Book II to 
 show cases combining all these forms of social trouble in vari- 
 ous ways. If it were quite certain where the trouble of each 
 concrete case should be classified, the task would be relatively 
 
394 THE KINGDOM OF EVILS 
 
 simple. For example in practice many social workers are in- 
 clined to ascribe to ignorance much that ought to be called 
 feeble-mindedness. Elsewhere we have given other instances 
 of the improper placement of concrete facts in these groupings. 
 Practical experience goes a good way towards abolishing these 
 errors of the social worker. The didactic part of any curricu- 
 lum can never be counted on to prevent such errors. Frequent 
 conferences are necessary to keep the workers on the right track 
 during their practical experience. 
 
 Book II shows the advantage of considering social facts in 
 a definite order. Everybody will concede that some order is 
 better than no order, and everybody knows that a brief list can 
 be borne in mind better than a long list of categories. We do 
 not want to dogmatize about our plan. The future may well 
 yield up a better order for the consideration of social facts; 
 but we are inclined to prophesy that social work, so far as it 
 remains a systematic and scientific affair, will surely cling to 
 some order rather than no order in its analysis of the facts 
 in hand. Again the social work of the future may provide 
 a quite different list of categories than the fivefold list of evils 
 discussed in Book II; but we are inclined to predict that the 
 final list chosen by the perfected art of social work will not be 
 a long list of categories, and probably not much longer than 
 our own fivefold grouping. The very fact, which was pointed 
 out above, that six items would require sixty-four separate set- 
 ups of social fact to illustrate the possible combinations of the 
 six items, means that the social worker would find her sixfold 
 load too great to bear. 
 
 Be it remembered, as developed a little further on in this 
 summary, that oftentimes the difficulties are not merely sepa- 
 rate items added to one another to form a mere heap of sep- 
 arate facts, but that in numberless instances the evils multiply 
 themselves into each other in a bewildering way. Let the social 
 worker think for a moment of the extraordinary complications 
 which may ensue when poor moral training is combined with 
 psychopathic trends. In the body of the book we have abun- 
 dantly demonstrated the production of social difficulty of this 
 higher order. A patient combining in himself the effects of 
 poor moral training and the effects of psychopathic tendencies 
 may fall into such a status that neither measures of moral 
 reform nor the procedures of medical treatment will serve to 
 
THE KINGDOM OF EVILS 395 
 
 remove any important fraction of the trouble. For such in- 
 timate comphcations of combined moral and psychopathic 
 trouble, the experts of the future will be required to find com- 
 binations of moral and medical training and treatment not yet 
 dreamed of. 
 
 We must acknowledge, too, that the perfect art of social 
 work might well in the future shorten the list of categories. 
 There is a widespread tendency amongst social thinkers to re- 
 gard immorality and crime as forms of disease. We believe 
 that no serious philosopher of the social life is today willing 
 to concede that either vice or crime is in the bulk ready to go 
 over to the group of diseases. The Vitia and the Litigia are 
 not soon, if ever, as a whole to go over to the Morbi. (We 
 do not deny that many instances of so-called Vitia really be- 
 long in the group of Morbi. But that is a matter of erron- 
 eous diagnosis in the given instance, and not a matter of scien- 
 tific reclassification of Vitia as Morbi. And a like argument 
 holds for various Litigia. It is worth incidentally consider- 
 ing that the jurists ought increasingly to admit that many of 
 their Litigia or conditions of being "at-law," would be thor- 
 oughly resolved if the medical and mental aspects of one or 
 more parties in the case were to be recognized. Nor are signs 
 lacking that, with the tremendous increase of the idea of in- 
 dividualization in at least the criminal part of the law, the 
 jurists will come to see the point of psychiatry.) But we must 
 theoretically allow the possibility of the telescoping of our list. 
 If the list could be telescoped by so much as the subtraction 
 of one item — for example, the item of poverty and the like 
 (what we here call Penuriae), there would be but sixteen 
 major combinations of the four remaining great items rather 
 than the thirty-two which form the basis of our studies in 
 Book II of this volume. With the unlocking of great and 
 increasing amounts of energy from the universe by modern 
 research, there can be no doubt that pauperism, poverty, and 
 other forms of resourcelessness, here termed Penuriae, are 
 undergoing a decline slower than we might wish but faster 
 than some congenital pessimists readily acknowledge. Some- 
 one, the other day, claimed that the science of the last few 
 hundred years, and especially of the last century, had blessed 
 the human being on the average with an amount of energy 
 equal to that of, say, some thirty body slaves (the analysis 
 
396 THE KINGDOM OF EVILS 
 
 presumably took into account the great reservoirs of electric, 
 chemical, and thermic energy which we see displayed about 
 us so profusely, though perhaps irregularly, in the great cities). 
 Every social worker, like every other good citizen, should 
 support with all that is in him the cause of scientific research, 
 to the end that more and more energy be unlocked from the 
 infinite quantities available to man. A doubling of the amount 
 of energy unlocked in the last few hundred years ought to 
 diminish the tale of the Penuriae to a very visible degree. 
 Available slave power in non-human forms would bring back 
 at least the memory of the Golden Age. 
 
 For the moment, no social worker can hope to put the 
 Penuriae out of mind or to lose contact with any other of 
 our five categories of social evil. To be sure, in large sections 
 of the American community there is less and less evidence of 
 the effect of raw ignorance or of the result of any other forms 
 of the group that we have called Errores. Literacy rules 
 in many communities and illiteracy is a problem that can be 
 far more readily surrounded, it would seem, than the problem 
 of the vices and bad habits (Vitia) or of many forms of dis- 
 ease ; for example, cancer and mental disease. It has been a 
 matter of curious observation with the authors how relatively 
 few instances of the pure and uncomplicated effect of igno- 
 rance could be found in the Psychopathic Hospital material 
 which lies at the basis of this book. Language difficulties 
 were of course frequently in evidence. The misdeeds of quack 
 doctors and their advertisements turned up now and again in 
 the shape of misinformation distinctly hurtful to our patients. 
 Some instances of the evil effect upon the intellect (as well, 
 of course, as upon the morals) of the movies were discovered 
 in certain patients. Sundry housewives had plainly not been 
 taught the rudiments of good housekeeping by their parents 
 or guardians, and extraordinary success in their social treat- 
 ment was found to follow the education of these patients in 
 very simple procedures. Education serves to remove the bodily 
 filth characterizing sundry immigrants, so that the members 
 of the filial generation look with genuine horror on habits of 
 the parental generation. We are willing to acknowledge cer- 
 tain prejudices born doubtless of our special experience, and one 
 of these prejudices runs in the direction of assigning not quite 
 so much weight to the virtues and importance of education as 
 
THE KINGDOM OF EVILS 397 
 
 its worthy devotees are likely to assign. We here allude to edu- 
 cation in its narrower, intellectual sense, rather than in the 
 broader usage of education to cover moral as well as mental 
 factors. Our prejudice runs to the claim of far greater value 
 for moral training than for intellectual teaching. It has be- 
 come a commonplace with many modern observers that the 
 senses are easier to educate than the emotions are to train. 
 The senses are after all a somewhat simpler affair than the 
 emotions; for the latter dig very deep into the "skin and its 
 contents." Those, however, who observe the wonderful re- 
 sults of animal training whether by the technique of terrorism 
 or by the technique of tact, can only be optimistic as to the 
 powers of man to form character. Man can no doubt form 
 character more easily than he can reform character. Man 
 can build and turn his temperament in a variety of ways far 
 more easily than he can reform and divert his temperament 
 after its dilapidation or distortion. 
 
 Up to this point we have argued that some arrangement 
 of social facts was better than no arrangement, that a short 
 list was superior to a long list, and that a further abbreviation 
 of our present list was devoutly to be hoped for but hardly 
 to be expected. Let us now ask the further question, Is there 
 a warrant for terming the present list of five forms of evil 
 a sequence rather than a list? If some order is better than 
 no order, why do the forms of evil listed as we list them fall 
 into this particular sequence? The particular sequence we 
 have adopted is a much more doubtful affair than the prin- 
 ciple of the sequence itself. The social thinker might well 
 accept the principle of the sequence of evils in this book with- 
 out wanting to adopt the order chosen. Why should the social 
 worker, it might be questioned, always begin with the topic 
 of disease? Why not begin with the topic of morals, or the 
 topic of poverty, as being the prime logical factor in the par- 
 ticular case in hand? Of course nobody will doubt for a 
 moment that psychopathic hospital material by and large de- 
 mands and must demand prime consideration for disease. 
 Indeed it is plain that medical social work as a whole demands 
 prime consideration for disease, if only because the patients 
 that come up for social treatment are sick patients. But, the 
 general social worker may inquire, why, in the non-medical 
 and non-psychiatric field, should the consideration of disease 
 
398 THE KINGDOM OF EVILS 
 
 SO inevitably come up; and why in particular should we think 
 of disease in the beginning rather than in some subordinate 
 place? There are a number of good reasons that we might 
 adduce for our choice. For example, we might claim that 
 the social worker who fixes her mind on the illiteracy in the 
 social situation so frequently forgets the feeble-mindedness 
 or slight subnormality of her patient (or even of several mem- 
 bers of the family) that all sorts of effects get erroneously laid 
 at the door of ignorance rather than of mental defect. If a 
 social worker gets firmly fixed in mind at the outset of her 
 work some apparent instances of the effect of ignorance, she 
 may never during the rest of her social work be able to forget 
 that initial concrete instance. She gets dazzlingly in mind the 
 idea of education for all, thinking that education will solve 
 every problem of apparent ignorance as well as every problem 
 of real ignorance. But if this selfsame social worker raises 
 the question of feeble-mindedness or subnormality in the situa- 
 tion she faces, she will time and again be rewarded with a 
 point of view entirely new to her; that is, with a medical and 
 mental point of view, which as a child and in her youth she 
 had no means of grasping. 
 
 Again, there are still social workers who have their minds 
 fixed on pauperism, poverty, and other forms of resourceless- 
 ness (in this book summed up under the term Penuriae) and 
 leap to the explanation by defect of wages or compensation 
 of all the difficulties in the case. We hinted above, this idea 
 was no doubt the idea in the minds of the earlier philan- 
 thropists. Although no doubt the early workers in the field of 
 social science in our country recognized that not all history 
 could be given an "economic interpretation," yet the supporters 
 of philanthropy were perhaps more informed with the idea 
 of helping out the resourcelessness of their less fortunate 
 brethren than penetrated with the. ideal of consciously altering 
 the entire hygienic, educational, moral, and legal orders. 
 Financial relief is today so much more obvious than legal aid, 
 moral training, intellectual teaching, and medical care, that 
 not a few workers virtually stop in their minds with the idea 
 of monetary aid for their problems. At least we can help out 
 with money, is their feeling. With money we can get for our 
 sick ones proper medical care. As for education, that is now 
 largely a matter of public service. How barren and abstract 
 
THE KINGDOAI OF EVILS 399 
 
 seem the suggestions for moral training and legal counsel that 
 we have to offer! There is no doubt a certain truth at the 
 bottom of this idea of primacy of so-called "poor relief" in 
 social work. We are all aware that even in the advanced 
 community where a charity organization approaches perfec- 
 tion, there are very many instances in which pauperism or 
 severe degrees of poverty fail to get duly met. Such situa- 
 tions in rural communities can almost be left to the unin- 
 structed neighbor. In the urban community, the organization 
 of charity is, so far as poor relief is concerned, undeniably a 
 statistical success in places. (We do not here refer to any 
 questions of the general raising of the wage level or of other 
 methods than wage-control for establishing the entire com- 
 munity on a higher terrace of wealth and resourcefulness. We 
 can only hope that in the end the slumless condition of cer- 
 tain of our middle western towns and cities can be made to 
 extend the world over, perhaps by the process of scientific in- 
 vestigation, for which the National Research Council, de- 
 veloped in our country during the war and paralleled by simi- 
 lar organizations in several belligerent countries, so boldly and 
 efficiently stands.) But we are entirely sure that the social 
 worker who leaps to the idea of poor relief is rather apt to 
 get breathlessly impaled thereon. She is apt to remain quite 
 incapable of giving due emphasis to the possibility of these 
 other factors, of disease, of ignorance, of immorality, and of 
 legal entanglement, as vv^hole or partial causes for the out- 
 standing poverty. We felt compelled practically to place the 
 Penuriae at the bottom of our sequence of evils. 
 
 Assuming that the Penuriae, that is, poverty and other 
 forms of resourcelessness, may well be placed at the bottom 
 of our sequence, is it not possible to argue that some other 
 group than the Morbi (diseases) ought to be placed first? 
 Certainly not ignorance, as was above argued but — and here 
 we approach the crux of many faulty points of view, to our 
 thinking — would it not be wiser to consider any given par- 
 ticular bad social situation as probably the effect of immoral- 
 ity or of bad habits, rather than of, say, disease? Should 
 not the Vitia head the list? Everybody who has passed 
 through childhood at all recently or has the childhood experi- 
 ence vividly in mind, knows and feels the immense and almost 
 universal values of moral training, and almost everybody finds 
 
400 THE KINGDOM OF EVILS 
 
 in his life a smaller or larger trace of some great moral mis- 
 take touching some portion of his life. Most of us, as the 
 years travel on, get a bit of cynicism or a slice of fatigue about 
 our own possible reformation of character. But we see vari- 
 ous persons about us whose characters are undergoing a trans- 
 formation and we are irresistibly led to think how these neigh- 
 bors of ours might rather cleverly be reformed by simple 
 devices, and how many of them might have their characters 
 built and molded anew with the proper models for imitation 
 and the proper tools of training in hand. If our neighbor 
 gets drunk we think of him as probably addicted to a vice — 
 the vice of inebriety. We do not at the very first inquire 
 whether he has not some character defect or is not the victim 
 of some early misapprehension as to the values of a little wine. 
 If the neighbors' children write impossible legends on our 
 backyard fences, we are apt to regard the children as vicious, 
 and we do not charitably trace out the ignorance of their 
 parents or even the feeble-mindedness of parents or children. 
 We feel that the perpetrators of these vices, these ''sinners," 
 ought to be morally trained or reformed. We know instances 
 of the successful training or reformation of just such persons. 
 We run to the hypothesis of immorality, vice, or bad habits 
 forthwith, and practically on a basis of our own experience. 
 We see in these "sinners" precisely ourselves, and — charitably 
 or maliciously, according to our natures — we would like to 
 have these persons given what in our American slang is some- 
 times termed a "course of sprouts." Now "sprouts" is a most 
 optimistic term for the plight of our neighbors, who may be 
 in no condition to allow the new growth of moral ideas by 
 reason of mental twist or lack, by reason of mere ignorance 
 of the socially good. Now it is plainly most uncharitable and 
 itself well-nigh a form of immorality to charge up vice and 
 sin to a mentally defective or merely ignorant person. It is 
 the charitable and right thing to raise the hypothesis in every 
 serious case of social maladjustment whether the center of the 
 situation may not be medical (and often actually psychopathic) 
 or mental (in the sense of misinformation on the part of the 
 supposedly sinful or immoral person). It is assuredly not 
 more "insulting" to charge an alleged sinner with disease, 
 bodily or mental, than to charge him with vice or sin. To 
 be sure, the layman when he thinks of disease is rather apt 
 
THE KINGDOM OF EVILS 4OI 
 
 to think of severe disease, and when he thinks of moral defect, 
 he is apt to think of mild defect. This is no doubt because he 
 bears in mind only his own severe diseases and only his own 
 mild moral difficulties. In short, the average citizen thinks 
 of disease with a feeling of terror, and of vice with a leaning 
 towards exculpation. He thinks of himself as just a little 
 sinful and of his neighbors as equally excusable. 
 
 But whether this ethical account of the average citizen's 
 attitude on these matters be a correct one or not, there is to 
 our minds no doubt in the world that the serviceable formula 
 for the social worker to bear in mind is to think of each social 
 situation as possibly bearing within it a kernel of disease, espe- 
 cially of mental disease, and particularly of the mildest forms 
 of mental disease known as temperamental deviations and 
 mere eccentricities. If the social worker analyzes her situation 
 from the standpoint of these contained kernels of mild mental 
 deviation and eccentricity, she will gradually lose the terrors 
 associated with the idea of insanity, and will more and more 
 adopt the attitude of William James, which we discussed at 
 length at the beginning of this summary. She will get the 
 psychopathological point of view which the keen spirit of the 
 late Carleton Parker, himself not at all medical in training, got 
 from his practical contacts in living amongst laborers and 
 miners. Carleton Parker, though an economist, got the point 
 of what might be termed the "psychopathic interpretation of 
 history" as opposed to the long famous "economic interpreta- 
 tion of history." Nor will the reader of this book mistake 
 our meaning when we use the phrase "psychopathic interpreta- 
 tion of history." We do not mean an interpretation of history 
 as a product of psychopaths. We mean that history (at all 
 events, the history of our individual instances of maladjust- 
 ment) can best be interpreted by the technique which starts 
 from the outset to observe the minor deviations and 
 variations, the differences and the contrasts, rather than 
 the similarities and the analogies that so fill the mind of 
 the observer of "averages." 
 
 There will, we think, be far less objection to our ordering 
 of other factors than the ones just discussed ; namely, the or- 
 dering of Penuriae, the Morbi, and the Vitia. If a man is 
 not in full possession of his bodily and mental health, it is 
 just a little idle to discuss at length the quantity of his knowl- 
 
402 THE KINGDOM OF EVILS 
 
 edge and the quality of his wisdom. But if a person is not 
 mentally healthy and reasonably well informed, no doubt in- 
 quiries as to his moral turpitude are a bit futile. Again, if 
 we do not know a man's health, education, and morals, how 
 can we adjudge the nature, cause, effect, and manner of 
 extrication of his legal entanglements? Finally, if we do 
 not know the medical data, the educational status, the^moral 
 tendencies, and the civil standing of the man, how can we 
 sensibly talk about his economic level? 
 
 We assume that the reader is now thoroughly convinced 
 that some order in social case analysis is better than no 
 order; that a short list of categories is better than a long 
 list ; and that our sequence has a good deal to recommend 
 it, both from the practical standpoint of psychiatric and med- 
 ical work, and from sundry more general standpoints. But a 
 more general question may be raised. Why do we advocate 
 the analysis of evils at all? Why discuss liabilities instead 
 of assets? Why discuss negatives instead of positives? We 
 might answer and remain content with the answer, that it all 
 amounts to the same thing, and that what looks like a re- 
 mainder is as a matter of fact a sum. Or again, we might an- 
 swer that much depends upon the point of view. That is, we 
 might say that some persons like to analyze from the side of 
 evil, and others like to analyze from the side of good, and 
 that we are writing for those who prefer in the first instance 
 to slay dragons rather than to seek the Grail. No doubt we 
 should be on very safe ground if we claimed the existence of 
 these two temperaments ; the temperament of the dragon- 
 slayers and the temperament of the Grail-hunters. Moreover, 
 we might point out that the dragon-slayers have perhaps in 
 the past secured as many Grails as those who started Grail- 
 hunting from the first. 
 
 IV 
 
 COMPARISON OF THE KINGDOM OF EVILS WITH OTHER SCHEMES 
 OF SOCIOLOGICAL ANALYSIS 
 
 Our attention has been called to a formula of Malthus, re- 
 sembling in its categorization our own grouping of the evils. 
 Malthus, like his father (a friend and executor of Rousseau) 
 was in a sense a perfectibilian. He thought that societies tend 
 
THE KINGDOM OF EVILS 4O3 
 
 to happiness but have been checked by miseries due to an in- 
 crease of population. He showed that the positive checks to 
 the increase of population were war, vice, crime, disease, and 
 poverty. Four of these five Malthusian checks upon the in- 
 crease of population roughly correspond with four of our own 
 categories. It will be easy to show, we think, that war is in 
 itself by no means a category quite so simple as any of the 
 other four. No doubt also Malthus would have been happy 
 to acknowledge that ignorance was a great cause of an over- 
 increase of population. Indeed Malthus or any other theorist, 
 following Socrates, might well feel that ignorance lay at the 
 bottom of several of our own categories. Population some- 
 times increases, sometimes decreases. It would be equally 
 easy to show, we think, that either the Malthusian five cate- 
 gories or our own might be as capable of decreasing popula- 
 tion as of increasing it. To claim that the increase of popula- 
 tion or the decrease of population is in itself an evil is some- 
 thing like the claim that superficial thinkers might make that 
 war is an evil. It is indeed unwise to assert that any condi- 
 tion is or is not intrinsically an evil. It is far better to weigh 
 observed conditions or factors in the light of a set of categories 
 like the ones suggested. 
 
 Malthus, it will be recalled, used the phrase "struggle for 
 existence" in relation to social competition. Here again 
 is a phrase that suggests that a given condition can be set 
 down as essentially an evil or as essentially a good. The idea 
 that the struggle for existence was not all happy was repug- 
 nant to sundry theologists, when Darwin gave reflected luster 
 to Malthus in his new contentions concerning evils. On the 
 other hand it would seem that German thinkers, say of the 
 Ernst Haeckel stripe, might w^ell find the struggle for exist- 
 ence in no sense an evil, but think it rather a good. 
 
 It seems to us that this concept of the struggle for exist- 
 ence also will greatly benefit from an analysis of what 
 might be called its evil constituents. We might find that 
 the pathology of the individual was a negligible factor in that 
 development. We might fi.nd the struggle for existence a 
 function of intellectual development in different species and 
 describe it in plain terms in an attractively simple fashion. We 
 might note the moral values of the struggle for existence or 
 again the vicious effects of centering one's life upon rnere 
 
404 THE KINGDOM OF EVILS 
 
 existence. We might study law and order in its lowest terms 
 (insect life) or work upon the human level, and again find 
 components of a constructive and beneficent nature and com- 
 ponents of a destructive, maleficent nature. The field of eco- 
 nomics would also blossom under this double analysis. Dar- 
 win believed that the struggle for existence greatly aided man 
 and that his rapid multiplication was largely responsible for 
 his success in the world. He fully conceded the values of 
 these moral influences that in the end supersede the simpler 
 factors. Still, even upon the moral level, Darwin was inclined 
 to depreciate measures which would reduce the natural ratio of 
 increase for man. On the whole, he took an anti-Malthusian 
 view of man's multiplication in the world. A blanket view 
 of the evils or of the excellence in to to of increase or decrease 
 of population within prescribed limits is, no doubt, apt to be 
 an erroneous view. The analyst will benefit himself and the 
 world if he clearly conceives in his own mind whether he is 
 analyzing for forms of evil or for forms of goodness in the 
 heap of factors that he sees before him. Having made his 
 major decision as to whether he is studying the negative, 
 privative, and destructive factors or the positive, additive, and 
 constructive factors in his world, the analyst will further bene- 
 fit by an orderly approach in his study of particular situations. 
 The five checks of Malthus upon the increase of population 
 which we found so nearly to correspond with our own five 
 categories were, no doubt, not original with Malthus. Many 
 of his arguments were derived from thinkers like David Hume, 
 Adam Smith, and Montesquieu. The same set of categories 
 with various additions will be found amongst modern 
 writers. Thus Small classifies the interests of man un-'^er six 
 headings ; namely, health, wealth, sociability, knowledge, 
 beauty. Tightness. It will be observed that these six cate- 
 gories fairly well correspond, though in a different order, with 
 our own five categories. 
 
 We have omitted any craving for beauty and its lack of 
 satisfaction from amongst our categories, not because it is 
 non-existent, but because to the practical adult ugliness seems 
 not to be a primary or highly important evil in the world of 
 social difficulty. Small himself can find hardly more than a 
 paragraph of ideas concerning the beauty interest of man ; he 
 quotes from Schiller and is virtually clone. There seems to 
 
THE KINGDOM OP EVILS 4O5 
 
 be no completed esthetic theory amongst philosophical doc- 
 trines even at the present day. The majority of the esthetic 
 dissatisfactions which we have found in our social case work 
 can rather readily be placed amongst the Errores as matters 
 of misinterpretation or misinformation: in fact that Platonic 
 theory of beauty which reduces it to a kind of harmony is a 
 theory very consistent with the practical placement of the 
 ugliness evil in our group of Errores, but in any event the 
 esthetic dissatisfaction is at the present day wholly upon a 
 practical level of investigation. Small quotes from Emerson's 
 essay on Resources an interesting passage which we give be- 
 low, a passage which also omits from its categories the 
 esthetic. This is the more remarkable as Emerson was doubt- 
 less more a litterateur than a philosopher or at all events was a 
 I'itterateur of first magnitude. 
 
 Ross has quarreled with Small's groupings on a variety 
 of grounds. He sees the main interests in man, hunger and 
 love, as specific demands of man, not at all to be covered in 
 under the designation, "desire for health," and points out that 
 health is more of a sine qua non than an object of desire as an 
 end. Concerning the latter point we would commend the 
 placement of health first in Small's series of desires — a place- 
 ment analogous to our own placing of the Morb'i at the head 
 of our own list. Furthermore we would take advantage of 
 Ross's critique of Small to point out that, when the morbid 
 side of nutrition and of reproduction comes into view, Ross's 
 objection to Small's grouping to a great extent falls away. 
 We may not regard hunger and love as items in our health 
 program, but when there is disease affecting nutrition and 
 reproduction, certainly these particular categories do impera- 
 tively cry for attention. 
 
 The desire for wealth (Ross again asserts) is not a pri- 
 mary desire but depends upon a still more fundamental opera- 
 tion of the ego (so-called egotic desires of Stuckenberg) ; but, 
 if we approach the wealth or economic question from its nega- 
 tive and privative side {i.e., from the standpoint of what we 
 had termed the Penuriae or resourcelessnesses) we shall find 
 that by changing our point of view we have escaped this par- 
 ticular critique. The desire for wealth may not "dififer in 
 principle," as Ross says, "from the lust of lordship over per- 
 sons (power), or lordship over man's admiration (glory), 
 
406 THE KINGDOM OF EVILS 
 
 or lordship over man's judgment (influence)" ; but where there 
 is absolute resourcelessness, the very ego itself is hindered in 
 its progress. Resourcelessness hurts life, as one may say, 
 more than increasing resourcefulness helps life. This is at 
 least true on any particular level of attainment. By setting 
 the mind on the sort of Grail that some men take wealth to be, 
 we may miss various dragons of resourcelessness that could be 
 readily slain. 
 
 Ross objects to Small's category of sociability on the 
 ground that the craving for companionship is one sort of thing 
 and an eagerness for appreciation quite another sort of thing. 
 But again consider this phenomenon of sociability in its nega- 
 tive form (as one might say, dissociability). The craving for 
 no companionship amounts to an almost psychopathic trend of 
 seclusiveness,^ or is at all events a vicious attitude or bad habit 
 which helps neither the race nor the individual. Again an 
 absence, like an excess, of desire for appreciation would form 
 an important attitude of viciousness or a bad habit sometimes 
 developed in degree or kind almost to the point of mental 
 disease. 
 
 Concerning Small's categories of knowledge and rightness, 
 Ross makes no particular objection. We can see, then, that, 
 in general, Ross's strictures concerning Small's categories can 
 be readily avoided by change of point of view from the analysis 
 of those interests as positive to an analysis of them in their 
 negative or privative form. Had Small taken the pathological 
 view he would, we think, have uncovered rich leads in the 
 analysis of society. 
 
 The passage from Emerson mentioned above is at the end 
 of his essay on Resources and runs as follows : — 
 
 "But the one fact that shines through all this plenitude of 
 powers is, that, as is the receiver, so is the gift; that all these 
 acquisitions are victories of the good lirain and ])rave heart ; 
 that the world belongs to the energetic, belongs to the wise. It 
 is vain to make a paradise for good men. The tropics are one 
 vast garden ; yet man is more miserably fed and conditioned 
 there than in the cold and stingy zones. The healthy, the 
 
 CIVIL, THE INDUSTRIOUS, THE LEARNED, THE MORAL RACE 
 
 Nature herself only yields her secret to these. And 
 the resources of America and its future will be immense only 
 to wise and virtuous men." 
 
 ' The name of a familiar symptom in psychiatry. 
 
THE KINGDOM OF EVILS 407 
 
 There are thus five kinds of thing that are essential in the 
 Emersonian search for Nature's secret. But it is interesting 
 to note the order in which Emerson has put the assets of the 
 favorites of Nature. He gives the honorable first and last 
 places to health and morality, but as he sums up the whole 
 situation concerning the resources of America in the future 
 he considers that wisdom and morality are, after all, the great- 
 est aids to the unlocking of the immensest resources of his 
 country. Health he too would regard as indispensable and 
 may on this account put it first amongst the qualities of the 
 race to which Nature will yield her secret. That a race shall 
 be civil, that is a race under government and law — here also 
 is an indispensable rather than an essential from Emerson's 
 standpoint. To be industrious was doubtless also to the New 
 England mind of Emerson a mere indispensable rather than 
 an essential. Upon the basis of three indispensables, 
 health, civic order, and industry, Emerson builds the more 
 essential science and morals. 
 
 The Emersonian ordering of these five categories is as well 
 thought out as it is sublime in implications. The Emersonian 
 order is, no doubt, the important order leading from the in- 
 dispensables to the essentials in human endeavor. But, from 
 the standpoint of the analysis of a world run down or of a 
 bad social situation, it may w^ell be that this order is not the 
 best one. Lack of health remains a primary consideration, but 
 ignorance, misinformation, and misinterpretation have far 
 wider scope than the operations of organized law and indeed 
 are found at work in the innermost sanctums of private life, 
 where they destroy morality, render legal advice useless or 
 harmful, and are a prolific source of resourcelessness in 
 themselves. 
 
 To be healthy, wealthy, and wise is the desire expressed in 
 an ancient adage. To be healthy is as always indispensable ; 
 but hardly any reflective person would rather be wealthy than 
 wise. For our part we are inclined to place education next 
 in order upon the indispensable lower layer of health, not be- 
 cause virtue has really been proved to be knowledge, but 
 because without a healthy and trained intelligence it is im- 
 possible to meet successfully the complex moral problems that 
 compose so large a part of the field of social work, not to say 
 of the world's work so far as it concerns the individual. 
 
40S THE KINGDOM OF EVILS 
 
 DEFINITIONS OF THE FIVE GROUPS OF EVILS 
 
 We have thought it worth while to set down in a special 
 part of this general discussion some approximate definitions 
 of evil and its major groups. Elsev/here we refer briefly 
 to certain philosophical viewpoints about the nature of evil in 
 general. Here our statement must confine itself to a few 
 phrases. 
 
 The term evil itself seems to be related in root to the words 
 up and over. Ev and ov of evil and over respectively stand 
 very close from the standpoint of those who investigate the 
 origin of words. Apparently evil carries within itself more 
 the idea of excess than of defect. This would be the nat- 
 ural view of the early thinkers and word-makers since they 
 would naturally people evil situations with something super- 
 added in the nature of spirits or demons. In fact, in the field 
 of disease itself in relatively recent times there has been a ten- 
 dency to ascribe disease to an Archeus or an Incubus, that is 
 to something thrown in, as it were, on top of the situation. 
 
 By far the greater number of terms which we use for 
 evil are used for positive qualities although there are a good 
 many privative ones. Thus to be evil (following the Century 
 Dictionary) is to be merely "depraved, bad, wicked, vicious"; 
 or again, to be "harmful, hurtful, mischievous, prejudicial, mis- 
 leading, boding ill"; or again, "causing discomfort, pain, or 
 trouble" ; or again, "unfortunate, miserable, wretched" ; or 
 again, "as in reference to misfortune, sorrowful, bad luck, dis- 
 aster." Several of these terms are positive from one aspect and 
 negative (or privative) from another, but apparently the ma- 
 jority of the words are used in the positive sense. We do not 
 need to take a philosophical attitude towards the existence of 
 evil as such in the world. Even if there were philosophically 
 no evil, still these named conditions would exist to be met in 
 some way or other. 
 
 There are also a variety of privative meanings, such as the 
 meaning of being insane, that is of having an "evil head" or 
 again, "unwholesome, of inferior quality, poor, unsatisfactory, 
 defective, unskillful." Evil, in general, is censurable, mischiev- 
 ous, undesirable, painful, disastrous, and the like. It is in- 
 teresting to note that the term "ill" is the same as the word 
 evil by a natural omission of the consonant "v." We would 
 
THE KINGDOM OF EVILS 409 
 
 especially insist that we should not like to have the term evil 
 used for specific evils where it is possible to give it a more 
 exact and specific term such as are to be found under the major 
 subgroups that we describe. The theologians say that the term 
 "evil" is likely to become obsolete. Yet it is used in a number 
 of important places in the Bible. For example, in Genesis we 
 hear of the tree of knowledge of good and evil. In the second 
 book of Esdras the evil is broken in pieces and the good 
 created. 
 
 It will be, as a rule, a confession of relative ignorance con- 
 cerning the fact if all we can say of a situation is that it is a 
 bad one, that it is a maladjusted situation, that it, so to speak, 
 belongs somewhere in the Regnmn Malorum. We must 
 specify further. Our point in speaking of definitions is to 
 insist that the majority of evil's meanings in a practical 
 workaday sense of the term refer to positive rather than 
 to privative badness of situation. 
 
 (a) Morhi: Diseases and Defects of Body and Mind 
 
 As to disease, this term upon its face looks like a priva- 
 tive term for lack or absence of ease, and such terms as 
 uneasiness, pain, distress, trouble, and discomfort are synony- 
 mous of the term as used outside of pathology. Huxley terms 
 disease as "perversions of normal activities of a living body"; 
 but a question might here turn upon what is normal activity 
 of a living body. Sometimes we try to define disease quanti- 
 tatively. We seek to show that it means an excess of some- 
 thing or a defect of something. We gather valuable data 
 about disease from the weights and measures of the organs 
 and tissues and the plotting of curves and their reactions. But 
 those same weights and measures and to some extent the curves 
 of reactions may be found in the dead as well as in the living 
 organism of constituent part of the organism. 
 
 Another way in which it has been attempted to define dis- 
 ease is, first to describe some norm, pattern or model or struc- 
 ture and function, to which a body and its organs are supposed 
 to conform. Here it is not so much a question of weights and 
 measures of the body and its organs as of the conformity of 
 these weights and measures to some standard set. The stand- 
 ard body and the standard organs that constitute it are de- 
 
4IO THE KINGDOM OF EVILS 
 
 veloped perhaps by some evolutionary process. The hypoth- 
 esis would be that that body or organ survived which was 
 of greatest use in the struggle for existence of the species own- 
 ing such a body and such constituent organs or tissues. 
 
 On the whole perhaps it is best to define disease as an inter- 
 ference with the life of the body or of any part thereof or 
 with the persistence of any activity or function of the body 
 and its constituents. Thus disease interferes with life of the 
 body as a whole, which lives or dies. But again disease may 
 affect entire organs and, though it destroy them, may not de- 
 stroy life unless these organs are (as we say) capital organs. 
 But the organs are made up of tissues, great portions of which 
 may die and be either partially or not at all replaced by re- 
 generative processes. Herein would be an example of disease 
 and recovery with defect. There are constituent factors of 
 safety in the make-up of the total organism, so that many 
 elements of it may die without death of the whole. Disease 
 may doubtless affect even the smallest cell of the body, though 
 the study of such minute processes of health and disease is a 
 difficult one. But the lay student must not get too much in 
 mind the idea of an organism, an organ, a tissue, a cell in 
 the structural aspects of all things. He must likewise think 
 of disease as affecting function, of the curves of response to 
 certain stimuli as damagingly in excess or in defect. The 
 holding fast to this idea of the functional in disease is particu- 
 larly necessary in the field of mental disease, where so many 
 of the entities have not been proved to be due to loss of 
 structure. 
 
 The difference between a structural and a functional disease 
 is hard to define. We have spoken of disease as an interfer- 
 ence with the life of vital units (like the cell tissues or organ) 
 and as interference with the persistence of a given function 
 such as breathing, the heart beat, or the food exchange in 
 tissues. Professor Royce once remarked that almost, if not 
 quite, the total meaning he could extract from the term func- 
 tional was the idea of reversibility. A functional disease is, 
 on this definition, a disease whose phenomena are reversible 
 to the state antecedent to the perturbing factor. To ask, 
 then. Is the present situation a reversible one? is often of 
 practical value. 
 
 Disease, then, consists of an interference with the life of 
 
THE KINGDOM OF EVILS 4II 
 
 living Structure or interference with the persistence of func- 
 tions of those living structures. In the former event there is 
 apt to be something discoverable by the microscope, by the 
 more or less elaborate methods of the pathological laboratory. 
 In the latter event, that is, in the case of the interference with 
 the persistence of vital functions, there may be nothing micro- 
 scopically to be found ; perhaps even theoretically nothing need 
 be found by the microscope in pure perturbations of function. 
 
 (b) Err ores: Educational Deficiencies and Misinformation 
 
 Let us turn to a definition of the Err ores. Probably we 
 have often spoken of our group of Err ores under the English 
 term "ignorance." The Err ores do indeed contain a large 
 fraction of pure ignorance whether in the shape of mere lack 
 of education or in the shape of an immigrant's not knowing 
 the language of the country of his adoption. But the Errores 
 contain positive as well as negative terms. A man may be 
 not merely uneducated but actually maleducated in that he has 
 been given actual misinformation. So far as the maleducated 
 man is concerned, we may say, it is no fault of his (that is, 
 we do not lay it up against any vice or bad habit of his or 
 charge it up to disease). To be sure, his teacher may'have been 
 mentally deficient or twisted, or may have been the victim of 
 some vice or bad habit of thought, or may have harbored a 
 vicious design in teaching him certain things. But from the 
 standpoint of the maleducated man himself, he belongs in the 
 group of Errores in an analysis of the total situation. His 
 psychopathic or vicious teacher would have to fall in other 
 categories than those of Errores. But a still more important 
 sub-group of Errores exists. A man may be not merely un- 
 educated or maleducated, but he may be a victim of misappre- 
 hension or given to misinterpretation. To be 3ure, any pro- 
 longed trend toward misapprehension or misinterpretation 
 would doubtless throw one into some psychopathic group. 
 Practically there would be hardly any difficulty in determining 
 that degree or kind of error which falls within the adage "To 
 err is human." We do find the inexperienced social worker 
 charging up to ignorance, misinformation, and misinterpreta- 
 tion much that belongs in the field of feeble-mindedness. With 
 a little more experience, the social worker, as elsewhere inti- 
 
412 THE KINGDOM OF EVILS 
 
 mated, may swing too far in the other direction and find 
 feeble-mindedness where there has been nothing but lack of 
 education or maleducation. Common blunders and mistakes, 
 as well as logical fallacies of reasoning, belong in this group 
 of the Err ores, where they do not argue mental disease itself. 
 
 When Sir Benjamin Brodie says that much of the evil which 
 exists in the world may be traced to mere ignorance, he is, 
 no doubt, functioning as an optimist. As social workers we 
 must see to it that we hew to the line in both directions. Let 
 us never be content with ascribing the situation for long as a 
 mixture of feeble-mindedness and ignorance. Let us analyze 
 these constituents of maladjustment and try to cure or com- 
 pensate the one and educate or reeducate the other. 
 
 In the dictionaries we can find a number of phrases that 
 indicate the sort of thing that should be included under the 
 Err ores, such as experience, lack of information, misappre- 
 hension, misinformation, malinstruction, no schooling, poor 
 schooling, deception, sophistry, unsoundness of argument, mis- 
 taken notions, false belief, delusion (sane), inaccuracy, am- 
 biguity, illiteracy, blunder, misinterpretation. Sometimes the 
 term error is used in a moral sense to indicate a wrong doing 
 or transgression, but to ascribe a sin to a mere wandering from 
 the path is to take away from the sin most, if not all, of its 
 responsibility; it is an over-charitable way of viewing a sin 
 or vice in the eye of the ordinary man. 
 
 (c) Vitia: Vices and Bad Habits 
 
 We now come to that which we shall, no doubt, fail to de- 
 fine thoroughly, namely the group of the J'^itia. One advan- 
 tage of the Latin names here adopted is that they are rather 
 more comprehensive than any single English equivalent. Thus 
 the Morbi we use to include not only disease in the narrower 
 sense but also defect and anomaly. Again we are using 
 Err ores not only in the negative sense of ignorance, but in the 
 more positive sense of misinformation and misinterpretation. 
 Again Vitia is a term which we intend to use more compre- 
 hensively to cover not merely vices but also bad habits. Thus 
 we can see that not merely the most opprobrious vices but also 
 such a bad habit as laziness about brushing one's teeth are to 
 be included under the Vitia. There is an extremely long list 
 
THE KINGDOM OF EVILS 413 
 
 of synonyms and variants upon the ideas of vice and sin which 
 we do not here reproduce. It will repay the reader to consult 
 a good dictionary and trace down a large number of these con- 
 ceptions to their final ramifications in meaning. We have not 
 used the term sin to any extent in this book, because we have 
 regarded this term as a theological term and have not cared 
 to venture into the debatable questions of the kinds and de- 
 grees of theological sin. Still, in a practical view, we regard 
 most of the sins as falling, socially speaking, into our group 
 of the Vitia. Some of them, no doubt, in old times and in 
 certain theological systems of the present day would fall into 
 a field of ecclesiastical jurisprudence (penance questions and 
 the like) and therefore belong in our group of the Litigia, but 
 these considerations have nothing to do with the main thread 
 of our argument, which is quite innocent of theology. 
 
 A practical question to lodge when one wants to decide 
 whether a thing is a disease, a matter of error (in our special 
 sense), or belongs amongst the Vitia, is the following: Is this 
 factor something I should like to cure in a medical sense 
 of the term cure? or is it something I am fain to meet by a 
 process of reeducation? or again is it a factor subject to some 
 process of reformation? We try to prevent disease or to 
 cure it. We try to .avoid ignorance and misinterpretation by 
 teaching or by so-called reeducation. We try to train for the 
 moral life or to reform the immoral. The pragmatic question 
 what ought to be done at this point is often the successful step 
 in analysis. If you can't help wanting to reform Tom's char- 
 acter, whereas you want to reeducate Dick's intellect and are 
 fain to cure Harry's mental deficiency, you may find that you 
 are unconsciously on the right track when elaborate final 
 analysis will fail you. 
 
 (d) Litigia: Legal Entanglements 
 
 As for the Litigia, here is a knotty question which presum- 
 ably none but jurists should strive to answer. It is a nice ques- 
 tion whether being-at-law actually or potentially is always an 
 evil. The legal order seeks to secure a variety of interests, 
 many of which are of positive significance to the man or the 
 community. But nevertheless we conceive that being-at-law, 
 whether in or out of court and whether in esse or in posse is 
 
414 THE KINGDOM OF EVILS 
 
 in some sense a maladjustment. Somehow the whole connec- 
 tion of the law is that of a process for securing order where 
 there was disorder. There may be a legal order which is of 
 purely positive and constructive value to the world. If so we 
 should exclude its processes from our group of the Litigia. 
 Litigia is a term which is much broader than most terms for 
 legal situations. Its usage accordingly allows the inclusion of 
 arbitration and other processes of law outside of the judiciary. 
 Apparently it is the best term available for the situations we 
 are here attempting to designate. A delinquent falls into this 
 group, but delinquency on the part of somebody else than the 
 patient makes also a situation of litighim. There need be no 
 moral attributes (although there may be such) in a contro- 
 versy against the law. Ignorance is, as we say, no excuse in 
 the eyes of the law, so that one may still be involved in Litigia 
 even though one has been ignorant of automobile ordinances. 
 One may inherit legal difficulties as in the celebrated case in 
 Dickens of Jarndyce vs. Jarndycc. 
 
 Enough has been said to indicate the breadth of this con- 
 cept of Litigia, which runs altogether beyond the considera- 
 tions even of law books on personal relations and domestic 
 relations. General social work and much of ordinary medical 
 social work may fail to show much sign, of the Litigia, but 
 the moment one gets into any serious family situation or into 
 any complication of mental disease, there is apt to appear a 
 smaller or larger trace of legal entanglement. The whole con- 
 cept should be subject to a proper definition. No doubt this 
 proper definition will obtain when sociological jurisprudence 
 has been further developed. 
 
 Let us review instances of Litigia that appear in this vol- 
 ume. In thirty-five of our one hundred cases legal entangle- 
 ment of some sort is a major factor of the social difficulty. 
 Minor considerations of legal interest enter into another four- 
 teen cases, — questions of legal commitment (cases 47, 75, 76, 
 yy, 79, 85) ; also matters potentially legal that never developed 
 to the point of legal action, such as instances of illegitimacy 
 (cases 36, 48, 52, 66), non-support (case 78), desertion (cases 
 32, 74), pilfering (case 25). There are then in this book 
 forty-nine cases of possible interest to jurists. We list below 
 the forms of Litigia presented in these cases : — adoption, case 
 12 ; adultery, case 8 ; alcohol and drugs, cases 58, 61, 63 ; arson, 
 
THE KINGDOM Ol^ EVILS 4I5 
 
 case 9; assault, case 97; cohabitation, case 81; commitment, 
 cases 47, 75, y6, yy, 79, 85; damage suit, case 7; deportation, 
 cases I, 5; desertion, cases 32, 74; sex disguise, case 23; 
 divorce, cases 13, 17; forgery, cases 2, 80; guardianship, case 
 70; illegitimacy, cases 36, 48, 52, 66; juvenile delinquents, cases 
 20, 31, 65, 84; murder, case 54; neglected child, case 22; non- 
 support, cases 4, 2)7 y 7^; pilfering, case 25; sexual assault, 
 cases 15, 92; stealing, case 3; technical deserter, case 29; va- 
 grancy, cases 51, y2; "work or fight," case 26; workmen's com- 
 pensation, cases II, 19, 90. 
 
 {e) Penuriae: Poverty and Other Forms of Resourcelessness 
 
 We have insisted throughout upon the fact that our group 
 bi Penuriae includes not merely poverty in the everyday sense 
 of that term but also all other forms of resourcelessness, which 
 can be defined as belonging to any one of the other categories. 
 A man might be wealthy in the technical sense of a bank ac- 
 count, but be placed in a desert or on an inaccessible island. 
 He would be then resourceless. In the wake of wars such non- 
 pecuniary resourcelessnesses are to be found. 
 
ERRORES 
 
 Trust in Inadequate Authority 
 Force of Custom 
 Opinion of Inexperienced Crowd 
 Parading of Superficial Wisdom 
 
CAUSES OF ERROR 
 
 It was Roger Bacon (c. 1214-c. 1294) who dealt systemat- 
 ically with the causes of error ; namely, the four Offendicula. 
 These causes of error were: (i) trust in inadequate authority, 
 (2) force of custom, (3) opinion of the inexperienced crowd, 
 (4) concealment of real ignorance by a parading of superficial 
 wisdom. Of these four errors the fourth was to Roger 
 Bacon's mind the most dangerous. The concealment of down- 
 right ignorance by a pretense of knowledge was perhaps the 
 cause of all the others. Apparently Bacon had no doubt that 
 some kind of knowledge would be available to everyone. What 
 he feared far more was the foisting upon the world misin- 
 formation; he apparently felt that the fourth of the Offen- 
 dicula, the parading of superficial wisdom, would not in itself 
 produce error had not the thinker been somewhat deceived. 
 Why should one (i) trust in inadequate authority, (2) be 
 overawed by the force of custom, (3) follow the opinion of 
 the unskilled many, (4) be cheated by a pretense of knowl- 
 edge, if there were not a certain weakness of mind in the 
 recipient of the false ideas. Put another way, the stumbling- 
 blocks to knowledge that Roger Bacon tried to chart reduce 
 largely to a false or weak-willed attitude in the thinker. Over- 
 weening authority, the cake of custom, the herd instinct, in- 
 tellectual fraud, would probably not be effective were it not 
 for a certain frailty of will. In short, to modern analysis the 
 stumbling-blocks of Roger Bacon are at least in a large meas- 
 ure inside the stumbler's mind. The victims of what we might 
 term "raw ignorance" will be fewer and fewer to the close in- 
 vestigator of the causes of error. The Errores of our own. 
 classification tend to flow over into the Morhi in the, form; oft- 
 greater or lesser degrees of pathological weak-willednesSi 
 (aboulia, hypoboulia) or over into the Vitici: in- the form of^ 
 over-compliances with authority, easy-going habits of thought, 
 following the crowd, facile deception by those who, in modern 
 phrase, are "putting it over." Possibly this tendency of mod- 
 ejn, science to classify the obstacles to knowledge under the 
 
 419 
 
420 THE KINGDOM OF EVILS 
 
 heading of mental or moral disorder rather than as plain errors 
 due to ignorance, misinformation, or misinterpretation will 
 explain why we find in our social patients so little that unre- 
 servedly flows into the group of Errores. We quote Sir Ben- 
 jamin Brodie to the effect that the world's evil might largely 
 be traced to mere ignorance — this we might grant as also the 
 truth of the formula "virtue is knowledge." But ignorance 
 and other obstacles to knowledge turned out so frequently to 
 be inborn or acquired mental disorder or character defect 
 or ingrained moral defect that Sir Benjamin's formula sounds 
 to the modern ear a bit hollow. 
 
 Francis Bacon (c. 1561-c. 1626) has yet another fourfold 
 classification of the general causes of error in the human mind. 
 He laid them down so as to clear the path for the introduction 
 of the new method pf science which he was to advance. The 
 doctrine of fallacies appears in final form in the Novum 
 Organon as the four Idola. The first of the Idola bears some 
 resemblance to his namesake's stumbling-blocks, — the opinion 
 of the unskilled many; these are the Idola Trihus, idols of the 
 tribe, fallacies to which the human race is one and all subject. 
 But for that matter it would seem that all of the Offendicula 
 of Roger Bacon might well be put under the tribal fallacies 
 of Francis Bacon. When we looked at the second kind of 
 Idola of Francis Bacon we saw how much more modern is the 
 point of view of Baron Verulam. The Idola Speciis, the idols 
 of the cave (probably here is meant the hollow of the skull), 
 are fallacies that depend upon the individuality of the particu- 
 lar man. Apparently, for his namesake and predecessor, 
 everybody in general is more or less subject to identical stum- 
 bling-blocks. For Francis Bacon the individualities of men 
 stood out. Under this head the Baconian practical rule for 
 avoiding individual tendencies to error runs as follows : "Let 
 every student of nature in general take this as a rule, that 
 whatever his mind seizes, dwells upon with particular satis- 
 faction, is to be held in suspicion." Whereas Roger Bacon 
 sees ignorant men, trust in inadequate authority exerted from 
 without, Francis Bacon sees clearly the error of trusting over- 
 much one's own internal authority based upon his mental or 
 bodily construction. The psychopathic personalities that ap- 
 pear so frequently in this volume are pronounced instances of 
 subjection to the Idola Speciis, or idols of the cave, of Francis 
 
THE KINGDOM OF EVILS 421 
 
 Bacon. Of course we suspect that these "Idols of the Hollow 
 of the Skull" are somewhere dependent upon peculiarities of 
 the brains contained within the skull or upon peculiar influ- 
 ences streaming in upon those brains from the rest of the 
 body. It is clear that the classification formulated for the 
 Idols of one's brain pan must be our familiar war cry in all 
 forms of mental hygiene — "individualization." If we are to 
 adjust inner relations to outer relations, as Spencer contends, 
 for a perfect life, we shall be compelled to hold sharply to it 
 when the inner relations themselves are defective. What a 
 rigid aspect the notion of "cure" takes on when by "cure" 
 we compromise all the individualizing processes of adjustment 
 entailed by the individual peculiarity of man ! 
 
 The third class of Idola were the Idola Fori, or Idols of 
 the Market Place. These errors or fallacies Francis Bacon 
 contended arose from the influence exerted upon the mind by 
 mere words. This class of Idola corresponds somewhat to 
 Roger Bacon's stumbling-blocks of the parading of superficial 
 wisdom. How many empty formulae exist in social work, 
 not to say also in the work of physicians and of public serv- 
 ants, that ought to be classed in the Baconian Idola Fori ! 
 Book II presented at length cases that illustrate a variety of 
 formulae of social difficulties in a series of cases. The cases 
 run, for example, all the way from that of Rose Talbot (case 
 8), in which all five forms of social difficulty were presented 
 to the five instances (cases 34 to 38) in which one class only 
 of social difficulty were found. Now in point of actual prac- 
 tice the social worker is altogether too much inclined to classify 
 a given case as one of disease alone, or of ignorance alone (or 
 other form of error), of legal entanglement, or of poverty 
 alone. This tendency may simplify the keeping of social 
 record books but it does not comport with the actual situation 
 in point of social fact. It is a tendency that belongs with the 
 Idola Fori, or Idols of the Market Place, in the Baconian sense, 
 to fall under the spell of this particular error, — to classify 
 under but one head. How simple social work would be if 
 cases all fell smoothly into place as cases to cure merely, merely 
 to reeducate, or again merely to reform, to supply with legal 
 aid, or to compensate in any monetary sense ! 
 
 Let us call especial attention at this point also to that group 
 of cases in Book II which exhibits simple binary combinations 
 
422 THE KINGDOM OF EVILS 
 
 of two forms of social difficulty. If we should consider the 
 simplest case of medical social work — namely, a case which 
 showed but two factors say, (i) need of orthopedic splint, 
 (2) need of money — possibly these two needs could be sepa- 
 rately met. Possibly the granting of financial relief would 
 forthwith settle the question of getting a splint. In such an 
 instance the primary social difficulty might well turn out to be 
 poverty. Whilst the orthopedic need might be a very remote 
 and secondary phenomenon. But suppose we have a combina- 
 tion of poverty with such a weak will disorder as lack of ambi- 
 tion. Let us suppose this lack of ambition is not psychopathic. 
 Then it is obvious with half an eye that the dole-giving is not 
 going to settle the problem. Yet to quote Richmond's "Social 
 Diagnosis," there was in charity organization work "at first 
 no accepted program of treatment other than the giving or 
 withholding of relief." Here and there advanced agencies 
 formed more thorough programs of what could be done; but 
 in the earlier days these were carried out with difficulty against 
 the main current of charity activity which ran strongly toward 
 dole-giving. These two instances may suffice to raise the im- 
 portant point that we shall learn more and more about social 
 work if we study merely binary combinations of social diffi- 
 culty. That is the combinations of Morbus with Error or 
 Morbus with Vitiuin, or Morbus with Litigium, or Morbus 
 with Penuria, or Error with Pcmiria, or Vitium with Litigium, 
 Vitium with Penuria, Litigium with Penuria-. The cases of 
 binary combination (cases 24 to 33 inclusive) in Book II of 
 course present only a simple indication of the possibilities of 
 each of the five main groups. A vast deal of work must be 
 done when we get into the main outlines of social work en- 
 tailed by a study of binary combinations. When two social 
 difficulties are loosely associated with one another, so that each 
 may be simply and separately treated, social work will be rela- 
 tively easy. But when two difficulties are multiplied into one 
 another social work will be relatively hard. 
 
 To continue with our remarks upon the four classes of 
 Idola, according to Francis Bacon we find the fourth and last 
 class to be the Idola Tlieatri, or so-called Idols of the Theater. 
 (The theater here means the speculative or "theorizing" mind 
 and does not refer to theater in the ordinary sense.) The 
 victims of this class of Idola are those who force nature into 
 
THE KINGDOM OF EVILS 423 
 
 empty, abstract schemes and want to explain existing condi- 
 tions by mere definition. Again there are those that leap to 
 general conclusions by too few experiments, or again those that 
 work in an imaginative way by the overuse of analogies. This 
 particular type of error is one which the theorists of social 
 work must take to heart. The existence of these Idola of the 
 speculative mind is the best reason for our having chosen to 
 place the case material of this volume at the outset rather than 
 as merely illustrative material. We have tried to analyze some 
 of the cases available to us, with the richest display of facts 
 and most intensive social treatment, and to deduce from these 
 data certain general principles. If the reader dissents from 
 the principles he has the recourse of going back to the facts. 
 Moreover, as the cases are for the most part still alive and 
 both capable of investigation and willing to tell their stories, 
 we shall in the long run be able to test the validity of our own 
 conclusions by the test of time. 
 
 THE PROBLEM OF EVIL 
 
 Although we have drawn the analysis of this volume upon 
 a classification of the social evils taken in their broadest sense, 
 we cannot pretend to be competent in the theory of morals or 
 to write a textbook of ethics. No doubt the historical de- 
 velopment of the idea of medical social work (and naturally 
 of its related branch psychiatric social work) are, in the New 
 England community in which we write, greatly influenced by 
 the philosophical work of Professor Josiah Royce upon the 
 problem of evil. Professor Royce's work upon evil as well 
 as upon social consciousness and later upon the logical theories 
 of order have unquestionably prescribed some of the most im- 
 portant lines in Dr. Richard C. Cabot's development of medical 
 social work and in our own additions to the concept from the 
 field of mental hygiene. We have been compelled to choose 
 mottoes for the four books from Job. The initial paper in 
 Professor Royce's Studies of Good and Evil deals with the 
 problem of Job. The problem of Job, according to Royce, is 
 the problem of unearned ill fortune. Whatever evil is, Royce 
 is most cordially of the opinion that it is a "distinctly real fact, 
 a fact just as real as the most helpless and hopeless sufferer 
 finds it to be when he is in pain." Elsewhere he speaks of 
 
.424 THE KINGDOM OF EVILS 
 
 another view, "that essentially pernicious view nowadays some- 
 what current amongst a certain class of gentle but inconsequent 
 people — the view that all evil is merely an illusion and that 
 there is no such thing in God's world." Good and evil, ac- 
 cording to Royce, do not exist as opponents but merely as ex- 
 clusive agents side by side in experience. A longer account 
 of this view runs as follows : — 
 
 "Taking a wider view, one may observe that the greater part 
 of the freest products of the activity of civilization in cere- 
 monies, in formalities, in the long social drama of flight, of 
 pursuit, of repartee, of contest and of courtesy, involve an 
 elaborate and systematic delaying and hindering of elemental 
 human desires, which we continually outwit, postpone, and 
 thwart, even while we nourish them. When students of human 
 nature assert that hunger and love rule the social world, they 
 recognize that the elemental in human nature is trained by 
 civilization into the service of the highest demands of the 
 Spirit." 
 
 A briefer formula is as follows : — 
 
 "It is impossible for one to know a higher good than comes 
 from the subordination of evil to good in a total experience. 
 Love of moral good is the thwarting of lower loves for the 
 sake of higher organization." 
 
 It will be seen that, according to Royce, "the eternal world 
 contains Gethsemane." 
 
 This point of view ot Royce's is the point of view of the 
 so-called philosophical idealism ("your sufferings are God's 
 sufferings"). It is obvious that the considerations of the pres- 
 ent volume do not depend in the slightest upon any philosoph- 
 ical view whatever. Even if we should run with the "essen- 
 tially pernicious view" which regards all evil as an illusion, we 
 should nevertheless have to grant the existence of the illusion 
 as a distinctly real fact. The illusions and delusions of the 
 sane we should be inclined to place in our group of Errores. 
 We should regard those who identify diseases, sins, crimes, re- 
 sourcelessness with the delusions as unwise persons who have 
 made singularly poor use of some of the formulae of philo- 
 sophical idealism. 
 
 In the course of writing this volume we have met sundry 
 persons who have denied the existence of evil under that name, 
 maintaining that evil is an illusion or an error. We have 
 
THE KINGDOM OF EVILS 425 
 
 wondered whether they were not all unconsciously identifying 
 the genus with the species and abolishing the regmini malorum 
 with its subgroup Err ores. We are the more inclined to draw 
 this conclusion from our observation that these verbal de- 
 stroyers of evil are ordinarily turned to the hypothesis that 
 the illusions and errors, or surrogates of evil, are to be de- 
 stroyed by "taking thought," by adopting certain beliefs and 
 sometimes by the plain anodyne of forgetting. Even the so- 
 called Christian Science may fall back upon establishing sana- 
 toria, thereby conceding that there is a special form of error 
 needing hospital treatment. Christian Scientists also would 
 be righteously incensed if their opponents should charge them 
 with not encouraging morality or the legal order. If the repre- 
 sentatives of sundry movements for faith cure have been 
 charged with a loss of interest in the problems of poor relief 
 and charity in certain communities, in any event the believers 
 in these cults are for the most part kindly persons as interested 
 in the economic successes of the community as their fellow 
 beings. Accordingly, we repeat, the point of view of the pres- 
 ent work does not, strictly speaking, need to take account of 
 any philosophical view of evil, even such a view as that of 
 Christian Science, which turns even disease into a form of 
 error. Perhaps, we should concede that the point of view of 
 the ingrained pessimist cannot be the point of view of social 
 work. The point of view of Voltaire or Nietzsche is not the 
 point of view of the social worker, although be it remembered 
 to the credit of Voltaire that he leaves his wretched heroes and 
 heroines at the end of Candide working in a garden, and even 
 Nietzsche insisted that the strong were strengthened by evil. 
 
 There can be no doubt that the practical social worker needs 
 to have some philosophical and religious views of the nature 
 of good and evil, not alone for the social worker's own per- 
 sonal guidance but for the sake of grasping ingenious argu- 
 ments which sundry depressed, deluded patients are prone to 
 offer. According to Royce, the first hypothesis concerning 
 evil is that it is nothing but natural phenomena — "dirt of the 
 natural order, whose value is, that when you wash it off you 
 learn the charm of the bath of evolution." The second hy- 
 pothesis is that evil has a medicinal and disciplinary value. 
 The third hypothesis runs to the effect that all real evils are the 
 results of free finite moral agents. And finally, according to. 
 
426 THE KINGDOM OF EVILS 
 
 Royce, the fourth hypothesis of philosophical idealism runs 
 to the effect that the entire world is built on a basis of "inner 
 tension of manifold impulses and interests," which, as he re- 
 marks, are not "mere accidents of rather imperfect human 
 nature but must be a type of the organization of every rational 
 life." 
 
 Our own study has dealt not so much with the definition of 
 evil as with the classification of the evils as they have presented 
 themselves in the Psychopathic Hospital, a clearing-house for 
 the evils of individual man. Our study has been an inductive 
 one from the concrete facts to a classification of these facts in 
 certain groups. These groups, it appeared to us, might effec- 
 tively be united in a greater group of evils taken in a more 
 general way. We have thus come upon an idea of the social 
 worker as a person professionally at work amongst all types 
 of evil. The social worker, as we remarked above, must re- 
 main a layman with regard to the great special fields of medi- 
 cine, education, morals, jurisprudence, and economics. But 
 the social worker is a very intensive sort of layman with, some 
 might say, an exaggerated amount of common sense — that 
 kind of comprehensive insight which utilizes the professional 
 specialist without supplanting him. 
 
 The Roycean formula of the inner tension of manifold im- 
 pulses and interests within our natures goes a step further 
 than the Spencerian formula of the adjustment of inner to 
 outer relations. In the first place Royce calls attention to the 
 existence of tensions within our own make-ups, and in the 
 second place he seems to define ethics in terms of the relations 
 of the interior tensions. We have had abundant cause to ob- 
 serve a practical truth in our patients of this hypothesis of 
 interior tensions. But the world's evil, even according to 
 Royce, is not confined to the inner life of a man but has spread 
 through the universe. Certainly in that part of the universe 
 with which we are dealing ; namely, society, some sort of ten- 
 sions have been found to prevail. But can we conceive that 
 the analyses of the present work do not hang upon the com- 
 parative richness of the Spencerian or the Roycean formulae 
 concerning relations in the universe ? The cases here presented 
 are presented on a practical level and the workers who worked 
 with them have as a rule paid no heed to philosophical 
 questions. 
 
THE KINGDOM OF EVILS 427 
 
 But the social worker must not think that because she is 
 practical she is inevitably just like everybody else in her point 
 of view toward the world. It would seem that the social 
 worker possesses a special temperament. At least the medical 
 and psychiatric social workers have a greater interest pri- 
 marily in the destruction of evil than in the construction of 
 good. When such workers rationalize their attitudes they say 
 to themselves that by destroying evils they are helping to 
 create, or allowing to be distributed, goods, but the tempera- 
 ment which sees evil as the proximate task of destruction and 
 good as the ultimate goal is nevertheless a temperament. And 
 it is a temperament that not everybody possesses. It would 
 seem that there are dragon-slayers and Grail-hunters. There 
 are those who prefer to be St. George and others who would 
 rather be Sir Galahad. 
 
 It is doubtful whether the decision to be one or the other is 
 always a conscious or rational one. Those of us who are 
 informed of the spirit of medicine or medical and psychiatric 
 social work, or of nursing, or of the probation officer and the 
 like, are wakened up in astonishment to the fact that there are 
 perfectly good citizens in the world who prefer to put diseases 
 and other forms of evil entirely out of mind. Nor can we 
 set down these persons who are not interested in evil as merely 
 materialistic. Often they prove perfectly admirable seekers 
 after a Grail of one kind or other. The devotees of religion, 
 wizards of scientific invention, and the artists, do not have, 
 as a rule, any interests that might be termed malecidal: they 
 are not built for the destruction of evil, nor should we wish 
 to swerve these zealots of the Grail from their goal. In fact 
 the Grail-hunting temperament in its highest development is 
 next to impossible to divert. We had best not waste our time 
 and theirs by offering wares of social work to the inborn Grail- 
 seekers. But there remains a great mass of people whose 
 parental and filial, and especially whose maternal, joys give 
 them the fundaments of social interest. From amongst the 
 common people we shall draw many of our best workers if we 
 can interest them in the social task, and if we can believe that 
 through evolution habits of destruction are deeply imbedded 
 in all of us. Let us point these destructive powers in the di- 
 rection of evil. That is the essence of strategy underlying 
 this particular kind of social work. In our task of persuading 
 
428 THE KINGDOM OF EVILS 
 
 the everyday citizen that his proximate task is to destroy evil 
 we have a number of points in our favor. If he repHes that 
 he would rather do good than merely undo evil we can reply 
 to him "What after all is the good which you would like to 
 do?" The chances are that his first response would have to 
 do with getting rid of some near-by evil. We can point out 
 to him that evil is very easy to perceive about us. Evil is 
 easier to perceive than good is even to conceive. Percep- 
 tion was ever easier than conception. We see evil all about 
 us. We do not need to make elaborate conceptions or inter- 
 pretations of the evil that is at hand. Again, evil is not only 
 easier to perceive than good to conceive but evil subdivides 
 very readily into plurality of evils. The good is rather apt 
 to remain a unit or to subdivide itself far less readily. The 
 farmer has sick cattle. It is plain that they must be cured or 
 for their own comfort be killed. But suppose the farmer tries 
 a program of construction. Shall he breed for beef or for 
 milk? The plot thickens at once. If we look into the vocabu- 
 lary for words descriptive of good and evil respectively, we 
 are certain to find in most languages a far larger number of 
 words dealing with evils than with the goods. 
 
 Evils can thus be seen about us (and be items for destruc- 
 tion) far more readily than the goods. It is obvious too that 
 evil gets more clearly into the mind than does good. For 
 whatever evolutionary reason this is so we do not delay to dis- 
 cuss, but there is something insictent, pricking, sensationally 
 painful about evils. They attract our attention more readily 
 and are on the whole more definable than goods. Finally, as 
 above insisted, concerning our relative powers of destruction 
 and construction, we men are built more for destruction than 
 for construction, or at all events are more used to the destruc- 
 tive processes in our daily lives. We should, therefore, take 
 advantage of this ingrained destructive trend and endeavor in 
 the first instance to destroy definite concrete, and observable 
 evils rather than try to construct indefinite, abstract, hardly 
 conceivable good. Let the proximate task of evil destruction 
 be accomplished and the ultimate task of constructive good- 
 ness will shortly follow. The formula might run "Get the 
 Grail but first slay the dragon." These are perhaps the 
 main arguments to the hypothesis of evil's primacy in the 
 realm of social tasks. We are entirely certain that various 
 
THE KINGDOM OF EVILS 429 
 
 readers of the Grail-hunting group will persist in misunder- 
 standing our program. They will not distinguish a technique 
 that deals with proximates from a program that runs towards 
 ultimates. We conceive that social work is a kind of human 
 technique of proximate nature whose lines are laid down in 
 the interest of ultimate good. 
 
 We have been bold enough to borrow mottoes from the book 
 of Job. We have taken care to take them from the words of 
 Job himself rather than from the words of his friends. These 
 friends, however, skillful in rhetoric, would perhaps not prove 
 the most successful of social adjusters. Without undertaking 
 elaborate analysis of the endeavors of Job's friends, for which 
 we are entirely incompetent, we are nevertheless inclined to 
 assert that the world has made a considerable advance upon 
 the ethical situation depicted in Job. Job said that his error 
 remained with himself, that when he cried out of wrong he 
 was not heard, that there was no justice, and that the hand of 
 God had touched him. He thus made an almost complete 
 analysis of his plight, finding concrete evils in most of the 
 departments we have discussed. Is it too much to say that 
 the spirit of civilization, the spirit of Christianity if you will, 
 has shifted the universe of evil at least by a few units? That 
 the land of the shadow of death could contain any sort of 
 order hardly entered Job's mind. It was to him the highest 
 of rhetorical flights to think of the weighing of his calamities. 
 In all these respects the modern world has gained a plan of 
 attack which Job's world certainly possessed not. 
 
 Finally as to the motto with which we have introduced 
 Book IV, the nineteenth century by its researches has served 
 to magnify the interest of man, if not yet to offer a perfect 
 technique for preserving him. Remarks like these are petty 
 enough beside the terror of the facts. We do not find the 
 social worker irreligious; but if the social worker were at the 
 outset irreligious, she speedily comes to a sufficient solemnity 
 — the solemnity of the interrelations of the deeper things in 
 mind and morals. 
 
 Thus we conclude certain generalities about the evils. By 
 the very order of presentation of the material in this work we 
 have intended to show that our work ran from observed de- 
 tails upward to more or less tentative general statements, and 
 not at all from any preconceived principles downward to the 
 
430 
 
 THE KINGDOM OF EVILS 
 
 facts. Our study, as we have repeatedly maintained, is induc- 
 tive and not deductive. In point of fact the observations made 
 were made in the first instance without any grouping of the 
 evils and the maladjustments whatever. It was only when we 
 came to put our work together that we found our material 
 grouping itself in the way most elaborately presented in Book 
 II of this work. We think some such classification presented 
 in some order on the principles of this work will maintain 
 itself in future social work; but whether it does or not, the 
 materials for this particular analysis were not collected with 
 these categories in mind, but were collected with the general 
 principles of psychiatric social investigation in mind. 
 
 APPLICATIONS OF THE FIVEFOLD CLASSIFICATION OF EVILS 
 OUTSIDE THE FIELD OF SOCIAL WORK 
 
 Our fivefold classification of evils, to which Book II is 
 largely devoted, is a classification that might be applied with 
 great generality to vast areas of phenomena outside the field 
 of social case work. It is beyond the province of this volume 
 to discuss these wider applications, though the entire social 
 problem would plainly profit thereby. We shall confine our- 
 selves to two instances of the possible application of our 
 method of orderly approach to the classification of difficulties 
 of whatever sort. Let these two instances be the Great War 
 and bolshevism. 
 
 Is war in itself an evil? The Crusaders and the American 
 Revolutionists might well resent the charge so far as it con- 
 cerned their own aims and duties. Yet they would be com- 
 pelled to grant the unfolding of numerous evils in the train of 
 crusades or revolutions. To our minds the assertion that war 
 is an ez'il is logically far less accurate a statement than that 
 war entails ez'ils. War entails a plurality of evils. What, 
 now, are these evils ? We think they can readily be distributed 
 amongst our five groups, though some might desire that we 
 add a sixth miscellaneous group for troubles not specifically 
 listed as disease, error, vice, legal difficulty, and poverty. In 
 the wake of war comes disease and pestilence. Educational 
 systems crumble in war time, vicious attitudes abound. The 
 legal order is assailed. Poverty reigns. 
 
 If every analyst of reconstruction were to catalogue the 
 
THE KINGDOM OF EVILS 43I 
 
 evils of war even in this rough manner, he would greatly 
 assist in the definition of every post bellum task. Re- 
 formers with but a single nostrum would have no preferred 
 standing in political councils, whether amongst government 
 officials or amongst the voluntary associations of the com- 
 munity. An eventual combined development of health pro- 
 grams with educational programs would be assured. The 
 representatives of the church, the lecture platform, and the 
 theater, as shapers for better or worse of community morals, 
 would find themselves shoulder to shoulder with the representa- 
 tives of government and law. In particular, nobody with an 
 economic panacea would be allowed to run wild without com- 
 petition amongst theories of reconstruction. To split evil into 
 such great rough groups as our chosen five of evils would 
 represent an advance in social reconstruction hardly to be hoped 
 for in an era of single-track minds. Yet there would be a 
 place in the sun, a true locus for the single-track minds in the 
 pragmatic attack upon each of the evils taken separately and 
 distributively by some single specialist — a specialist, as you 
 might say, in the slaying of a particular variety of dragon. The 
 higher speed and the greater safety can no doubt be attained 
 upon the single, switchless track, and the straighter the better. 
 In short, the trouble is the ancient trouble of the many and 
 the one, that is, the determining, amongst a plurality of things 
 to do, the pragmatic unit, the thing that "makes a difference." 
 
 We may again insist, as particularly pertinent to these gen- 
 eralized applications of our method of orderly approach, that 
 the items in the list and the order to be adopted in their 
 consideration. are of lesser consequence than the adoption 
 of some order in the consideration of chosen categories. 
 Suppose now, that we were to analyze'phenomena of the Great 
 War, no longer from the standpoint of the immediate task of 
 reconstruction but rather from the standpoint of historical 
 analysis to the end of the prevention of future wars. We 
 should be looking into causes. Here again the method of 
 orderly approach in the analysis of data has value. 
 
 Was there a morbid factor at the bottom of the Great 
 War or, more moderately speaking, were morbid factors at 
 all seriously in evidence? Of course some German propa- 
 gandists went so far as to describe the French attitude at the 
 outset of the Great War, and at various times when the French 
 
432 THE KINGDOM OF EVILS 
 
 refused to treat for peace, as an example of Psycho pathia 
 Gallica. This Psychopathia Gallica was a national revenge- 
 psychosis! One German disputant objected. He noted a re- 
 sponsibihty on the part of the Germans to France if France 
 was a national victim of mental disease: France would then 
 have to be pitied ! But, seriously speaking, was there, or was 
 there not, a morbid and especially a psychopathic factor in the 
 Great War? Was the Kaiser a psychopath? The lay reader 
 must take note that psychopath means, as elsewhere in this 
 book, not necessarily an insane person in the medico-legal sense 
 of that term. The Kaiser might be a psychopath and, as 
 French writers have for years insisted, have still a degree of 
 responsibility. 
 
 But we are not here inquiring about the degree of personal 
 responsibility which might be laid at the door of a psycho- 
 pathic or non-psychopathic Kaiser. We are inquiring into 
 the causes of the Great War. It would be a nice question to 
 determine whether the Hohenzollerns are in so far eccentric 
 or "off-center" or "deviate" that they have had an essential 
 share in shaping European destinies. There are two views 
 about all such matters which frequently blanket or forestall 
 concrete investigations. There are those who believe in some 
 variant of the Great-Man theory of history. There are others 
 who are equally certain that all big social movements are mass 
 movements, reminding one of the prodigies of the social life 
 of ants, bees, and wasps. It is a question whether the real 
 facts concerning the Hohenzollerns and in particular concern- 
 ing the now living representatives of this group will ever be 
 examined by psychiatric experts. Great educators, wise philos- 
 ophers, exalted preachers, profound moralists, learned judges, 
 ingenious advocates, formulating political economists and 
 sociologists, to say nothing of estimable laymen, will claim 
 the right to make this momentous decision. Many decades will 
 go by, possibly a century or more, before we can replace the 
 current interpretations of history with a psychiatric interpreta- 
 tion. Yet until that psychiatric interpretation comes we shall 
 not have tried out one of the likeliest measures of prevention. 
 Who now knows whether both the origin of tyranny and 
 tyranny's fate were not matters of psychopathic interest? 
 
 But now let us suppose either that there were no morbid 
 factors or only partially effective morbid factors in the Great 
 
THE KINGDOM OF EVILS 433 
 
 War, shall we not assign the Great War's origin to our 
 group of Errores? Was not Darwinism misinterpreted by 
 German expounders? Was not the German populace misin- 
 formed concerning political causes and effects? Did the Ger- 
 mans not proceed upon an erroneous theory of morals incul- 
 cated under the influence of the Hohenzollerns, Bismarck, 
 Treitschke, and Nietzsche? Here is a very pretty inquiry, 
 localized in the field of popular education and the general opin- 
 ion of German society. Did not Willisen and Clausewitz mis- 
 interpret the Napoleonic successes and method and supply the 
 German community with nationalistic ideas basically wrong? 
 In this part of our inquiry we should need to abstain absolutely 
 from any considerations of mental disease or of false morals. 
 Should it be inquired whether perhaps Nietzsche was not a 
 psychopath and his Will to Power the reflection of a psycho- 
 pathic pessimism, then our inquiry would run back to the group 
 of Morbi. Should we determine that Nietzsche, like his 
 predecessor Schopenhauer, was importantly a psychopath, then 
 our ideas concerning the origin of the war would change and 
 some of our measures for prevention would take into account 
 the necessity of analyzing the claims of a Schopenhauer or of a 
 Nietzsche long before political economists usually think phi- 
 losophy needs attention. Yet the ideas of a Schopenhauer and 
 of a Nietzsche, let them be as vitriolic and destructive by 
 nature as they list, would perhaps not be dangerous to society 
 if they were not spread by an educational process, either by 
 chance or by design. 
 
 If it should be discovered that leaders of German thought 
 for national political purpose deliberately encouraged the 
 spread of the psychopathic ideas of a Nietzsche or a 
 Schopenhauer, then the inquiry might throw back once more 
 to the question whether the leaders of German thought were 
 themselves psychopathic or whether they were merely mis- 
 taught by predecessors who were possibly psychopathic, or 
 whether they were persons with a vicious streak. In short, 
 this inquiry concerning the spread of ideas ultimately trace- 
 able to a psychopathic origin might lead us at the outset to 
 moral attitudes falling in our group of the V'itia; but, at one 
 degree removed and in the second generation of educators, we 
 might find that the total immediate cause of the German atti- 
 tude towards world domination lay in our second group of 
 
434 ' THE KINGDOM OF EVILS 
 
 Errores. That is to say, ideas might arise in the group Morbi 
 or they might not, but these ideas might be promulgated as 
 misinterpretation, or misinformation by the mistaken leaders 
 of a given generation (belonging in group E), themselves not 
 at all psychopathic (i.e. not in group M) and even not at all 
 vicious ( not in group V ) . They would secure our forgiveness 
 "for they know not what they do." But again there might be 
 certain vicious leaders of thought (group V) who would in- 
 fluence a circle of less powerful thinkers (group E), who 
 would spread ideas derived from the vicious politicians, who,- 
 however, might have obtained their ideas from psychopaths 
 (group M). The analysis might run in a variety of ways; 
 but our general thesis ought, we think, to be accepted, namely, 
 that analysis under some such groups or categories as we have 
 here chosen would be of the greatest advantage to the world. 
 
 It is even possible that the exponents of a peculiar form 
 of legal order might have greatly influenced the origins of 
 the Great War. Men firmly convinced of the values of the 
 German legal code might well regard such code and under- 
 lying principles as the real skeleton and support of world 
 civilization. Jurists of this kidney would not be psychopaths. 
 Their ideas would not fall into the field of education, as com- 
 monly accepted, nor could we charge their system with being 
 in any obvious way a result of misinformation or of misinter- 
 pretation. There is no doubt that the representatives of medi- 
 cine, natural science, morals, religion, economics, and politics 
 take too little account of juristic developments. And the jurists 
 too are doubtless guilty of groping about in the same way 
 in their own water-tight compartment. Only the sociologists 
 appear to try to encompass all these points of view; yet, even 
 where the sociologists have a wide range and a sure touch, 
 they seem to us to fail to take account in an even and repre- 
 sentative way of all these divisions of human interest. This is 
 particularly true of the neglect by sociologists, up to very re- 
 cent days, of any right view of the importance of the psycho- 
 path in history. 
 
 Lastly we may consider that an economic interpretation of 
 history might prove that the basis of the Great War was 
 economic. Of course this dictum means very little if we are 
 listening to economists who regard virtually everything in the 
 
THE KINGDOM OF EVILS 435 
 
 world as essentially economic in its basis. But surely that 
 proof has never been brought. 
 
 Enough has been said to intimate the sure advantage which 
 would follow analyzing the Great War in an orderly way con- 
 cerning both its origins and its effects. Advantage would 
 accrue if the phenomena of the Great War were analyzed under 
 the podtive categories of health, education, morals, law and 
 order, and economics. But we contend that the negative and 
 corresponding categories of our five groups would possess a 
 still greater advantage for the analyst. 
 
 Let us now turn to bolshevism. It would be of funda- 
 mental importance and value, could we discover and disen- 
 tangle any psychopathic elements in bolshevism. Marx 
 was, no doubt, not at all a psychopath. Bakunin on the other 
 hand was no doubt a psychopath. Socialism and anarchism 
 need not be set down as non-psychopathic and psychopathic in 
 origin on account of the nature of the lives of their founders, 
 Marx and Bakunin. Modern anarchists are a little impatient 
 of any attribution of great movements like socialism and 
 bolshevism to great men like Marx and Bakunin. They are 
 prone to leap into another category when the argument waxes 
 hot concerning individual founders and to begin to talk about 
 general, economic, legal, and moral or educational tendencies, 
 of mass movements and the like. There is a time for the con- 
 sideration of these other categories, but we can see that there 
 is a time for rounding up all the psychopathic elements that 
 there may be. Let psychiatric specialists deal to the best of 
 their special knowledge and training with these facts, and let 
 dll the facts be considered that might have a bearing on the 
 morbid sides of certain bolshevistic, socialistic, governmental, 
 or capitalist trends. (For in this skeleton of an argument con- 
 cerning bolshevism we must not be understood to say that the 
 various proponents of law and order and of capitalistic ven- 
 tures are not also sometimes in an important way psycho- 
 pathic.) After decades it may be allowable to think of George 
 III as a psychopath. How impatient a politician of the present 
 day would be if an inquiry along this line were made concerning 
 the Lenin who lives today ! These are very sharp tools, the ob- 
 jector to our program of the psychiatric analysis of present- 
 day politics may urge. But the tools we suggest are after all 
 
436 THE KINGDOM OF EVILS 
 
 no sharper than the political tools of terrorism used by a 
 Hohenzollern or a Lenin. Finally the world will learn not to 
 flinch under the application of expert analysis. 
 
 But suppose we decide that Lenin and the rest are not 
 psychopathic or not importantly so, how much of the situa- 
 tion of bolshevism is an educational affair? How much is 
 it due to vicious or quixotic moral attitudes? How much is 
 it due to reaction against certain more or less false ideas of 
 law and order and how much, finally, is it due to the economic 
 resourcelessness of Russian peasants? We are not com- 
 petent to offer positive points concerning this analysis, but we 
 are inclined to think that every dispassionate person will agree 
 that the present-day type of analysis of such conditions does 
 not make for clarity. We can see that it is because the analyst 
 continually changes his categories, leaping from positive to 
 negative phenomena and leaping from group to group of each, 
 perhaps making each of his arguments swerve in a particular 
 and favorite direction. 
 
 The contentions in the last few paragraphs concerning the 
 possible analysis of the Great War and of bolshevism do not 
 touch the argument concerning the utility of our classification 
 of evils as applied to the individual psychopath. Our conten- 
 tions do not rest upon a thorough study of historical and po- 
 litical phenomena. We shall be entirely satisfied if the reader 
 regards these contentions as pure hypotheses. The argument 
 will at least serve to bring out into stronger relief the method 
 of orderly approach in the classification of social difficulties 
 as applied in the body of our work. 
 
 THE METHOD OF BOOK III : MAIN GROUPS OF MENTAL DISEASES 
 
 The cases of Book III are arranged according to their oc- 
 currence in the Major Groups of Mental Disease. Precisely 
 the same types of patient are presented in Book III as in Book 
 I, which dealt with the spheres of influence and in Book II, 
 which dealt with the various forms of evil. Our volume is 
 in no sense a treatise on psychiatry. Yet for several reasons 
 the arrangement of Book HI is a desirable one. In the first 
 place physicians, both psychiatrists and others, may want to 
 learn what kinds of social work are likely to be most applicable 
 in the major groups of mental disease; and, whereas the m 
 
THE KINGDOM OF EVILS 437 
 
 count here presented is far from complete, we conceive that 
 the major issues of social treatment of the mental diseases are 
 clearly indicated. In the second place the social worker must 
 understand the larger features of mental disease as shown in 
 the great groups which physicians recognize; even if the social 
 worker's ideas are limited to very rough ideas concerning the 
 prognosis in the major groups of mental disease, she will un- 
 derstand the physician's point of view certainly better than do 
 many teachers, pastors, lawyers, and business men, with all of 
 whom the social worker may have to deal. In the third place 
 the cases of Book III may be used by the reader for the pur- 
 pose of independent judgment whether Book I's conclusions 
 on the spheres of influence and Book II's conclusions on the 
 forms of evil are sound conclusions; for the cases of Book III 
 are presented in far bolder form and with more reference to 
 treatment and outcome than to the technique of authority 
 brought to bear or of diagnostic details. 
 
 What are mental diseases? Luckily this is not a textbook 
 of psychiatry and we are not stringently required to ofifer a 
 definition. For practical purposes the mental diseases are dis- 
 eases which common consent leaves in the hands of a special 
 group of physicians for diagnosis and treatment ; namely, the 
 group of so-called psychiatrists. Common consent means that 
 the medical schools, the medical associations, and the medical 
 textbooks are practically unanimous in conceding the existence 
 of a field of mental diseases, related somewhat closely with 
 the so-called nervous diseases but rather less closely with all 
 other forms of disease. Medical schools have formally recog- 
 nized, though as a rule very inadequately, in their curricula 
 departments of mental disease or of psychiatry. National as- 
 sociations, like the American Medico-Psychological Associa- 
 tion, now the American Psychiatric Association, exist for 
 the purpose of promoting the study of mental diseases as op- 
 posed to all other forms of disease. Until recent years 
 these associations have been far from "scientific" in the 
 sense of presenting programs of investigation and research. 
 Although the American Medico-Psychological Association is 
 the oldest national medical association in this country, yet its 
 progress upon lines of research and investigation has up to 
 recent times been singularly slow. The predominance in its 
 programs of administrative and other practical features has, 
 
438 THE KINGDOM OF EVILS 
 
 however, one point to commend itself in the eyes of the social 
 worker, — the social worker will find that the practitioner in 
 mental diseases, i.e., the psychiatrist, is probably by nature and 
 training a man especially accessible to ideas of social work. 
 In fact the superintendent of a hospital for the insane and his 
 subordinate officers have often been engaged in a type of work 
 not far removed from social work performed as a rule inade- 
 quately from a central office desk and without due emphasis, 
 perhaps, upon the educational, moral, legal, and economic sides 
 of the problem. On the whole, however, the psychiatrists had, 
 by virtue of the very nature of their material, made much 
 greater progress toward "socialization" than had practitioners 
 in other fields of medicine. Many of the underlying concepts 
 of social work are far more deeply imbedded in the mind of 
 the psychiatrist than in the minds of other practitioners of 
 medicine. 
 
 Psychiatry is that field of medicine devoted to mental dis- 
 eases, and psychiatrists are the practitioners in that field. 
 Many readers are aware that the term "psychiatrist" has only 
 recently taken hold of this country. The term "alienist" is 
 still used rather freely by the older generation. There is, to 
 be sure, not much difference between these terms, yet the slight 
 distinction is one which is of the greatest importance to the 
 development of mental hygiene. The situation is somewhat 
 as follows. Insanity and mental disease 'are not synonymous. 
 Insanity is a legal concept, mental disease is a medical concept. 
 A man is sane or insane or as yet indeterminate as to his in- 
 sanity. Many hold that there are no degrees of sanity or 
 insanity. A multitude of courts will still be found holding 
 that there is but one degree and but one kind of sanity or of 
 insanity. 
 
 On the other hand there are all degrees of mental health 
 and mental disease and there are many kinds of mental disease. 
 Insanity, we may say, depends upon medico-legal decisions. 
 Mental disease is an affair of medicine alone. Sanity and 
 mental health, decided respectively by the law and by medi- 
 cine, may characterize the same human subjects. But — and 
 here is the definite point — sanity may characterise many sub- 
 jects of mental disease. These sane subjects of mental dis- 
 ease are subject to mental disease, mild or severe, of a kind 
 or degree that does not concern the courts. It would even be 
 
THE KINGDOM OF EVILS 439 
 
 permissible to say that no man is either sane or insane until 
 properly reviewed and adjudged by the courts. It is perhaps 
 enough to claim that sanity and insanity are characteristics 
 such that courts decide them within limits of accuracy of 
 courts. Accordingly sanity and insanity are legal, govern- 
 mental, public matters. On the other hand mental health and 
 disease are matters of individual medicine and individual 
 psychology, and while of familial, district, group, or com- 
 munity interest, they do not necessarily even approach govern- 
 mental regime. Insanity is a public matter, mental disease a 
 social, family, or personal matter. 
 
 We believe that the above statements will be commonplaces 
 in the minds of many, perhaps of most advanced medical men. 
 It is probable that many competent jurists hold identical con- 
 cepts. It was on this basis that the senior author of this work 
 proposed some years since that the medical specialists, who 
 are medico-legal aids, be given the familiar and appropriate 
 designation, alienists, and that the term psychiatrists be re- 
 served for those specialists who act as physicians only, — in 
 short that the insanity expert be spoken of as an alienist and 
 the mental-disease expert be called a psychiatrist. In a some- 
 what revolutionary way the suggestion was at that time made 
 that the records on mental cases might run as follows. (The 
 reader must take note that these suggestions have not to any 
 extent been applied practically up to this time and are here 
 offered purely to bring out the existence of border-line cases 
 of mental disease that are not medic o-le gaily insane.) 
 
 Example i. — "As alienist I consider this person insane. As 
 psychiatrist I consider this patient subject to general paresis." 
 
 Example 2.- — -"As alienist I consider this person sane. As 
 psychiatrist I consider him in complete mental health." 
 
 Example 3. — "As alienist I consider this person sane. As 
 psychiatrist I consider him subject to mental disease; namely, 
 subject to a psychoneurosis of hysterical form." 
 
 Exa'mple 4. — "As alienist I consider this person sane. As 
 psychiatrist I consider him subject to dementia praecox in a 
 mild degree." 
 
 Example 5. — "As alienist I consider this person sane. As 
 psychiatrist I consider him subject to paranoia of great severity. 
 This mental disease (which I find as psychiatrist) I regard, in 
 this case, as of no public interest (when I review the findings 
 as alienist)." 
 
ALIENISTS 
 Field: Insanity, The Insane 
 
 Field : Public, Governmental, 
 Legal 
 
 Field : Opinion for Court Use 
 
 Decisions Alternative : San- 
 ity versus Insanity 
 
 Insanity Implies Mental Dis- 
 ease 
 
 Sanity : Insanity = i : o 
 
 PSYCHIATRISTS 
 
 Field: Psychiatry, the Men- 
 tally Diseased 
 
 Field: Social, Private, Medi- 
 cal 
 
 Field : Medical, Psychological, 
 and Social Diagnosis and 
 Treatment 
 
 Decisions Selective: e.g., 
 Syphilitic, Feeble-minded, 
 Epileptic, Alcoholic, Coarse 
 Brain Disease, Sympto- 
 matic, Senescent - senile. 
 Schizophrenic, Cyclothymic, 
 Psychoneurotic, etc. 
 
 Sanity Consistent with Mental 
 Disease of Mild Degree or 
 of Special Type 
 
 Mental Disease of All De- 
 grees of Many Kinds 
 
The hypothetical and indeed Utopian reports (Examples 1-5) 
 are made, it will be observed, by a physician who announces 
 himself to be both an aHenist and a psychiatrist. No doubt 
 every good physician must, in the nature of things, be a good 
 alienist, since the expert in mental diseases, as a rule, must be 
 an expert in those mental diseases which are, from the legal 
 point of view, insanities. No doubt, too, every alienist (in the 
 narrow legal sense here adopted) ought to be a good psychia- 
 trist. Yet it is still true that many alienists are to be found 
 who have no interest in mental diseases outside the field of the 
 medico-legal insanities, and having no interest (especially no 
 therapeutic interest) therein really never do become psychia- 
 trists in a deep sense. This unfortunate state of affairs will 
 persist in most states until the best available technique for 
 handling border-line cases (namely the psychopathic hospital) 
 is established. We place upon another page in parallel columns 
 several of these points. 
 
 As we have throughout insisted, psychiatry is an art, a 
 branch of practical medicine. Yet it cannot be denied that 
 there are many generalities about psychiatry which go to make 
 up a respectable body of theory. Some authors distinguish a 
 special psychiatry from a general psychiatry, the former con- 
 taining descriptions of separate forms of mental disease and 
 the latter presenting a variety of general statements. The bet- 
 ter usage is to apply the term "psychopathology" to the body 
 of scientific theory which has been built up out of psychiatry 
 taken in relation to medicine, psychology, and other mental 
 sciences as a whole. The best usage would define the psycho- 
 pathologist as a theorist in mental disease and the psychiatrist 
 as a practitioner therein. To be sure every practitioner needs 
 a body of theory to go upon and must therefore be trained in 
 psychopathology. The reverse is, no doubt, not at all the case ; 
 and non-practitioners, even non-medical men, have made enor- 
 mous additions to our knowledge of the theory of mental 
 disease. The lay reader who dips into modern works on the 
 topic of psychiatry will almost always find long sections deal- 
 
 443 
 
444 THE KINGDOM OF EVILS 
 
 ing with "general" psychiatry or with psychopathology and 
 will find therein descriptions of, for example, hallucinations, 
 delusions, morbid emotions, and will-disorders taken in a gen- 
 eral way and outside their setting in the special forms of men- 
 tal disease. The lay reader must be warned against trans- 
 ferring ideas from these theoretical parts of textbooks directly 
 to the patients. On the other hand it is rather easy for the 
 lay reader to gain some notion of the special forms of mental 
 disease in their larger outlines. Indeed we have known medical 
 students, social workers, psychologists, and even jurists who 
 possessed more exact ideas about some forms of mental disease 
 than do many general practitioners of medicine. 
 
 A word concerning clinical neurology. Medical school cur- 
 ricula, national medical associations, and a variety of textbooks 
 assure us of the existence of a field of nervous diseases sepa- 
 rate from that of mental diseases. The relations here are a 
 little difficult for the lay reader to grasp. The mind has close 
 relations with the nervous system, and the term neurology 
 seems to specify a science of everything nervous. Accordingly 
 the neurologist living up to the Greek roots of his professional 
 title is apt tp regard himself as ex officio a psychiatrist. On 
 the other hand the psychiatrist in his practical diagnostic work 
 has to use many of the coarser methods of the neurologist and 
 finds himself nolens volens in the end a sort of neurologist. 
 
 In the Great War the surgeon general of the army developed 
 a division of neurology and psychiatry, and practically no dis- 
 tinction was made between the officers working under this 
 division. In fact, they were often termed neuro psychiatrists. 
 Some think that a new art of neuropsychiatry combining the 
 neurological and psychiatric branches of older medicine is to 
 be established. This is not the place to discuss or to define 
 the fields of clinical neurology and psychiatry. After all, both 
 the clinical neurologist and the psychiatrist are physicians and 
 have the same fundamental medical training. Many men unite 
 theoretical and practical knowledge in two fields. The senior 
 author of this work has elsewhere tried to define the present- 
 day differences in these two types of professional men by de- 
 scribing the clinical neurologists as rather more analytical and 
 the psychiatrists as rather more synthetical in their viewpoints. 
 This means to say that the clinical neurologist is on the whole 
 rather more apt to leave his patient a mass of reflexes, and the 
 
THE KINGDOM OF EVILS 445 
 
 psychiatrist is rather more apt to talk of his patient in general 
 terms. It is easy to see that each method readily slips into over- 
 emphasis of details or generalities. The middle of the road 
 must be taken. 
 
 We pass to a brief summary of the major forms of mental 
 diseases as they occur in practice. It is customary to say that 
 textbooks on psychiatry greatly disagree upon their subject 
 matter. But there is far more disagreement upon terms than 
 upon facts. And there is naturally far more disagreement 
 about details than about the major groups of mental disease. 
 The cases in Book III have been presented in groups which are 
 found in most textbooks of psychiatry. These groups are pre- 
 sented in a special order. We do not here need to argue for 
 the virtues of an orderly approach in diagnosis, since our entire 
 work must be regarded as perfectly hopeless if the reader has 
 not been convinced of the value of the orderly approach as 
 shown in Book I and especially in Book II. The value of 
 order in the world's work is a truism. The orderly diagnosis 
 of mental disease is as valuable a method as the orderly diag- 
 nosis of the social factors which we have grouped in this 
 book under the title of the Forms of Evil. In fact the impulse 
 to the classification of evils herein adopted was derived from 
 the senior author's work on the orderly diagnosis of mental 
 diseases. 
 
 We have thrown our cases into eleven groups, of which the 
 eleventh is a miscellaneous or rag-bag group of mental dis- 
 eases either severe or mild (but for the most part mild) that 
 do not fit the definitions of the other ten major groups of 
 mental disease. This eleventh miscellaneous group would be 
 of special abhorrence to the old-time alienist limited in his 
 view of mental disease to the notion of medico-legal insanity. 
 The old-time alienist who cannot think of insanity except in 
 terms of internment in an asylum or of testamentary incapac- 
 ity, cannot readily be got to deal with the psychopathic per- 
 sonalities and other disorders of this eleventh group. It is 
 somewhat as if the general practitioner of medicine should 
 refuse to consider any case of disease which was not bedridden. 
 The eleventh group of the psychopathies, psychopathic person- 
 alities, etc., must comprise, it will be seen, many of the cases 
 of mild and dubious mental disease which the modern psycho- 
 pathic hospital has been especially established to class and treat. 
 
446 THE KINGDOM OF EVILS 
 
 The eleventh group is placed last, because the attempt should 
 be made to class every mental suspect more definitely in one of 
 the preceding groups. Concerning these preceding ten groups, 
 it is worth while to insist that nothing ultimate is claimed 
 either for the number or the nature or the special order of the 
 groups. That some order of disease groups should be adopted 
 for the purposes of diagnosis is highly desirable. That this 
 particular order is the best at the present day is perhaps doubt- 
 ful. Nor will anyone maintain that this particular order will 
 outlast the decade. 
 
 The first four groups in this sequence are of particular social 
 interest. The first group contains the mental diseases due to 
 syphilis, a group of diseases of increasing importance in prac- 
 tical psychiatry and the bridge over which the new associations 
 between mental hygiene and public health will pass owing to 
 the fact that the most concrete contributions to the technique 
 of mental hygiene have been made in this field. Nor can any- 
 one doubt that feeble-mindedness is a leading social problem. 
 Epilepsy, particularly in its milder and so-called "equivalent" 
 forms, is another topic of social interest both because public 
 institutions must always eventually be built for epileptics of a 
 given state and because there are always so many "sane" epi- 
 leptics who are in no sense asylum cases but are very proper sub- 
 jects for social work and mental hygiene. Fourthly, alcohol- 
 ism is, or has been in this country up to the passage of the 
 national prohibition legislation, a most important social factor 
 of mental hygiene. Inasmuch as the group here defined con- 
 tains the drug addicts (so far as drugs produce mental dis- 
 ease and disorder), the group may, no doubt, always remain of 
 practical social significance. 
 
 Though the main reason for arranging these disease groups 
 in this particular order (first proposed in 191 7) was the 
 reliability of tests and other diagnostic criteria in the groups, 
 yet the order was adopted with a weather eye to the social 
 values of the groups. If the psychiatrist could be made to con- 
 sider definitely such socially interesting matters as (a) syphilis, 
 (b) feeble-mindedness, (c) epilepsy, (d) alcohol and drugs, 
 the battle was almost won for a broad conception of psychiatry. 
 If the psychiatrist was compelled by routine to learn whether 
 his mental patient was syphilitic, he was compelled to resort to 
 laboratory methods of a certain refinement. If he took seri- 
 
THE KINGDOM OF EViLS 447 
 
 ously the question of feeble-mindedness, he had perforce to 
 resort to standardized methods of mental testing. If he was 
 to make up his mind about either epilepsy or alcoholism he had 
 to have by him the means of securing a social history. In short, 
 the psychiatrist who should deal scientifically with the ques- 
 tions raised in these first four groups would have to have at his 
 command the services of a proper modern clinical laboratory, 
 the resources of a psychological service, and the resources of 
 psychiatric social work. 
 
 It will be known, even to the layman who has had contacts 
 with this field, that the majority of cases in these first four 
 groups are cases of the so-called "organic" type. That is to 
 say, these cases will be found upon autopsy to show serious 
 disorder of the nervous system which can be demonstrated 
 either by the naked eye or by the microscope. In fact the 
 whole table of groups is found to have, roughly speaking, the 
 property of being more "organic" at its upper end and more 
 "functional" at its lower end. But the sequence was not chosen 
 upon this particular basis, but rather, as stated above, on the 
 basis of the reliability of diagnostic tests and criteria. Above 
 all, the lay reader should not conclude that "organic" means 
 incurable or permanent as to symptoms. 
 
 The fifth group is a group of mental diseases in which the 
 brain shows demonstrable lesions. It is the "organic" group 
 par excellence with the syphilitic, feeble-minded, and epileptic 
 cases removed therefrom. The sixth group is a group of 
 mental diseases in which the brain is relatively normal and in 
 which the cause seems to reside outside the brain in some one 
 or more organs of the body. So far as asylum material goes 
 this group of somatic cases has seemed up to recent times to 
 be limited. The seventh group is the group of the senile psy- 
 choses. The remaining three groups deal with topics of great 
 difficulty and of doubtful scientific standing even today. The 
 eighth and ninth groups of the so-called dementia praecox and 
 of manic-depressive psychosis are groups whose distinction is 
 a practical matter of difficult diagnosis almost daily in every 
 hospital for the insane and even more so in psychopathic hos- 
 pitals. These two disease groups may be regarded as "sister" 
 groups of mental disease. The tenth group is that of the psy- 
 choneuroses, Avith which the reader of the first three books has 
 to become familiar, in striking instances in which mental fac- 
 
448 THE KINGDOM OF EVII^ 
 
 tors, operating apparently by themselves, have directly pro- 
 duced mental disorders. So far as we are aware, practically 
 every psychiatrist of today recognizes the existence of these 
 major groups or of their most important single representatives 
 amongst the diseases. 
 
 The alert reader may well have inquired long before this 
 point in our exposition whether a patient may not fall into two 
 or more of these groups. Let us emphatically say that it is 
 entirely possible that a patient shall be syphilitic, feeble-minded, 
 epileptic, alcoholic, a victim of coarse brain injury, a victim of 
 somatic disorder operating from outside the nervous system 
 and a senile ; that is, a patient may possess characteristics that 
 fall in every one of the first seven groups. To be sure it may 
 be better to describe him chronologically. He inight be de- 
 scribed as a feeble-minded person whose brain lesion was such 
 as to have produced epilepsy, who had not only acquired syphilis 
 of the nervous system but had sundry other destructive in- 
 juries of his brain and who had, in the vicissitudes of life, 
 become alcoholic, had developed diseases in the body at large 
 which had in turn reflected themselves in the patient's mind 
 and who had at last become senile in such wise that the senile 
 brain changes were contributing a dementia to the already 
 complicated picture. To be sure for the present we have no 
 such case to offer, and such extensive combinations of factors 
 are, no doubt, rare. But can we continue to catalogue on a 
 theoretical basis? Is it, for example, possible for a feeble- 
 minded person to become a victim of dementia praecox? The 
 answer to this question cannot be given with certainty at this 
 time; but on the whole there is considerable evidence for an 
 affirmative answer, and some authors freely assert that de- 
 mentia praecox may be grafted upon feeble-mindedness. As 
 for manic-depressive psychosis its phenomena are found in the 
 majority of mental diseases, which may develop periodical 
 emotional disturbances ; but it is doubtful whether we should 
 term all such instances of an apparently cyclothymic nature 
 cases of manic-depressive psychosis. As for the psychoneu- 
 roses, no doubt they can develop upon any or all of the bases 
 above enumerated. But if a case of mental disease exhibits 
 phenomena that might, at first glance, place him in one of the 
 lower groups in our sequence, then, in fact, it is the usual rule 
 to give him the diagnosis of the earliest group to which he can 
 
THE KINGDOM OF EVILS 449 
 
 be found related. This is probably on account of the prag- 
 matic and therapeutic value of so classing the patient. 
 
 Let us indicate some of the more important social values of 
 these groups. 
 
 Group I, the syphilitic group of mental disorders, is a very 
 important one to the social worker. In the first place the 
 establishment of the diagnosis almost always means the pos- 
 sible suggestion of treatment, which treatment may be rela- 
 tively expensive and sometimes hard to persuade the patient to 
 take. In the next place, the spouse and children of the neuro- 
 syphilitic need examination to determine whether they are not 
 likewise infected with syphilis. If so, they can come before 
 they have developed mental symptoms and in their own interest 
 be treated in suitable clinics or otherwise. It is the task of 
 the social worker to see that this family work in neurosyphilis 
 be carried out. Some of the points in this work have been set 
 forth in a work by Southard and Solomon entitled Neurosyph- 
 ilis, Modern Systematic Diagnosis and Treatment (191 7), one 
 whole section of which is devoted to medico-legal and social 
 problems. Some of the cases in this book have been presented 
 again in this work redescribed from the standpoint of social 
 work. This group is the group of the popularly known dis- 
 ease, general paresis, sometimes known as "softening of the 
 brain." Southard and Solomon in 191 7 reported that some- 
 thing like twenty-five per cent of their cases of general paresis 
 yielded considerably to treatment. This percentage is higher 
 than other authenticated percentages. Perhaps the lay reader 
 will not be too much impressed with a twenty-five per cent 
 yield of therapeutic successes; but if the layman considers the 
 results in chronic diseases in general and remembers that this 
 disease comes as a rule ten years after the initial infection with 
 syphilis, he will see that such results as twenty-five per cent 
 recoveries are important. 
 
 The social values of Group II, of the feeble-minded, are 
 too much in the public eye at the present moment to require 
 exposition here. Not only have the psychologists following 
 Binet produced mental tests of value but these tests have been 
 very widely employed by the more or less competent lay work- 
 ers and the whole topic has absorbed public interest. The 
 articulation of this problem with the problems of crime and 
 prostitution is well known, not to say overdrawn, in the public 
 
450 THE KINGDOM OF EVILS 
 
 prints. Practically half of the prostitutes examined by the 
 White Slave Traffic Commission of Massachusetts turned out 
 to be in some degree feeble-minded. 
 
 Concerning Group III, note was made above of the popular 
 interest in the "sane epileptic." Some authors have empha- 
 sized the relation of the so-called epileptic personality with its 
 very pronounced egotism and ill-humor. Doubtless in this field 
 there will be much scope for mental hygiene in the future. 
 But the social worker can do the most good by remembering 
 that epilepsy has a large number of subgroups. The formula 
 to bear in mind is that it is much truer to speak of "epilepsies" 
 than of "epilepsy." 
 
 Concerning Group IV, the alcoholic group and the drug 
 group, we have at times referred to the special values of the 
 Men's Club as employed for some years at the Psychopathic 
 Hospital in Boston. But the idea is an old one. The Salvation 
 Army has in the past done much good in the rescue of alco- 
 holics from their habits. The victim of delirium tremens is 
 an especially good social risk, as he often cooperates extremely 
 well upon recovery. 
 
 Groups V, VI, and VII are of lesser social importance since 
 for the most part the problems that arise therein are either 
 not at all to be settled by social work or else can be settled 
 with considerable ease. 
 
 Groups VIII, IX, X (that is, dementia praecox. manic-de- 
 pressive psychosis, and psychoneurosis) become once more of 
 prime interest to the social worker. Dementia praecox and 
 manic-depressive cases are constantly apt to fall into the dubious 
 position, whether they require interning in an asylum or do not. 
 The relations of the friends to this situation then become criti- 
 cal. Apparently a multitude of adjustments may need to be 
 made in these groups by the social worker. Mild cases of both 
 of these diseases, but especially of the manic-depressive group, 
 often want to go home prematurely and often do go home 
 against the advice of the physicians. The social worker may 
 here become of great practical value. Somehow the laity is 
 rather apt to regard the psychiatrist as a kind of ogre who 
 wishes to get even the mildest and most doubtful psychop- 
 athies into his institutional net for safe-keeping or observation. 
 The social worker can help to dissolve this idea of something 
 ogreish in the psychiatrist. Patients recovering from depres- 
 
THE KINGDOM OF EVILS 45 1 
 
 sion (manic-depressive psychoses) are particularly difficult 
 cases to handle. During convalescence these patients are ap- 
 proximately normal; yet at a time when the depression still 
 persists but the power of the will has steadily increased comes 
 the zone of danger of suicide. The patient is still dominated 
 by depressing thoughts but is no longer protected against sui- 
 cide by the weakness of will which prevailed in the peak of 
 his illness. The relatives need to be convinced that their patient 
 should be retained in hospital a few weeks longer to pass 
 through this zone of will weakness. 
 
 Finally nothing in this book has been more convincing than 
 the need of social work in the field of psychopathic personalties, 
 here grouped in the last Group XI. 
 
 Now and then from a general social worker comes a request 
 for lists of symptoms by which, supposedly, the different men- 
 tal diseases may be recognized. Social workers who have 
 dipped into works upon psychiatry can follow us when we say 
 it is not at all impossible to match the symptoms of any dis- 
 ease which we may confront with the symptoms of several dis- 
 eases as described in the medical books. In fact, the more 
 thorough and accurate the psychiatric textbook, the more likely 
 would be the facts in the particular case to match with the facts 
 in the books as presented under a great variety of headings. It 
 is not alone the tyro, but also the expert, who is amazed to find 
 that all the symptoms in his case can be found, let us say, 
 under the different headings of syphilis, dementia praecox, 
 manic-depressive psychosis, etc. To use the language of medi- 
 cal logic, we can- briefly put the situation by saying that in the 
 field of mental diseases, there are few or no indicator symp- 
 toms. Any symptom, e.g., mania, depression, persecutory 
 ideas, grandiosity, hallucinations, and so on through the list, 
 may be found alone or even in multiple combination with other 
 symptoms of the list in virtually any one of the great groups 
 of mental diseases. 
 
 A good many persons believe that a disease is composed of 
 symptoms, but nothing is more erroneous. The symptom indi- 
 cates the disease. The disease is an infinite mass of processes 
 and of arrangements. It is a mistake to think that because it 
 can be shown that general paresis has a certain kind of pupil- 
 lary disorder and a certain kind of speech disorder, and a cer- 
 tain mental state characterized by feelings of grandeur, these 
 
452 THE KINGDOM OF EVILS 
 
 three things, disorder of pupils, disorder of speech, delusions 
 of grandeur, in any sense constitute the disease. No symptom 
 constitutes the disease. No group of symptoms constitutes a 
 disease. One rather comforting fact about mental disease is 
 that, after all, there are so few symptoms to a given disease. 
 The most complicated disease that runs through the entire 
 make-up of the person, influences every move of his entire 
 future, goes back to his entire past, will be found to have but 
 one symptom, or two or three, rarely more than ten or a dozen 
 symptoms. These must be, in the nature of things, mere indi- 
 cators of the situation. 
 
 In short there are no indicator symptoms, or what are called 
 in the books pathognomonic symptoms. In medicine there are 
 certain pathognomonic symptoms; thus in smallpox, the pock 
 of smallpox is pathognomonic; it does not occur in any other 
 disease, and you get it when you have that disease. Of course 
 there are some doubtful cases where you cannot make out 
 whether you have got a pock or not of this characteristic sort. 
 The pock of smallpox is so characteristic that we regard it as 
 pathognomonic. The tubercle bacillus in tuberculosis is pathog- 
 nomonic, — it does not occur except in tuberculosis. But in 
 mental disease we have not any such pathognomonic symptoms 
 that point to any certain disease. 
 
 There are a few combinations of symptoms or signs that 
 indicate certain diseases. However, these combinations are 
 probably beyond the range of a person not trained in medicine 
 to use. There may be ope or two small exceptions to this in 
 the whole of medicine. A nurse, a layman, anyone can learn 
 to diagnosticate smallpox from the pock just as well and per- 
 haps better than a physician. Just as a man without knowing 
 a thing about engineering says about his automobile "the en- 
 gine is skipping." The man may not know what to do about 
 it, or he may, without knowing anything about engineering, be 
 able to fix it ; so that people ca,n make certain diagnoses which 
 are merely recognitions of things, of data. But when it comes 
 to mental disease this is not so. There are not any simple 
 points by which to recognize it, and its complicated ways are 
 not too easy for the medical mind or for any other mind. 
 
MAIN FORMS OF NEUROSYPHILIS 
 
 DIFFUSE NEUROSYPHILIS 
 
 (non-vascular forms of "cerebral," "spinal," and "cere- 
 brospinal syphilis") 
 
 VASCULAR NEUROSYPHILIS 
 
 ("cerebral arteriosclerosis," "cerebral thrombosis") 
 
 PARETIC NEUROSYPHILIS 
 ("general paresis") 
 
 TABETIC NEUROSYPHILIS 
 ("tabes dorsalis") 
 
 GUMMATOUS NEUROSYPHILIS 
 
 ("gumma of membranes, of brain") 
 
 JUVENILE NEUROSYPHILIS 
 (paretic, tabetic, diffuse) 
 
NEUROSYPHILIS 
 
 The problems of neurosyphilis (Group I) are presented in 
 eight cases (39 to 46) at the beginning of Book III. In the 
 book of the senior author written in collaboration with Dr. H. 
 C. Solomon, Neitrosyphilis: Modern Systematic Diagnosis and 
 Treatment presented in one hundred and thirty-seven case his- 
 tories, there had already been given sixteen cases of neuro- 
 syphilis having medico-legal social interests in the foreground. 
 Numerous other cases in that series also possessed social inter- 
 est. Case 39 of our present series, Greeley Harrison, was 
 case 9 of the book Neurosyphilis. Greta Meyer (case 40), 
 Walter Heinmas (case 41), David Collins (case 42), Archi- 
 bald Sherry (case 45) were also all cases from the Neuro- 
 syphilis book, being cases 107, 97, 61, and 38. A whole vol- 
 ume might be written concerning the social aspects of the prob- 
 lem of neurosyphilis. The lay reader must bear in mind that 
 the medical men are apt to term protean the nature of neuro- 
 syphilis. Practically every form of mental disease can be 
 imitated by syphilis of the nervous system. Lesions pro- 
 duced by the spirochsete in the nervous system are of several 
 kinds and of widely varying degree. In the first place syphilis 
 may affect the membranes that surround the nervous system 
 giving rise to the various forms of meningeal syphilis (both the 
 delicate pia mater that immediately invests the brain and spinal 
 cord and the thicker dura mater that overlies the pia mater are 
 affected by lesions that may be either isolated or widespread). 
 The blood vessels of the brain and spinal cord may be the par- 
 ticular target of attack by the spirochsetes and the lesions of 
 these blood vessels may give rise to destruction of the brain 
 and spinal-cord tissues which they supply with blood. Again, 
 when neither the investing membranes nor the blood vessels 
 are severely or at all affected, the tissues themselves may be the 
 point of attack by the spirochsete. 
 
 We present upon page 453 the main forms of neuro- 
 syphilis as classified for practical purposes in the above men- 
 tioned book of Southard and Solomon. Of these six main 
 
 455 
 
456 THE KINGDOM OF EVILS 
 
 forms of neurosyphilis we illustrate in the present volume five 
 forms. The form omitted from the present volume is the 
 form known as gummatous neurosyphilis, that is a gumma of 
 the membranes of the brain. This lesion is sometimes open to 
 surgical attack and sometimes to treatment by antisyphilitic 
 drugs, such as salvarsan, mercury, and the like ; but the prob- 
 lems of the disease would have nothing of special interest from 
 the social standpoint. Diffuse neurosyphilis is represented in 
 this volume by Greta Meyer (case 40). This disease may be 
 a long-standing one. There is no prognosis of comparatively 
 early death such as attends the diagnosis of general paresis 
 represented in our series by Greeley Harrison (case 39), Hein- 
 mas (case 41), Collins (case 42), Spindler (case 43). In 
 cases of diffuse neurosyphilis, such as that of Greta Meyer, ac- 
 cordingly the social worker may look for a long history of 
 gradual development, numerous variations, remissions, and 
 an outlook of considerable success in medical treatment. With 
 respect to the paretic form of neurosyphilis, commonly called 
 general paresis, we have brought out in our discussion of Gree- 
 ley Harrison (case 40) that the paretic form of neurosyphilis 
 is not necessarily completely intractable to treatment. We 
 here point out that this point is a most important conception 
 not yet well established in the medical mind. Southard and 
 Solomon felt from their work published in 191 7 that intensive 
 treatment had proved to be of the greatest value in a number 
 of cases of general paresis. They felt that they had cured an 
 excellent salesman of forty-six years of age who had suffered 
 from most aggravated mental symptoms. He not only recov- 
 ered symptomatically but all his tests have been rendered nega- 
 tive and he has remained entirely well and economically effi- 
 cient for about five years even without further treatment. 
 
 Southard and Solomon pointed out also that two or three 
 months of active treatment will often be carried out before 
 any signs of improvement whatever are seen. They con- 
 cluded that it was "unfair" to give an entirely grave prog- 
 nosis in any case of neurosyphilis until the effect of treat- 
 ment had been tried. But whatever the outcome of the medi- 
 cal treatment of neurosyphilis in any of its forms, we can hope 
 to prove in the present volume that social treatment yields 
 efficient results and should be carried out even if the medical 
 prognosis be regarded as grave. 
 
THE KINGDOM OF EVILS 457 
 
 The case of Walter Heinmas is a particular one from the 
 standpoint of the social worker. As we pointed out, the rather 
 obvious motto should be adopted by social workers, namely, — 
 the families of paretics are the families of syphilitics. This 
 motto should be followed by action. This action should con- 
 sist in having the blood serum of each member of the family 
 of the paretic (that is, his spouse and children) examined by 
 blood tests for syphilis. The two children of Walter Heinmas 
 had fortunately been absolutely healthy. The patient himself 
 and his wife had no idea that there had ever been syphilis and 
 could remember no symptoms or suspicions. Mother and 
 daughter were well endowed in mind and general physical 
 health, yet blood tests of all three proved positive for syphilis. 
 
 The case of David Collins is particularly valuable for the 
 social worker. The data of this case seemed to show that 
 neither intense medical care alone nor elaborate social care 
 alone would ever turn the trick. Neither form of treatment 
 would have been quite justifiable from a practical point of 
 view if carried out alone. Whatever is to be the outcome in the 
 case of David Collins, we must concede that partial or tem- 
 porary cure by social service methods must be scored for the 
 Collins family. At the present writing we have a history of 
 five years since the first appearance of David Collins at the 
 hospital after his falling into convulsions on the street, and we 
 have a history of three years since the initiation of a period 
 of regular treatment. 
 
 Archibald Sherry (case 45) is a very unusual case medically, 
 a case of juvenile tabes, sometimes known as locomotor ataxia. 
 Rather good therapeutic results were obtained for this twelve- 
 year-old boy, although social work was difficult by reason of 
 lack of cooperation on the part of the child's mother. 
 
 Harold Gordon (case 46) falls into the group of vascular 
 neurosyphilis (see table of main forms). These cases may be 
 completely arrested by medical treatment leaving a certain in- 
 curable but not necessarily incapacitating impairment. The 
 point of these results lodges in the fact that the loss of power 
 on the one side of the body (hemiparaplegia) is due to lesions 
 of blood vessels in the brain, which lesions may be cured com- 
 pletely by antisyphilitic treatment, but the destruction of brain 
 tissue entailed by the temporary or permanent plugging or rup- 
 ture of the artery cannot be made good. Tissue of the cen- 
 
45^ THE KINGDOM OF EVILS 
 
 tral nervous system, once destroyed, cannot be regenerated. 
 However, the victim of such a disease as syphiUtic hemiparesis 
 may recover without excessive impairment, as in the case of 
 Harold Gordon. 
 
 Neurosyphihs is then one of the most protean of diseases. 
 The blood test for syphilis is one of the most reliable, if not 
 the most reliable, single blood test available to the worker in 
 mental disease. Inasmuch as syphilis of the nervous system 
 may through its special ways of affecting brain and spinal cord 
 imitate practically every other kind of mental disease it becomes 
 important to eliminate the hypothesis of neurosyphilis from 
 virtually all cases of long-standing mental disease, particularly 
 if this disease occurs in the male sex. It is possible for the 
 nervous system to harbor spirochsetes that cause syphilis with- 
 out yielding any symptoms whatever, at all events for years 
 or even decades. We sometimes find elaborate evidence for 
 syphilis of the nervous system in persons who show absolutely 
 no sign or symptom of nervous disease. But again spiro- 
 chsetes may produce extraordinary effects or produce huge 
 tumor-like masses known as gummata. These gummata are in 
 their practical effects rather more like tumors than like most 
 syphilitic lesions. 
 
 Again it would seem as though the process is a sort of siege 
 of the nervous system, the spirochaetes affecting certain nerve 
 tracts. This is the case in tabes dorsalis (locomotor ataxia) 
 where the destructive process is largely limited to the posterior 
 tracts of the spinal cord. The form of attack in diffuse neuro- 
 syphilis is quite different, as if the nervous system were not 
 so much attacked by siege as taken by storm, and the results 
 are disseminated over a large area. Again neurosyphilis is a 
 simple secondary effect of blood vessel disease which results in 
 the scooping out of huge masses of tissue which die and give 
 rise to so-called secondary degeneration in different parts of 
 the nervous system. These lesions or spirochsetes may be over- 
 looked and disappear and the lesions may resemble extin- 
 guished volcanoes. Yet again the diffuse process may run on 
 apparently with perfectly fatal results to mortality in a few 
 years both with and without treatment. However, in other 
 cases, as we have insisted, treatment appears to accomplish 
 much. As Southard and Solomon insist, the prognosis of 
 neurosyphilis is not worse than that of the chronic dis- 
 
THE KINGDOM OF EVILS 459 
 
 eases in general. The prognosis of neurosyphilis so far as 
 length of life goes is certainly not bad. Remissions are always 
 possible though they are not frequent. We found amongst 
 three hundred untreated committed cases of paretic neuro- 
 syphilis five that were capable of self-support and ten more 
 that seemed normal enough to live at home. The patients were 
 said to have "remissions." Perhaps the most important thing 
 for the investigator to bear in mind is this : During a good 
 part of the early period of the course of neurosyphilis, it is 
 difficult or impossible to tell the paretic from the non-paretic 
 forms of diffuse neurosyphilis by any combination or single 
 observations and tests. In short we should take any diagnosis 
 either of general paresis (with its outlook that the patient is 
 going to die in from three to five years) or of diffuse neuro- 
 syphilis (with its much better prognosis) with a grain of salt. 
 In either case, however, it is desirable to proceed along the best 
 lines of social treatment whatever is to be the outcome of the 
 neurosyphilitic. In each instance also it is important to remem- 
 ber the other members of the family and to submit them to 
 blood tests. It would be an important addition to the tech- 
 nique of preventive medicine if the spouses and children of 
 all paretics were subjected to blood tests for their own 
 individual interest and in the interest of the health of the 
 community. 
 
FEEBLE-MINDEDNESS 
 
 FIELDS OF INQUIRY 
 
 Physical Examination 
 
 Family History 
 
 Personal and Developmental History 
 
 School Progress 
 
 Examination in School Work 
 
 Practical Knowledge 
 
 Social History and Reactions 
 
 Economic Efficiency 
 
 Moral Reactions 
 
 Mental Examination 
 
 Walter E. Fernald, 191; 
 
FEEBLE-MINDEDNESS 
 
 We present the topic of social work in connection with 
 feeble-mindedness (Group II of Book III) in six cases (47- 
 52) in Book III. But the topic has been extensively covered 
 also in Books I and II, more particularly in cases 2, 9, 11, 13, 
 15. 26, 32, 35. 
 
 The social worker must become familiar with at least the 
 generalities concerning the major subgroups of feeble-minded- 
 ness from the standpoint of the measurement of their mental 
 levels. American usage counts amongst the feeble-minded 
 (a) the idiots or feeble-minded of the lowest grade, (b) the 
 imbeciles or feeble-minded of middle grade, and (c) the morons 
 or feeble-minded proper. (English usage often employs the 
 term feeble-minded for the morons only.) Modern work 
 seems to show that between the feeble-minded proper or so- 
 called morons and normal persons there is a group of (d) 
 subnormal persons measuring by mental tests at a higher level 
 than the morons. If this new definition is established, we shall 
 then count from below upwards, four groups of the "feeble- 
 minded" ; namely idiots, with a mental level corresponding to 
 that of infants; imbeciles with a mental level corresponding to 
 that of young children ; morons with a mentality corresponding 
 to that of older children before puberty, and subnormal persons 
 with a higher mentality but still a mentality falling short of 
 the normal. It must be granted, however, that the mental 
 tests at present available do not serve to mark out these higher 
 subnormals with perfect accuracy. Indeed the term "feeble- 
 minded" seems to have become much too strong a term to use 
 of many persons whom we can still put down as clearly sub- 
 normal. It may be well enough to term imbeciles and idiots 
 simply more and more pronounced examples of feeble-minded- 
 ness. It is, however, a shock to the layman's mind to hear 
 persons of but slightly substandard mentality termed feeble- 
 minded. Indeed, when we examine the brains of these sub- 
 normal persons, post mortem, we find that they are in general 
 appearance but slightly, if at all, removed from normality, 
 
 463 
 
464 THE KINGDOM OF EVILS 
 
 When we perceive normal-looking brains in subnormal persons 
 (even in morons we are apt to find brams that are not strik- 
 ingly abnormal in the gross) we are likely to think that, by a 
 slight twist of the wheel of fortune, such substandard persons 
 might possibly be made proper inhabitants of the world, proper 
 voters, and even proper parents. Perhaps a slight variation 
 of the glands of internal secretion might serve to turn the scale ! 
 Or the trick might be accomplished, we are apt to think, by a 
 little more intensive education ! Meantime it is almost or quite 
 impossible to draw a line between those subaverage subjects 
 that go to make up the group of normals from these substand- 
 ard persons that we are willing to term definitely subnormal. 
 The social worker remains as much at a loss as does the psy- 
 chologist. Lawyers and even judges flounder in a morass of 
 doubt when it comes to calling these but slightly substandard 
 subjects "feeble-minded." 
 
 Is there a group of (as it were) superfeehle-minded above 
 the group of the feeble-minded proper (morons) and far 
 above the imbeciles and idiots? The senior author of this 
 work has sometimes argued for a new term to cover all the 
 forms of feeble-mindedness, including the unnamed slight de- 
 gree of subnormality that lies above the so-called moronity. 
 The term chosen was hypo phrenic and the condition of feeble- 
 mindedness of whatever degree may be known as hypophrenia. 
 We believe that, if the layman, lawyer, or judge feels quite 
 smcerely averse to calling certain persons "feeble-minded," 
 particularly persons in this subnormal group above the level 
 of moronity, he ought to be far more willing to have the term 
 "hypophrenic" used. Moreover in our public discussion of 
 these cases (particularly in the presence of the patients them- 
 selves), would it not be highly convenient to be able to use the 
 term hypophrenic, a term which is of unknown insignificance 
 to the patient himself. When a patient who is slightly sub- 
 normal and perhaps (as often) is rather acutely conscious of 
 his subnormality, hears himself dubbed "feeble-minded," he 
 has a certain right to feel nettled. We feel that the employ- 
 ment of the term feeble-minded, even for morons of the upper 
 grade and certainly for the subnormals that are above the level 
 of morons, sometimes makes a kind of permanent scar in the 
 patient's mind. We have also seen persons, who upon dis- 
 covering themselves to be "feeble-minded," have forthwith 
 
THE KINGDOM OF EVILS 465 
 
 denied all responsibility for any acts of theirs and given them- 
 selves serenely up to behavior which they could very readily 
 and profitably restrain. It is all very well to be, as Dr. Richard 
 Cabot has often insisted, belligerent in truth-seeking and in 
 telling the truth, but if we employ the term feeble-minded in 
 a very extended sense, not consistent with the lay usage of the 
 adjective feeble, we are not telling the whole truth about our 
 patients. It is worth while to insist upon this little point since 
 so much important psychiatric social work has to be carried 
 out with persons that are feeble-minded. 
 
 Feeble-mindedness is of interest to a great number of work- 
 ers in the world. For example, (a) educators, responsible for 
 the laggards, truants, dullards, "exceptionals" ; (b) court au- 
 thorities to whom the educators' problems in part drift and 
 figure as psychopathic cases, defective delinquents, prostitutes, 
 and the like; (c) eugenists and other persons interested in 
 heredity who are inclined to advocate segregation in institu- 
 tions or perhaps even sterilization of the feeble-minded on the 
 basis that the entire problem is a hereditary one; (d) legisla- 
 tors, to whom of late feeble-mindedness has become the most 
 interesting of social problems. 
 
 Under the case of Florence Warner (case 47) we have 
 spoken of conditions under which mental tests must be carried 
 out (absence of fatigue on the part of the examiner and pa- 
 tient; absence of all clouding of consciousness, such as infec- 
 tious disease, alcohol, drugs, and the like may produce ; and the 
 absence of all stupor or dullness of mental faculties incident 
 to mental diseases like dementia praecox). 
 
 Florence Warner illustrates the relations of feeble-minded- 
 ness to prostitution or at all events to sex irregularity. The 
 White Slave Traffic Commission of the Commonwealth of 
 Massachusetts did indeed find that about one-half of the pros- 
 titutes examined for their mental levels turned out to be in 
 some degree feeble-minded. But, even if all or almost all 
 prostitutes were feeble-minded, it does not do for the social 
 worker to think of all feeble-mindedness in women as fatally 
 determining irregular sex life. Further investigations of the 
 lives of feeble-minded persons released from schools for the 
 feeble-minded, after their schooling has been completed, has 
 shown that many frankly feeble-minded persons, even of the 
 female sex, have not fallen into the group of sex delinquents, 
 
466 THE KINGDOM OF EVILS 
 
 Even when feeble-mindedness is present in the sex dehnquent 
 it is not always possible to assign prostitution to feeble-minded- 
 ness as a cause. The most we can say in this contingency is 
 that a feeble-minded person whose sex irregularities may be 
 due to something quite other than feeble-mindedness may still 
 be tmable to react zvith proper judgment to the measures taken 
 to stop the sex irregularity and to divert the patient's interest. 
 
 We may also refer to the discussions under case 47 of the 
 differential values of the psychiatrist, the psychologist, and the 
 social worker in the handling of feeble-mindedness. 
 
 The case of Bessie Newman (case 48) will be remembered 
 as a very striking family case in which it was psychologically 
 desirable to consider every one of the ten members of the 
 family from the psychiatric point of view. Amongst all the 
 cases of this work that of Bessie Newman is the one which 
 will perhaps most repay study. The Rosenthal family (case 
 49) has also shown that three out of five of its members are 
 psychopathic. The case of Bernard Bornstein (case 50) 
 shows how a moron boy in a protected environment could be 
 the support of his family; whereas navy life proved to be 
 beyond his powers. 
 
 Beatrice Cellini (case 52) was handled as an out-patient 
 under the social service without ever being in the wards of the 
 Psychopathic Hospital. Reference may be made to the remarks 
 under the discussion of Beatrice Cellini concerning variations 
 in her moods. 
 
EPILEPTOSES 
 
 Syphilitic Symptomatic 
 
 Alcoholic Idiopathic 
 
 Traumatic Psychic 
 
 Encephalopathic Narcoleptic 
 
 Jacksonian Borderland 
 
EPILEPSIES 
 
 Epilepsy (Group III of Book III) is ordinarily a disease 
 with at least (a) unconsciousness and (b) convulsions. An 
 attack of unconsciousness alone does not constitute epilepsy 
 and does not in itself prove the existence of epilepsy. Neither 
 would a single convulsion, even though it were very character- 
 istic in its appearance, prove the existence of epilepsy. If, 
 however, the diagnosis of epilepsy is once established through 
 medical observation of several attacks of unconsciousness with 
 convulsions, then it becomes possible for the physician to iden- 
 tify certain minor attacks and disorders of consciousness with 
 little or no evidence of convulsions, as epileptic. Accordingly 
 when fainting spells, abstraction, blank feelings, and episodes 
 of loss of memory occur, the physician is very apt to think 
 of the possibility of epilepsy. 
 
 Modern work seems to have shown that there is an epileptic 
 temperament or personality in which self -consciousness (ego- 
 centricity) and inharmony and irritability are found. The 
 epileptic mind seems, on the whole, a little childlike, even when 
 there- is little proof of feeble-mindedness. Modern study of 
 epilepsy has shown that it is much more exact to speak of 
 epilepsies than of epilepsy. 
 
 The major or so-called grand mal attack of epilepsy con- 
 sists in a fall with unconsciousness and spasm. The spasm 
 is at first a steady tonic spasm, but there shortly appear inter- 
 rupted or clonic spasms. Automatic movements follow these 
 clonic spasms. The patient then either wakes up or passes 
 into a deep sleep. On waking the victim feels lame and weak 
 in the convulsed muscles, and his head may ache. There is 
 often absolutely no warning of these attacks though very 
 striking warnings or so-called aiirae (such as flashes of light, 
 sounds, or smells) may occur and as a rule always in exactly 
 the same form. The muscles are apt to be affected, always in 
 the same order, and the convulsion is then said to "march" in 
 a characteristic way. Tongue-biting and frothing at the mouth 
 are observed, and the patient may involuntarily urinate. It can 
 
 469 
 
470 THE KINGDOM OF EVILS 
 
 readily be seen that the social worker who secures the history 
 of tongue-biting or urination in an attack of epilepsy may be 
 contributing most important evidence for medical diagnosis. 
 
 It seems to have been proved that the epileptic attack of the 
 nature above described may sometimes be represented by an 
 acute mental attack without convulsion and even without evi- 
 dent loss of consciousness. Such an attack without characteris- 
 tic features of epilepsy is termed an epileptiform equivalent. 
 The patient may fall into a state of automatism or into a dream- 
 state in which violent and destructive or criminal acts get done, 
 of which the patient will have no remembrance. The crimes of 
 violence commited by epileptics may be of the greatest brutality 
 (see our case 54, Patrick Donovan, who killed his mother). 
 Luigi Silva (case 53) had also been violent and destructive 
 during a fit. The episode in Silva's case followed a heavy 
 drinking bout. Alcohol is clinically known to bring out epilep- 
 tic attacks. 
 
 MENTAL DISEASES CAUSED BY ALCOHOL AND DRUGS 
 
 In our account of the pharmacopsychoses, that is, the mental 
 diseases due to alcohol and drugs (Group IV of Book III), 
 we have presented five cases, four alcoholic and one drug 
 (Marian Spring, case 63). 
 
 The four alcoholic cases are intended to exemplify the four 
 forms of alcoholic mental disease that come to the attention 
 of the social worker. John Logan (case 58) is a case of acute 
 alcoholism. We may remind the lay reader that acute alcohol- 
 ism is not identical with acute alcoholic psychosis. Of 
 course it is true in one sense that drunkenness is a temporary 
 mental disorder, but drunkenness is not a disease in the sense 
 of an entity with a characteristic onset, course, and duration. 
 Drunkenness is not commonly accounted a mental disease. 
 Acute alcoholism is a term frequently used to cover drunken- 
 ness and other comparatively mild mental effects of alcoholism, 
 falling short of our conception of mental disease. Chronic 
 alcoholism is a term used to describe a habit of drinking which, 
 though it may be the basis of a development of mental dis- 
 order, is also not in itself a mental disease. Drunkenness and 
 alcoholism, acute or chronic, are conditions, according to pres- 
 ent usage, outside the field of mental diseases. 
 
THE KINGDOM OF EVILS 471 
 
 Patrick Nolan (case 59) is a case of delirium tremens 
 which may be compared in its symptoms with the case of John 
 Sullivan (case 60) an instance of so-called alcoholic hallucin- 
 osis. Delirium tremens, the better known and somewhat com- 
 moner of these two affections, is a comparatively brief disease 
 whose acute symptoms commonly do not run beyond a week 
 in duration. Alcoholic hallucinosis, on the other hand, is apt 
 to run two or more weeks. Neither delirium tremens nor alco- 
 holic hallucinosis depends for its severity upon the amount of 
 alcohol consumed. Both diseases, as a rule, appear in persons 
 who have long been victims of alcoholism. (Here again it is 
 impossible to assert that the severity of a mental disease can 
 be measured by the duration or extent of the alcoholic habit.) 
 
 The distinction between these two diseases is even to the 
 physician far less easy in practice than in theory. The most 
 striking mental difference in the two diseases is the presence 
 of hallucinations of sight in delirium tremens and hallucina- 
 tions of hearing in alcoholic hallucinosis. Yet even this dis- 
 tinction may fail us in certain cases. The name delirium tre- 
 mens in itself points to the extreme severity of the symptoms, 
 that is to the existence of (a) delirium and of (b) tremors, 
 and the victim of delirium tremens is, on the whole, a much 
 sicker-looking man than the victim of alcoholic hallucinosis. 
 Of the two diseases, alcoholic hallucinosis is ordinarily the 
 worse one, since the capricious scolding voices readily lead to 
 suspiciousness and delusions of persecution that may outlast 
 the pronounced mental symptoms and reach into the convales- 
 cent life of the patient. In fact some of these latter cases dur- 
 ing their state of recovery and for long periods after the acute 
 symptoms are over, very strikingly resemble victims of de- 
 mentia praecox. Moreover cases of alcoholic hallucinosis are 
 not apt to get well so frequently or so completely as victims of 
 delirium tremens. 
 
 Michael Piso (case 62) we have used to represent the so- 
 called alcoholic jealousy-psychosis. The theory here seems 
 to be that long-continued alcoholism has reduced the sexual 
 power of its victim, who then becomes jealous of the relations 
 of the spouse to some supposed paramour. The case in the 
 text shows a comparatively happy outcome through medical 
 and social effort. 
 
 Our case of morphinism, Marian Spring (case 63) is, no 
 
472 THE KINGDOM OF EVILS 
 
 doubt, an example of the so-called psychopathic personality, as 
 are many victims of morphinism and cocainism. We count the 
 case as a social-service failure, but the details (note especially 
 the patient's lying) are of interest. Marian Spring also illus- 
 trates the tendency of morphinists and other drug addicts to 
 work in groups. 
 
 That the reader may obtain some inkling of the conditions 
 in certain other major groups of mental disease, we present in 
 cases 63-68 two instances each of mental disease due to de- 
 structive disease of the brain, the disease of the eye indirectly 
 affecting the mind, and to certain complications of old age. 
 
 BRAIN DISEASE 
 
 It is plain that destructive disease of the brain (Group V of 
 Book III) will, as a rule, send its victim pretty promptly to 
 some hospital for nervous or jnental disease, leaving the fam- 
 ily problem a comparatively simple one, not as a rule troubled 
 by any special mental feature on the part of the patient him- 
 self. The group, a fairly small one in this line of practice, is 
 of no great statistical consequence to social workers. 
 
 BODILY DISEASE 
 
 As to mental disease due to diseases of the body at large 
 (Group VI of Book III) such as diseases of the glands of 
 internal secretion, typhoid fever, pneumonia, influenza, pellagra, 
 and the like, there are on the whole very few cases, statistically 
 speaking, and still fewer that come under the social worker's 
 care. An exception would need to be made for pellagra in the 
 southern states and no doubt an important piece of social 
 research could be carried out upon the pellagra situation in the 
 southern states. Most important data concerning the culinary 
 and sanitary relations of pellagra could be made by social 
 workers. 
 
 We have chosen to illustrate this group by a case of hyper- 
 thyroidism, Ethel Murphy (case 66) and one of mental dis- 
 ease due to influenza, Joseph O'Brien (case 67). 
 
 OLD AGE 
 
 Problems of great interest are associated with social work 
 amongst seniles (Group VII of Book III). Of course it is 
 
THE KINGDOM OF EVILS 473 
 
 well known that not all old persons pass into anything like a 
 condition of dementia or evident deterioration. Some authors, 
 it is true, speak of a physiological dementia ( ?) and seem to 
 think of old age as capable of producing mental disease or at 
 least dementia. We must guard ourselves against generalizing 
 in this way. We have chosen two cases which ordinarily would 
 seem a bit hopeless from the standpoint of social work but 
 which proved very amenable to social-service methods. We are 
 under the impression that the psychiatric point of view, if it 
 should penetrate to the homes for aged persons and old sol- 
 diers, might prove of singular value in the handling of con- 
 crete problems of senescence. 
 
 DEMENTIA PRAECOX 
 
 The schizophrenic cases — dementia praecox (Group VII of 
 Book III), form a large and important group in the field of 
 psychiatry. Beginning most frequently during adolescence or 
 early adult life and having a very grave prognosis, schizo- 
 phrenia affords many distressing social situations. This psy- 
 chosis has two main characteristics : (a) a splitting of the per- 
 sonality (schizophrenia) and (&) a tendency to deterioration. 
 "Splitting" means that there is no longer a congruity between 
 the three psychological elements that form the personality; 
 namely, the intellect, the affective reactions, and the will. The 
 result is emotional apathy, loss of interest in one's family, lack 
 of normal activity, inability to carry out one's purpose. The 
 majority of persons afflicted with this form of disease develop 
 ideas of persecution, believe they are being followed, interfered 
 with, not given a square deal, and the like. Hallucinations 
 are apt to be prominent. These disorders associated with a 
 general psychic decrepitude may necessitate commitment in an 
 institution for the insane. When the disease remains chronic, 
 the patient may continue in an institution for the remainder 
 of his life. The social procedures in the chronic committed 
 cases are relatively simple. It is not, however, correct to as- 
 sume that no case recovers. Many patients with dementia 
 praecox make fair recoveries and are able to live in the com- 
 munity. Often the defect resulting from the disease is mild 
 in degree. Even so, these patients need guidance and aid, and 
 most of them require some form of social assistance. 
 
474 THE KINGDOM OF EVILS 
 
 The schizophrenic group is brought to the attention of the 
 social worker chiefly, during the early or incipient period of the 
 disease. For months and often for years before a patient has 
 the outstanding symptoms of a psychosis, mental peculiarities, 
 character anomalies, unusual actions, and maladjustments lead 
 to observation by social agencies. Unless an astute psychiatrist 
 sees the patient in this early state, the person is likely to be 
 considered as stubborn, unreliable, delinquent, obtuse, peculiar, 
 or lazy, rather than ill and a proper subject for understanding, 
 sympathy, and help. Many are the difficulties, delinquencies, 
 and misfortunes due to early symptoms of the disease. 
 
 Despite the relative impossibility of affecting cures in the 
 disease with our present knowledge, it is surprising how much 
 may often be accomplished to improve the social reactions of 
 these patients by proper social adjustments. Unfortunately 
 much useless effort is expended by social workers in attempts 
 to aid such persons before their disease has been diagnosed. 
 
 The symptoms which may be manifested by schizophrenia 
 patients are numerous and varied. In fact, Kraepelin, in his 
 latest classifications, considers seven varieties of dementia 
 praecox and the closely allied paraphrenias. It is obviously not 
 desirable to present the medical points of this complex disease 
 except in a medical treatise. It may be noted that the symp- 
 toms result in peculiarities in the patients that lead to a lack 
 of "empathy." 
 
 Medical science has not solved the major problems of 
 schizophrenia, i.e., etiolog}^ and pathology. As a corollary no 
 specific treatment is known. Every case must be carefully 
 considered, however, from the purely medical side for evi- 
 dences of endocrine disorder, organic disease, and metabolic 
 disorder, as well as for psychological factors in the life of the 
 patient. Life experience and environmental conditions play 
 an important role in the development of the psychosis. So the 
 social worker may have a function in prevention and treatment 
 as well as in social adjustment. 
 
 It is important to place schizophrenic patients under care 
 at the earliest possible moment ; as it is with any person devel- 
 oping a disease, acute or chronic. Many schizophrenics show 
 character anomalies from early childhood that are suggestive. 
 Among these traits may be mentioned "shut in" personality, 
 inability to make friends and take part in communal activities 
 
'THE "KINGDOM -DF EVILS 475 
 
 "with zest, supef sensitiveness, over-conscientiousness, egocen- 
 tricity, metaphysical ruminations, obstinacy, phantasy- forma- 
 tion, or day-dreaming. These characteristics cause such per- 
 sons to be considered peculiar, eccentric, exceptional, or 
 difficult; whereas they should indicate a careful psychiatric 
 examination. 
 
 Some of the problems of schizophrenia are presented in 
 twelve cases of Book III, cases 70-81. Dana Scott (case 70) 
 is a case of the simplex form, a type that is often undiagnosed. 
 This type of schizophrenia is seldom seen in the institutions 
 for the chronic insane, the victims usually remaining in the 
 community, presenting difficulties to society and finding life 
 a serious problem. Proper environmental treatment met with 
 relative success in the case of Scott. 
 
 Ralph Johnson (case 71) is another patient who presented 
 numerous problems to society, which arose, presumably, as a 
 result of his mental state, diagnosed as dementia praecox. 
 Wanderlust, alcoholism, idleness and poverty, hypochondria, 
 hallucinations and delusions, punctuated the life history of this 
 man. Improvement in his attitude and conduct was shown 
 after the combination of medical and social treatment. Per- 
 sons with this type of mental disease are familiar to social 
 agencies as prostitutes, tramps, almshouse habitues, and 
 dependents. 
 
 Paraphrenia is a diagnosis applied to cases akin to dementia 
 praecox, but showing less dissociation of the personality and a 
 slower progress toward deterioration. These cases are rela- 
 tively rare and present problems similar to the dementia prae- 
 cox cases. In fact, the paraphrenias are described in a sub- 
 heading under the schizophrenic group. Manual Rizzo (case 
 72) is presented as an illustration of this type of disease, diag- 
 nosed paraphrenia systematica. (See also case 58.) 
 
 The case of Paul Ernst (case 73) emphasized the difficulty 
 in the dififerentiation of schizophrenia (dementia praecox) and 
 cyclothymia (manic-depressive psychosis) and offers a good 
 lesson in the value of optimism. Hasty conclusions may lead 
 one to a pessimistic inactivity in cases called dementia praecox. 
 It is well to suspect the worst but to act on the optimistic as- 
 sumption that effort will be repaid. It was so in this case. 
 
 The "spoiled child" should always make one suspicious of 
 the possibility of a future psychosis. Nora McCarthy (case 
 
476 THE KINGDOM OF EVILS 
 
 74) was considered a spoiled child. Her later reactions led to 
 a psychiatric diagnosis of dementia praecox. However, with a 
 comparatively small amount of assistance, she learned to get on 
 fairly well. 
 
 The usual mistake, especially outside of psychiatric clinics, 
 is not that of making too serious a diagnosis and prognosis, 
 as might be assumed to have been the case with Nora McCar- 
 thy (case 74) but, on the other hand, the tendency is to diag- 
 nose the early stage of a mental disease as psychoneurosis. A 
 large number of schizophrenias are at first considered psycho- 
 neuroses. Clara Goldberg (case 75) received much attention 
 under the diagnosis of psychoneurosis, but after three years 
 of unsuccessful efforts at social adjustment the diagnosis was 
 changed to dementia praecox, and she was put under the care 
 of a state hospital. 
 
 George Stone (case 76) calls attention to the difficulty of 
 deciding whether a paranoid individual should be committed. 
 At times such patients are able to get on fairly well in the com- 
 munity under supervision. Stone was unable to get along, 
 however, and had to be committed. George Mullen (case jy^ 
 on the other hand, was able to serve in the front lines of the 
 British Army after a five months' stay in a state hospital. His 
 improvement proved to be but temporary, and he had to be 
 committed again after his discharge from the army. 
 
 Paul Dawson (case 78) had been a problem from early life. 
 At the Mexican border he "broke" and received a diagnosis 
 of dementia praecox with his discharge. He then became a 
 "difficult case" for his family. Drafted into the army, he was 
 again discharged with the label dementia praecox. He claimed 
 to have "faked" mental disease to get out of the army. Experi- 
 ence has taught that most malingerers are psychopaths and 
 likely to become definitely psychotic. Dawson was considered 
 a real case of dementia praecox. Nevertheless he made good in 
 the merchant marine. It is a question how long he will remain 
 well. 
 
 Howard Lancaster (case 79.) seems to show that environ- 
 ment is an important factor in the development of mental 
 disease. Under civilian conditions he did well but became ill 
 in the military service, recovering when again placed under the 
 conditions of civil life. 
 
 The relationship of psychiatry and criminology is depicted 
 
THE KINGDOM OF EVILS 477 
 
 by Major Dobson (Captain Hill, case 80), whose dementia 
 praecox symptoms took, in one instance, the form of forgery. 
 His marriage may also be considered as having a psychopatho- 
 logical basis. It may be assumed that many of his past ad- 
 ventures and his instability were forerunners of more overt 
 symptoms. 
 
 MANIC-DEPRESSIVE PSYCHOSES 
 
 In many ways the cyclothymic group — manic-depressive psy- 
 chosis (Group IX of Book III), offers more of interest to the 
 psychiatrist and psychiatric social worker than any other group 
 of cases. The mental disorder called cyclothymia is character- 
 ized by occasional attacks with remissions, or intervals of good 
 health. The attacks usually vary from a few days or weeks to 
 a year or more, while the remissions may last for years or 
 decades, or the disease may be limited to one attack. The 
 severity of the symptoms likewise varies from very mild emo- 
 tional changes to the severest types of mania and depression. 
 The disease is chiefly an affective one, causing pathological 
 exaggeration of the emotions. Depression, with feelings of 
 insufficiency, self-accusatory ideas, difficulty in thinking, and 
 general slowing up of mental and physical activity are present 
 fn the depressive stage of the disease. In direct contrast to 
 this are the symptoms of the maniacal phase, feeling of well- 
 being, self-appreciation, exaggerated ideas of one's own power, 
 and mental and physical activity. In the so-called mixed 
 phases of the disease a combination of the symptoms of depres- 
 sion and mania exist. Most of the symptoms are easily under- 
 stood by a second person, because they are exaggerations of the 
 normal feelings rather than new or "different" or "peculiar" 
 reactions. Hence it can be said that one's "empathic index" 
 is usually high toward such patients. 
 
 Cyclothymic patients do not deteriorate. No matter how 
 severe the symptoms, how long the attack lasts, or how fre- 
 quent the attacks may be, there is no resultant dementia. And 
 as may be expected if this statement is true there is no patho- 
 logical destructive brain lesion. 
 
 The hospital for mental patients is only a temporary refuge 
 for the cyclothymic, if such hospital care becomes necessary at 
 all. Winifred Reed (case 81) spent but a few days in the hos- 
 pital for purposes of diagnosis during the first seventeen 
 
478 THE KINGDOM OF EVILS 
 
 months of her acquaintance with the Psychopathic Hospital, 
 and WilHam Donahue (case 82) has never been an inmate of 
 an institution for his mental diseases. Mild attacks of excite- 
 ment or depression are frequently not diagnosed, and in the 
 absence of proper diagnosis the patient may be entirely mis- 
 understood and wrongly handled. When one correctly under- 
 stands Winifred's eroticism as a symptom of the maniacal 
 stage of a manic-depressive psychosis of only temporary dura- 
 tion, sympathy is evoked and proper treatment is available. 
 Likewise one is ready and able to help Donahue over his 
 "grouches" and spells of "lost initiative" on the ground of 
 treating a depressed patient. 
 
 Marie Dubois (case 83) is presented as a case of manic- 
 depressive psychosis, having a first attack at thirty years of 
 age and a second at forty. The first attack was one of de- 
 pression, the second beginning with depression went over 
 into a mild excitement before recovery. Such a sequence is 
 by no means rare. Her return to the community after a fairly 
 severe attack of mental disease brings into prominence the 
 problem of the complete readjustment that is necessitated. 
 Such a patient must again take her place in a community all 
 too ready to be suspicious of anyone who has been "insane." 
 Friends who comprehend the situation and who can aid are 
 quite essential. The family, even if possessed of sufficient 
 means, are rarely capable of offering intelligent aid. Here 
 the psychiatric social worker is invaluable. 
 
 Hypomania falls in the group of cyclothymias. It is a very 
 mild degree of mania. Joe Marino (case 84) developed this 
 condition when but fifteen years of age. Difficulty after diffi- 
 culty resulted from his overactivity. His activities were rather 
 typical of the hypomanic — frequent changes of position and 
 actions that led to arrest punctuated his useful career. The 
 hyperactivity in Joe, as is typical in cases of hypomania, lasted 
 a comparatively short period, and then he settled down. Dur- 
 ing the period of excitement, however, he was a very difficult 
 problem, and, as during a large portion of his disease he was 
 able to live outside of the hospital, one can see the great need 
 for some oversight in order to steady him. 
 
 Robert MacPherson (case 85) is another example of the 
 hypomanic condition. When the excitement is mild enough, 
 the overactivity that is characteristic of this state may lead to 
 
THE KINGDOM OF EVILS 479 
 
 useful accomplishments. This, of course, is not the rule, but 
 at times patients are seen who are more successful during this 
 period because of the lessened inhibitions. They may be more 
 capable as salesmen. They execute their ideas without further 
 thought. MacPherson made more money during his hypo- 
 manic state than he would have made had he been normal. 
 However, he squandered it with great abandon. Frequently 
 patients in this condition, as well as patients in the early stage 
 of general paresis, will squander their possessions and run up 
 debts, as well as spoiling their reputations by fast and lascivi- 
 ous living. From this point of view, if from no other, it is 
 very important that recognition of this condition be made 
 early, in order that the patient may be prevented from per- 
 forming foolish and dangerous acts. 
 
 Two main characteristics of the manic-depressive psychosis, 
 namely, repeated attacks and complete recovery, are well illus- 
 trated by the case of Clarence Adams (case 86). For the 
 rest his case shows the same type of problem as the two pre- 
 ceding cases. 
 
 A word should perhaps be said about one important social 
 complication of the depressive phase of the manic-depressive 
 psychosis. This is the potentiality of suicide. While it is 
 quite possible to supervise maniacal patients outside of the 
 hospital, despite their tendencies toward fast living and delin- 
 quency, it is much more dangerous to handle a depressed pa- 
 tient outside of the hospital. Although the symptoms may be 
 mild and the patient quite willing to sit about the house, and 
 so may be easily cared for, it is an exceedingly risky matter 
 to leave the depressed patient at home and in the community 
 because of his great tendency to suicidal attempts. It is for 
 this reason that one is prone to advise hospitalization for 
 the depressed case until recovery is quite complete. 
 
METHODS OF PSYCHOTHERAPY 
 
 HYPNOSIS 
 
 Verbal Suggestion 
 Fixation 
 Fascination 
 Various 
 
 SUGGESTION (WAKING) 
 
 Verbal 
 
 Drug 
 
 Apparatus 
 
 AUTOSUGGESTION 
 
 DISTRACTION 
 
 TERRORISM 
 
 INFLICTION OF PAIN 
 
 PERSUASION 
 
 WILL TRAINING 
 
 OCCUPATION THERAPY 
 
 ISOLATION 
 
 PSYCHOANALYSIS 
 
PSYCHONEUROSES 
 
 Various classifications have been offered for the cases that 
 fall under the general heading of psychoneuroses (Group X 
 of Book III). A fairly generally accepted and workable 
 classification is that which divides the psychoneuroses into 
 cases of (a) neurasthenia, (b) psychasthenia, (c) hysteria, 
 and (d) anxiety neuroses. These various cases were placed 
 together in a group called psychoneuroses on the assumption 
 that there was no definite underlying organic pathology to ex- 
 plain the symptoms. The mental attitude or psychological 
 condition is supposed to have a prominent place in the de- 
 velopment of these conditions. The diagnosis is usually diffi- 
 cult. It must be made only after a careful physical examina- 
 tion which rules out bodily disease. Neurasthenics are usually 
 considered by the laity as imagining numerous organic dis- 
 eases. They feel tired and worn; complain of peculiar sensa- 
 tions in their heads and inability to concentrate; and are apt 
 to fear many types of disease. Psychasthenia may be con- 
 sidered as something of a psychological anomaly. Under this 
 diagnosis are placed those people who are known as worriers 
 and doubters, who have many fears and obsessions, who often 
 have difficulty in thinking clearly and logically, becoming 
 "mixed up" as they often say. This condition is usually pres- 
 ent from early life, but is subject to exacerbation of symptoms. 
 The hysterics are those patients who present numerous symp- 
 toms, such as paralysis, blindness, deafness, mutism, convul- 
 sions, sensory disturbances, in fact, almost any symptom with- 
 out evidence of organic disease. The anxiety neurosis is 
 characterized by a condition of anxious fear, which may over- 
 come the patient at any time. 
 
 Patients suffering from one form or another of the psycho- 
 neuroses are very common at all medical clinics, and are 
 usually the despair of the physicians. Finally they make their 
 way to the psychiatrist, possibly after months or years of 
 treatment in the general clinic; possibly after having numer- 
 ous operations in the attempt to relieve symptoms which it 
 
 483 
 
484 THE KINGDOM OF EVILS 
 
 is later believed were dependent upon a mental state rather 
 than upon a visceral pathology. Only in the severe exacerba- 
 tions of their symptoms do these patients become inmates of 
 a state hospital for the care of mental cases. During a large 
 portion of their disease they remain in their homes, frequent- 
 ing physicians' offices or dispensaries. Occasionally an out- 
 break of marked symptoms may lead to residence in a state 
 hospital. As a rule, these attacks last only for a short period, 
 and they are not at all frequent. It is more usual for those 
 patients who can afford the expense to go to a sanatorium for 
 treatment of a "nervous breakdown." A modern psycho- 
 pathic hospital will treat numerous examples of these cases. 
 
 Patients of the psychoneurotic group are patients par excel- 
 lence for psychotherapy. Under efficient psychotherapy must 
 be considered all those factors that affect the mind and life of 
 the patient. Among these should be included the patient's 
 environment. It is generally conceded that the experiences of 
 a person and the conditions under which he lives have much 
 to do with the development of a psychoneurosis. Therefore 
 it is logical that efforts to improve the general environment, 
 habits of life, and living conditions, must have a valuable 
 place in any psychotherapeutic treatment. In conjunction 
 with whatever form of treatment, psychotherapeutic or or- 
 ganic, is applied to the patient, the shaping of his living con- 
 ditions is very important, and this work must fall, in large 
 part, upon the social worker. 
 
 Maurice Eastman (case 87) is presented as a case of neu- 
 rasthenia, and shows in a degree how much can be accom- 
 plished by intelligent social work. 
 
 Sadie Strauss (case 88) manifests a fairly typical hysterical 
 condition, and is a good case in point to show the value of 
 social work in addition to formal psychotherapy. The assist- 
 ance in ironing out the family difficulties was certainly of 
 great value to the psychiatrist in aiding him to get results by 
 his analysis. It is pointed out in the case history that the in- 
 formation obtained by the social worker of the home conditions 
 and environment of Sadie was a valuable addition in giving 
 a rounded view of the case. 
 
 Joseph Fangillo (case 89) received the diagnosis of psy- 
 chasthenia. A hyperconscientious individual, prone to doubt, 
 finding decisions difficult, he had upon such a background at 
 
THE KINGDOM OF EVILS 485 
 
 least five acute exacerbations of symptoms. From all of these he 
 recovered fairly satisfactorily, but during a large portion of 
 the period of convalescence he lacked sufficient force to hold 
 himself in line without outside assistance. He had to have 
 someone reassure him. The aid in obtaining work was very 
 important. The family also had to be assisted over the diffi- 
 cult period of his "nervous breakdown." Maintaining the 
 family in good condition was an important aid in the recovery 
 of the patient. 
 
 Cases of traumatic hysteria, that is, cases in which the hys- 
 terical phenomena follow upon an accident, are always open 
 to the suspicion of malingering on the part of the patient in 
 order to obtain compensation. It is quite true that in many 
 of the cases improvement is delayed until the financial settle- 
 ment is accomplished, and the physician handicapped in his 
 treatment until this matter is adjusted. Something of this 
 matter is brought out in the case of Dennis O'Donnell (case 
 90) and the question is brought forward concerning the value 
 of social-service assistance in the case. 
 
 Another case of traumatic hysteria is that of Walter Nelson 
 (case 91). This man developing an injury during his service 
 in the Aviation Corps, fell to the lot of the social workers of 
 the Red Cross, and presents a similar type of difficulty to that 
 of Dennis O'Donnell. 
 
 Hysteria very frequently develops upon what is considered 
 as poor soil or constitutional inferiority. The early history of 
 Martin O'Hara (case 92) certainly showed enough instability 
 to make one consider him pretty poor material. Under army 
 conditions he apparently broke down with what was consid- 
 ered to be hysteria. Upon discharge from the army, he was 
 better, but after running into a very unsuccessful marital ex- 
 perience, his symptoms came on again. This case might be 
 used to show the importance of environment on the appearance 
 of symptoms of a hysteric nature. Assistance to Martin in 
 adjusting his life was followed by improvement of symptoms 
 and an ability to care for himself again. 
 
 Another illustration of the effect of environment on the 
 production of psychoneurotic symptoms is brought forward 
 in the case of Joseph Levenson (case 93), who developed 
 while in the army symptoms considered sufficient to make a 
 diagnosis of psychasthenia. Much social work was expended 
 
486 THE KINGDOM OF EVILS 
 
 Upon this patient in attempts to find him satisfactory occupa- 
 tion, with a more or less satisfactory result. 
 
 Most of the cases of the psychoneurotic group must be con- 
 sidered as potential patients during a large portion of their 
 lives. Improvement and retrogression alternate. Unfavor- 
 able conditions of life are likely to lead to renewed difficulties, 
 so that these patients represent a fertile field for continued 
 work and are likely to be known to the social agency year 
 after year. Nowhere is this service more valuable or neces- 
 sary, and social adjustment is nearly always essential be- 
 fore the physician can get very far with his treatment. 
 
 DUBIOUS AND SPECIAL PSYCHOPATHIAS 
 
 The last group" (Group XI of Book III) includes a pot- 
 pourri of cases that fit in none of the preceding ten groups. 
 Among the cases that would fall into this group may be men- 
 tioned prison psychosis, sense deprivation psychosis, folic a 
 deux, litigation psychosis, paranoia, monomania, psychopathia 
 sexualis, psychopathic personality, and a number of undiag- 
 nosed cases. Most of the cases bearing these diagnoses are not 
 legally committable. They are, rather, individuals with pe- 
 culiarities, eccentricities, and psychological anomalies. Living 
 in the community at large, as they usually do, they are likely 
 to be the victims of one difficulty after another. Their peculiar 
 mental reactions are rarely compatible with success in life. 
 Social agencies, courts, and reformatories are frequently con- 
 fronted with the problems that these persons present. Com- 
 prehensive understanding of these people necessitates a psy- 
 chiatric knowledge and insight into their disease conditions. 
 
 Possibly the most frequent of all these types is that spoken 
 as the psychopathic personality or the constitutional psycho- 
 pathic inferior. Military experience showed how numerous 
 are individuals of this type. Many of the conscientious ob- 
 jectors, malingerers, and deserters fell into this group. They 
 have in common a personality defect, which usually works 
 against the best advantage of the patient leading him into a 
 continuous series of difficulties. 
 
 Previous to the military experience, the feeling was that the 
 vast majority of cases of psychopathic personality or consti- 
 tutional psychopathic inferiority were of the female sex. This 
 
THE KINGDOM OF EVILS .487 
 
 was largely due no doubt to the fact that it was sex delinquency 
 that brought many girls to the attention of social agencies and 
 public authorities. The characterization of "defective delin- 
 quent" was usually given to these girls, and every social agency 
 was familiar with this problem. 
 
 A study of defective delinquency was made by Dr. Her- 
 man M. Adler. Some of his ideas were published in an article 
 entitled, A Psychiatric Contribution to the Study of Delin- 
 quency} A brief review of Dr. Adler's paper will illuminate 
 the subject. He calls attention, first, to the six groups of 
 psychopathic personalities described by Kraepelin : the excit- 
 able, the unstable, those with psychopathic trend, the eccentric, 
 the antisocial individuals, and the contentious individuals. Dr. 
 Adler states : — 
 
 "It is clear that we are dealing with a group of individuals 
 who are so nearly normal that it is only in the course of years 
 and by the effect of cumulative evidence that they appear in 
 any way different from the average. 
 
 "There are two main factors to be considered. The one is 
 the intelligence of the individual, his ability consciously and 
 logically to direct his conduct. The other is the emotions. . . . 
 In health the two are well integrated." 
 
 As a result of his experience with a group o'f defective de- 
 linquents. Dr. Adler believes that they can be classified some- 
 what more simply than Kraepelin has grouped them or at least 
 that a simpler classification may be offered as a working basis 
 to understand the reactions of these individuals. He says : — 
 
 "I propose to classify the individuals who present mental 
 or social difficulties in three groups. These groups are under- 
 stood to be meant as symbols for unknown quantities rather 
 than as explanation or precise definitions. The three groups 
 are, in the first place, the group in which the intelligence is 
 found to be below the lowest normal level. This is called the 
 group of defectives or the inadequate. Into this group fall the 
 feeble-minded, the 'Oligophrenias' of Kraepelin, the end states 
 of dementia praecox, and of other deteriorating psychoses, of 
 presenile, organic dementia, and so forth. 
 
 "The next group, emotionally unstable, includes individuals 
 who have average intelligence or better, but who show in their 
 
 ^ Adler, Herman M., M.D. In Journal of the American Institute of Criminal Law 
 and Criminology, Vol. 8, No. 1, May, 1917, pp. 45-68. 
 
488 THE KINGDOM OF EVILS 
 
 conduct and in their careers the predominating influence of the 
 emotions. They are moody, changeable, impulsive, and in gen- 
 eral it may be said that their conduct itself does not correspond 
 to their beliefs, or intentions. 
 
 "The third group, the paranoid, includes individuals of aver- 
 age intelligence or better in whose careers the emotional in- 
 fluences are of secondary importance, but whose main difficul- 
 ties are a result of mistakes in logical thought processes. The 
 well-known characteristics which are exhibited in extreme form 
 by the paranoid psychoses, these individuals show often to a 
 degree which falls just short of a delusional state, egocentric 
 ideas, and prejudices. Everything that occurs about them is 
 referred to themselves. Their first reaction is to determine 
 what effect any extraneous circumstance may have upon them- 
 selves. They are selfish, vain, arrogant. If they feel in 
 optimistic mood, they are contemptuous of others. If de- 
 pressed, they are resentful. Though this is a trait of their 
 intellect, it does not necessarily interfere with their intellectual 
 abilities, and these people are often very efficient. 
 
 "These three groups can be separated only theoretically. 
 There are many cases that are composite, so that their charac- 
 teristics fall into two or into all of these groups. Thus, few 
 paranoid individuals go through life without strong emotional 
 reactions which often lead to social difficulties. Similarly, the 
 emotionally unstable will, especially during paroxysms of rage 
 or depression, often exhiliit paranoid symptoms. The defective 
 group may show paranoid tendencies and emotional instability. 
 
 "The distinction lies rather in the behaviour of the individual 
 as observed in the course of years than in a definite quantitative 
 difference to be observed at a single examination. The intro- 
 spective psychologist will attempt to determine in each indi- 
 vidual by psychoanalysis or other means what the mechanism 
 of the disturbance is. He may succeed in doing this, and still 
 be unable to predict the future course of the individual. 
 
 "The behaviourist psychologist will not lay too much weight 
 on the results of a single examination by whatever method, but 
 will lay more emphasis upon the history of the case, and the 
 previous experiences of the individual and. above all. upon the 
 reaction of the individual to certain test situations during a pe- 
 riod of observation. This behaviourist method offers the hope 
 of a short cut in dealing with these individuals." 
 
 Dr. Adler then gives some considerations of a practical 
 nature upon which to base the care and treatment of such 
 people. We quote : — 
 
THE KINGDOM OF EVILS 489 
 
 "In every given case of delinquency or social difficulty it 
 should be determined whether the difficulty is chiefly due to in- 
 adequate intelligence, to emotional instability or to paranoid dis- 
 position. Nothing can be gained by endeavoring to increase the 
 intelligence of a mental defective. Nothing can be expected 
 from an attempt to change the personality of the paranoid in- 
 dividual. A great deal can be accomplished, however, in con- 
 trolling the emotional instability of those whose chief difficulty 
 is the result of such instability as well as the emotional diffi- 
 culties of the paranoid and defective group. 
 
 "Classification such as the one suggested in this communica- 
 tion is, of course, entirely too simple to completely satisfy all 
 the demands in the individual cases, and it is to be hoped that 
 this classification may be altered and amplified, or perhaps com- 
 pletely reconstructed till finally a working method may result, 
 but even now, without general information of the subject, such a 
 simple scheme as this one proposed has served not only to keep 
 the ideas of the examiner grouped in orderly fashion, and this 
 to prevent disorderly and unclear thinking on his part, but it has 
 actually appeared to be of benefit when it was applied as a basis 
 of therapy in these cases." 
 
 A variety of character defects was shown by the twenty- 
 eight-year-old Harriet Farmer (case 94) who, after a history 
 of unreliability, a long period of fabrication, alcoholism, and 
 inability to make her own way, came to the attention of the 
 Psychopathic Hospital as the result of a suicidal attempt. She 
 clearly fitted into the group of psychopathic personalities. The 
 outcome of the case showed how much improvement a char- 
 acter of this type is capable of making when handled by social 
 workers guided by psychiatric knowledge. 
 
 That the type of hypoboulic (weak-willed) individuals who 
 despite a sufficient modicum of intelligence are fated to be 
 failures because of their defect is illustrated by Louis Sand 
 (case 95). A Belgian of considerable education, with the 
 best intentions in the world, with ambition but without power 
 of concentrated effort, he had wandered from place to place. 
 Such might be considered the classical type of constitutional 
 inferior. 
 
 The case of Theresa Beauvais (case 96) should be a liberal 
 lesson to the moralist and social worker. Sexual immorality 
 in this girl is explained on the basis of a hypersexuality which 
 might be characterized as falling into the group of psycho- 
 
490 THE KINGDOM OF EVILS 
 
 pathia sexualis or into the larger group of constitutional 
 psychopathic inferiority. Her promiscuity is to be considered 
 rather as a symptom of a disease than as a pure moral deflec- 
 tion. With a background of exceedingly poor heredity ( father 
 a professional thief, mother a prostitute) and as vicious an 
 early environment as could be conceived, one is justified in ex- 
 pecting a rather poor social result. Theresa certainly showed 
 enough evidence of instability, will defect, and emotional out- 
 '-breaks to justify a diagnosis of psychopathic inferiority or 
 ipsychopathic personality. Appearances might have led to the 
 conclusion that this girl was a moron, but psychological tests 
 showed her of sufficient intellectual ability. It was rather in 
 the sphere of affectivity and will that the disorder lay. It is 
 quite important to keep this idea in mind ; namely, that the 
 affective life and the will are often more important in deter- 
 mining the social reactions of an individual than the intellect 
 alone. One cannot avoid the assumption that it would take 
 more than the ordinary amount of will-power to overcome the 
 sexual desires of such a hypersexual individual, and one would 
 be expecting too much if one hoped for a great deal of steady- 
 ing of such a person after adult life had been reached and 
 many pernicious habits had been formed in youth, but one 
 should have sympathy for this girl as a victim of disease rather 
 than as merely vicious. One arrives at this conclusion from 
 a psychiatric study of the whole life of the patient. 
 
 The value of the psychiatric attack on a patient not neces- 
 sarily markedly psychopathic is discussed in the case of Leon 
 Blumer (case 97). Pseudologia fantastica, or pathological 
 lying, falls under the general heading of the psychopathic per- 
 sonality or constitutional psychopathic inferiority. It is 
 usually associated with other evidence of character defect or 
 psychopathia. A person afflicted with this type of abnormality 
 is certain to be considered a "difficult case" and pretty thor- 
 oughly disliked by those with whom he comes into association. 
 This was indeed the fact with Francis Corcoran (case 98). 
 
 The results of a constitutional inferiority may only be 
 brought about under the stress of circumstances. Manuel 
 Giordani (case 99), a flute-player, got along well enough in 
 civilian life, but under the stress of military training he had 
 a psychopathic upset which resulted in his discharge from the 
 army. Back in civilian life, he again succeeded. 
 
THE KINGDOM OF EVILS 49I 
 
 Until his fiftieth year Henry Allen (case lOo) had been 
 considered from the results of his work, merely as a not very 
 efficient constructional designer. A personality study at the 
 age of fifty by a psychiatrist brought out the fact that he was 
 of a melancholy disposition, unhappy in his work because he 
 believed he was being made fun of by his fellow employees. 
 He disliked the type of work he was doing and considered him- 
 self only twenty-five per cent efficient, and felt that he was 
 physically ill. Considering Allen from this point of view, it 
 was possible to change his working conditions, encourage him 
 and give him a type of work that was more to his taste. Where- 
 upon he developed greater efficiency and was able to earn twice 
 as much as previously. This type of analysis has great pros- 
 pects from the vocational-guidance standpoint, and can add to 
 the efficiency of the individual both to the benefit of himself 
 and of the firms employing him. 
 
RECENT APPLICATIONS OF MENTAL 
 HYGIENE 
 
 MENTAL DISEASE IN THE GREAT WAR 
 
 Military experience in the Great War brought out many 
 cases of mental disorder, and showed the large part that the 
 psychology of individuals played in their adjustment to mili- 
 tary conditions. Twenty-five cases are submitted in this work 
 to illustrate, in part, some of the problems with which the 
 military service, the public health service, and the Red Cross 
 have had to deal. 
 
 In any large group of men, it is of course evident that all 
 varieties of mental disease will be found to occur, and among 
 the four million men in the American military service, there 
 were of course all varieties of mental disorder and difficulty. 
 The term "shell-shock" which grew up at the beginning of the 
 war from the experience of the English has led to great con- 
 fusion in terminolog}'. Originally applied by the British to 
 cases of mental disorder, mostly of the type of psychoneuroses, 
 under the misapprehension that these conditions were the effect 
 of high explosives, it has been used variously to include, on 
 the one hand, only the pure psychoneurotic manifestations, 
 and, on the other hand, to include all types of mental disorder. 
 This matter has been treated in full detail in a book recently 
 published by the senior author under the title, Shell-Shock. 
 
 The Great War brouglit out a large number of cases of 
 psychoneurotic disorder, to which a great deal of attention has 
 been paid. The American Army treated these cases abroad, in 
 large measure, at base hospital number 117, known colloqui- 
 ally as the "Shell-Shock Hospital." A description of these 
 cases is very adequately presented in a book by Schwab and 
 Fenton, entitled, The Psychology of Conflict. On the whole 
 it may be said that there are no new problems rising out of 
 the psychiatric cases occurring in the military service. Many 
 of the mental difficulties would have occurred to the same 
 patients in civilian life. However, the fact that they did occur 
 in military service has added a very natural sentimental inter- 
 
 492 
 
THE KINGDOM OF EVILS 493 
 
 est, which would probably not have been accorded these same 
 patients had their difficulty occurred during ordinary peace 
 times. 
 
 A new interest in mental disease has been awakened and 
 this is particularly true in Great Britain, where a veritable 
 renaissance has occurred. This has been one of the subsidiary 
 benefits of the war. The American Red Cross has established 
 psychiatric social units throughout the country, and the prob- 
 lems that confront these psychiatric social units, as will be seen 
 by a perusal of the war cases herein described, are in no par- 
 ticular way different from psychiatric social problems of our 
 civilian population. It is, therefore, proper to employ the same 
 technique, medical and social, in the handling of the war neu- 
 roses and psychoses that is applied to the civil cases. As will 
 be seen, many of the military cases have been turned over to 
 civilian hospitals. 
 
 One feature that is present in the military cases, which is 
 not often found in the civilian ones, is that of pecuniary com- 
 pensation. When the mental disorder "did not exist prior to 
 enlistment" and occurred "in line of duty" it has been generally 
 held that the patient is entitled to compensation for disability. 
 The situation in this regard is similar to that which would 
 hold for tuberculosis or any other chronic disease. 
 
 Seven of the eleven psychotic groups that have been de- 
 scribed are exemplified by the twenty-five patients having rela- 
 tions with the military service. 
 
 Carl Spindler (case 43) and Thomas Scannell (case 44) 
 were patients suffering with syphilopsychosis. Carl Spindler 
 was transferred to a civilian hospital with a diagnosis of gen- 
 eral paresis. Symptoms of this disease had developed while 
 he was in the service, but the syphilitic infection which led to 
 the development of paresis was acquired long before entering 
 the service. Nevertheless, it is often assumed in these cases, 
 that the government is somewhat liable in the way of com- 
 pensation, the argument being that the mental symptoms de- 
 veloped during service, they were not present prior to enlist- 
 ment, and that possibly these symptoms would not have arisen 
 had the patient not undergone the hardships of military life. 
 
 Thomas Scannell was probably a case of juvenile paresis, 
 that is, he had the symptoms of general paresis which had 
 developed from congenital syphilis. He was being cared for 
 
494 THE KINGDOM OF EVILS 
 
 by the Red Cross. Here, again, the same question would arise 
 as to whether or not the government was responsible for his 
 care on the grounds that his mental enfeeblement had occurred 
 while he was in the military service. 
 
 The problem of feeble-mindedness was much diminished in 
 the army by the psychological testing and the rejection of 
 feeble-minded individuals by the neuropsychiatric division. 
 Despite this, many feeble-minded were in the army, and it 
 was held by many that for certain work behind the lines the 
 feeble-minded had a very definite place. However this may 
 be, there were numerous examples of the feeble-minded in the 
 army. The navy and the marine corps were not so careful 
 to eliminate individuals of low mental status. 
 
 Thomas Fuller (case 9) had had a bad record in civilian 
 life. It was felt that this was largely the result of his mental 
 retardation, his mental age being only 9.2 years. Despite this 
 fact, he made good in the marines, and even rose to the rank 
 of corporal. The obvious reason is that under proper super- 
 vision a person of inferior mentality may be a very valuable 
 worker. 
 
 It does not follow, however, that all feeble-minded indi- 
 viduals make good under the type of supervision given in the 
 army or navy. Bernard Bornstein (case 50) did fairly well 
 in civilian life, earning between fifteen and twenty dollars a 
 week, but was quite unable to succeed when he joinetl the navy. 
 His mates plagued him and he was such a misfit that it was 
 necessary to discharge him. The feeble-minded individual is 
 likely to be unreliable, and when this is markedly the case, he 
 cannot be of course fitted into the discipline of military service. 
 
 The sort of difficulty that a feeble-minded individual may 
 get into in the army is well illustrated by the case of Howard 
 Driscoll (case 51). His army record was sprinkled with 
 A.W.O.L.'s and after his discharge from the army he was sen- 
 tenced to a reformatory. He returned to the army during the 
 war, where he got into difficulty by leaving his post for four 
 days because he got angry. He did not receive the treatment 
 that would ordinarily be accorded to a normal individual, but 
 was given his discharge as a feeble-minded person. Super- 
 vision will be necessary for this man throughout life and he 
 would probably be best served if he could be put under the 
 paternal care of an institution. 
 
THE KINGDOM OF EVILS 495 
 
 One of the important pieces of neuropsychiatric informa- 
 tion that came out of the army experience was the frequency 
 of epilepsy in the community at large. In our series four cases 
 of epileptic psychosis are presented in patients who came within 
 the purview of the military service. John Manaos (case 29) 
 was arrested for not properly filling out his draft papers. In 
 prison he developed a clouded mental state, and at the hospital 
 the diagnosis of epilepsy was made. Upon this finding, of 
 course, the charges against him were dropped, as it was felt 
 that he was not a responsible individual. 
 
 Charles Lovell (case 55) was given his discharge from the 
 army because of epileptic attacks. The epileptic phenomena 
 occurred for the first time while in the army service in the 
 cases of Frank Wayne (case 56) and John Bristol (case 57). 
 Wayne had been a weakling throughout his life, was recog- 
 nized as somewhat simple-minded, and incapable of hard work. 
 Under the stress of the army, the seizures of epilepsy made 
 their appearance, and after discharge he was, of course, a sub- 
 ject for compensation. John Bristol, on the other hand, had 
 been a very healthy and stalwart individual, serving on the 
 police force before his enlistment, and being athletic instructor 
 at camp. For some reason, seizures began after typhoid inocu- 
 lation, and have continued with great frequency to the present 
 time. He is, therefore, another subject for compensation, and 
 has been obtaining assistance from the Red Cross in securing 
 work that he is capable of performing. 
 
 The types of manic-depressive psychosis will have to be 
 considered. In a general way, it was considered before the 
 war experience was at hand that the conditions of the military 
 service would produce a great many cases of manic-depressive 
 psychosis, and that the individual who had had a psychosis 
 would be very likely, indeed, to break down. 
 
 Robert MacPherson (case 85) developed a hypomanic con- 
 dition which was probably the cause of his discharge from 
 military service. 
 
 On the other hand, Clarence Adams (case 86) had had 
 psychotic symptoms from which he recovered before entering 
 the service. He did very well, being at the front and being 
 gassed without having any return of his symptoms. After his 
 discharge, while in civilian life, he again developed psychotic 
 symptoms which led him to the hospital. It is indeed to be 
 
496 THE KINGDOM OF EVILS 
 
 borne in mind that the change from the military back to 
 civihan Hfe is quite a severe shock at times, and it takes a 
 considerable amount of ability to make a successful and easy 
 change. 
 
 Dementia praecox cases were frequent enough during the 
 war, and are still occurring as a problem in men who have 
 been in the service. If there is one feature that might be con- 
 sidered as somewhat different in the military cases from those 
 in civil life, it is that the prognosis of soldiers who were ap- 
 parently schizophrenic was much better during the war period 
 than in the usual prognosis of this type of case as seen in civil 
 life. 
 
 Of the war cases described in this book, five had the diag- 
 nosis of dementia praecox. Kevork Ardinian (case 26) was 
 never actually in the army, but was picked up under the "Work 
 or Fight" law after which it was discovered that he was really 
 a victim of dementia praecox. 
 
 George Stone (case 76) had done well in the army, where 
 he had won the croix de guerre. After his discharge he de- 
 veloped a psychosis which was diagnosed as dementia praecox, 
 and while outside of an institution he gave a good deal of 
 concern to the Red Cross. 
 
 Howard Lancaster (case 79), on the contrary, developed 
 his mental symptoms while in the army and did well when he 
 returned to civilian life. Whereas George Mullen (case yy) 
 was much like Clarence Adams (case 86). Mullen was com- 
 mitted as a case of dementia praecox in 191 5, but was dis- 
 charged. He joined the English Army, where he did well, and 
 was given an honorable discharge after being wounded. On 
 his return to civilian life, he developed a psychosis which 
 brought him into an institution with the diagnosis of dementia 
 praecox. 
 
 Major Mark Dobson (case 80) would have been in very 
 serious difficulty for forgery had his condition not been recog- 
 nized as dementia praecox. 
 
 The cases in the psychoneurotic group were very frequent 
 throughout the war. Abroad they came chiefly under the acute 
 manifestations of shell-shock. The cases as seen in America, 
 following the war, or during the war among those patients 
 who had not been abroad, were very much less dramatic. 
 
 James Bailey (case 7) developed neurasthenic symptoms 
 
THE KINGDOM OF EVILS 497 
 
 following a street-car accident. These symptoms did not give 
 him very much difficulty, however, until he was at camp, when 
 they became quite manifest, and led to his discharge. 
 
 A good example of traumatic hysteria is presented by 
 Walter Nelson (case 91) who developed his symptoms fol- 
 lowing a blow on the head by a tent-pole which blew over in 
 the wind. His symptoms were those that one ordinarily sees 
 from the same type of injury in civilians, but, occurring while 
 he was in the aviation service, it was distinctly a psychoneu- 
 rosis occurring in the military service. 
 
 Martin O'Hara (case 92) had had evidences of hysteria 
 before his army experiences. He was discharged from the 
 army for physical disability, and after getting into an un- 
 pleasant marital arrangement, developed his hysterical symp- 
 toms again. 
 
 The picture of neurasthenia was not an infrequent one in 
 the military service. An example is given in the case of Joseph 
 Levenson (case 93). 
 
 The constitutional psychopathic inferiors presented them- 
 selves to the military surgeons in considerable numbers, and 
 their vagaries will be before the people who deal with returned 
 soldiers for many years to come. Francis Corcoran (case 98) 
 had been a ne'er-do-well all his life. After his military expe- 
 rience, he became a burden to the public health service, and 
 will probably remain a "case" for many years. Paul Daw- 
 son (case 78) had been discharged from the army for mental 
 disease, both at the time of the Mexican border affair, and 
 during the Great War. He claims that in both these instances 
 he malingered. As a rule it is true that individuals malingering 
 mental disease are really the victims of some form of mental 
 disease. Whether or not Paul Dawson was a case of dementia 
 praecox, as some considered, or of psychopathic personality, 
 it is hard to state. At any rate, he did not fit into the condi- 
 tions of military life. 
 
 From the standpoint of the psychiatric social worker, the 
 military man may be of interest not as the main actor in the 
 drama, but as a subsidiary. Thus, Elliot Calderwood (case 
 22) who was thought to be more sinned against than sinning, 
 as he had been deserted by his father, a soldier in the Cana- 
 dian Army. Nora McCarthy (case 74) was the fiancee of a 
 soldier and was pregnant. Her mental difficulties arose aftey 
 
498 THE KINGDOM OF EVILS 
 
 his departure for France, and were to a large degree patched 
 up by marriage after his return from overseas. 
 
 MENTAL HYGIENE OF INDUSTRY 
 
 There are at least forty-two cases in this volume that have 
 interest from the standpoint of the new mental hygiene of 
 industry, a movement which we conceive may prove of pri- 
 mary value in the general social situation of the world. But 
 we also know that it will be difficult to persuade either the 
 theoretical psychiatrist or the practical industrialist that he 
 must build his sociology or his practical plan of meeting 
 the economic unrest, from the very bottom, namely from 
 the individual. The standpoint of theoretical sociology and 
 likewise the standpoint of practical industrialism has interested 
 itself in man's movements rather than in the individual. Mod- 
 ern sociology feels Herbert Spencer too much of an indi- 
 vidualist, yet some sociologists note with alarm the generality 
 of sociologists. Ross says : "How futile is the endeavor to 
 establish laws of succession based on the parallelism in all 
 societies of any special development (e.g., domestic or politi- 
 cal) taken in its entirety. The error here lies in taking too 
 large a unit of social life." Tarde also is right in saying, 
 "This attempt to confine social facts within lines of develop- 
 ment, which would compel them to repeat themselves en masse 
 with merely insignificant variations, has hitherto been the chief 
 pitfall of sociology." "Even the keen-eyed Marx," says Ross, 
 "opposes to a social Past dominated by class struggle a class- 
 less, strifeless Future under the collectivist regime." But he 
 does not come down upon the individual as the true bottom 
 factor. "The individual," says he, "is a true factor," but he 
 goes on to identify individualism with the "Great-Man" theory 
 and says, "There is little of value in the Great-Man theory, 
 which sets up a Hero for each epoch or movement and subjects 
 multitudes of men through centuries to the spell of his purpose 
 or ideal." He continues, "We cannot take the individual as our 
 unit." Groups, relations, institutions, imperatives, uniformi- 
 ties are five units favorably considered by Ross who says 
 "They precede the individual and they survive him ; neverthe- 
 less they have all risen at some time out of the actions and in- 
 teractions of men. To understand their jrenesis we must 
 
THE KINGDOM OF EVILS 
 
 499 
 
 ascend to that primordial fact known as the social process/' 
 From our point of view we rather hold that these social prod- 
 ucts can best be studied by analyses of interactions of men 
 starting even in the simplest groups. This point of view is as 
 true in industrial psychiatry as in other situations. 
 
 We found that many of our patients who were started on 
 an industrial decline were competent and even excellent work- 
 men, and that with a little assistance in adapting themselves 
 to their employment and an explanation of their condition to 
 their employers, they could be refitted into industry. This 
 led at once to the idea that similar methods of understanding 
 and assistance might keep other employees from falling into 
 the condition of hospital patients, and further to the thought 
 that mental hygiene, necessary for the psychopathic employee, 
 would be beneficial to all persons in employment to the end of 
 promoting their efiiciency and personal satisfaction. A com- 
 mittee was formed in 1914 to carry on a special investiga- 
 tion of the subject, on which psychiatry was represented by 
 Dr. Herman Adler and industry by Robert Valentine. A spe- 
 cial social worker for psychopathic employees was engaged, 
 and men patients between the ages of twenty-five and fifty-five 
 were selected for the study. In addition to the cases assisted, 
 industrial histories over a period of five years have been se- 
 cured for two hundred and fifty cases. The continuation of 
 this study until 1920 was made possible by contributions from 
 the Committee of the Permanent Charity Fund, Incorporated, 
 Boston Safe Deposit and Trust Company, Trustee. 
 
 As an outgrowth of this work, the Engineering Foundation 
 of New York, in 191 9, undertook an investigation of the pos- 
 sible applications of psychiatry in industry. The term "mental 
 hygiene of industry" was devised by the senior author to in- 
 clude the contributions of three fields — psychiatry, psychology, 
 and psychiatric social work. Four papers were written as a 
 result of this inquiry.^ 
 
 One of our anchor cases, Henry Loyal, steamfitter (case 4), 
 
 » Southard, E. E., M.D.: "The Movement for a Mental Hygiene of Industry," 
 Mental Hygiene, January, 1920. Also Industrial Management,^ February, 1920. 
 
 "The Modern Specialist in Unrest: A Place for the Psychiatrist in Industry," 
 
 The Journal of Industrial Hygiene, May, igzo. Also Mental Hygiene, July, 1920. 
 Trade Unionism and Temperament: Notes Upon the Psychiatric Point of 
 
 View in Industry." Mental Hygiene, April, 1920. 
 
 Jarrett, Mary C: "The Mental Hygiene of Industry: Report of Progress on Work 
 
 Undertaken under the Engineering Foundation of New York," Mental Hygiene, 
 
 October, 1920. Also Proceedings of the National Conference of Social Work, 1920. 
 
500 THE KINGDOM OF EVILS 
 
 was a productive, competent, skilled worker and for the most 
 part fairly steady in employment. The irregularity in his 
 employment was due to his mental disease, his psychopathic 
 personality with its periodical waves. He should not figure in 
 the turnover analyses. 
 
 The Portuguese laborer, John Manaos (case 29), epileptic, 
 was an irregular worker and brings up certain problems of 
 epilepsy which every employer of labor should bear in mind. 
 On the one hand epileptics are prone to exhibitions of extreme 
 irascibility and bad humor from time to time. On the other 
 hand they are often of a strongly religious cast exceedingly 
 faithful in work, as shown to the most casual visitor at insti- 
 tutions for epileptics where even the so-called insane are under 
 proper conditions made to work ably and willingly. 
 
 The nickel-polisher, Luigi Silva (case 53) is another epilep- 
 tic unable to work in a community but finally successfully put 
 to work on a farm. 
 
 The chemist John Logan (case 58) was a most steady em- 
 ployee and most valuable to his firm. In fact his firm was 
 willing to allow occasional absences due to his alcoholic at- 
 tacks. There can be no doubt that these occasional alcoholics 
 would be greatly benefited if the plants employing them Avould 
 call upon consultant psychiatrists for analyses of these often 
 very valuable men. In fact such alcoholics might be saved 
 almost completely for the community. 
 
 The salesman Paul Ernst (case y2>) ^^as a victim of periodic 
 disease, manic-depressive psychosis (at first thought to be a 
 case of dementia praecox). 
 
 The waiter William Donahue (case 82) had always been 
 irregular in employment. His irregularity was no doubt due 
 to the same cause as that operating in Paul Ernst. Another 
 type of irregular worker is found in Louis Sand (case 95) 
 who was a rover and had worked during five years in as many 
 as twelve states, having originally wandered from Belgium 
 where he had been well educated and came from a good family. 
 We, however, likewise were unsuccessful in keeping him at a 
 job for more than a few months. 
 
 There may be more types of irregular employment than here 
 illustrated. We have seen instances of the periodic disease, 
 manic-depressive psychosis, and of the permanent disease 
 epilepsy, both of which may lead to irregularity of employ- 
 
THE KINGDOM OF EVILS 5OI 
 
 ment due to the mental disorder. Especially in the case of 
 manic-depressive psychosis will it be true that mild attacks of 
 depression hardly visible to the lay observer may lead to the 
 throwing up of a job and to premature discharge. Some of 
 these are amongst the cleverest workmen and the fact that 
 they figure at all in the turnover is probably on the whole a 
 great loss to industry. We have seen instances of periodic 
 alcoholism (the laity is familiar with these cases under the 
 name of dipsomania) and have called attention to the sales 
 values to industry of some of these men. Indeed employers 
 are fairly familiar with the necessity of letting these men 
 have their sprees. We have become familiar with the rover or 
 victim of wanderlust, a tendency perhaps allied to that shown 
 in the psychopath Henry Loyal (case 4). 
 
 Alfred Mack, the packer (case 6), was one of our industrial 
 successes. A man, it will be remembered, made better than 
 he was to start with. His physical disability was removed and 
 his alcoholism stopped. He has since remained a steady 
 worker and one of the best employees in his plant. We might 
 count the case of the woman who lived as a man, the factory 
 worker Julia Brown (case 23), as another instance of alco- 
 holism with certain complications of character, who after social 
 treatment became a competent and trusted worker in her plant. 
 
 The real estate sales agent, John Sullivan (case 60), had 
 a bad attack of alcoholic hallucinosis but was encouraged to 
 discontinue alcohol and did so. He was advised to return to 
 gardening and did well at it. Another alcoholic, Patrick 
 Nolan (case 59), returned to work after D. T.'s that lasted 
 ten days. He has since discontinued alcohol. National pro- 
 hibition will tend to solve many of these problems but we 
 must not be too optimistic concerning the relief of all prob- 
 lems of alcoholism by prohibition. We do not here refer to 
 the possibility of getting alcohol illegally. We refer rather 
 to the fact that alcoholism when it reaches the psychopathic 
 degree or comes out in a psychopathic way is perhaps per- 
 mitted to do so by some hereditary taint or acquired soil in 
 the nervous system. We may look now for the pure illustra- 
 tion of such hereditary taint or acquired soil in persons who 
 can punctuate such taint or soil by drinking. 
 
 The industrialists must be interested particularly in cases 
 of disability from a functional neurosis, that is theoretically 
 
502 THE KINGDOM OF EViLS 
 
 an always curable disease. The laundry worker, James Bailty 
 (case 7) was apparently saved from permanent disability due 
 to hysterical paralysis. The cure was slow. 
 
 The roofer's helper Lewis Goldstein (case 11) made a slow 
 recovery from an industrial accident, but there were economic 
 complications in the Goldstein case. The shipping clerk Mark 
 White (case 16) was industrially disabled from a psycho- 
 pathic condition that dated back to an accident. He was re- 
 stored to industrial efficiency under social treatment, as was 
 also Hamilton Green (case 18). John Flynn (case 19) was 
 one of complete disability following traumatic neurosis. He 
 was given work of no great difficulty — made slow improve- 
 ment and after two years was restored to full efficiency. The 
 machinist Dennis O'Donnell (case 90) had a psychoneurosis 
 following an industrial accident. There are a number of 
 problems in the O'Donnell case; owing to the new economic 
 conditions of the war he is able to get higher wages in his new 
 job than before. 
 
 David Collins (case 42), the paretic machinist, had to have 
 money raised for his treatment and his wife also had to be 
 put under treatment. The child, fortunately, when examined 
 as to its blood serum, proved negative to syphilis. 
 
 This is not always the case as the special work of H. C. and 
 M. H. Solomon, working in the Massachusetts State Psychia- 
 tric Institute, under the Interdepartmental Social Hyg'iene 
 Board, has shown : 
 
 "Figures for the two years 1917 and 1918 show that the 
 social worker dealt with 301 families of syphilitics, of whom 70 
 per cent reported to the hospital for examination. In 40 per 
 cent of the families every memlier reported. Among these 
 families 579 individuals were desired for examination. Sixty- 
 nine per cent were actually examined and an additional 10 
 per cent came but were not examined for special reasons. 
 
 "As a result of this examination of families, much undis- 
 covered syphilis — both conjugal and congenital — is found. Of 
 394 individuals examined, 21 per cent showed a positive Was- 
 sermann reaction. Of those found to need treatment, 51 per 
 cent were treated at the hospital and 40 per cent were referred 
 elsewhere for treatment." ^ 
 
 A very interesting and complicated case of psychoneurosis 
 was the case of the cigar-maker David Stone (case 24), who 
 
 ' Maida H. Solomon: "Social Work and Neurosyphilis," Social Hygiene Quarterly, 
 January, 1920. 
 
THE KINGDOM OF EVILS 503' 
 
 Was handicapped by a fear of open spaces. He has now re- 
 covered from this fear and works regularly at good pay as an 
 insurance agent. Herman Simonson (case 27) also had his 
 employment changed. He had a neurosis from which he made 
 slow improvement. He was originally a clothes-presser and 
 has now become efficient as a porter. The plumber Daniel 
 Griffin (case 34), unable to work for six years as a result of 
 psychoneurosis, was treated for a year and a half and will not 
 yet go out alone. He has become far more active about his 
 house and hopes are entertained that he will finally become 
 able to work again at his trade. The machinist Ralph John- 
 son (case 71) was another rover and was suicidal. Under 
 treatment he has become a steady workman. 
 
 An especially interesting case was that of the architect Henry 
 Allen (case 100). Allen imagined unfriendly attitudes on 
 the part of the employees and did not want to work in a large 
 room full of fellow employees. He has now found a chance 
 to work by himself and is doing well. The cigar-maker 
 Maurice Eastman (case 87) was a neurotic in employment 
 quite distasteful to him. With encouragement and occasional 
 vacations he has been kept at work steadily. A man in the 
 liquor business, Joseph Fangillo (case 89), had a breakdown. 
 He was gotten into the state hospital under voluntary com- 
 mitment. It was his second time in a state hospital. He has 
 now recovered and has gone to work. A typesetter, Harriet 
 Farmer (case 94), attempted suicide. She was at odds with 
 her family and friends, was in poor health, and was earning 
 low wages. Under treatment she became self-sustaining and 
 has even been advanced in her work. 
 
 We have attempted to give in this volume all the manifold 
 psychiatric suggestions that come from industrial accidents. 
 We conceive that industrial accident boards all over the coun- 
 try should make increasing use of psychiatrists, expert medical 
 men, but especially of the psychiatric social worker. The In- 
 dustrial Accident Board of Massachusetts has to our knowl- 
 edge in numerous cases got most important results from such 
 social investigations. 
 
 That the high-grade feeble-minded person, or so-called 
 moron, may make a good worker is shown in a number of 
 cases. Take for instance the elevator operator Thomas Fuller 
 (case 9). Fuller was even promoted to be corporal of the 
 
504 THE KINGDOM OF EVILS 
 
 marines in war time. The army authorities are not too sure 
 that they want to get rid of all their morons, some of whom 
 may do very good work in menial tasks that the more normal 
 soldiers balk at. The moron Agnes O'Brien (case 13) whose 
 trouble was complicated by hysteria was finally made self-sup- 
 porting in factory work. The laborer Rosenthal (case 49) 
 was another moron with psychoneurotic complication, and 
 might in fact have been figured amongst our accident cases 
 since his symptoms date chiefly from an accident. He is now 
 a perfectly steady and capable worker. 
 
 Whilst writing this volume we have heard of an up-to-date 
 industrial firm that is adopting the policy of establishing a 
 school for its morons. Such a policy is to psychiatrists en- 
 couraging since it follows the lines of Seguin and Madame 
 Montessori. 
 
 No doubt almost every employment manager would hesitate 
 to employ a known syphilitic. Let us, however,, call attention 
 to Greta Meyer (case 40), a case of cerebrospinal syphilis ; that 
 is to say, syphilis affecting several parts of the nervous system 
 in a more or less diffuse way. Mrs. Meyer, after her improve- 
 ment under medical treatment with salvarsan, became a social 
 problem which could actually be closed and referred to the 
 voluntary division of the service after a period of a year. 
 
 Another syphilitic case is that of David Collins (case 42), 
 a machinist, a victim of general paresis ; that is to say, a dis- 
 ease whose duration seldom runs beyond three to five years 
 from the onset of symptoms. Many social workers and per- 
 haps a majority of employment managers would regard such 
 a man as hardly worth the expenditure of an extraordinary 
 amount of time, and no doubt more time might well be placed 
 upon other members of the family than upon the syphilitic. 
 Still, an examination of the records of David Collins shows 
 that he was made industrially competent and was even pro- 
 moted to a job as foreman. Consider also Harold Gordon 
 (case 46), a victim of syphilis in that form which is char- 
 acterized by paralysis on one side of the body due to a de- 
 structive lesion of the brain. The medical outlook for Gordon 
 is one of persistent paralysis on the side affected so far as this 
 fails to be improved by orthopedic means and by the methods 
 recommended by Dr. S. I. Franz of Washington. Gordon is 
 now working regularly at his trade, that of steamfitter. We 
 
THE KINGDOM OF EVILS 505 
 
 Single out these three cases of Greta Meyer, David ColHns, and 
 Harold Gordon as illustrative of three of the major groups of 
 syphilitic diseases of the nervous system, each with a different 
 outlook as to duration and impairment. Application of the 
 best methods of social work secured surprisingly good results. 
 
 The jail-bird group of psychopaths would doubtless be 
 scouted as potential employees by many employment managers. 
 Plain jail-birds might he regarded as bad enough; crazy ones 
 would be thought impossible. Consider, however, the elevator- 
 operator, Alfred Stevens (case 25) discharged for pilfering. 
 After recovery from depression this elevator-operator became 
 one of the best employees in another plant. We were also able 
 to secure for Ignatz Simanski (case 33), a forger, something 
 like a good future. He was a capable workman and was gotten 
 work by us after his discharge from the house of correction. 
 It is to be sure doubtful whether Simanski was at all psycho- 
 pathic. Ordinarily he might have been handled by some agency 
 for discharged prisoners. However, he got into the Psycho- 
 pathic Hospital's hands through the suggestion of a layman 
 and on the basis that he might possibly be a victim of psycho- 
 pathic personality. 
 
 We are also afraid that after approaching the matter from 
 a psychopathic point of view, most persons would be disposed 
 to look with suspicion upon such a person as the mill worker 
 Julia Brown (case 23), who lived for so long as a man. 
 Nevertheless with proper measures of social work, Julia Brown 
 has become a competent and trusted factory worker. No doubt 
 her mental twist is a profound one. "The inner relations" of 
 such a person are hard to integrate ; or shall we say that there 
 is integration of grotesque independence in Julia Brown to start 
 with? At all events it has been found possible to adjust the 
 "outer relations" of the environment in such a manner that 
 this particular psychopath is getting on well. Almost equally 
 hard to deal with is such a matter as the fear of open spaces 
 exhibited in the cigar-maker David Stone (case 24). Yet Stone 
 has recovered and is now working regularly at good pay as an 
 insurance agent. 
 
 Perhaps such interior difficulties as those of Michael Piso 
 (case 62) might be regarded as still more difficult of adjust- 
 ment. Piso had illusions of jealousy that interfered with his 
 employment; but as his jealousy was made to subside (or shall 
 
506 THE KINGDOM OF EVILS 
 
 we say, as the jealousy subsided of itself?) Piso went back to 
 work and got his wages raised. 
 
 Another apparently disconcerting fact is the long duration 
 of disability in some cases, which seems to argue that little 
 enough can ever be done. But consider the case of the plumber 
 Daniel Griffin (case 34) who is a psychoneurotic and had actu- 
 ally been unable to work for six years. After a year's treat- 
 ment he has become more active about his home, although up 
 to date he is not willing to go out alone. 
 
 We now turn to an analysis of the family interests in the in- 
 dustrial cases which we have just summed up from their stand- 
 points as individuals. Certainly twenty-three out of forty-two 
 industrial cases of this volume are cases with the family prob- 
 lem in sharp focus. 
 
 Consider the case of Henry Loyal (case 4). Here was the 
 family problem of non-support with marital discord. The 
 wife was sick; one child had chorea; the second tuberculosis; 
 the third required special feeding; one daughter was a sex 
 delinquent. Every member of the family was an object of 
 special attention. Industrial rehabilitation of Henry Loyal 
 meant happiness to at least six separate persons. We are in- 
 clined to think that the non-psychiatric social worker would 
 have taken the Loyal family situation as not particularly psy- 
 chiatric. The questionnaires concerning deserted families, got- 
 ten out by various social agencies, do not bring the psychiatric 
 question into sufficient relief. It would have been easy to dis- 
 miss Henry Loyal as a "degenerate." Particularly Mrs. Loyal, 
 his wife, the sex-delinquent daughter, and the choreic child, 
 that is at least four of the six members of the Loyal family, 
 should be more or less constantly under psychiatric review. 
 
 Alfred Stevens (case 25), the elevator-operator discharged 
 for pilfering, had his case complicated by the situation reverse 
 to that of Henry Loyal, since Stevens' wife left him taking 
 their child, a child to whom Stevens was greatly devoted. Upon 
 Stevens' recovery from his depression the family was reunited. 
 
 Martin O'Hara (case 92), a loafer, presented another story 
 of family problem. He had been recently married but never 
 lived with his wife. He found that she had had an illegiti- 
 mate baby. The medical problem was one of hysteria on the 
 part of O'Hara. No doubt the hysteria was on the basis of 
 
THE KINGDOM OF EVILS 507 
 
 psychopathic personaHty, from which O'Hara will not recover. 
 The problem of social work will be a chronic one. 
 
 More or less continuous financial aid had to be granted in a 
 number of cases. Lewis Goldstein, a roofer's helper, during 
 his slow recovery from an industrial accident had to be helped 
 and the health of his wife and children made the whole situa- 
 tion difficult, — practically difficult, however theoretically simple 
 enough. 
 
 The case of John Flynn (case 19) resembles that of Lewis 
 Goldstein; Flynn required two years of care before he could 
 be restored to full efficiency following his complete disability 
 from traumatic neurosis. The Flynn family also had a num- 
 ber of sick children to care for. 
 
 David Stone (case 24), the cigar-maker who feared open 
 spaces, was also another case not of individual disease alone, 
 since through the process of his becoming industrially com- 
 petent ran also the problem of supporting Stone's family and 
 steering his wife through illness. 
 
 Paul Ernst (case y^^), the excellent salesman who had been 
 discharged alter a manic attack, had an income decidedly in- 
 sufficient for his family. Assistance was given the family in 
 the form of clothes and vacations for the children. One of the 
 nine Ernst children also had chorea. The social worker had to 
 contend with Ernst's rather natural worry about the family 
 finances. 
 
 Hamilton Green was psychopathic with a mother to support 
 and the Green family had been in receipt of aid from public 
 funds. The improvement in Green's mental disease permitting 
 work regularly abolished the problem of public aid. 
 
 Ignatz Simanski (case 33) showed in some sense the oppo- 
 site situation since he was making financial demands upon his 
 sister who was only able to support herself with difficulty. 
 
 The health of the child of the divorcee Agnes O'Brien (case 
 13) had to be considered and the second (illegitimate) child 
 had to be provided for in public custody. 
 
 Nathan Rosenthal (case 49), a laborer, was a moron with 
 psychoneurotic symptoms dating from an accident. The 
 Rosenthal family first came under observation through the 
 examination of a son — another example of the rather frequent 
 uncovering of family problems through the resort to a mental 
 
5o8 tHE ktKGDOM OF EVILS 
 
 clinic of sottle psychiatric case. The Rosenthal family entirely 
 was put under social care. Work was procured for the father. 
 The mother was given suitable encouragement. The son was 
 placed under supervision. Meantime the family had an insuf- 
 ficient income. 
 
 Another special problem of advice was offered by the case 
 of Maurice Eastman (case 87), the cigar-maker whose trade 
 was distasteful to him. The family problem proved a long 
 one. The fact that the family was inclined to maintain a high 
 standard of living made the small income seem more than 
 ordinarily insufficient. Aid with clothes was given. But more 
 particularly a specialized kind of encouragement and advice had 
 to be given with relation to the children's education. The East- 
 man family showed the usual Jewish ambition for the chil- 
 dren's education. All the children were bright, and there was 
 even an indication of special talent in one or two thereof. The 
 problem of the right kind of encouragement for the education 
 of a psychoneurotic is a psychiatric one. Of course we may 
 say that not even psychiatrists find always the right way in 
 such a plight. Yet, perhaps the psychiatrists should have more 
 to say in the premises than some other person exempt from any 
 knowledge of psychoneuroses whatever. 
 
 That the industrial problem could not be treated in and for 
 itself successfully and that the ordinary non-psychiatric view 
 of the family problem would be decidedly insufficient are points 
 illustrated also in a case like that of Harold Gordon (case 46). 
 Here there had been cohabitation with a woman probably 
 psychopathic. 
 
 Paul Dawson (case 78) separated from his wife, failed to 
 support her and was perhaps a case of dementia praecox. He 
 had always worked irregularly and under our care could not 
 be got to take a job. However, upon being drafted he made 
 an allotment to his wife. Upon his discharge he went into the 
 merchant marine. 
 
 Other cases of family interest amongst the industrial group 
 are those of Herman Simonson (case 2"]^ with a wife and six 
 children and wife's parents in Russia dependent upon this 
 clothes-presser ; Nathan Blumberg (case 37), a case of non- 
 support in financial difficulty, confused about his affairs, sep- 
 arated from his wife; John Logan (case 58), the expert chem- 
 ist whose wife was at first afraid to live with him but upon 
 
THE KINGDOM OF EVILS 509 
 
 advice and encouragement kept up the home ; Patrick Nolan, a 
 laborer whose family was dependent upon his wages and who 
 was gotten to return to work after recovery from delirium 
 tremens; the jealous teamster Michael Piso (case 62), whose 
 family required material aid and also the care of health of the 
 wife and children; the paranoid case of George Stone (case 
 76), whose delusions were not severe enough to permit his 
 being committed to a state institution and who wandered about 
 not working and threatening his wife; Joseph Fangillo (case 
 89), whose illness ate up his savings so that his wife might 
 be maintained ; the industrial-accident case of the machinist 
 Dennis O'Donnell (case 90), where there was an economic 
 problem of the family and the problem of advice to the wife. 
 
 We have added up the more striking problems amongst the 
 twenty-three family cases in our industrial group of forty-two 
 and find that no less than eighteen of the twenty-three cases 
 yielded acute economic problems for the family as well as for 
 the industrially disabled patient. When the non-psychiatric 
 family case worker approaches such a case as a purely family 
 problem she has unquestionably in the past been inclined to 
 regard the psychopath as an unfortunate additional complica- 
 tion. We submit that the treatment of these family cases 
 with the psychopath as the primary target of attack is the ra- 
 tional strategy of the present day. Nine of the twenty-three 
 cases show degrees of sickness in the wife or children. The 
 medical social worker will no doubt give proper attention to 
 these physical sicknesses ; and perhaps the medical social worker 
 from her hospital community experience may exhibit an ad- 
 vance in social attitude upon that of the philanthropic family 
 case worker of a former generation. But here again we are 
 inclined to say that the data of this book proved that the stand- 
 point of physical health, valuable as it is, is very frequently not 
 the central problem. Let the central problem of the psycho- 
 neuroses or other mental diseases in the father or mother be 
 properly treated and the problems of sickness on the part of the 
 wife and children will get solved upon comparatively small 
 lines. But if we try to solve the problem of sickness of the 
 non-psychopathic spouse or children upon a purely health basis 
 the psychopathic difficulty in the parent will be apt to run on 
 indefinitely. (See particularly such a case as that of Henry 
 Loyal, case 4, or Nathan Rosenthal, case 49, or Maurice 
 
5IO THE KINGDOM OF EVILS 
 
 Eastman, case 87.) There were nine cases also of marital dis- 
 cord. Marital discord is perhaps a purely primary and moral 
 difficulty, though we are not aware that any proper statistics 
 on this point of marital discord with relation to psychopathy 
 have ever been collected. The point of this volume largely 
 turns upon our considering every case of social difficulty as 
 possibly in the first instance medical, and perhaps psychopathic. 
 This point, as we repeatedly insist, is not grounded upon sta- 
 tistical frequency of mental disease amongst cases of social 
 difficulty ; we do not feel that there are anywhere in the world 
 proper statistics on this matter. Our point is that every in- 
 stance of social difficulty should first or last receive considera- 
 tion as possibly a medical matter. So with these nine cases of 
 marital discord. In the Loyal (case 4) family the wife was 
 possibly slightly psychopathic although the big problem of 
 non-support was unquestionably grounded in the psychopathic 
 personality of the husband and father. Nathan Blumberg 
 (case 37) was separated from his wife after a quarrel, but we 
 do not here find evidence of mental diseases on both sides of 
 the family. The discord in the case of Michael Piso (case 62) 
 was unquestionably due to this teamster's delusions rather than 
 to any attitude on the part of the wife. Likewise with George 
 Stone (case 76). 
 
 There were two cases complicated by illegitimacy of a child. 
 Agnes O'Brien (case 13) had an illegitimate second child. 
 Martin O'Hara married a wife with an illegitimate baby. 
 Agnes O'Brien illustrates one problem of illegitimacy in the 
 fact that she was a hysterical moron whom we should not 
 regard as too responsible for the fact of illegitimacy. On the 
 other hand the wife of Martin O'Hara was as far as we know 
 not in any sense psychopathic. As with the questionnaires re- 
 garding non-support, so with the questionnaires regarding 
 unmarried mothers; we do not find that these questionnaires 
 take sufficiently into account the possibility of feeble-minded - 
 ness on the part of the unmarried mother or father. We have 
 not the slightest doubt that the problem of illegitimacy will 
 have a flood of light thrown upon it by intensive study from 
 the psychiatric point of view. 
 
 To sum up concerning the family interests in the industrial 
 group of cases, we must emphasize the fact that first, each in- 
 dustrial case must be handled upon its merits as a psychopathic 
 
THE KINGDOM OF EVILS 5I I 
 
 case ; second, the members of the industrial psychopath's family 
 must be treated socially like the members of any other family 
 case group; third, the treatment of such a family case group 
 containing a psychopath as a central figure, should not be 
 treated as a family unit (that is, from the ordinary standpoint 
 of the family case worker dealing with the situation largely 
 from the economic side) ; fourth, the point of view of the ordi- 
 nary medical social worker (that is, the point of view which 
 takes into account the physical health of each member of the 
 family), is an inadequate approach, good so far as it goes but 
 missing the psychiatric point. Cases of industrial disability 
 might well seem, even to the educated layman, primarily cases 
 for economic handling from the standpoint of the so-called 
 family case work. Yet the educated layman who should think 
 that this primarily could be handled by financial aid alone would 
 fall far short of the ideals of the present day. Let us empha- 
 size as ever that both the family case worker and the medical 
 social worker do their best as moral advisers in these situations. 
 But the kind of moral advice they are equipped by nature and 
 training to give needs supplementation by psychiatric training 
 if the best results are to be obtained. 
 
 The moral advice given by the worker untrained in the con- 
 trast of temperament and the peculiarities of the different 
 major forms of mental diseases and defects is but too apt to 
 follow some particular slant of the social worker's own nature 
 and experience. She is but too apt to try to make the family 
 as a whole and the central psychopathic figure conform to 
 some set ideal of action. It is these industrial cases that bring 
 very acutely the combination of diseases, moral defect, and 
 economic disability. The formula of these cases is rather apt 
 to be M. V. P., to use our abbreviated terminology. That is, 
 we find in these cases some examples of the morbi, some ex- 
 amples of the vitia, and some examples of the penuriae rolled 
 in one. 
 
 Our complaint as to the shortcomings of the present-day 
 social work is that too great emphasis may readily be laid upon 
 economic disabilities (penuriae). Furthermore, even if the 
 hypothesis of disease (morbi) is brought into the foreground 
 we find that the morbi are taken in a physical sense rather than 
 in a mental sense ; the medical social worker is not sufficiently a 
 psychiatric social worker. With respect to the vitia, our chief 
 
512 THE KINGDOM OF EVILS 
 
 complaint reduces perhaps to the charge that the non-psychi- 
 atrically trained person is but too apt to think that all men con- 
 form to or fall short of certain standards of morality, whereas 
 the psychiatrically trained person is apt to see many types of 
 moral shortcoming following the lines of temperament and 
 the psychiatric worker suspects that there has been too great 
 emphasis upon the uniting of moral standards in the human 
 race as a whole. 
 
 All moralists admit that the moral situation (that is, the 
 situation which considers good and evil, right and wrong) 
 involves voluntary activity — a point handed down from Aris- 
 totle. "The agent must know," say Dewey and Tufts, "what 
 he is about; he must have some idea of what he is doing; he 
 must not be a somnambulist, or an imbecile, or an infant." 
 They go on to say that such unformed or deformed personali- 
 ties exhibit voluntary activities and in moral activity they may 
 show character or herein necessarily be viewed morally. Now 
 this standpoint may be perfectly well chosen from the stand- 
 point of voluntary moral life (we are inclined to concede even 
 this point, to grant it for the sake of argument), but the stand- 
 point is assuredly not well chosen if we are trying to evaluate 
 the vitia; that is, tell just how far the acts formed are immoral 
 acts and how far they are the acts of untrained or immature 
 persons or how far they are actually psychopathic. In short, 
 we feel that the study of morals will greatly benefit from psy- 
 chiatric analyses. But this point takes us far out of the im- 
 mediate range of industrial interest. The most prominent 
 difficulties in the handling of family situations of industrial 
 disability is the tendency on the part of persons without a 
 psychiatric training or experience to deal with families upon a 
 purely economic basis or upon a basis of mere physical health. 
 
 OUT-PATIENT SERVICE 
 
 Some patients resort upon their own initiative to the out- 
 patient service (for example, Ethel Murphy, case 66, and 
 Jeanette Burroughs, case 68) and are then, if desirable, readily 
 persuaded to enter the hospital wards. William Donahue 
 (case 82) came of his own initiative to the out-patient depart- 
 ment and never seemed to need treatment in the wards. 
 Maurice Eastman (case 87) was treated as an out-patient only 
 
THE KINGDOM OF EVILS 513 
 
 by psychotherapeutic means. And though Eastman's troubles 
 seemed to require at least three types of worker and much 
 individualization, yet ward treatment never came in question. 
 Louis Sand (case 95), the roving Belgian immigrant, re- 
 mained also an out-patient case throughout a long and rather 
 intensive social treatment. 
 
 Shall mental treatment be carried out in hospital beds or 
 in the out-patient department? Many states still possess no 
 means of treating mental cases in adequate out-patient depart- 
 ments, such as those provided for example by Massachusetts 
 and New York. Yet the establishment of such out-patient de- 
 partments should be easily brought about in forward-looking 
 states, since it must be apparent to the most fiscally-minded 
 legislators that out-patient departments are cheaper to run 
 than hospital wards. It is obvious that many patients can 
 be got in for out-patient examinations who would not readily 
 consent to come even as voluntary patients who stay in beds. 
 The values of out-patient department work are shown in the 
 majority of our cases, first from analysis of their reports 
 thereto through the follow-up work after they have been re- 
 leased from the wards. But a number of cases are particularly 
 interesting from the standpoint of the values of the out-patient 
 department mental examination. Consider Bessie Silver- 
 man (case 21). This Jewess came herself upon her own 
 recognizance to the out-patient department of the hospital to 
 find out the degree of her mental capacity. Bessie, it will be 
 remembered, was that case of disharmony between ambition 
 and ability who was bent upon somehow going through college. 
 
 Emma Marburg (case 30) came to the out-patient depart- 
 ment through the advice of another patient. She was unable 
 to hold out any longer on account of her fatigue and worry. 
 
 Some cases are treated with success as out-patients only; 
 compare Beatrice Cellini (case 52), who came of a family 
 known to at least twenty-four social agencies. The diagnosis 
 in the Cellini case could be rendered with apparent safety with- 
 out resorting to the hospital wards. 
 
 We may properly use these cases to prove the independent 
 value of out-patient services and dispensaries for mental cases. 
 Yet, we must not forget that where an out-patient service is a 
 departmental service and lodged in an imposing hospital struc- 
 ture surrounded by evidences of intensive medical, educational, 
 
514 THE KINGDOM OF EVILS 
 
 social, psychological, occupational, and nursing work, the 
 effects gained are not purely those of the out-patient service 
 per se. The out-patient service in this sense is under the aus- 
 pices of something big, complex, almost sacred, ever in the 
 eye of the patient as a vista of resources for help. 
 
 We have spoken of imposing structures. The state hospital 
 structures whether of the Bastile type or of the more modern 
 scattered cottage description (sometimes, we regret to say, 
 like a lot of small Bastiles!) will no doubt ever remain forbid- 
 ding to certain types of mind in difficulty, which will be entirely 
 willing to visit the out-patient department of a psychopathic 
 hospital or the consulting room of a mental hygiene society. 
 These values are very delicate ones to estimate. The consult- 
 ing office specialist cannot quite see how his type of patient 
 could willingly resort to any form of out-patient department, 
 if he could possibly get the money to resort to a private medi- 
 cal consulting office. 
 
 Yet there are certain types of men and women that seem 
 to abhor private consulting offices and much prefer public con- 
 tacts. Again there is a certain class of persons who are effec- 
 tively drawn under observation by the state and local mental 
 hygiene societies whose rooms are found in office buildings and 
 may be resorted to without fear of observation at the door or 
 in the corridors. Another type of patient is drawn to the 
 modern psychopathic hospital divorced in construction and in its 
 practical associations from the district state institution. The 
 Psychopathic Hospital in Boston has without artificial stimulus 
 an out-patient department that usually runs to the number of 
 fifteen hundred per annum. It would be entirely impossible, 
 we venture to say, for any district institution primarily for the 
 committable insane to show such a record — a record partly 
 founded in the public recognition of especially trained physi- 
 cians, psychologists, and social workers to be found therein, 
 but more effectively still in the good effects advertised from 
 neighbor to neighbor as shown by returning patients. We 
 doubt whether any institution not primarily constructed for the 
 voluntary class of patients and for the so-called temporary care 
 group of non-committable patients, will ever draw from the 
 community so important and extensive a group of out-patients. 
 
 The scope of this work does not include a special discussion 
 of methods of psychotherapy. We give upon another page 
 
THE KINGDOM OF EVILS 515 
 
 the main methods of psychotherapy mentioned in textbooks (a 
 list drawn from Shell-Shock and Other Neuropsychiatric 
 Problems, 1919, by the senior author). The adjustment of 
 man to himself is not primarily a function of social work 
 and we are prepared to admit that there are numerous cases 
 of complete adjustment of man to himself altogether outside 
 the field of social work. The works of Janet are filled with 
 instances of such interior adjustment by the psychotherapeu- 
 tists. We may call attention to several cases in our group. 
 
 Daniel Griffin (case 34) was a case in which there were 
 many psychogenic factors; that is, factors of mental diseases 
 that took their rise from troubles inside the patient's own mind. 
 This was the case of the man who did not work and never went 
 out in the daytime for a period of about six years. A psycho- 
 therapy by persuasion was adopted. Another instance of this 
 is that of Louis Sand (case 95). And Maurice Eastman (case 
 87) should be carefully reread by the reader interested in psy- 
 chotherapy. This man had been coached by physicians to 
 know that his disease was "all foolishness" — an instance in 
 which psychotherapy may defeat itself. He was given a sort 
 of talking cure by a psychologist in the Psychopathic Hospital 
 and was made to read popular works of psychotherapy. We 
 shall not repeat the remarks under this case concerning the fact 
 that psychiatric social work is not psychotherapeutic in the full 
 sense of the term (at all events not in the medical sense of the 
 term), and is decidedly not competent to decide upon the re- 
 spective values of the different forms of psychotherapy listed 
 in the chart (page 481), especially upon the values of such 
 methods of psychotherapy as hypnosis and psychoanalysis. 
 The spheres of influence of the psychiatric social worker as of 
 any social worker are decidedly not either the public or the 
 personal spheres. The social worker cannot take the place of 
 the judge or public administrator and must not feel irked by 
 her inability to act as a substitute for the public servants. As 
 we have repeatedly said, she must use the public service as ful- 
 crum. But it is even more true, though perhaps less obvious, 
 that the psychiatric social worker cannot replace the physician 
 in the most intimate and personal matters of treatment. 
 
 The reason why this is not too obvious to every psychiatric 
 social worker is that everybody is aware that the methods of 
 psychotherapy grade very gently over into methods of convic- 
 
5l6 THE KINGDOM OF EVILS 
 
 tion and persuasion, in short of suggestion, as employed in 
 everyday life. Every father or mother, brother or sister — 
 everybody who has served in any dominant way in relation to 
 some human being — is aware of his or her suggestive powers. 
 It is very natural therefore for the psychiatric social worker 
 to fall victim to the belief that she might solve the problems of 
 suggestion in her psychopathic patients as well as the physician. 
 She knows that she can in fact exert certain suggestive powers 
 under certain conditions of time and place that the physician 
 can exert. She -has in mind certain successes in conviction or 
 persuasion as exerted upon given cases in her experience. Yet 
 mutual adaptation of the interior relations of the mind to one 
 another under psychopathic circumstances is not at all easy. 
 Suggestion is easy but the right suggestion is difficult ; when we 
 examine the life histories of certain patients we find them a 
 succession of layers of suggestions like the layers of paint in 
 certafn ancient canvases. Universally the human mind is a lit- 
 tle more like water-color painting than one in oils, so that' it is 
 often impossible to eradicate the earlier impressions by fresh 
 ones. Armed with new knowledge about suggestion and plied 
 with the histories of successful adaptation by psychotherapeu- 
 tic means, the youthful social worker may be inclined to enter 
 where the psychotherapeutist would hardly dare to tread. 
 
 Is it wiser to let the public service adjust its own environ- 
 mental services, gradually molded into proper shape by improve- 
 ment in communal opinion, and to let the specialist in psycho- 
 therapy pursue his own difficult course of the mutual adjust- 
 ment of inner relations without undue interference by the 
 social worker? To be sure communal opinion about improve- 
 ments in the public service will never acquire greater strength 
 than when supported by the concrete facts supplied by the ex- 
 perienced social worker. By the same token the psychothera- 
 peutist may be unable to make his weighty decisions (whether 
 he or she act by conviction or persuasion, terrorism or the vel- 
 vet glove, hypnotism or psychoanalysis) only in virtue of some 
 little special indication that the social observer has recorded. 
 
PSYCHIATRIC SOCIAL WORK 
 
 HISTORY 
 
 In the development of a new profession, from time to time 
 new interests come to the front, dominate the scene for a while, 
 and gradually become assimilated into the body of experience. 
 A new branch remains upon the main trunk, and at the same 
 time the parent stem is strengthened. This process is the cur- 
 rent history of psychiatric social work. In the multiform ac- 
 tivities of social work, gradually taking shape in a new pro- 
 fession, there are found many traces of interest in mind as a 
 primary factor in social life, — the keynote principle of psychi- 
 atric social work. St. Vincent de Paul's efforts to relieve the 
 sick poor, among the earliest attempts at organized social work, 
 had for their object "to teach the poor to be provident for 
 themselves," as well as "to point out to them sources of em- 
 ployment." Cicero considered the mental effect of alms : "We 
 must take care that our bounty is a real blessing to those we 
 relieve, that the claims of gratitude and justice are preferred 
 to mere compassion, and that due regard is given both to the 
 character and the wants of the recipient." 
 
 The aim of all modern social work has been to build up char- 
 acter. Nevertheless, until recently, there has been no system- 
 atic attempt to study character by exact methods. Social 
 work has not heretofore attempted to apply the mental sciences 
 to understanding of the individual. "Common-sense" methods 
 have been relied upon in estimating personality, and "trial-and- 
 error" methods in solving mental problems. While the world 
 is far from possessing a science of character, there is a certain 
 amount of .knowledge derived from the mental sciences, psy- 
 chology and psychopathology, that can be applied to advantage 
 in dealing with human beings. Even a small amount of sci- 
 entific knowledge may afford a large amount of practical 
 value. The benefit to the individual, whose difficulties are 
 better understood by reason of some bit of science, may be 
 incalculable. 
 
 517 
 
5l8 THE KINGDOM OF EVILS 
 
 This new branch of social work known as psychiatric social 
 work is a new emphasis rather than a new function. It has 
 grown out of ideas and activities that already existed in scat- 
 tered forms. A similar situation is found in the development 
 of medical social work during the last fifteen years. The new 
 emphasis upon attention to disease and care of health spread 
 rapidly in general social work, until now the idea of using 
 scientific methods to maintain health is part of the equipment 
 of every well-trained social worker. Theory, to be sure, is 
 ahead of practice, as it must always be, and social work has 
 far to go before it can be said to be making the best use of 
 medical science; but the principle of a medical point of view 
 is established. 
 
 At first social work was dominated by the economis point of 
 view. Economic features of social disorder are most con- 
 spicuous (food and shelter are the first obvious needs), and 
 therefore receive first attention. Moreover, the social worker's 
 special contribution to social problems is knowledge of the 
 environment (the social worker is a specialist in environment), 
 and here also the outstanding features are economic. Again, 
 the origin of systematized social work in "poor relief" put eco- 
 nomic considerations in the lead. But just as the medical point 
 of view came to the front and was assimilated, so at the present 
 time the psychiatric point of view is in the foreground and is 
 in process of being absorbed into the movement. 
 
 The history of psychiatric social work is the focusing of 
 various recent influences leading to more attention to the 
 mind in social practice, under pressure from psychiatry 
 demanding more attention to social needs in medical prac- 
 tice. In social work, among these trends, one that stands out 
 prominently is the increasing insistence of the family welfare 
 group upon better understanding of motives and more exact 
 methods of arousing interest and purpose. In the children's 
 agencies, there has been growing a sense of the need of apply- 
 ing child psychology in the education of young wards. Agencies 
 caring for the unmarried mother have come to recognize the 
 primary importance of mental conditions in these cases. Psy- 
 chiatric clinics established in connection with courts (of which 
 Dr. Healy's clinic in the Chicago juvenile court was the fore- 
 runner), and in connection with prisons and reformatories 
 (such as the clinic started by Dr. Glueck at Sing Sing prison), 
 
THE KINGDOM OF EVILS 519 
 
 have given impetus to the psychiatric interest in social work. 
 From medical social work came another influence in the insist- 
 ence of Dr. Cabot that social work was essentially the develop- 
 ment of character under adversity. 
 
 In medicine many definite trends may be seen that have 
 contributed to the present development of psychiatric social 
 work. A very explicit statement of the need of social work 
 in the practice of psychiatry w^as made twenty years ago by 
 Dr. Theodore H. Kellogg, superintendent of a hospital for 
 mental diseases, in his Textbook on Mental Diseases: "In- 
 sanity practically is loss of the power of conformity to the 
 social medium in which the patient lives. This power is re- 
 gained in convalescence gradually, and it is a part of psycho- 
 therapy to furnish a normal personal environment to which the 
 patient is to practice adjustment;" and again: "The physician 
 who has conducted a case of mental disorder through all the 
 vicissitudes of an acute attack to perfect recovery has a final 
 duty to perform. There are to be laid down definite rules of 
 life, points in physical and mental hygiene, suggestions of the 
 best way to meet social and business difficulties, and advice as 
 to domestic relations." It was some fifteen years later that 
 systematic provision began to be made for seeing that these 
 "rules of life" laid down by the physician were actually fol- 
 lowed by the patient. It was thought that the physician could 
 perform this function of social readjustment and many hospital 
 superintendents and physicians did so to the best of their abil- 
 ity. Others were beginning to see the possibility of specially 
 trained lay workers for this purpose. 
 
 Meanwhile psychiatrists were coming into closer association 
 with social workers. It is of some interest that at the first 
 meeting of the National Conference of Social Work (then the 
 Conference of Charities and Correction), in 1874, the first 
 subject considered was "The Duty of the States toward Their 
 Insane Poor," in a paper by a state-hospital superintendent: 
 and the subject of "insanity" figured largely in the programs 
 of the early years. A section on feeble-mindedness and insan- 
 ity was created and in 191 7 became the mental-hygiene section. 
 Another medical influence, which no doubt gave considerable 
 impetus to the development of psychiatric social work, was the 
 growing appreciation of physicians in general hospitals of the 
 value of the social service, and the experience of psychiatrists 
 
520 THE KINGDOM OF EVILS 
 
 in mental clinics of these hospitals that the assistance of social 
 workers became indispensable. 
 
 The chronology of psychiatric social work down its main 
 line of development, social care for cases of mental disease, 
 begins with the Society for the After-Care of the Insane in 
 England, which as early as 1880 was engaged in giving friendly 
 supervision to patients discharged from hospitals. The first 
 attempt in this country to employ social work in the care of 
 patients with nervous and mental disorders seems to have been 
 in the Neurological Clinic of the Massachusetts General Hos- 
 pital in Boston in 1905, when Dr. James J. Putnam, who was 
 in charge of the clinic, secured the assistance of a social worker, 
 Miss Edith N. Burleigh, and personally trained her for the 
 work. A year later a social worker was placed in the psycho- 
 pathic wards of Bellevue Hospital, New York. The New York 
 State Charities Aid Association was a leading influence in de- 
 veloping this field through its Committee on Mental Hygiene, 
 which in 1910 appointed an "after-care worker" to supervise pa- 
 tients discharged from two of the state hospitals of New York. 
 The first social worker to be placed upon the payroll of a state 
 hospital for mental diseases was employed through the influ- 
 ence of this Committee in 1911, by the Manhattan State Hos- 
 pital, New York, where she had previously been engaged upon 
 salary paid by the Committee. Two years later, 1913, two 
 Massachusetts hospitals, Danvers State Hospital and Boston 
 State Hospital, each added a social worker to the staff. 
 
 The same year the Psychopathic Hospital began to organize 
 its social service. Although the original plans provided for a 
 social service, the work was not regularly started until a year 
 after the hospital was opened. The ideas of the Director con- 
 cerning the introduction of this new agency into the institution 
 are expressed in some notes written a year or two later : — 
 
 "The social service movement seems to be waxing fast, al- 
 though not fast enough for its problems. Personally I seem to 
 have been greatly influenced by some of Professor Royce's 
 earlier ethical papers touching the social 'consciousness' so- 
 called, by Professor Putnam's contentions, and by the point of 
 view of Professor James which culminated in his marvelous 
 address on The Moral Equivalent of War. Then came brief 
 but uplifting observations of the Social Service Department of 
 the Massachusetts General Hospital under the leadership of 
 
THE KINGDOM OF EVILS 521 
 
 Miss Ida M. Cannon. After the establishment of the Psycho- 
 pathic Hospital, I began to get light from a group of persons 
 interested in social service, among whom, besides Miss Cannon, 
 I should especially count my colleague Dr. W. P. Lucas, Mr. 
 Michael M. Davis, and Miss Katherine McMahon. 
 
 "My own ideas are derived from many sources. The need 
 of a social service in the new Psychopathic Hospital became 
 obvious at once when the plans were tentativel}' begun in 1909- 
 1910 and the obvious need was expressed in so many words in 
 the State Board of Insanity's report of 1910. So far as I can 
 remember, space was reserved for social service in the very 
 first of the plans from which the eventual plan was developed. 
 To be sure, many physicians who were shown the plans af- 
 fected astonishment at the large space assigned to the out- 
 patient work as a whole, and there was almost no general 
 appreciation of either the whole out-patient work or its social 
 service constituents. These critics are now easily won over 
 by the practical results obtained." 
 
 We claim no novelty or originality for the social work of 
 the Psychopathic Hospital, but rather, we would claim to have 
 created the part that the social worker is to play in the 
 mental hygiene movement and to have given it a name — 
 psychiatric social work. The bases of this new division of 
 social work are the principles common to all forms of social 
 case work. It is the application of old methods in a new field. 
 It will, we expect, develop some new methods, which will in 
 time be applied in the older fields. In the new field there was 
 need of bringing to a focus existing trends, of defining func- 
 tions, outlining requirements of special training, and giving 
 the whole a distinctive name. 
 
 The Great War had an important influence upon the spread 
 of psychiatric social w^ork. It was clear to those who had seen 
 the importance of social service in civilian hospitals that psy- 
 chiatric social workers would be needed for army hospitals. 
 But there w^ere only a handful of social workers with this spe- 
 cial training in the whole country. Plans to enlarge the capac- 
 ity of the training course at the Psychopathic Hospital were 
 proceeding when it was found possible to combine with Smith 
 College in a course, given in 191 8- 191 9, under the auspices of 
 a committee of the National Committee for Mental Hygiene. 
 Similar courses, conceived as emergency measures or as per- 
 manent developments of the curriculum, were offered by other 
 
522 THE KINGDOM OF EVILS 
 
 schools in New York, Philadelphia, and Chicago, In Canada 
 a similar course was given at Toronto University. Fifty-odd 
 graduates of the Smith College course went into army hospitals 
 or Red Cross organizations. The pioneer piece of psychiatric 
 social work in the army was done in the neuro-psychiatric hos- 
 pital at Plattsburg, b}' Miss Margherita Ryther, who had 
 been for some years social worker in the Neurological Clinic 
 of the Massachusetts General Hospital, Boston. The need for , 
 social service in any program for adequate care of neuropsy- 
 chiatric cases among soldiers was demonstrated. This princi- 
 ple established in the army hospitals has carried over into the 
 public health hospitals. The Red Cross in connection with the 
 public health service and the Veterans' Bureau are now en- 
 deavoring to develop a complete organization of psychiatric 
 social work for the care of ex-service men with neuropsychiat- 
 ric disabilities. 
 
 The effect of psychiatric social work upon general social 
 work came into focus in a surprising way at the National Con- 
 ference of Social Work in Atlantic City in May, 1919. There 
 was suddenly a realization in many quarters that psychiatry's 
 contribution to general social work ought to be made available. 
 Dr. Cabot spoke of the new force, "new, not in name, but in 
 efficiency and energy — which has come into social work — the 
 force represented by psychiatric social work. In thirty years I 
 have never seen anything so important as the irruption of psy- 
 chiatric social work into social work." The idea is now widely 
 accepted that social case work calls for psychiatric knowledge 
 and the psychiatric point of view. It remains to find ways and 
 means to enable social workers at large to get what psychiatry 
 can offer. A number of means are at hand, — the best perhaps 
 are the summer courses in social psychiatry offered by certain 
 schools of social work. Evening courses may be arranged. 
 Brief extension courses as an introduction to the subject are 
 offered by some schools, with clinics to demonstrate types of 
 mental disorder. Reading help^, but the literature of social 
 psychiatry is mostly in the form of detached articles. In Bos- 
 ton, a group of twenty-five executives of social agencies and 
 leading social workers formed a class to study with a psychia- 
 trist, who was familiar with their field, the best means of ap- 
 plying psychiatry in social work. 
 
 To avoid confusion of terms, it may be well to state here 
 
THE KINGDOM OF EVILS 523 
 
 that "social psychiatry" is not used as an alternate for "psy- 
 chiatric social ivork." Psychiatric social work is the special 
 form of social work in which psychiatric knowledge is particu- 
 larly required. Social psychiatry is an art now in the course 
 of development by which the psychiatrist deals with social prob- 
 lems. Social psychiatry is a branch of psychiatry and a special 
 kind of medical art. That part of the knowledge of psychiatry 
 which has a bearing upon social problems is given to social 
 workers in courses named social psychiatry, — that is, the es- 
 sentials of psychiatry from the standpoint of social work. The 
 special preparation of the psychiatric social worker should 
 consist not only of courses in social psychiatry but also of prac- 
 tice in social work with psychiatric cases. The inclusive term 
 mental hygiene is used to cover the activities of psychiatrist, 
 psychologist, the psychiatric social worker in promoting mental 
 health wheresoever. 
 
 ORGANIZATION AND FUNCTIONS OF THE SOCIAL SERVICE AT 
 THE BOSTON PSYCHOPATHIC HOSPITAL 
 
 Some account of the development and organization of the 
 social service of the Psychopathic Hospital may be suggestive 
 to similar departments in process of formation. Any scheme 
 of organization is a growth determined largely by local condi- 
 tions, and therefore may not be suitable to transplant. There 
 are, however, some fundamental principles and practices com- 
 mon to all similar institutions, in regard to which experiences 
 may be exchanged with profit. The psychopathic hospital and 
 the state hospital for mental diseases will differ in the organiza- 
 tion of their social service as well as of their medical service; 
 but both types of hospital will have common features in both 
 medical and social work. This account is by no means intended 
 to present a model form of organization. The system here 
 developed, however, works on the whole with reasonable effec- 
 tiveness, and most of its fundamental principles and chief de- 
 vices we would recommend with confidence. 
 
 The question of the proper organization of the social service 
 depends fundamentally upon whether a hospital is regarded as 
 a community institution, in which medical and social depart- 
 ments cooperate, or as a medical institution controlled and di- 
 rected by physicians with social assistants. This question of 
 
524 THE KINGDOM OF EVILS 
 
 organization arises irrespective of the question of functional 
 control and direction of social work in a hospital. Besides the 
 question of immediate direction (or supervision) of the social 
 worker's activities, there is a question of the right administra- 
 tive relation between medical work and social work. The 
 position taken by a particular hospital on this point affects the 
 development of its social service in both frank and subtle ways. 
 A confused policy on this point leads to misunderstandings 
 and retardation of the work of the social service. 
 
 At the present time most of our hospitals are acknowledged 
 medical institutions, primarily for the treatment and study of 
 disease, and they are administered by medical men. Therefore 
 the social work should properly be subordinated to the medical 
 work, the physician employing social assistants and relying 
 upon their special skill (without attempt to direct a form of 
 practice in which he is not trained) to promote the medical 
 work. As the horizons of medicine widen, it is conceivable 
 that the hospital of the future may be a social institution, ad- 
 ministered by men of sociological-medical training. The com- 
 mimity no doubt will more and more demand that the hospital 
 treat the whole man, that the treatment of disease aim at com- 
 plete social adjustment, and that the hospital go outside its walls 
 to prevent disease. 
 
 At the Psychopathic Hospital the social service was organ- 
 ized to assist in the medical work of studying and treating men- 
 tal disease. Its function of assisting in treatment was con- 
 strued in the broadest sense to mean (a) restoration of capac- 
 ity for normal living, or (b) provision for greatest possible 
 comfort. The out-patient department and the social service 
 have developed with close interrelations. While many social- 
 service cases first receive attention on the wards, the greater 
 part of the work is of course with patients in the community. 
 The medical and social aspects of out-patient treatment for 
 nervous and mental disorders are so closely interwoven that 
 they can hardly be discussed separately. An occasional case 
 may be free from social complications and call for treatment by 
 the physician only. Also, in an occasional case the physician 
 may find that the root of the difficulty is social and may leave 
 the case in the hands of the social worker. In most cases, 
 medical treatment is supplemented and reinforced by social 
 care. The efforts of the social worker in such cases must, 
 
THE KINGDOM OF EVILS 525 
 
 of course, be definitely designed to contribute to medical treat- 
 ment. 
 
 For the best results, social work should be immediately under 
 social direction, but the practice of the social worker in every 
 case must be strictly in accordance with the doctor's ideas for 
 the patient; and if in any case a conflict of social and medical 
 interests arise, the medical decision obviously must prevail; 
 since the treatment of a mentally sick person is primarily a 
 medical problem. This relation between medical and social 
 work is sometimes not understood by observers, who see the 
 large amount of responsibility borne by the social worker in 
 certain cases that the physician sees infrequently, and who do 
 not realize that the physician has delegated responsibility to the 
 social worker to carry out social treatment in conformity with 
 the medical plan. 
 
 A routine social examination for all admissions was our ulti- 
 mate aim,^ but was impossible with the number of social 
 workers available. Therefore the expedient was adopted of 
 relying upon the physicians to report cases in which social work 
 was required. About one-fourth of the cases referred by 
 physicians are likely to be cases where a history is required 
 for medical diagnosis, but social care is not required. (See cases 
 54 and 72.) The physician is apt to look upon this function of 
 the social service as its most important duty, since his primary 
 responsibility to the patient is to endeavor to make a correct 
 diagnosis. In a sense it is also the primary responsibility of 
 the social worker to contribute to this object, which is the 
 hospital's first duty to the patient. Equally important to the 
 social worker, in addition, is the welfare of the patient in the 
 community. Moreover, the benefit of careful diagnosis can be 
 secured in many cases only by painstaking, thorough social 
 care. The social worker, engaged in social treatment, is bound 
 to feel a sense of interruption if histories for medical diagnosis 
 cause deferred attention to social cases. The success of social 
 treatment may depend upon timeliness, steadiness, persistence, 
 or close application; and emergencies continually arise when 
 least expected. No matter how thoroughly the social worker 
 recognizes the importance of the medical-social history, she 
 cannot feel the same enthusiasm that the physician would feel 
 
 ^ From Annual Report of the Director, Psychopathic Department, Boston State 
 Hospital, 191 5: "Of course with a properly increased staff, we should like to secure 
 a social examination for every patient on admission." 
 
526 THE KINGDOM OF EVILS 
 
 in devoting a day's work to it, while perhaps neglecting work 
 that is her own immediate responsibility. This is especially 
 likely to be true if the significance of the history turns upon 
 some fine medical point. Therefore it might be more effective 
 to have certain social workers give their time wholly to getting 
 medical-social histories. 
 
 Individual case work is the nucleus of the department. Since 
 it was impossible to treat all cases with thoroughness, on ac- 
 count of an insufficient number of workers, a distinction was 
 adopted between "intensive"' and "slight service" cases based 
 upon the degree of responsibility for social care assumed by 
 the department. In the intensive cases the social service at- 
 tempts to assume responsibility for making a full inquiry into 
 the social condition of the patient and his family and endeavors 
 to secure the largest measure of social well-being possible for 
 both patient and family. The "slight service" cases are those 
 in which assistance is given without inquiry beyond the appar- 
 ent facts or responsibility beyond the immediate service. (For 
 examples of slight service cases, see cases 39, 41, and 67.) 
 
 An attempt was made to estimate the staff of social workers 
 needed to cover the case work. There is no direct precedent or 
 definite standard for determining how many cases one social 
 worker in a psychopathic hospital can carry, but by a compari- 
 son of the experience of the Committee on Mental Hygiene 
 of the New York State Charities Aid Association and that of 
 other agencies doing somewhat similar work, it was estimated 
 that one social worker could take in a year one hundred and 
 fifty cases for investigation and miscellaneous services or could 
 care for about fifty patients a year under supervision (that is, 
 ten under treatment at one time for an average period of three 
 months each), so that a social worker engaged in both inves- 
 tigation and supervision would average one hundred cases a 
 year. 
 
 Not every patient will require the care of the social service. 
 In a city with well-developed social agencies, about twenty-five 
 per cent of admissions may be already in the care of other 
 social workers, and about twenty-five per cent of the patients 
 appear not to require social care, the majority being patients 
 committed to hospitals, who have no one dependent upon them 
 or whose families have already become adjusted to their men- 
 tal condition. Others have families able and intelligent enough 
 
THE KINGDOM OF EVILS 52/ 
 
 to do for them all that can be done ; a few are unmarried per- 
 sons who habitually wander, so that it is impossible to keep in 
 communication with them. So' it is possible to estimate roughly 
 that for every two hundred admissions a social worker will be 
 required for individual case work. The additional functions 
 of research and teaching will call for additional workers. 
 
 The expense of the social service of a psychopathic hospital 
 considered from the standpoint of efficient hospital administra- 
 tion (with the object of restoring patients to competency as far 
 as possible) has yet to be carefully estimated. We have a few 
 notions on the matter. (See also case 71.) The saving of 
 expense to the state in the prevention of crimes by psychopathic 
 individuals through social supervision cannot be calculated ; but 
 special instances indicate that it may be considerable. Through 
 the care of social workers many patients who would become a 
 charge upon the state are kept at home, either self-supporting 
 or maintained by relatives. During our first two years' work 
 at the Psychopathic Hospital, twenty patients, who by all indi- 
 cations would otherwise have required institutional care, were 
 kept in the community through the activities of the social serv- 
 ice. Averaged at a saving to the state of one year's main- 
 tenance each, these cases showed a saving of $5,200 which was 
 more than the amount paid by the state in salaries to our social 
 workers during that period. As three of these patients, who 
 were insane, were returned to relatives in their native countries, 
 the state was probably saved in their cases many years' support. 
 So that, in relation to the state treasury, the department was 
 then more than paying for itself. 
 
 In systematizing the case work, the social service borrowed 
 a number of devices from the organization of the medical serv- 
 ice, when Dr. Herman M. Adler was -chief of staff. Workers 
 and students are divided into "groups" (the "head of the 
 group" being the most experienced worker on that duty), and 
 cases as referred are assigned in rotation to the groups, record 
 being made on a "rotation sheet" The head of the group is 
 responsible for assigning the case within her group in the best 
 way to get the work done promptly and well. A worker (or 
 advanced student) is assigned each day to duty as "visitor for 
 the day" to receive inquiries and deal with emergencies and to 
 attend to certain routine duties. The whole staff meet every 
 morning for the first half hour for discussion of cases. On 
 
528 THE KINGDOM OF EVILS 
 
 the fourth day after assignment new cases are presented in 
 summary with an analysis of "social symptoms" so-called (fac- 
 tors of social maladjustment) indicated so far as it has been 
 possible to carry the investigation. Results of social treatment 
 are reported every three months at the "morning discussion." 
 
 A method of giving each case worker a "daily reminder" of 
 her work for the day has been found serviceable. An explana- 
 tion of this method and a sample of the card that the social 
 worker receives each day are here given. 
 
 August 15, 
 
 1916 
 
 H. A. 
 
 I day case 
 
 
 George Brown 
 
 4 « « 
 
 
 Beulah King 
 
 14 " " 
 
 
 John Sheehan 
 
 I month case 
 
 
 Grace Haskell 
 Bessie Snow 
 
 3 " " 
 
 
 James Johnson 
 Ada Jones 
 
 Records up to 
 
 date 
 
 
 Explanation: Cards are to be marked witli a check after the patient's 
 name if the work has been done, and returned at the end of the day to 
 the stenographer. If the work has not been done, the name will be carried 
 forward onto the card of the following day with the number of days over- 
 due indicated. 
 
 I day case, twenty-four hours after assignment. — Preliminary examina- 
 tion to be made, including interview with examining physician. 
 
 4 day case, fourth day after assignment. — To be presented at morning 
 discussion. 
 
 14 day case. — Investigation to be completed. (If an intensive case, sum- 
 mary to be completed.) 
 
 I month case. — Status to be reconsidered (whether case should be closed 
 or should be continued for advice and supervision). 
 
 3 month case. — Summary of results to be made. 
 
 15th of each month records to be brought up to date. 
 
 30th of each month monthly statistics to be made up. 
 
 A procedure for the work upon a new case has been devel- 
 oped as follows : 
 
 a. Case assigned by recommendation slip. 
 
 b. Assignment noted on rotation sheet. 
 
 c. Memorandum slip filled out (see Appendix B, Form I). 
 
 d. Examining physician seen. 
 
THE KINGDOM OF EVILS 529 
 
 e. Patient's story obtained by interview. 
 
 /. Registration slip made. 
 
 g. Entry made on visitor's monthly statistical sheet. 
 
 h. Case folder made. 
 
 i. Inquiry slip filled out (see Appendix B, Form II). 
 
 y. Decision whether to be dealt with as "intensive" or "slight service" 
 
 case made within twenty-four hours if possible. Otherwise case 
 
 registered as "slight service," and later if desirable changed to 
 
 "intensive." 
 k. Record folder made out on fourth day (for intensive cases; records 
 
 of slight service cases kept in form of "Notes" only). 
 /. Case presented at morning discussion on fourth day. 
 
 The memorandum slip is for rough notes taken from the 
 medical record or obtained from the patient for use in the in- 
 vestigation. It is taken along on visits and filed on return to 
 the office in the folder for the case; so that even before the 
 record is written there will be some identifying information in 
 the folder. After the information contained on the memoran- 
 dum slip has been copied into the record, the slip is destroyed. 
 The inquiry slip is for the purpose of laying out a plan of in- 
 vestigation. As soon as all clues immediately obtainable are in 
 hand, the informants to be interviewed by visit or telephone or 
 to be written to are listed. Others may be added later on, or 
 the original plan may be altered. The inquiry slip is taken 
 along on visits and filed in the case-folder on return. It is 
 destroyed when the investigation has been completed. 
 
 The interview with the patient before any steps in investiga- 
 tion are taken is considered important. In addition to the 
 information obtained by the doctor, the social worker needs 
 certain sociological data for the purposes of investigation, such 
 as (a) exact names and addresses of relatives, employers, 
 neighbors, teachers, clergymen, friends, who are possible in- 
 formants ; (b) resources among relatives and friends that may 
 be a help in social readjustment ; (c) details about the home and 
 neighborhood: (d) exact knowledge of all the members of the 
 family group and other close associates; (e) the patient's atti- 
 tude toward his family and his idea of their attitude toward 
 him; (/) the ratio between income and expenditures, and the 
 relation between income and standard of living; (g) the pa- 
 tient's tastes in regard to employment, recreation, occupation 
 in leisure time; (h) what relatives or friends have most influ- 
 ence with him; (i) his own plans for the future. 
 
 From the beginning of the department it was considered 
 
530 THE KINGDOM OF EVILS 
 
 important to differentiate clearly between the various functions 
 of the social service. Even when different parts of the work 
 must be performed by the same person, because of an inade- 
 quate staff, it is desirable to keep different forms of work 
 clearly separate, so that each may receive its due share of atten- 
 tion and may be in line for expansion. After individual case 
 work, the first duty of the social service that stood out was 
 assistance in the out-patient clinic, and the first assistant se- 
 cured was the clinic manager, whose duties are : — 
 
 Executive: 
 
 a. To direct patients to the examiners during the clinic. 
 
 b. To keep in order the records. 
 
 c. To keep statistics. 
 
 d. To see that reports of examinations are sent to social agen- 
 cies. 
 
 Social: 
 
 a. To take the social history of new patients. 
 
 b. To assist in discovering and dealing with the social prob- 
 lems of out-patients. 
 
 c. To see that patients and friends with them understand 
 physician's directions and are able to carry them out. 
 
 d. To act as a go-between for outside social workers and the 
 physicians. 
 
 Among other divisions of the social service developed as the 
 opportunity arose is the follow-up service,^ a routine method 
 of keeping informed by a card system of the failure of patients 
 to keep their appointments and inducing them by letter, tele- 
 phone, or visit to report. This work, besides its clerical as- 
 pects, has been found to require fine judgment and the point of 
 view of a social worker, and to show good results in so far as 
 these factors are present in the worker in charge. 
 
 The syphilis service " was developed as a routine system for 
 keeping syphilitic patients under treatment and securing exam- 
 ination of their relatives. Here skill and judgment are obvi- 
 ously required in suggesting to relatives apparently healthy in 
 most instances a blood test for syphilis. Of 579 persons for 
 whom examination was sought in the years 191 7 and 1918, 69 
 
 » Boston State Hospital, Annual Report 1917 — Report of Director, Psychopathic 
 Department — Follow-up Service by Dorothy Q. Hale, pp. S3-S7- 
 
 = The same — Social Work with Syphilitics and Their Families, by Maida H. Solo- 
 mon, pp. S7-65- 
 
THE KINGDOM OF EVILS 531 
 
 per cent were examined; and of these 21 per cent required 
 treatment (see cases 41 and 45). 
 
 The Men's Club, started at the suggestion of Dr. A. Warren 
 Stearns as a means of therapy for alcohoHc patients (see cases 
 6, 58, and 71), proved to be an effective aid in social treatment 
 for men patients with the habit of alcohoHsm. 
 
 The aim of research has been kept in view and as far as 
 possible material (records, statistics) has been gathered 
 with a view to possible use in the future in medical and social 
 investigations. 
 
 A study of the psychopathic employee in industry, begun in 
 19 14, was continued until 1920, through a special social worker 
 to assist men patients with difficulties of industrial adaptation, 
 and led to an investigation in the mental hygiene of industry 
 conducted by the Engineering Foundation of New York. (See 
 also page 499.) 
 
 The principle has been maintained that the search for new 
 truth concerning human beings rests at bottom upon careful 
 study of the individual in action. Research and assistance to 
 the individual in social work are two aspects of the same mat- 
 ter. This seems to be a truism too simple to require statement ; 
 but research has become associated with laboratory experi- 
 ments in the minds of some persons, to such a degree that they 
 are apt to lose sight of the human value to individual patients 
 of social case work that is done with the ultimate object of 
 research. 
 
 Plans for special research in methods of social case work 
 were interrupted by the war. Studies of technique of social 
 investigation and treatment by the most thoughtful and experi- 
 enced social workers to be found are clearly the next step in the 
 development of scientific methods in case work. The psychiat- 
 ric social service affords unusually favorable conditions for 
 such study, — with psychologist and psychiatrist at hand to give 
 their aid, which is indispensable. Moreover, traits of human 
 nature are more conspicuous and therefore more readily studied 
 in psychopathic patients. Just as principles of education were 
 discovered through teaching the feeble-minded, so we may 
 look for principles of social work to be found in case work 
 with psychopaths. 
 
 The department was organized from the start to permit the 
 traming of stitdents, for we felt a responsibility to prepare new 
 
532 THE KINGDOM OF EVILS 
 
 workers for this field. As none of the schools of social work 
 had yet developed training courses in psychiatric social work, 
 we offered an apprenticeship course in which the student gave 
 full time for six months. The term was later increased to 
 eight months, as six months was found insufficient for acquir- 
 ing even the rudiments of social work and social psychiatry. 
 Several attempts were made to take students on part time for a 
 longer period, but this plan was unsatisfactory, for the inter- 
 ruptions in the students' work increased the difficulties of 
 organization to such an extent that part-time students became 
 more of a burden than a help. From the students' point of 
 view, it was apparent that they received much less benefit 
 from part-time work than from an equal number of days' work 
 on full time. The full-time student is an asset, taking her 
 share in routine duties and after a few months giving valuable 
 assistance in the case work. The presence of students in the 
 daily morning discussion adds greatly to the value of these 
 conferences. The alert, inquiring attitude of the student is 
 stimulating, and the necessity for being definite and clear 
 enough to be understood by the beginner helps to keep the more 
 experienced workers in perpetual training. 
 
 Another function of the social service from the beginning 
 has been public education — to promote understanding of men- 
 tal disease and to reduce prejudice against mental hospitals, and 
 particularly to help social workers acquire the essentials of 
 psychiatry. Social workers were encouraged to seek from the 
 physicians an explanation of the patient's condition and needs 
 in every case brought by them for examination. In order to 
 make sure that a correct statement of the examination was filed 
 with the case record in the agency which had responsibility for 
 the patient's care, this verbal report was supplemented by a 
 routine written report consisting of brief summaries of the 
 physical and mental examinations and intelligence tests. Some 
 social workers came to depend upon this report without con- 
 sulting the medical or social workers of the hospital, although 
 the brief summary of medical findings furnished them was 
 not sufficient in most cases to serve as a guide to social 
 treatment. 
 
 The social worker would like a written report giving a full 
 exposition of the case, — the character of the difficulty, the 
 prognosis, and practical measures of treatment. Such a re- 
 
THE KINGDOM OF EVILS 533 
 
 port, however, seems to be so complete that there is still more 
 danger that the social worker will rely upon it entirely without 
 further consultation. And there is danger that misleading 
 or superficial conclusions may be drawn from any written re- 
 port alone. Moreover, the time required for a physician to 
 write a careful explanation of the case, adapted to the under- 
 standing of the particular type of social worker to whom it is 
 to go, is prohibitive in most clinics and hospitals. The time 
 required for a stenographer to make a transcript from the 
 medical record is another matter. It is true that in the present 
 state of education for social work, a report expressed in med- 
 ical terms will not be understood by all social workers; but 
 in every case the worker responsible has the opportunity to 
 find out the meaning of the medical report. On the whole, the 
 method of furnishing a transcript from the medical record 
 and requiring a personal consultation has seemed best calcu- 
 lated to secure the interests of the patients. 
 
 Social clinics have been held every year, sometimes for a 
 particular group (the Boston Conference on Illegitimacy, a 
 Red Cross Institute, classes taking extension courses in social 
 psychiatry at the Boston School of Social Work) and some- 
 times for social workers at large. A series of clinics for em- 
 ployment managers was also given. The history and the 
 actual patient are, as a rule, both introduced. Patients suitable 
 for demonstration are carefully chosen with an eye to seeing 
 that the patients do not themselves suffer. In the majority 
 of instances the patients are actually helped by the clinic, in 
 that they are made to see the nature of the problems which 
 they present, and yet are not overborne by the legal authority 
 which a court appearance would assert. Some of the most 
 instructive cases, from the standpoint of diagnosis and dis- 
 position, are in fact cases of delinquency or suspected delin- 
 quency, in which the clinical demonstration is far less of an 
 ordeal than would be an appearance in court. As a rule, from 
 forty to sixty social workers have appeared at the social clinics 
 so far carried on. Amongst these workers will appear, as a 
 rule, persons greatly sympathetic with the patient, and the 
 "third degree" aspect of the meetings is reduced to practically 
 nil. To many patients, instead of being a severe ordeal, the 
 experience is rather agreeable. In many cases it is really 
 beneficial to the patient who is forced by the interest of so 
 
534 THE KINGDOM OF EVILS 
 
 many persons to confront his own mental difficulties ana »« 
 put on his mettle to do the best he can to overcome his limita- 
 tions. At a clinic for employment managers, one patient suffer- 
 ing from a persistent traumatic neurosis, John Flynn (case 
 19), was presented and apparently enjoyed the meeting. A 
 few weeks later he sent several of his themes, part of an eve- 
 ning course in English that he was taking at the Trade Union 
 College, for the physician whom he had met on that occasion 
 to see, confident that he had a new friend in the doctor. 
 
 SOCIAL CASE RECORDS 
 
 Most existing record forms in social agencies are admitted 
 by everybody concerned to be unsatisfactory, either because 
 they do not contain the material they should or because the 
 material they contain is not readily accessible. Notwithstand- 
 ing abundant discussion, very little work has been done on 
 improved methods of social case-recording. The only avail- 
 able studies of the subject are the work of Miss Georgia G. 
 Ralph, Elements of Record Keeping for Child-Helping Or- 
 ganizations and recent books by Mrs. Ada D. Sheffield, The 
 Social Case History: Its Construction and Contents, and by 
 Miss Gertrude L. Farmer, A Form of Record for Hospital 
 Social Work. 
 
 The stage at which a life history was recorded by means of 
 a printed form seems to have passed. Most agencies now have 
 an outline of facts adapted to the particular needs of their work 
 to serve as a guide in recording the social examination. Prob- 
 ably no record system could be devised that would meet fully 
 the needs of all agencies. Within the same agency it may 
 appear economical to use a different form of recording for 
 "slight service" and "intensive" cases. As a rule the record 
 of a "slight service" case reduces itself to a brief memorandum 
 on an index card or a record sheet. It is in the cases where 
 responsibility is assumed for a complete history and thorough 
 treatment that the record problem arises. 
 
 While the same form will not meet the needs of all sorts of 
 social agencies, it might seem that the main outline of the 
 facts to be secured would be the same in any case whatsoever 
 under social care. The records of different agencies would 
 vary in the details of some of the subheadings of such a gen- 
 eral outline. The children's agency would be likely to go into 
 
THE KINGDOM OF EVILS 535 
 
 more detail concerning the developmental history of a particu- 
 lar child than the family agency would need to; the society 
 for protecting neglected children would require details of evi- 
 dence not essential to the work of other children's agencies; 
 in a medical social service certain items of bodily condition 
 not significant for the general agency might be needed ; certain 
 details of mental states bearing upon the mental diagnosis 
 would be found only in the records of the psychiatric social 
 service. In general the social service of a psychopathic hos- 
 pital requires for its work just such a record as would be 
 needed by a children's agency, the parole department of a 
 reformatory, or a family agency (in individual cases). With 
 certain modifications, a standard history outline for all social 
 records might prove very serviceable. It must always be borne 
 in mind, however, that the value of the record depends not 
 upon the outline but on knowledge of what facts are significant 
 and on skill in obtaining information. Given, however, a 
 skillful and intelligent social worker, a good history outline 
 as a framework for investigation is a helpful support. With 
 beginners and less reliable workers, it is an essential. 
 
 In considering social case-recording we are of course think- 
 ing of the history of an individual. The so-called "family 
 record" is another thing, — there is the story of the family life 
 to be written. But each member of the family has his own 
 individual history, which has a claim to be separately recorded. 
 Each member of the family must be studied separately in 
 order to understand the family group. And for study of the 
 individuals of the group, individual histories are required. If 
 information concerning the different members of the family 
 is not sorted out and recorded separately, the effect of the 
 record will be very much like a composite photograph. There 
 will be a hint of this or that individual member of the group, 
 but no clear picture. To individualize each member of the 
 family, it would seem to be essential to record his history sepa- 
 rately. Certain facts that relate to all members of the family 
 might be referred to by cross reference in order to save space 
 and time. The family case worker would perhaps object that 
 in the process of making individual records the story of the 
 family group life would tend to get lost. It may be that a 
 summary of the fofivily would meet this need. We have no 
 claim to offer a solution for any of the perplexities of record- 
 
536 THE KINGDOM OF EVILS 
 
 keeping, — we aim here only to emphasize individuahzation in 
 social case work. 
 
 There is hardly a question anywhere today as to whether 
 social records should be or not be, — the case is proved that 
 good records help to make good work. Yet the relative value 
 of a good record system is indistinctly seen; and many agen- 
 cies question the proportion of time that it pays to give to 
 record-keeping. This depends first of all upon the purposes 
 that the record serves — the ways in which it promotes the wel- 
 fare of the patient or client. 
 
 The immediate purposes of the record are to make the his- 
 tory available for use (by physicians, as well as social workers) 
 in a hospital; to save reinvestigation if the case is renewed 
 after being closed ; to enable a new worker who must take up 
 the case to understand the situation; and to oblige the worker 
 to think clearly and to make her work definite. Social records 
 serve also the ultimate purposes of furnishing material in ac- 
 cessible form for social and medical research ; making it pos- 
 sible to study the work of the agency and estimate its 
 performance; furnishing standards for bringing the work of 
 other agencies to a higher level ; and affording material for 
 teaching students. » 
 
 The necessary documents of the record we have found to be : 
 
 a. A brief first sheet giving identifying information and facts 
 needed for statistics (see Appendix B, Form I). 
 
 h. History (record of the investigation or social examination; 
 for outline see Appendix B, Form II). 
 
 c. Treatment (record of the action taken, the current history 
 of the case under social care). 
 
 d. Summary of history. 
 
 e. Summaries of treatment and results at regular intervals and 
 when the case is closed. 
 
 /. Address sheet for addresses in current use. 
 
 g. Financial sheet for expenditures or special donations. 
 
 h. Correspondence arranged chronologically. 
 
 Examples of full records of cases 46, 89, 94 are given in 
 Appendix A; examples of "Summary" will be found in cases 
 20, 24, 32; and examples of "Results" will be found in cases 
 31 and 62. The summary of the history is prepared under 
 the divisions of social, physical, and mental history, and re- 
 sults are summarized every three months in the same manner. 
 
THE KINGDOM OF EVILS 537 
 
 In the discussions of social workers there seems to be an un- 
 certainty of opinion as to the nature and uses of a summary. 
 Some look to it for a full presentation of the case, a complete 
 digest of the history, which is recorded elsewhere in the form 
 of interviews and letters. We conceive the summary as the 
 briefest possible statement of the essential facts of the case, 
 following in form the outline used for collecting the data. The 
 judgment of the worker in selecting the essential facts neces- 
 sarily enters into the summary. A thorough consideration of 
 a case cannot be based upon a summary alone. In our case 
 conferences the summary is supplemented by comments and 
 questions. There have been certain attempts to adapt the five- 
 fold classification of the Kingdom of Evils to the purpose of the 
 summary by using the positive aspects of the evils there com- 
 prised as headings for a summary, but this is a mistake; for 
 the fivefold classification is far from being a scheme for the 
 collection of data but is proposed as an orderly method of 
 case analysis. The summary is a synthesis of the case, in- 
 tended to present a vivid picture of the main outlines of the 
 individual's history. 
 
 One of the chief difficulties in studying methods and results 
 in social treatment is the lack of information in the record 
 concerning the plans and purposes of the social worker. It is 
 usually impossible to form any idea of what the patient owes 
 to social care and what to "nature." The technique of treat- 
 ment can rarely be discovered from the record. There may 
 or may not have been a method in the treatment, as far as the 
 record shows. One way of supplying this deficiency is to 
 record at the beginning of the "treatment record" the general 
 plan that is to be followed and to indicate in the periodical 
 summaries of results the modifications of the plan later adopted. 
 Sometimes a social record will go to the opposite extreme and 
 consist largely of the worker's own plans and opinions to the 
 exclusion of information concerning the patient. It is easy to 
 slip into the habit of recording intentions and impressions 
 rather than to make the effort to secure facts. 
 
 In order to make a clear distinction between the current his- 
 tory of the patient under care and the social worker's plan and 
 methods in treatment, an effort was made for a time to keep 
 a "treatment sheet" separate from the main case record. (For 
 examples, see cases 14, 17, and 36.) This attempt had to be 
 
538 THE KINGDOM OF EVILS 
 
 given up under pressure of work after a short trial ; but the 
 device seems to us to offer promise of better study of method 
 in social case work. At the same time it has a tendency to 
 make the treatment more definite and effective, and to stimu- 
 late ingenuity and resourcefulness in the social worker. It 
 might be just as well to make the "treatment" entries on the 
 regular record instead of on a separate "treatment sheet," pro- 
 vided the statements of aims and methods were arranged in 
 such a way that they would stand out clearly. 
 
 TECHNIQUE OF SOCIAL DIAGNOSIS AND TREATMENT 
 
 Concerning the technique of social diagnosis and treatment 
 we do not claim any approach to complete discussion, even of 
 the facts which we note in this book. As a preface to such 
 remarks as we make below upon social technique and diag- 
 nosis, we wish to speak of what has been called "family case 
 work" and to make a general remark about it. The unit of 
 interest in social case work, like the unit of interest in social 
 reform and even in theoretical sociology, has often been the 
 family group. "As society is now organized," says Richmond 
 in Social Diagnosis, "we can neither doctor people nor edu- 
 cate them, nor launch them into industry, nor rescue them 
 from dependence in a thoroughly social way without taking 
 their family into account. Even if our measures were for the 
 welfare of the individual solely we should find that the good 
 results of individual treatment crumble away often because 
 the case worker has been ignorant of his client's family his- 
 tory." (Richmond used the term client instead of the term 
 patient, which at least in medical social work seems to us 
 preferable.) Briefly put individualization in social treatment 
 unconditionally requires consideration of the family group. 
 Richmond quotes the Swiss neurologist Dubois and the Ameri- 
 can neurologists Healy and Putnam in support of these con- 
 tentions with which we must all perforce agree. The follow- 
 ing items in the family group relations are discussed by Rich- 
 mond. The main drift of the family life, what is it on the 
 whole? The important distinction between the united family 
 and the unstable family (especially emphasized by Mrs. 
 Bosanquet in her book The Family). The necessity of "see- 
 ing the man" as well as the mother of the family and of seeing 
 
THE KINGDOM OF EVILS 539 
 
 him at home; the question of the unmarried father; the ques- 
 tion of the young couple requiring reUef ; problems of de- 
 sertion and inebriety; the wife and mother; the home situa- 
 tion; the family housing; children (here we find the blood 
 relationship and all those undercurrents of antagonism which 
 it implies) ; the other members of the family group including 
 undesirable relatives. Volumes should and must be written 
 upon these questions of the family group. Of particular value 
 in a study of family cohesions (the united and the unstable 
 family as distinguished by Le Play) will be the psychiatric 
 point of view. Families are said to "arrange themselves along 
 a scale with the degenerate family at one end and the best type 
 of united family at the other." But what is the degenerate 
 family in many or most instances except a family with psycho- 
 pathic trends in one or more members? Then there are in- 
 stances like that of Henry Loyal (case 4) of Book I in which, 
 except at times, there was extraordinary close cohesion of a 
 degenerate family. Even in this instance the family "solidarity" 
 proved as social workers have always insisted to be the greatest 
 asset. Another good psychiatric point is the systematic point 
 of seeing husband and wife separately so that each may get an 
 individual opportunity to present the personal view. .Where 
 character deviation enters, this point comes out in strong relief. 
 With respect to the unmarried father as well as the unmarried 
 mother, an enormous insistence has to be made according to our 
 view upon the question of greater or lesser feeble-mindedness 
 in the erring parent. If a wife and one or two babies of a 
 young able-bodied man in ordinary times need any service that 
 involves social work, this is a situation that demands the 
 closest scrutiny and to our mind the closest psychiatric 
 scrutiny. Neglectfulness, slackness of such degree as to in- 
 volve the necessity of dole-giving, certainly need a psychia- 
 trist's attention. "Laziness" is another phenomenon which 
 not seldom turns out to be in some way psychological. 
 
 Inebriates would nowadays one and all be subject to psy- 
 chiatric scrutiny. There is one set of statements that can 
 safely be made about all inebriates. Richmond quotes Neff 
 favorably to the effect that "the treatment of the inebriate can 
 best be expressed in the word individualization." The like can 
 be said of the family deserters, male or female. Perhaps the 
 relation of psychiatry is not too evident in questions of home- 
 
540 THE KINGDOM OF EVILS 
 
 making and family housing and many programs of social re- 
 form have in the past endeavored to center upon conditions of 
 housing and home-making, which w^ould in part at least derive 
 not so much from economical disability as from ignorance, 
 bad habits, or even mental defect. It is extraordinary what 
 different reports will be rendered concerning some family sit- 
 uations by workers who have the economic view uppermost 
 and by psychiatric workers. As for children, here the work 
 of Healy, as Richmond rightly claims, is far beyond his chosen 
 scope of mere delinquency and points the path of psychiatric 
 social work far beyond the confines of potential crime. The 
 psychiatric worker tends to look at social situations rather than 
 at family groups. The psychiatric social worker finds social 
 situations dominated by psychopaths, by one or more persons 
 whose mental disease or disorder may be extremely mild and 
 entirely invisible to members of the social group in question. 
 Sometimes the remote members of the family group or the 
 boarders and lodgers, and even the neighbors, may have a 
 more penetrating view of what is really going on. 
 
 We are more and more tending to insist that each social 
 situation, looked into by the psychiatric social worker, shall be 
 analyzed in the end according to the number of persons in- 
 volved. This number of involved persons may be small or 
 large. But we almost always find that the number of distinct 
 and separate points of view in each social situation is com- 
 paratively small. In a quarrel between a husband and wife 
 there may be two points of view and the social worker may 
 add the third point of view. Whereas the husband and wife 
 are agreeing to disagree within four walls, the social worker 
 may upon analysis advise another policy, that of separating 
 husband and wife for a longer or shorter period. Of course 
 the worker cannot execute any such policy without the consent 
 and approval of all legal, ecclesiastical, and medical authorities 
 engaged ; the supposition in the textbook is that the decision 
 of the social \\orker is supported by these authorities. Or 
 again the husband and wife may have separated and entertain 
 antagonistic views of what the family ought to do, whereas 
 the social worker may leap into the situation with the idea of 
 reunion. The point we here make is that after all the persons 
 in the social situation have been listed (somewhat after the 
 manner of the dramatis personae in plays) the really distinct 
 
THE KINGDOM OF EVILS 541 
 
 and separate points of view in the social situation are to be 
 analyzed and listed (just as one might distinguish the prin- 
 cipals and accessories in a dramatic cast). We have not con- 
 sciously adopted this method to any extent in the analysis of 
 the material of this volume, although in effect we have often 
 got practical results, — consider, for example, Henry Loyal 
 (case 4) or Alice Nardini (case 31). 
 
 But how shall we distinguish the principals and the acces- 
 sories and the less important units in the social situation ? The 
 psychiatric social worker learns that the family is not the unit 
 of interest for psychiatric social work but finds that the unit 
 of interest is the individual in his group. There will be found 
 one, two, three, four, or perhaps sometimes five, but rarely 
 more than five, human units of interest in social situations. 
 The children may split as to what they want done, some going 
 with the father and some going with the mother. Relatives 
 may take a third point of view separate from that of the father 
 and mother. Sometimes the social worker may enter with 
 still a fourth point of view and so on. But many of the per- 
 sons listed as engaged in the social situation turn out to be of 
 subordinate importance in that situation. They add themselves 
 in to enforce a little more strongly some particular policy but 
 they are accessories agreeing with the policies of some prin- 
 cipal. How shall these principals be defined? They are, we 
 think, non-interchangeable elements in the social situation. 
 They are not merely associates like the members of a club 
 but they are consociates like the officers of a club that have 
 separate functions not interchangeable with one another. How 
 many separate, non-compatible, non-interchangeable points of 
 view are logically to be found in a social situation? This is 
 the real question which the social case worker must strive to 
 answer. The family is a consociate group of persons (as 
 father, mother, children) having separate and non-interchange- 
 able functions. Their intimacy of relation, or, as we may say, 
 their consociate relationship may fall apart, particularly under 
 the influence of something psychopathic in some member of 
 the group. They become mere associate members of the group 
 — that is to say, they are no longer intimately united with one 
 another or even possibly quite antagonistic. Indeed, their an- 
 tagonisms may be so intimate that they become almost friendly 
 enemies, suggesting mutual antagonism, like two universities 
 
542 THE KINGDOM OF EVILS 
 
 such as Harvard and Yale. These members of the group whose 
 views simply add themselves into the views of some principals 
 in the situation are merely associates in the situation. Their 
 views are interchangeable with one another. They numerically 
 strengthen a point of view — they do not determine it. 
 
 It is upon these lines that we predict the careful social 
 analyses of the future will run. Upon these lines we shall 
 study more effectively the relations of man to man, man to 
 woman, and woman to woman, whether these relations are 
 dual, triple, quadruple, or still more complex. Throughout all 
 this study the psychiatric social worker will be apt to see with 
 great clearness the predominate importance of the psycho- 
 path. But the psychiatric social worker will study each mem- 
 ber of the social situation individually, and each from his own 
 personal point of view, so that there will be no psychiatric 
 prejudice in the long run. We conceive that this kind of 
 analysis has a range much greater than yet afforded by avail- 
 able analyses of the family group. But we also know that it 
 would take a long time to reach the confines of the vista. 
 
 Discrimination between the summation of evils and the 
 multiplication of evils has been referred to (case 8) as hav- 
 ing a bearing upon social treatment. In one case the elements 
 of disorder may be loosely combined, heaped, while in another 
 case they are tightly combined, coiled. It is important to know 
 whether we are dealing with siinnnands or factors. Evils 
 multiply into one another. The effect of hypersexuality and 
 lack of information about sex lead to more difficulty com- 
 bined than the sum of the two evils alone. (See also 
 Book IV.) The case of Rose Talbot, intelligent sex delin- 
 quent (case 8), gives an elaborate example of tightly coiled 
 troubles. A contrast of our first case, Agnes Jackson, with 
 this case brings out clearly the sum of troubles versus the 
 product. The Jackson case is a simple additive case, 
 M-|-E-|-V+L+P, while Rose Talbot is a complex multiplica- 
 tive case, MXEXVXLXP. In a multiplicative, 
 interpretative case, if you remove poverty you change the whole 
 situation; but in the simpler additive case you may send the 
 patient for various sorts of help to various sources, dealing 
 with his difficulties one by one. The case of Elliot Calderwood, 
 misrepresented "little fiend" who proved quite amenable (case 
 22), as an example of educational, legal, and economic diffi- 
 
THE KINGDOM OF EVILS 543 
 
 cultles, is a case in which the factors of difficulty were not in- 
 terwoven in any practical sense and could be disposed of in 
 turn, — the misunderstanding with the court set right (L), a 
 home provided (P), education started (E). 
 
 Will the difficulty of social treatment vary with the tightness 
 of the coil, or on the other hand will the whole coil unravel 
 quickly when the secret is found? There may be cases for 
 quick treatment, where a single line of action will solve the 
 problem. Cases that are sums of social trouble mean increase 
 of steps to be taken in treatment, — they are logically simple 
 but time-consuming. We cannot hope to do more in this book 
 than suggest the idea of the social sum versus the social 
 product as a method of approach in social treatment. 
 
 Psychiatric social work employs the technique of general 
 social work in so far as systematic methods have been de- 
 veloped in social case work. There exists a certain amount of 
 technique of social examination (usually called "the investiga- 
 tion") that is now generally agreed upon and made available 
 in the literature of social work, and a smaller amount of tech- 
 nique of social treatment, which is fairly definite, although 
 still somewhat tentative. Scientific methods of examination 
 will naturally precede scientific methods of treatment, for al- 
 though in the development of its practice social work first 
 learned to treat and later learned to examine (or "investi- 
 gate"), in the development of scientific method examination 
 must necessarily come before treatment. So that the newly 
 created psychiatric social worker finds already at hand a con- 
 siderable body of systematized experience in examination and 
 a small amount in treatment. Obviously it is the part of wis- 
 dom to acquire this technique, which is the accumulated experi- 
 ence of twenty-five years or so of tentative effort toward scien- 
 tific method. The new psychiatric social worker impatient 
 with the disregard of mental science in the general technique 
 may have an impulse to discount the experience of social 
 workers in the past and begin all over again. Sometimes under 
 the influence of physicians whose acquaintance with social work 
 in the past has been slight, and perhaps on that account unsat- 
 isfactory, the psychiatric social worker is inclined to discard 
 the incomplete technique of social work altogether, and to feel 
 a naive responsibility to create a new profession. But the ex- 
 isting technique is not so much incorrect as it is incomplete. 
 
544 Tf"HE KINGDOM OF EVILS 
 
 The ambition of psychiatric social work should be to modify 
 and add to the general technique of social work new methods 
 developed by special experience with psychiatric cases. 
 
 Some of the more conspicuous points at which psychiatric 
 social work may be expected to influence the technique of case 
 work are: (a) individualization in both examination and 
 treatment; (b) objective accurate observation; and (c) train- 
 ing of character through use of the emotions. The subject of 
 individualization has been discussed elsewhere. (See cases 48 
 and 87, also pages 378 and 379.) 
 
 Focusing upon the individual soon leads to the recognition 
 of the fact that human beings are infinitely varied and cannot 
 be rated for practical purposes at certain levels of merit. 
 Within the same personality are to be found faults and virtues, 
 abilities and disabilities. This point of view often gains re- 
 spect for even the most unsuccessful individual. In cases 
 where failure is due to natural causes too strong for the in- 
 dividual's control, the knowledge of this fact will eliminate 
 the attitude of blame that we instinctively feel for misconduct. 
 The question of praise and blame is important for social 
 workers. Undoubtedly much harm is done by the discourage- 
 ment and loss of energy that blame produces; and praise is 
 obviously an effective therapeutic agent. One of the primary 
 aims of the social worker is to deepen the sense of moral re- 
 sponsibility ; a process which is apt to involve frequent expres- 
 sion of disapproval. But it is doubtful whether reproof and 
 blame promote this object. The truth of the matter probably 
 is that reproof or blame as ordinarily administered is com- 
 pounded of our knowledge of the error and our impatience 
 with it. It is perhaps the tinge of personal impatience that 
 gives blame its unpleasant quality. Many unfortunate psycho- 
 paths who have been censured and despised by acquaintances, 
 and often by social workers, when they meet the psychiatric 
 point of view, feel a sense of relief and renewed self-respect 
 and are stimulated to fresh effort. (See cases 2, 4, 6, 12, 13, 
 
 52' 98-) 
 
 Another product of the psychiatric point of view is the habit 
 of objective observation — the study of an individual as he 
 really is, not as we feel that we should be in his place, or as 
 he himself tells us that he is. In social case work we need to 
 know accurately the nature of our patient or client. We do 
 
THE KINGDOM OF EVILS 545 
 
 him an injustice if we form a conception of him in terms of 
 our own experience. His own account, though honestly 
 meant, may not be accurate. Through observation of his be- 
 havior and reports of other observers upon his conduct, the 
 best account of his character is to be obtained. When we come 
 to the point of trying to understand him, we must necessarily 
 think in terms of our own experience, but the objective study 
 should precede the interpretation. We first find out what an 
 individual is like, and then think how we should feel and act 
 if we were like that. This process of objective study, preced- 
 ing subjective understanding, simplifies many problems in 
 social work and promotes sympathy. Personalities quite un- 
 like our own when studied objectively become comprehensible. 
 Training through use of the emotions rather than through 
 appeal to reason is a familiar technique of everyday life in 
 dealing with children and in getting our own way. Everyone 
 is familiar with the practice of asking a favor when the pros- 
 pective donor is in a good humor, and upon the strength of the 
 resulting good feeling after a suitable interval asking another 
 favor, thereby helping to develop habits of generosity in the 
 donor. Such technique seems to be the most hopeful method 
 of training individuals in whom misconduct is the result of 
 emotional instability. In discussing this point we cannot do 
 better than to quote somewhat at length from A Psychiatric 
 Contribution to the Stu/^y of Delinquency, by Dr. Herman 
 M. Adler (see also page 487), who as chief of stafif at the Psy- 
 chopathic Hospital guided the first efforts of the social service 
 in cases of delinquency: — 
 
 "It would seem that by careful training based upon an analy- 
 sis of each individual — especially from the behaviorist's point 
 of view, considering the past life and career rather than self- 
 explanatory, subjective statements — it would be possible to 
 influence the future conduct of these individuals {i.e., the 
 emotionally unstable). While their fundamental equipment 
 cannot be changed, these people suffer more from the effects of 
 their conduct than from their subjective attitude towards them- 
 selves or their environment. 
 
 "Thus, as Kraepelin points out, alcohol is an important fac- 
 tor in producing the final downfall. Extravagance, profligacy, 
 sex excesses, bad companionship, and so forth, are the factors 
 which combine to cause the social difficulties. The suggesti- 
 bility of these individuals, their intelligence and insight, which 
 
546 THE KINGDOM OF EVILS 
 
 is usually adequate for their needs, can be made use of in 
 acquiring and strengthening the habits which the individual 
 would never be able to gain if left to himself. 
 
 "What is desired, therefore, is a system of mental and emo- 
 tional exercises for the purpose of habit formation. This 
 might be designated as orthopsy chics. This term is further 
 applicable in that a good many of those cases are instances not 
 of disease in the sense of an acquired, deteriorating process, but 
 rather comparable to physical deformities. For the present, 
 our experience in orthopsychics is limited. We have had a 
 few cases in which, after a preliminary survey at the Psycho- 
 pathic Hospital, a course of training has been applied, which 
 has consisted above all in arousing the interests and appealing 
 to the pleasure-loving side of the individual. It is a well- 
 known fact, for instance, in dealing with wayward young 
 people that even under the most advantageous circumstances 
 and even with the most favorable and friendly environment, 
 the individuals do not do well. This appears to be due to the 
 fact that the emotional impulses are of short duration and leave 
 no strong impressions behind them. Therefore, when the 
 novelty of a situation has worn ofif, there is nothing to hold the 
 interests of the delinquent and tide over the tedious days of 
 monotonous routine. 
 
 "We have proposed in a number of cases (and have carried 
 it out to some extent in a few) to arrange to change the en- 
 vironment of each individual before the novelty has quite worn 
 off. The length of time in which an individual stays in each 
 home varies in each instance, and must be determined carefully 
 each time. We are all so prejudiced by our early ethical 
 training that it is difficult to be ])erfectly objective in dealing 
 with these people. It is hard to eliminate pedagogic and purely 
 academic demands for that which we consider right. None 
 the less, this must be done, and in every instance, in every 
 disagreement, at every change in the routine of the individual, 
 emphasis must be laid on the fact that it is done from a medical: 
 point of view, that is, from a point of view of theirapy and! 
 help, with kindly feelings toward the patient, and' never- as a. 
 corrective or as a punishment, and al)Ove all. never- vind'ictiVel'y., 
 
 "Education and training, therefore, rather than punishment 
 are the methods that hold out a chance of success. These indi- 
 viduals are not able to team by experience. They receive the 
 equivalents of punishment in their daily life, which are suffi- 
 cient to influence the formation of adequate resistance in a 
 normal individual. In these individuals, while they often recog- 
 nize the full significance of those circumstances in which their 
 
THE KINGDOM OF EVILS 547 
 
 delinquencies placed them, their experi-inces have no corrective 
 influence. 
 
 "To punish such an individual, therefore, is to increase his 
 defeat rather than to strengthen his defenses. It is like admin- 
 istering alcohol to the patient suffering from delirium tremens. 
 It is like injecting diphtheria toxin into the circulation of a 
 patient suffering from diphtheria. We may draw a final anal- 
 ogy from immunology in applying this therapy : 
 
 "The first duty is protection against the immediate effects of 
 the acute attack. In our cases, this means freeing them from 
 their immediate difficulties, supplying them with food and lodg- 
 ing, helping them to recover from alcohol and drug intoxica- 
 tion, relieving their physical symptoms, curing them of venereal 
 disease, and building up their physical health. 
 
 "In the second place, immunization : This is often in the 
 nature of after care, and cannot be achieved at once, but can 
 be accomplished by a building up of the defense habits, by 
 training, and not by overwhelming an already breaking organ- 
 ism with the hostile conditions, but by gradually strengthening 
 their habits so that they will meet the particular unfavorable 
 conditions without fear of breakdown. In the group of emo- 
 tionally unstable, this offers great hope." 
 
 The relation of social worker to patient (or client) seems 
 to be causing the development of a new professional attitude. 
 The ideal attitude of the established professions, such as medi- 
 cine, education, theolog}', is one of authority and impersonal 
 friendliness. The effective attitude for the professional social 
 worker is essentially the same, but the proportions of authority 
 and friendliness are reversed, and the friendliness is less im- 
 personal. The social worker (except the probation officer) 
 carries no such authority as the institutions of hospital, school, 
 and church bestow, but must rely for prestige upon her ability 
 to help. The friendliness of her relation to the patient, in 
 sticcessfut treatment, i"s of a high degiree;- for almost imme-- 
 diiately she secures an exceptional intimacy with the patient's, 
 whol'e interior and exterior situation. The patient responds to. 
 this sudden intimacy by regarding her as a near friend. To 
 influence him throughout the intricacies of social adjustment 
 she must preserve this regard. She must identify herself with 
 him, directing him from his own point of view, giving him 
 the counsel of "a friend" not merely the advice of "an au- 
 thority." On the other hand she must preserve enough of 
 
548 THE KINGDOM OF EVILS 
 
 the element of authority to be a decided and respected influence. 
 This continuous intimate relationship is apt to make the social 
 worker very sympathetic ; but even in the most appealing cases 
 she must combine with her sympathy an objective impersonal 
 attitude that will leave her judgment free. When it is said 
 in justification of a social worker "she puts her heart into her 
 work," it must not be forgotten that the patients have a claim 
 upon her head as well. The social worker must find a way 
 to be at the same time a personal friend and an impersonal 
 adviser. 
 
 The fact that the social worker stands to the patient in the 
 light of a friend might seem to argue the importance of hav- 
 ing but one worker deal with a case throughout the period of 
 social treatment. But this In our experience is not so impor- 
 tant as it might seem. A change of workers can be made with- 
 out loss and may even be an advantage. In any case under 
 long-time treatment, with the changing stafif of a hospital, it 
 is unavoidable that there should be several different workers 
 in succession. Some of our most successful cases have had 
 as many as six or seven social workers, and three or four 
 workers not infrequently deal in turn with one case (see cases 
 8, 32, 94). The success of the transfer of a case to another 
 person depends of course upon the skill of the workers con- 
 cerned and upon their consideration for the feelings of the 
 patient. In some cases the patient likes his new social worker 
 better, and in most cases he feels it is some advantage to have 
 acquired a new friend. There may be of course some loss in 
 a case where tlie patient has gradually come to confide in the 
 first worker ; but such loss is apt to be overestimated. The 
 bringing in of new ideas and influences through a new worker 
 may be a positive advantage to the treatment. 
 
 The patient will feel decided opposition to the transfer if 
 he has formed an excessive attachment to the social worker, 
 but this relationship is not to be encouraged in any case. An- 
 other reason for objection from the patient may be that he 
 fears opposition from the new worker in something which he 
 has been allowed to persist in doing. On the whole we believe 
 the best results come from teaching the patient to look upon 
 the social agency or the hospital as the source of help and direc- 
 tion, medical and social, and inspiring him by uniformly con- 
 siderate treatment to feel confidence in every member of the 
 
THE KINGDOM OF EVILS 549 
 
 Staff who deals with him. This might appear as a theoretical 
 principle too ideal for application, were it not that it is a con- 
 clusion derived from actual experience. We have found the 
 point of view to be of more importance than the personality 
 of the worker (see also case 8). 
 
 MEDICAL TREATMENT IN SOCIAL CASE WORK 
 
 We do not deal systematically with medical treatment in 
 this volume. Hamilton Green (case i8) was an "eye" case — 
 a man with severe astigmatism. No doubt the treatment of 
 the astigmatism is indispensable in the handling of Hamilton 
 Green. Yet it would be improper to think of Green as merely 
 an eye case or of the treatment of his eyes as the essential 
 thing in his case. Good but subordinate effects were gained 
 by baths for Agnes Jackson (case i). In fact, the excellence 
 of hydriatric treatment in cases of dementia praecox has been 
 pointed out by our colleague, H. M. Adler, in his analysis of 
 the effects of baths in different forms of excitement (contrary 
 to expectation, Adler found that better effects of an important 
 nature were secured in cases of dementia praecox than in cases 
 of manic-depressive psychosis). It would be natural to draw 
 hydrotherapy into the foreground in this or in other cases 
 v/ith which we are familiar. The baths serve to draw patients 
 to hospitals, and an unfailing stimulus to the size of the out- 
 patient clinic is the establishment of a good hydrotherapy sys- 
 tem so associated with the clinic that proper hydriatric pre- 
 scriptions can be made for systematic treatment. It does not 
 do to scoff against these baths as some observers are apt to 
 scoff. Possibly they are not essential to the treatment of any 
 form of mental disease whatever (always excepting forms of 
 excitement) ; possibly they are not even indispensable aids in 
 treatment in many cases; but though they may be neither 
 essential nor indispensable in treatment, baths remain impor- 
 tant aids to any clinic. Moreover, it must be conceded that 
 the true effects of hydrotherapy have never been scientifically 
 measured by the metabolic chemists or otherwise. 
 
 Similarly with dental treatment which comes especially 
 into question in the case of Margaret Dolan (case 38) whose 
 dental defects and indigestion complicated a mental situation 
 which was itself the result of a well-founded wrong. Despite 
 
550 THE KINGDOM OF EVILS 
 
 all Margaret Dolan's financial trouble and the death of her sis- 
 ter, she recovered with social aid. Another dental case was that 
 of Nathan Rosenthal (case 49). The dental complication was 
 subordinated here also, but this always subordinate influence 
 was still important. Social workers so often ask what the 
 effect of dental treatment is upon mental diseases; owing to 
 the fact that extraordinary claims have been made on behalf 
 of dental work (especially extraction) in cases of mental dis- 
 ease. The public prints have in recent years been full of such 
 claims. The rational answer to this question is that a few 
 cases are marvelously benefited by proper dental treatment. 
 These improvable cases are no doubt those in which pyorrhea 
 or other infection about the teeth is responsible for mental 
 symptoms through a process of septicemia (with bacterial in- 
 vasion of the blood) or toxemia in which bacterial poisons find 
 their way into the blood. Michael Piso (case 62) suffered 
 extensively from pyorrhea but the dental treatment thereof was 
 only a part of the total treatment of Piso which served in the 
 end to raise his wages and procured relatively complete family 
 adjustment with abolition of jealousy. 
 
 Occupational therapy is a means of treatment of the in- 
 sane in institutions and of psychopaths outside of institutions. 
 In war time groups of occupational therapeutists were trained 
 to get ready for contingencies of disease amongst our Ameri- 
 can soldiers; and the work of these occupational therapeutists 
 was so good and the outlook for their need under civilian con- 
 ditions is so well established that the work is likely to be con- 
 tinued. An extensive literature has been built up around this 
 form of therapy. Instances of its employment are afforded by 
 Agnes Jackson (case i) and Kevork Ardinian (case 26), 
 though both cases illustrate relative failure rather than suc- 
 cess in occupational therapy. A successful instance of its use 
 is John Flynn (case 19). 
 
 Our group of cases is decidedly not representative of the 
 values of occupational therapy and it would be a highly 
 meritorious work for someone to collect a series of clearly diag- 
 nosticated cases of severe or mild mental disease and defect 
 for the purpose of tracing the exact ways in which occupa- 
 tional therapy works in the different forms of psychopathy. 
 For example, the reasons for the relative failure of occupa- 
 tional therapy in Agnes Jackson and its absolute failure in the 
 
THE KINGDOM OF EVILS 55 1 
 
 case of Kevork Ardinian are different reasons and conse- 
 quently do not have a word to say against the general values 
 of such therapy. We should not forget that in the background 
 of our minds the main value of sending the feeble-minded sub- 
 ject to a school for feeble-minded is the elaborate occupational 
 therapy which he wall there secure. Perhaps it is not too much 
 to say that the theory of occupational therapy will be built 
 up from the work of the schools for the feeble-minded. 
 Workers in Massachusetts and in the country at large are 
 familiar with the principles of such therapy for the feeble- 
 minded as developed by Dr. Walter E. Fernald at the Massa- 
 chusetts School for Feeble-minded in Waverly. These methods 
 were first proposed and in part carried out by the eminent 
 early worker with the feeble-minded, Seguin. An effect 
 of the new theory of occupational therapy for the feeble- 
 minded as proposed by Seguin, Fernald, and others is the 
 proposal by Madame Montessori for new methods of educa- 
 tion of the normal. We can forbear to insist that such workers 
 as Seguin and Fernald are working along lines more in the 
 interest of the normal than in the interest of the abnormal. 
 These men and all mental hygienists are not making the frontal 
 attack upon education which the teachers of the normal are 
 making; but the flank attack by these mental hygienists may 
 yet prove as successful as the more obvious forms of frontal 
 attack. 
 
 Whilst we are talking of occupational therapy it is impor- 
 tant to remember also the work for the chronic insane as car- 
 ried out in the industrial shops and on the farms by victims 
 of dementia praecox and other forms of mental deterioration. 
 Colonies for the systematic development of the working powers 
 of chronic patients have been established by some state gov- 
 ernments, either separately or in connection with existent and 
 exceptional units. From this source also it is to be hoped 
 that new theories concerning the fundamental principles of 
 work and industry may accrue. There is hardly any better 
 way to evaluate the excellence of state institutions for the 
 insane than to ask to see the industrial shop work and the 
 farm work of the hospital patients. The best hospitals have 
 efficiency recording devices which stimulate their officers to 
 the securing of higher quotas of active workers and to increase 
 in the number of hours of patient-occupation. Not so much 
 
552 THE KINGDOM OF EVILS 
 
 can be told from striking exhibition of arts and crafts by par- 
 ticular patients as from the statistical story afforded by the 
 annual reports of institutions. Occupational therapy is a most 
 important branch of mental hygiene. The theory of it is in- 
 complete. The value of what has been done is not doubtful. 
 
 EDUCATION FOR PSYCHIATRIC SOCIAL WORK 
 
 What difference will it make to the world whether we con- 
 sistently unfold the social side of the mental-hygiene program 
 and develop a group of trained psychiatric social workers? 
 The functioning elements in the mental hygiene of the present 
 day appear to be three in number, all indispensable though of 
 different scope and values. Mental hygiene would of course 
 be nowhere without the psychiatrist or neuropsychiatrist as 
 its professional leader. In mental hygiene conditions are the 
 same as in the general field of preventive medicine and public 
 health. After all, the things to be dealt with in the present 
 phase of civilization are diseases and defects, and the fact that 
 mental diseases and defects come in question does not mean 
 that physicians lose their responsibilities or can by any means 
 hand them over to psychologists or social workers. To be 
 sure, not all physicians have yet seen the light of their duties 
 in public health and there may be a few moribund psychiatrists 
 that do not see their responsibilities in mental hygiene. But 
 the topic of mental hygiene engrosses the interest of national 
 technical associations that deal with mental and nervous dis- 
 eases and plentifully scatters the literature, quarterly, monthly, 
 and weekly, with propagandist articles of high level. Even 
 certain daily newspapers carry mental hygiene topics under 
 the medical banter. 
 
 But let not the physician nor the psychiatrist feel that 
 mental hygiene begins and ends with medicine or psy- 
 chiatry. The recent extensive review of ten years' activities 
 in mental hygiene by Dr. Lewellys F. Barker shows the almost 
 universal relativity of mental hygiene, and discovers hardly a 
 field of human activity to which mental hygiene is not germane. 
 But the practical relations have so deepened and solidified in 
 certain places that their intensive values almost outstrip the 
 extensive relation which Barker so broadly expounds. By 
 practical relations are meant those above specified in addition 
 
THE KINGDOM OF EVILS 553 
 
 to medical relations ; namely, the relations with the psychologist 
 and the social worker. 
 
 For the moment it is not our duty to discuss the values of 
 the psychological examiner in the field. Those values do 
 not need to be justified. Recent analyses of concrete work 
 in our field have shown that the psychologist can often do 
 more in an hour's contact with the patient than the social 
 worker or even the psychiatrist can do in ten, twenty, or even 
 one hundred hours of contact. The trouble is that the psy- 
 chologist runs out of technique and method after his hour is 
 up. He can do nothing more in the second hour of contact 
 with a human being with whom he is in sympathy. Accord- 
 ingly the work of the psychiatrist and of the social worker, 
 though less intensive and powerful during the first hour of 
 contact with the patient, lasts much longer and may in the long 
 run effect far more. Both from the standpoint of prescrib- 
 ing medical or social adjustments and from the standpoint of 
 making these adjustments really work in a compound environ- 
 ment. Let no one, and especially let not the psychiatrist or 
 the social worker, look with contempt or with uneasy appre- 
 hensiveness on the work of the psychologist. But the psy- 
 chologist is a scientific rather than a practical person. He 
 has at his command more the method of a science than the 
 technique of an art. He differs in his relation to our topic 
 from the psychiatrist and from the social worker, both of 
 whom are primarily engaged in the practical arts of medicine 
 and social work. To be sure, the difference between applied 
 science and the technique of a highly advanced art is so very 
 slight that a pragmatist might well inquire whether they were 
 not identical. Now and then a psychologist will be found 
 claiming himself to be a sort of practitioner. He claims to 
 become a sort of social or psychic technician rather than a 
 methodologist at work at the fundaments of things. But on 
 the whole the psychologist remains "-ologist," a man of science, 
 and after he has exactly applied his strict categories in a brief 
 time to the problems of the patient or to the classifications 
 of an applicant for work, his province as a psychologist comes 
 to a sharp limit, beyond which hrs activities are little more 
 than those of an educated layman. 
 
 We trust that in all this we shall not be charged with be- 
 littling psychology which as a science, and as in some sense 
 
554 THE KINGDOM OF EVILS 
 
 the deepest of sciences, must in the long run prove as broad 
 a field as that o£ medicine or even as the fields of physics 
 and chemistry. There is nothing that one would like better 
 than to contribute to psychology as a science. Nevertheless 
 psychology contributes method rather than technique, is work- 
 ing at the fundaments and generalities rather than the outcrops 
 and specialties of social work. 
 
 What then shall we say about the social worker? In the 
 first place there may be some lingering doubts in the minds of 
 physicians, or administrators, of politicians, of various chari- 
 table authorities, whether there is a definite field of social 
 v/ork, but we take it that the National Conference of Charities 
 and Correction, recently renamed the National Conference of 
 Social Work, proves in all its recent transactions that there is 
 a field of social work. It is in point that Isaac Ray, perhaps 
 the greatest of the early American psychiatrists, was one of 
 the founders of the Social Science Association. Nowadays 
 we think more of social arts than social science and it was 
 rather a service to our cause to have the National Conference 
 name itself a Conference of Social Work, though the phrase 
 is at first sight bungling enough. The object of these workers 
 in selecting that title was not that they felt themselves the only 
 workers in the world but that they did not wish to be dubbed 
 "scientific" and, as we in the American scene so constantly 
 say, impractical. 
 
 It is entirely clear that social work is taken by most of its 
 votaries and propagandists as an art and not as a science. 
 This, it seems to me, is as it should be. The social worker 
 has in some ways identical aims and purposes with those of 
 the psychiatrist. Both are practical workers engaged in social 
 and medical arts which to some extent fuse and overlap but 
 which in the long run will not interfere with each other any 
 more than the physician and the nurse, or the public-health 
 man and the public health nurse, will interfere with one an- 
 other. Two psychic bodies can occupy the same place at the 
 same time without breaking any important laws of the world's 
 construction. It is perhaps hard to get both the physician on 
 the one side and the social worker on the other to acknowledge 
 the indispensability of each in a field where a single authority 
 appears to be necessary — the field, namely, of the family dis- 
 rupted by its central or subordinate psychopathic figures. 
 
THE KINGDOM OF EVILS 555 
 
 Let US assume in this argument that the physicians and the 
 social workers in general agree upon their respective duties 
 with respect to the same corpus vile. 
 
 What now about the medical social workers? Is not med- 
 ical social work a very special and limited field within social 
 work in general ? Is not social work, the technical or applied 
 side of sociology, an economic rather than a therapeutic field? 
 Will not the bulk of the problem be settled on an economic 
 line? What the statistical truth here is remains obscure. All 
 medical social workers will agree that whatever the statistical 
 truth about mere economics as applied to social difficulty, there 
 is enough to do in medical social work to require a large corps 
 of especially trained medical social workers. There is now 
 in its early years of development an association of medical 
 or hospital social workers, the American Association of Hos- 
 pital Social Workers, which is to meet an affiliation with the 
 National Conference of Social Work. The medical social 
 workers form, as it were, a neat little trades-union of their 
 own. They do not require laudation or special support from 
 any source. Medical social work has justified itself. 
 
 What about psychiatric social work? Every medical social 
 worker should obviously receive a large amount of social psy- 
 chiatric training in his or her school of social work, and 
 a fortiori should receive more and more if the mental hygien- 
 ists are right in thinking that more than one out of every two 
 cases of social trouble is a psychiatric case. Should there 
 not be courses developed in connection with every school of 
 social work that shall give a sufficient fundamental training 
 to social workers in psychiatry to allow them to effect proper 
 contacts in their practice? This is undeniable and we are 
 heartily in accord with a program for giving the psychiatric 
 touch SO' far as that is possible to every social worker. It is 
 almost inconceivable that social-work courses have not, for a 
 decade past, developed in their curricula lectures and demon- 
 strations dealing with the common, nay universal, phenomena 
 of syphilis, feeble-mindedness, epilepsy alcoholism, and even 
 somewhat concerning the obscure field of the so-called psycho- 
 pathic personalities. 
 
 Of course the social worker might readily get beyond the 
 range of everyday medical practitioner in these regards, at 
 all events if we consider the medical practitioner of elder 
 
556 THE KINGDOM OF EVILS 
 
 vintages. But this comparison is a bit odious and it is cer- 
 tainly not the duty of those who make the curricula of schools 
 for social work to dampen their ardor just because medical 
 schools have grievously neglected psychiatry. 
 
 Another question of deeper interest to the close student 
 of mental hygiene is the question whether there ought not 
 to be special schools or curricula that deal with psychiatric 
 social work with the endeavor to produce a special brand of 
 social workers, — ^psychiatric social workers. It is a matter 
 of history that Smith College, with the assistance of Dr. 
 Spaulding, the New York School of Social Work through 
 Dr. Glueck, and the Pennsylvania School for Social Service 
 through Dr. Taft did actually develop courses for training 
 psychiatric social workers. These courses were developed 
 during the war fervor. They attracted and are attracting 
 women as a rule with college degrees with very special interests 
 in the humanities and with a point of view perhaps a bit less 
 economic than the point of view of the ordinary social worker. 
 The infusion of this blood, a little more radical and fiery than 
 the sober reform blood of the type of social worker familiar 
 to us all, no doubt, will have some rather surprising results, 
 but we think the advantages of novelty and freshness of point 
 of view may counterbalance the disadvantage of oversobriety 
 and conservatism. 
 
 The comparative youth of sociology, of applied sociology 
 (social work), of applied medical sociology (medical social 
 work), and of the putative new branch (psychiatric social 
 work) entails a certain fluidity of nomenclature at first not 
 unserviceable. Nor would it be necessary or even desirable 
 to fix at the outset a nomenclature for logical compartments 
 of an undeveloped art, as we might thus condemn the art to 
 stasis or bad cuh-de-sac. We raise the question, therefore, 
 only on the practical ground of whether or no specialists, pro- 
 fessional or technical, have been developed or are in course of 
 development in this field of sociology. For, if so, that is, if 
 the new art has found its shoulder-to-shoulder workers, then 
 it is high time to state the principles of their alignment, and 
 the nature of curricula and practical experience necessary for 
 these workers. 
 
 We assume that medicine and applied sociology are profes- 
 sions with their professors and practitioners having due recog- 
 
THE KINGDOM OF EVILS 557 
 
 nition in university degrees, M.D. and Ph.D., respectively, 
 and in commonly accepted titles, physician and sociologist. 
 On account of the recency of sociology's foundation, every- 
 body is prepared to accord to many workers without the degree 
 Ph.D. just as good and perfectly equivalent dignity. Nor 
 should such a contention as that sociologists will more and 
 more tend to be Ph.D. bearers be regarded as propaganda of 
 Professor James' "Ph.D. octopus," since everybody is now 
 aware that novelty, in medicine, sociology, or any other branch, 
 is perhaps more likely than not to come from some distant 
 science. Thus the teaching branches of medicine are more 
 likely to get novelty from, e.g., chemistry, or physics, than 
 from their own more limited fields. And the teaching branches 
 of applied sociology are very likely to profit more from 
 anthropology or psychology than from the recognized rounds 
 of sociological research as narrowly conceived, e.g., in the field 
 of social statistics. Perhaps even it might be said that many 
 branches of didactic medicine and sociology would get more 
 food for new thought from each other than each from itself. 
 We are not here talking of the technique of research, but of 
 the sort of training which allows us to concede that such and 
 such a person is entitled to rank as a professional sociologist 
 alongside the physician. 
 
 There are, to repeat, persons to whom we accord an equal 
 professional rank as didactic or practical masters of their 
 fields — physicians and sociologists. But every profession must 
 develop apprentices or ancillary workers of various sorts. Thus 
 medicine has developed the nurse. Applied sociology, we 
 make bold to say, has developed quite on the same level — 
 the social worker. One has to be bold For many social 
 workers, perfectly modest as to their own private capacities, 
 have developed a surprising group-consciousness concerning 
 the proper dominance of the ideal social worker in all social 
 maladjustments. This group-consciousness of social workers 
 often leads to a not unwarranted derision on the part of physi- 
 cians, judges, men of the world. The point here is probably 
 simple: just because not every eminent sociologist is a Ph.D. 
 and because many sociologists prefer to call themselves 
 "workers" (from the American habit of denouncing theory 
 and suspecting all "-ologists" of carrying lugs), many humbler 
 persons conceive that there is no theory behind their prac- 
 
558 THE KINGDOM OF EVILS 
 
 tice, no sociology behind their social service. It is as if, on 
 the one hand, physicians seeing that medicine is so much a 
 matter of nursing should announce themselves as a kind of 
 nurse; it is as if, on the other hand, nurses seeing that the 
 physicians are so ignorant of many practical matters should 
 suddenly conceive that nurses were after all a sort of physi- 
 cian. Practically, too, in the present phase of social-service 
 development, social workers are apt to be of a finer grain and 
 a more finished higher education than the majority of nurses, 
 and accordingly the social workers are inclined to develop a 
 feeling of group-superiority to nurses. This attitude is of 
 course a matter of dispute as to its justifiability, but is none 
 the less existent. But we conceive that, unless a person wishes 
 to go to the length of special training of professional grade, 
 he can hardly claim equivalence to a man of professional 
 training. We conceive that professionally trained social 
 workers, of the Ph.D. level or equivalent, will finally admit 
 themselves to be sociologists, albeit applied sociologists. And 
 we hope that further there will be a group-consciousness de- 
 veloped of social workers iDelow the "-ologist" grade with 
 an attitude resembling that of nurses to their work — an atti- 
 tude, according to temperament, of humble pride or proud 
 hum.ility with respect to their acknowledged leaders, the ap- 
 •^lied sociologists. Nor should the term profession be made a 
 stumbhng-block : if nursing is a profession, so. ought social 
 work (below the level of sociology) to be ackno^vledged a pro- 
 fession also : this last is a matter of terms only. 
 
 But no two sciences or arts can in these days long exist 
 without fruitful contacts. Pathological and sociological prog- 
 ress have gone hand in hand. Many a physician is, we say, 
 really and by temper a sociologist : many a sociologist develops 
 so deep an interest in, e.g., sanitation problems that he becomes 
 in effect a physician, at least an expert in public health. 
 Social medicine and medical sociology have much in common : 
 either could receive the term theory of the public health 
 without special error of definition. 
 
 Not to linger over the definition of public health, hygiene, 
 and preventive medicine as against the non-medical branches 
 of sanitary science and art, it is clear that both social medi- 
 cine and medical sociology have brought to life auxiliary 
 groups of practical workers, viz., the public health nurse and 
 
THE KINGDOM OF EVILS 559 
 
 the medical social worker. It is clear, too, that just as 
 social medicine and medical sociology are different in their 
 points of view, so the aides in the practical work of each field 
 are likely to have a different point of view. If the lively 
 growth of the public health nurse group sometimes threatens 
 to engulf the medical social worker {e.g., by proposals that 
 the same curriculum will do for both), the fact is that no 
 such forced union will ever take place, judging by the quality 
 and nature of the persons each field has so far attracted. 
 
 Now it is obvious that the public health nurse of today is 
 no better prepared to be an aide to a psychiatrist than the 
 ordinary physician is trained to deal with psychopathic cases. 
 Should there not be a group of nurse-like human beings who 
 should be aides to psychiatrists in much the same sense as 
 public health nurses are aides to the public health physicians? 
 On the other hand, should not there be a special group of 
 social workers skilled in the psychiatric side of medical soci- 
 ology? Such a trained mental hygiene aide would be then an 
 assistant to the psychiatrist in medical treatment, — a special 
 type of public health nurse trained in the care of mental dis- 
 eases. She would be equipped with an understanding of social 
 conditions and remedies to the extent that such appreciation 
 of social problems has been found desirable for the public 
 health nurse. She should not be confused with the psychi- 
 atric social worker whose function is to assist in social diag- 
 nosis and treatment under sociological direction. In short, we 
 think it will be possible to show that the point of view of 
 medicine and the point of view of social work are at bottom 
 sundered from each other, so that the physician and the 
 sociologist, the nurse end the social zvorker, the mental hygiene 
 aide and the psychiatric social worker, will always remain per- 
 sons with somewhat separate sentiments. It is worth while 
 to insist that these sentiments though separate are not neces- 
 sarily opposed to one another. It is even possible that within 
 a single personality a worker can be an effective individualist, 
 on the one hand, and an effective social-groupist, on the other ; 
 that one can be both a physician and an applied sociologist 
 successfully; but the success attained will probably be like that 
 in which the right (or medical) hand will not know what the 
 left (or social) hand is doing. 
 
 So much for our theory of the future of education for psy- 
 
560 THE KINGDOM OF EVILS 
 
 chiatric social work. The present practice follows a middle 
 course, — the trained psychiatric social woricer today is not, 
 as a rule, the applied sociologist of Ph.D. grade, nor yet the 
 practical worker bearing the same relation to sociology that 
 the nurse bears to medicine, but something of both. 
 
 The special training courses for psychiatric work now given 
 in several schools (Smith College Training School for Social 
 Work; New York School of Social Work; Pennsylvania 
 School for Social Service) are graduate courses covering a 
 period of approximately two academic years. Such courses 
 approach the requirements for the A.M. degree. There are 
 persons who think that the degrees A.M. and Ph.D. may not 
 reasonably be offered in social work on the ground that such 
 education is practical rather than scientific. Even if it be 
 granted that social work is a form of applied science, there 
 are probably forces at work in a good many universities and 
 colleges that regard with suspicion all science that has the 
 flavor of practicality. 
 
 To meet the demand for social workers for the neuropsy- 
 chiatric hospitals of the army, the plan of the Smith College 
 Training School of Psychiatric Social Work was conceived 
 by us, in 191 8, as a war-emergency course. Intensive courses 
 of instruction were given at Smith College during eight weeks 
 of the summer, and the students were then distributed among 
 four cities — Boston, New York, Philadelphia, and Baltimore 
 — for six months of practice work in various hospitals and so- 
 cial agencies. Some experienced social workers were admitted 
 for the summer course only. The following year Smith Col- 
 lege continued the course as a permanent school under the 
 name of the Smith College Training School for Social Work. 
 The length of the course was changed from eight to thirteen 
 months, and training for other branches of social work also was 
 undertaken. The work falls into three divisions — a summer ses- 
 sion of eight weeks of theoretical instruction combined with 
 clinical observation; a training period of nine months of study 
 and practice carried on in cooperation with hospitals ; and a 
 concluding summer session of eight weeks of advanced study. 
 The summer sessions are held at Smith College, Northampton, 
 Massachusetts. The practical instruction is arranged by plac- 
 ing students with hospitals in different cities, under super- 
 
THE KINGDOM OF EVILS 561 
 
 vision, locally and centrally, by the staff of the Training 
 School. 
 
 This method of preliminary instruction followed by con- 
 tinuous practice was the outgrowth partly of the necessity for 
 training quickly a larger number of workers than could be 
 provided with practice facilities in any one city, and also 
 partly of our experience with an apprentice course given for 
 several years at the Psychopathic Hospital. We found that 
 a student who was on duty continuously, giving full time to 
 case work without the distraction of class work, acquired ex- 
 perience and skill more quickly and more confidently. If the 
 student gives full time in the hospital, is on duty regularly 
 and without interruption, she becomes completely assimilated 
 into the organization and so gains in depth of experience as 
 well as in drill and discipline. Moreover, a student who has 
 received preliminary instruction can from the beginning do 
 more responsible case work. It is doubtful whether prac- 
 tice work with social cases can be carried on satisfactorily 
 along with intensive instruction, for human problems cannot 
 be regulated so that experience will run parallel to theoretical 
 instruction. On the other hand, the concentration of study in 
 two periods at the beginning and end of the practice work 
 permits a high degree of mental application. A thread of 
 theory running through the practice period, in the form of a 
 weekly class, required reading, and preparation of a thesis, 
 serves to unite the two study periods. 
 
 The potential student then should in the first place be a 
 somewhat educated person, that is, the possessor of an A.B. 
 degree or else equally well educated by less formal methods 
 than a full college course. She will need both the qualities 
 requisite for all forms of intellectual work and the qualities 
 requisite for all forms of practical work. Further, she must 
 have the qualities that all social work requires — interest in 
 individuals and a liking to follow them into the scenes of their 
 daily lives, an impersonal attitude, the power of intelligent 
 sympathy, a high degree of disinterestedness, and the capacity 
 for sustained purpose. In addition, the special qualifications 
 that the psychiatric social work requires in a marked degree 
 are patience, analytical ability, and capacity for objective 
 observation. 
 
562 THE KINGDOM OF EVILS 
 
 A course in preparation for psychiatric social work presup- 
 poses the college branches — biology, psychology, sociology, 
 economics, and government. The content of the special grad- 
 uate course given at the Smith College Training School in- 
 cludes social psychiatry, the theory of mental tests, the essentials 
 of medicine, social psychology, government as related to social 
 work, organization of social work, and the theory and practice 
 of social case work. Theoretically it might seem desirable to 
 add such a course to a foundation of one year in general social 
 work, where the student would acquire the technique of social 
 case work and a knowledge of the organization of social work. 
 But there is reason to think that the best results are obtained 
 at present by admitting students at once to specialized training. 
 Schools of social work have not in the past given a place in their 
 general training to principles of mental hygiene, so that train- 
 ing in social work is apt to be deficient in the psychiatric point 
 of view, which it is desirable for the student in psychiatric 
 social work to acquire as early as possible. 
 
 Principles and technique of case work may be acquired as 
 readily in psychiatric cases as elsewhere. Nor is the experi- 
 ence of the student working on psychiatric cases limited to 
 psychopaths, for all the members of the family come within 
 the field of action. 
 
A NOTE UPON LEGAL ENTANGLEMENT AS A 
 DIVISION OF EVIL 
 
 RoscoE Pound 
 
 In civilized society the individual must adjust not only to his 
 fellowmen and to groups of his fellowmen but to the political 
 organization of society and to the legal order. Maladjustments in 
 the latter respect, whether due to fault of the individual or inde- 
 pendent of his fault, whether inevitable because of inherent diffi- 
 culties in the administration of justice through law or remediable 
 by improved and better-operated legal machinery, are Litigia in 
 Dr. Southard's sense. Briefly, he means forms of social malad- 
 justment involving contacts with the law. For he conceives rightly 
 that mere involvement in a legal controversy is an evil, and an evil 
 to which we are naturally subject in society quite as much as to 
 disease or to poverty. The legal machine, like any other machine, 
 in the nature of things will operate mechanically, and in that 
 mechanical operation the just as well as the unjust are likely to 
 be caught. 
 
 Conditions of controversy and legal entanglement may be ag- 
 gravated by or may result from some of the other main types of 
 evil. But as disease or poverty or ignorance may be of inde- 
 pendent non-culpable origin, so conditions of controversy or legal 
 entanglement may arise quite without fault of him who suffers 
 therefrom. Moreover, whether we turn to the reported decisions 
 of the courts, or to the reports of legal aid societies or to the 
 accounts of actual experience of judicial administration of justice 
 which lawyers have put in the form of fiction, we may find abun- 
 dant testimony that those who for any reason become entangled in 
 legal controversy may suffer as acutely, without moral fault on 
 their part, from evils not easily separable from our social and 
 political and legal organization as their fellows who are burdened 
 with disease or poverty, or ignorance. In Ten Thousand a Year 
 and in Farmer Bumpkin's Law Suit, two lawyers have painted 
 in enduring colors what it means to be a party to a hard fought 
 law suit.^ The story may be told no less vividly from the actual 
 
 ^ The effect of protracted litigation in paralyzing the energies and sap- 
 ping the vitality of a litigant is set forth by Dickens in Bleak House 
 and by George Eliot in The Mill on the Floss, 
 
 563 
 
564 A NOTE UPON LEGAL ENTANGLEMENT 
 
 records of the courts. No doubt the social worker encounters legal 
 entanglement as a complication in cases primarily involving other 
 evils. But it may serve better to demonstrate Dr. Southard's point 
 if we look exclusively at cases of legal entanglement pure and 
 simple or cases where involvement in legal controversy is the pri- 
 mary factor. 
 
 One may find himself seriously involved in legal controversy, 
 without fault on his part, either as a matter of pure misfortune or 
 as the victim of the culpable action or inaction of others. In the 
 first category (pure misfortune) four all too common cases may 
 be noted : mistaken identity, circumstantial evidence, the chance 
 that one may be a casual eyewitness of another's crime, and in- 
 heritance of a bona fide litigated claim. The case of Lesurques,^ 
 positively identified by numerous witnesses and executed for a 
 crime of which the event showed he was wholly innocent and for 
 which the real perpetrator was afterwards brought to justice, and 
 of Adolf Beck,^ twice convicted and subjected to imprisonment for 
 crimes with which he had absolutely no connection upon mistaken 
 identifications by the victims and only saved by the apprehension 
 of the real offender for like crimes committee while Beck was 
 in custody, stand out in the annals of the criminal law. But 
 Lesurques and Beck were men of a certain social position, of edu- 
 cation and of some means. How many such cases occur where the 
 accused cannot invoke such resources and thereby bring the in- 
 justice to light we may but conjecture.* At the very least we must 
 admit a potential danger of legal entanglement through mistaken 
 identity as something never to be overlooked. How an innocent 
 person may be the victim of appearances and of circumstantial 
 evidence has been a fruitful theme for dramatists and novelists 
 and is continually illustrated in the courts, despite all provisions 
 for careful deliberate trial of the facts and presumptions of inno- 
 cence.^ Less serious, but bad enough, is the condition of the up- 
 right and busy or upright but indigent citizen who chances to be 
 an important witness to the commission of a felony. Mr. Train 
 has told us from first-hand observation what the witness must go 
 
 ^ As to Lesurques, see Fouquier, Caiuses cclchres de tons les peuples, 
 III, no. 12; I Green Bag, 72. 
 
 * See Report of the Committee of Inquiry into the Case of Mr. Adolf 
 Beck, 1904. Not only was Beck imprisoned for crimes with which he had 
 no connection, but he lost his property through inability to preserve it while 
 in prison. 
 
 * For the more notable older cases of mistaken convictions, see Loeiifler, 
 Die Opfer mangelhaftcr Justic, 3 vols., Jena, 1879. 
 
 "Examples are collected in Hellwig, Jtisticirrtiimer, 1914. For an 
 American case, see People v. Tcipcr, 186 App. Div. 830. Teiper was ac- 
 quitted upon a retrial. 
 
A NOTE UPON LEGAL ENTANGLEMENT 156 ^ 
 
 through with if he is able to give sureties to appear and testify.^ 
 If he cannot give security, he is likely to be committed to jail to 
 secure his appearance as a witness and to suffer almost as much 
 as if he had actually offended." But it is quite as possible to be 
 caught innocently in the mill of civil litigation. One type of case 
 is inheritance of a bona fide litigated claim. Dickens pictured what 
 this means in Jarndyce v. Jarndyce, and the Gaines case in the 
 United States may serve to show how impossible it is for fiction 
 to rival fact. The litigation which occupied the whole of her long 
 life came to Mrs. Gaines as an inheritance in 1813. In 1886 she 
 died at the age of eighty and bequeathed it to her grandchildren, 
 having outlived her children. In 1891 it finally came to an end 
 and the inheritance for which she had struggled all her days came 
 to her heirs. In the meantime the case had been fourteen times 
 before the Supreme Court of the United States and had been 
 fourteen times before the highest state court or the United States 
 Circuit Court on points of sufficient importance to call for reported 
 opinions.^ The reports are full of cases of which the Gaines case 
 is but an extreme example.^ 
 
 As to the second category (cases where one is the innocent vic- 
 tim of the fault or default of others) at least seven important 
 types are of common occurrence, (i) Cases are legion in which 
 the innocent have been drawn into ruinous litigation because of 
 judicial vacillation. Thus the chronicler of the Gaines case tells 
 us : "The decision in 12 Howard being thus overthrown by this 
 last decision, ruin was the consequence to many who confided in 
 its soundness and purchased ... on the faith of that decision." ^° 
 
 * Train, The Prisoner at the Bar, chap. 7, entitled, "If the Cook Should 
 Steal the Teapot. 
 
 ' California endeavored to meet this situation by a constitutional pro- 
 vision that witnesses should not be unreasonably detained. Under that 
 provision it was held that a witness might be released on habeas corpus 
 after he had been held for ninety days and the hearing of the prosecution 
 had been put off repeatedly. Ex parte Dressier, 67 Cal. 257. Compare Ex 
 parte Petrie, i Kan. App. 184. 
 
 * See Payne, A Celebrated Case, 14 Rep. Georgia Bar Association, 219, 
 'E.g., the case of Patience Swinfen, a widow whose father-in-law left 
 
 her his property as a tardy reparation for driving his son from home at the 
 time of his marriage. Nine years of litigation, involving ten reported deci- 
 sions, were required to enable her to hold the property. See Burnham, 
 Some Famous Litigants, 6 Green Bag, 399, 400-402. For an American case, 
 see Giles v. Little, 2 McCrary 370; Giles v. Little, 104 U. S. 291 ; Little v. 
 Giles, 118 U. S. 596; Little v. Giles, 25 Neb. 313; Little v. Giles, 27 Neb. 
 179; Giles V. Little, 134 U. S. 645; Chase v. Miles, 43 Neb. 686; Lincoln 
 Transit Co. v. Rundle, 34 Neb. 550; Roberts v. Lewis, 134 U. S. 153 — 
 thirteen years of litigation over the meaning of a gift to a widow in her 
 husband's will. 
 
 '" 14 Rep. Georgia Bar Association 239. Compare : "But in the mean- 
 time many whose purses were not long enough to keep up the fight yielded 
 
566 A NOTE UPON LEGAL ENTANGLEMENT 
 
 (2) Again the mere delay which is too common in all litigation, 
 may be aggravated to the substantial ruin of litigants.^^ (3) One 
 may be involved in protracted and even ruinous litigation through 
 the roguery of a plausible impostor. The Tichborne case in 
 England, ^yhich charged a goodly inheritance with a burden for 
 generations to come, is the classical example. But the United 
 States may furnish examples of its own.^^ (4) One may also be 
 the victim of a protracted prosecution based on false testimony 
 adduced to shift responsibility from the guilty to the innocent. ^^ 
 (5) Again one may be the victim of governmental dishonesty and 
 be compelled to spend his days in vain endeavors to procure justice 
 from a state that cannot legally be compelled to pay its just obli- 
 gations.^* (6) One of the most common types is willful aggres- 
 sion which compels him whose rights are infringed to engage in 
 prolonged and expensive litigation whether he will or no. Thus 
 it often happens that the victim of a malicious defamation or a 
 malicious prosecution must vindicate his reputation and his honor 
 in order to live a human life among his fellowmen. A striking 
 instance of what this may involve is afforded by the well-known 
 Jones County Calf Casc}^ In that case a farmer who had been 
 maliciously prosecuted by an organization found himself entangled 
 
 to judgments in ejectment in the federal court based on the first opinion in 
 the federal Supreme Court, and sued their grantors upon covenants of war- 
 ranty. As these grantors had not felt able to continue the litigation, they 
 were compelled to pay damages, although, in the event, they had conveyed 
 a good title." Pound, Principles of Procedural Reform, 4 Illinois Law 
 Rev. 491, 492-494 (referring to the litigation described at the end of note 9). 
 
 ""Hundreds of causes were remaining to be heard; thousands of 
 suitors had abandoned proceedings, and many were ruined under grievous 
 oppression merely because they were unable to afford the money or the time 
 necessary to enable them to proceed. Even those who found the means and 
 expended the money and time necessary to get their causes ready for hear- 
 ing, were kept in suspense for an unreasonable length of time, uncertain 
 whether they were thereafter to be rich or poor; many,_ f rom the tardy 
 steps of justice, were unable to form or settle their plans in life, and were 
 kept in a state of the most harassing wretchedness." Duffus Hardy, Life 
 of Lord Langdale, I, 349. 
 
 "E.g., Flora v. Anderson, 75 Fed. 217. For a sketch (founded on 
 fact) of the position in which innocent persons may be put by a plausible 
 impostor, see Mark Twain, The Major's Story. 
 
 "Those who have studied the case attentively believe the Frank case to 
 be one of this sort. See Connolly, The Truth about the Fralnk Case, 1915. 
 
 " Mark Twain has given us a picture of the condition of such a victim 
 in The Great Beef Contract. See Fleischmann, The Dishonesty of Sov- 
 ereignties, 22 Rep. N. Y. State Bar Association (1910), 229. Compare the 
 twenty-six years of litigation to which holders of coupons of Virginia bonds 
 were subjected, McCullough v. Virginia, 172 U. S. 102, and prior cases set 
 forth in the opinion of Mr. Justice Brewer. 
 
 ^Proceedings, Iowa State Bar Association (1920), 141-156. 
 
A NOTE UPON LEGAL ENTANGLEMENT 567 
 
 in twenty-five years of bitter litigation and was able to clear his 
 character only through persistence under discouragements which 
 would have worn out an ordinary litigant. (7) Finally there are 
 cases of what may be called parasitism — cases where swindlers and 
 extortioners, who have learned the possibilities of using the ma- 
 chinery of the law as a means of oppression, deliberately involve 
 their victims in legal entanglements, in the confidence (often but 
 too well founded) that they are too poor or too ignorant or too 
 busy to be able to extricate themselves and will thus become an 
 easy prey. The reports of Legal Aid Societies are full of such 
 cases. ^^ The innocent man of scanty means but high sense of duty 
 who seeks to help a near relative out of trouble and finds himself 
 caught in the web of litigation, the wage-earner whose wages are 
 held in an illegal attachment in the endeavor to take advantage of 
 his necessities and coerce him into what he is not bound to do, the 
 innocent victim of get-rich-quick swindlers who invests his savings 
 in worthless "securities" and finds himself involved in elaborate 
 winding-up proceedings, the loyal friend or relative who becomes 
 surety for a borrower from an unscrupulous and exacting lender 
 at extortionate interest — all these are but too well known. 
 
 It will not do to say that the state provides an elaborate and 
 expensive machinery for administering justice and that the law 
 operates to prevent conditions of controversy with one's fellowman 
 from being or becoming a serious type of evil. Public agencies for 
 preventing or suppressing vice, public health service, public poor 
 relief and public education do not prevent us from recognizing that 
 vice and disease and poverty and ignorance are evils with which 
 civilization must contend. Strife is one of the oldest evils in social 
 history and is the one toward which politically organized society 
 first directed its powers. Yet the legal order has but mitigated this 
 evil. It is by no means abolished. Moreover, the machinery 
 which the state has set up to obviate strife and put an end to 
 controversies has many possibilities of injury for the innocent, the 
 unwary and the impecunious. In part these possibilities of injury 
 are inseparable from legal administration of justice ; they grow out 
 of difficulties of proof and infirmities of judgment which are in- 
 cident to human action. In part they are due to reparable defects 
 in our legal system and judicial organization. In either event con- 
 ditions of legal entanglement, involved in the endeavor of the state 
 to put down strife, adjust controversies, and administer justice, are 
 not the least of the evils with which men must reckon in social 
 life and of which, therefore, the social worker must take account. 
 
 ^^ See Smith, Justice and the Poor, gff. 
 
APPENDICES 
 
APPENDIX A* 
 
 Case 46 
 PSYCHOPATHIC HOSPITAL 
 
 SOCIAL SERVICE 
 NUMBER 2004 
 FILE NUMBER 7938 
 
 0. P. D. NUMBER 3562 NAME Harold Gordon t 
 
 Residence Soldiers' Home, Derby, Mass. 
 
 Correspondent Mrs. Bessie Driscoll, 49 Glenwood St., Chelsea 
 
 Sex M Age 45 Color W. 
 
 Civil Condition S Place and Date of Birth U. S. 
 
 Religion P Occupation Steamfitter 
 
 Time in Boston 45 In Mass. 45 In U. S. 45 
 
 Previous addresses 
 
 When known to social service 1/16/18 
 When discharged from social service 7/1 /i8 
 Reason for being known to social service Employment 
 Report from confidential exchange No record 
 
 Name of father George Gordon 
 
 Address 61 Jackson St., Maiden, Mass. 
 
 Name of mother Jennie Drake 
 
 Address 972 Irving St., Chelsea, Mass. 
 
 Name of spouse 
 
 Address 
 
 Names and ages of children or siblings 
 
 Admitted to house 1/4/17 Authority Vol. 
 
 Discharged 1/10/17 Admitted to O. P. D. 1/16/18 
 
 Diagnosis Luetic hemiplegia ; Condition 
 Vascular lues 
 
 Social symptoms Date 2/5/18 
 
 Cohabitation 
 Industrial disability 
 Unemployment 
 
 Social diagnosis Disease Date 1/20/18 
 
 * These case records are printed as written by the social workers without revision, 
 f All names used in this record arc fictitious. 
 
 571 
 
^7^ 
 
 APPENDIX A 
 
 PSYCHOPATHIC HOSPITAL 
 
 SOCIAL SERVICE 
 CASE NO. 2004 
 
 FILE NO. 7938 NAME Harold Gordon 
 
 ADDRESSES 
 Patient: 
 
 Soldiers' Home, Derby, Mass. 
 49 Glenwood St., Chelsea. 
 
 Relatives and friends: 
 
 Brother-in-law, George Price, 
 
 12 Newbury St., Charlestown, Mass. 
 
 Brother-in-law, Xavier Price, 
 
 27 Tuttle St., Charlestown, Mass. 
 
 Patient's mother, Mrs. Jennie Gordon, 
 972 Irving St., Chelsea, Mass. 
 
 Patient's father, George Gordon 
 61 Jackson St., Maiden, Mass. 
 
 Paternal aunt, 61 Jackson St., Maiden, Mass. 
 
 Employers: 
 Mr. Yale, 
 SYz Glenwood Court, Boston, Mass. 
 
 Young & Daniels, 
 
 241 East 52nd St., New York City. 
 
 Mr. David F. Hyde, F. Q. Crawford Co., 
 Quint St., Boston, Mass. 
 
 Patient's wife's employer: 
 Mrs. Howell, 
 73 Quirk St., 
 Chelsea, Mass. 
 
 Patient's wife: 
 
 Bessie Driscoll, 
 
 49 Glenwood St., Chelsea. 
 
APPENDIX A 
 
 573 
 
 CASE NO. 2004 
 FILE NO. 7938 
 
 PSYCHOPATHIC HOSPITAL 
 
 SOCIAL SERVICE 
 
 NAME Harold Gordon 
 
 EXPENSE SHEET 
 
 Paid 
 1/23 Marriage certificate. .. .$ 1.02 
 
 1/29 Loan 50 
 
 5/1 Wedding 11.00 
 
 12.52 
 
 Received 
 
 2/6 From patient $ .50 
 
 5/1 " " i.oo 
 
 S/io " " 11.02 
 
 12.52 
 
 CASE NO. 2004 
 FILE NO. 7938 
 
 PSYCHOPATHIC HOSPITAL 
 
 SOCIAL SERVICE 
 
 NAME Harold Gordon 
 
 SUMMARY 
 1918 
 
 January 20. 
 Social History: 
 
 Patient is a single American man 45 years old, a veteran of the Spanish 
 War. He lives at the soldiers' home, Derby. There are no expenses 
 incurred there and patient has a little money which he has received from 
 the Steamfitters' Union. Patient is a steamfitter by trade and for 11 
 years prior to illness worked as such, making approximately $5 a day. 
 In October, 1916, patient became ill and as a result now drags one leg 
 and is slow and awkward on his feet. Patient's mother lives alone on 
 Irving St., Chelsea, having 3 small tidy rooms. She has a small saving 
 of her own. Patient's father was a Civil War veteran. Lives with his 
 sister in Maiden, Mass. The separation from his wife was due to the 
 fact that patient's mother wanted him to go to Maine to live with his 
 married daughter. Patient's father refused and, as a result, patient's 
 mother went to Maine without him. She apparently is a difficult woman 
 to get along with and soon friction occurred between her and her son- 
 in-law ; as a result she came back to Chelsea and, disliking patient's sister, 
 has refused to go to Maiden, She feels that her husband should come 
 
574 APPENDIX A 
 
 to her and says that his pension is being used to help take care of his 
 sister. Patient visits his mother every little while. 
 
 Patient has been having sex relations w^ith Mrs. Driscoll, a widow 
 with a daughter 13 yrs. old. She lives at 49 Glenwood St., Chelsea. 
 Patient stays two or three nights a week and Mrs. Driscoll is now prob- 
 ably pregnant by patient. Patient claimed at first that he was married, 
 but later confessed that he was not. Mrs. Driscoll does housework by the 
 day two or three days a week and her brothers pay her rent. Her 
 brothers are wealthy ; one owns a machine and is manager of the Hartford 
 Tire Company on Coolidge St, 
 
 Physical History: 
 
 October, 1916, patient had a shock and was taken to the City Hospital. 
 January, 1917, patient came to this hospital and was under treatment for 
 neurosyphilis and has reported regularly for treatment. He claims to 
 have had syphilis 18 yrs. ago. When patient first came to us he was 
 practically crippled and could not use his arms or legs to any extent. 
 Now he has control of his arms and control of one leg. He must report 
 regularly for treatment. 
 
 Mental History: 
 
 October, 1916, patient became very dizzy and confused; felt that he 
 might throw himself into a furnace when he attempted to throw wood in. 
 He was admitted to this hospital in January. Shortly after his admission 
 his confusion subsided and there have been no returns of symptoms. 
 Since, he has apparently been a steady worker and faithful, working 
 better, however, as an assistant than when sent off on a job of his own. 
 MN 
 
 RESULTS 
 
 January 18 to April 18, 1918. 
 Social: 
 
 Patient and woman with whom he had been having irregular sex 
 relations were married February 9. the money for the wedding service 
 being loaned by the Social Service Department. Patient's wife was ex- 
 amined at the Boston Dispensary and suspected of being 2 months' preg- 
 nant. Patient's brother-in-law feels that patient's wife has always been a 
 drag on them and they wish they might be well rid of her. Felt that her 
 marriage would merely mean one more person to support. They refuse to 
 assist her in any way if she marries, but later promised visitor that if she 
 loaned money to them they would be ready to pay it back should patient 
 fail, but felt they should at first be made to understand that they must 
 stand on their own feet. Patient and wife have moved to an apartment at 
 5 Yale Terrace; the rent is $35 a month, but as they do janitor work they 
 receive same rooms for $20. Work has been obtained for patient, F. Q. 
 Crawford & Co., and patient is making between $17 and $18 a week. He 
 has been raised and is now second to the foreman. There is a chance for 
 overtime work with extra pay, but patient tires easily and has not yet done 
 any overtime. 
 
 Physical: 
 
 Patient reports regularly for treatment and is improving. 
 
APPENDIX A 575 
 
 Mental: 
 
 Patient slowly improving. Feels better and gets tired less easily. He 
 hopes soon to be able to take up his old work as steamfitter. He has had 
 a position ofifered to him, but felt that he should not undertake it just yet. 
 Patient shows poor judgment, especially in money matters. He has a 
 happy attitude that everything will be all right and will occasionally spend 
 money for a steak and be obliged to borrow money for food the next 
 couple of days. Patient is rather proud of himself for having stuck by 
 his wife and married her. He occasionally will say, "H I hadn't done this 
 for Bessie I need not have worked ; I could have stayed at the soldiers' 
 home all my life, they would have had to take care of me." On the other 
 hand patient seems proud of the fact that he is able to support a home and 
 does not want his wife's brothers to think he has any intention of sponging 
 on them. 
 MN 
 
 HISTORY 
 1918 
 January 16. 
 
 Patient's story: Patient and alleged wife. Airs. Bessie Driscoll, seen 
 together at hospital. Patient states that he is living at the Soldier's Home 
 in Derby, being a veteran of the Spanish War. He is without any visible 
 means of support. His wife is living at 49 Glenwood St., Chelsea. She 
 has three rooms, for which her two brothers, living in Charlestown, pay 
 $15 a month rent for her. She has one child, now 11 years old, by her 
 first husband. Patient claims he was married about six months ago, but 
 cannot give the exact date or place of ceremony. He is a Protestant, and 
 his wife is a Catholic. His wife claims to be about two months pregnant, 
 at least she has had no menstrual periods for the past two months. She 
 talks of having an abortion, but apparently has no real intention of doing 
 so. 
 
 Patient is a steamfitter by trade, having worked steadily for Mr. Yale, 
 5H Glenwood Court, Boston, 11 years ago, then going to New York City, 
 working there for Young and Daniels, for 10 years. He returned then to 
 his former employer, where he worked until he was taken ill in October, 
 1916. 
 
 Patient tells of how crippled he was one year ago, — even six months 
 ago, — and how slowly and gradually he has regained the use of his arms, 
 and how he feels encouraged that before long his left leg will be cured. 
 
 Names and addresses of friends and relatives were obtained. Visitor 
 promises to look up possible openings whereby patient may make use of his 
 trade without the undue fatigue which would occur were he to resume 
 steamfitting. 
 
 Patient is well groomed, pleasing in appearance, affable personality, 
 though somewhat apathetic. Mrs. Driscoll appears nervous, less intel- 
 ligent, and less attractive. 
 
 January 18. 
 
 Soldiers' Home, Derby, Dr. Pearson, visited. Informant states that 
 patient has been under their care from Jan. 25, 1917, to the present time. 
 As a Spanish War Veteran, he is entitled, while disabled, to receive room 
 and board free. He receives no pension, but is permitted to leave prac- 
 
5/6 
 
 APPENDIX A 
 
 1918 
 
 tically whenever he requests. Patient as a rule receives a pass for the 
 duration of two or three days a week. 
 
 Informant considers patient irresponsible, claiming that he put him 
 on a job to run an elevator, the pay being $8 a month, and patient went ofif 
 several times, leaving the elevator with no one to man it. This was done 
 in spite of the fact that informant explained to him how embarrassing it 
 was at mealtime to have no elevator in order to assist the feeble men to 
 and from their meals. Patient seemed indifferent, and after three or four 
 months on the job, informant took someone else. Informant states that 
 it will be nearly impossible to find work for a man of patient's type. 
 
 January 18. 
 
 Impression: Somewhat cynical, but willing to cooperate in any pos- 
 sible way. 
 
 January 18. 
 
 Employer, Mr. Yale, 5^ Glemvood Court, visited. Informant states 
 that patient was a good worker, steady, no drinking, and that he would 
 take him back to-morrow at $5.50 a day, if patient would come. He states 
 that patient did his best work when he was on a job with others. If 
 given a small job to do himself, informant felt responsible to oversee the 
 job. He stated that probably patient could not take charge of men, but 
 was a willing and energetic and fast worker. 
 
 hnpression: Informant seemed to have no interest in patient as an 
 individual, but would be interested if patient were physically able to work, 
 as there is a great demand for steamfitters at the present time, 
 
 MN/S 
 
 January 18. 
 
 City Hall lisited. No record of marriage certificate is recorded. 
 
 January 18. 
 
 Alleged xvife, Mrs. Bessie Driscoll, 49 Glemvood St., visited. 
 
 Informant stated that she had known patient for about two years, and 
 told that she was not married to patient of her own accord. During this 
 time she has been having intercourse with patient, and claims that her 
 standing by him after he had had the paralytic stroke is one big factor in 
 patient's recovery. 
 
 Patient visits informant about once a week for a period of two or three 
 days. Informant claims to be without passion, and that patient is very 
 easily excited. Informant states that she does cleaning two or three days 
 a week, which gives her $4 to $5. Her two brothers pay her rent, and 
 their wives give her shirtwaists, and help her out in little ways. She has 
 one child dependent upon her. Her attitude toward her brothers is that 
 they must not know her condition until after she is married, because, as 
 she says, "they look up to me, and know I know better." She states that 
 they are better educated than she is, — that they went to High School and 
 business colleges. She went only as far as the 8th grade, being 16 years 
 old when she left. During her schooling she was obliged to be out long 
 periods of time owing to illness of first her own mother, and then of her 
 step-mother. Her step-mother died when she was 16, and she brought up 
 her two brothers. Six years later she married, and two years later, at the 
 time of her confinement, her husband was electrocuted at work. The 
 brothers take the little girl at times, as for vacations ; and once, four years 
 ago, when informant had an operation at the Boston City Hospital for 
 fallen womb. As soon as patient is able to work informant is willing to 
 
APPENDIX A 577 
 
 1918 
 
 marry, but does not wish to give up $15 a month, three attractive rooms, 
 etc., with no apparent means of support ahead. She feels also that patient, 
 who has a big appetite, had better stay at the Soldiers' Home until he gets 
 work. Informant states that patient's mother, living at 972 Irving St., 
 Chelsea, is very hard to get along with. She calls her "an indifferent, old- 
 fashioned Yankee, who cares more for the dollar than for anything else." 
 She states that patient's mother is jealous because she feels that when 
 patient gets to work he is going to give money to informant rather than 
 to her. Patient's mother has a small income of her own which enables 
 her to be independent. Patient's mother was in Maine visiting her only 
 daughter. Her husband refused to go to Maine, and he is now living with 
 a sister in Maiden. 
 
 Second impression: Informant seemed excited over her condition, 
 not for her own sake or reputation, but because of her family. She 
 appears more kind-hearted and intelligent than at the first interview. 
 
 January 23. 
 
 Patient's mother, Mrs. Jennie Gordon, 9/2 Irving St., Chelsea, Mass., 
 visited. Informant has three basement rooms in a congested district, but 
 the rooms are immaculately neat — even the floor looking as if scrubbed 
 daily. Informant is a frail, delicate-appearing woman. She gave for her 
 reasons for living alone that her married daughter's husband in Maine did 
 not really want her, so she thought she would come back to Chelsea. 
 She went to see her husband at his sister's, 61 Jackson St., Maiden, Mass., 
 and invited him to come and live with her. This was six months ago, and 
 he has never been to see her. She claims that he is feeble, and is in- 
 fluenced by his sister who wants, and probably needs, his pension of ^33. 
 He is a Civil War veteran. She says she does not know whether or not 
 she would live with them if they wanted her to. She has small savings of 
 her own, and realizes that she is entitled to share in her husband's pension. 
 
 Patient was spending the day with his mother. He took the "laissez 
 faire" attitude that everything would be all right when he went to work. 
 
 Patient walked out with visitor, and was asked what plans he had 
 made about marriage, etc. He promised, to see "Bess" and talk the matter 
 over with her. 
 
 February 5. 
 
 Brothers of patient's fiancee, George and Xazier Price, Hartford Tire 
 Co., 851 Coolidge St., visited. George is the manager and has an office to 
 himself. Xavier very prosperous looking. Informants stated that Mrs. 
 Driscoll had never been able to support herself, and that they had for years 
 paid her rent and given her a little money besides. Stated that they had 
 no use for patient, felt that they did not want him in their home, because 
 they knew that their sister had had a Wassermann taken and felt 
 that sexual relations must have taken place between her and patient. In- 
 formants asked if they would back the loan for the wedding fee. Xavier 
 stated that when they made out checks for this month's rent he would put 
 in some extra money. George said he would too, but on second thought 
 they both said they thought it would be better for patient to understand 
 that he could not get any help from them and both refused, stating, how- 
 ever, that if visitor loaned the money and did not get it back they would 
 pay visitor, but did not want their sister to know. They feel if their sister 
 marries it only means one more for them to care for. They want the 
 marriage plans discontinued. Mrs. Driscoll's condition is ascertained and 
 brothers both agree that marriage is the wisest thing. 
 MN/MCW " " - 
 
5/8 APPENDIX A 
 
 ACTION TAKEN 
 1918 
 
 Patient to report at regular stated intervals, at present two weeks 
 apart, for medical treatment. Patient to get lighter work. 
 
 January 23. 
 
 Eviployer, Mr. David F. Hyde, Supt., F. Q. Craivford Co., telephoned 
 to. Informant states that he would interview patient in regard to work. 
 Patient sent with note to Mr. Hyde. See letter No. i. Employer, Mr. 
 Hyde, telephoned visitor. He stated that he would employ patient pro- 
 vided a recurrent stroke was not likely to occur, as they have insurance 
 for employees over a limited period of time, and he did not wish to employ 
 men if the risk was too great. Visitor had informant connected with 
 Dr. Traiser by phone. 
 
 January 23. 
 
 Patient seen at Men's Club. He states that he is to begin work at the 
 F. Q. Crawford Co. to-morrow, salary $15 a week. 
 
 January 24. 
 
 Patient's fiancee, Mrs. Driscoll, taken by visitor to the Gynecological 
 Clinic of the Boston Dispensary. Dr. Kellogg examined her. Patient is 
 probably three months pregnant, and is to return in one month. Mrs. 
 Driscoll wants to get married quietly. This costs $16, $11 if announced 
 three consecutive weeks in the church. Application for license made at 
 the City Hall. License may be obtained on the 29th. 
 MN/S 
 
 January 29. 
 
 Patient to clinic. Seen by Dr. Traiser. Patient not to return for 3 
 weeks. Patient said that his work was lighter than steamfitting. Patient 
 promised loan for wedding fee. Patient loaned $0.50. Patient stated that 
 "Bess" had been to Worcester to attend the funeral of her uncle. 
 MN/MCW 
 
 January 30. 
 
 Patient to Men's Club. Patient enjoyed himself and talked a good 
 deal of the time. The conversation was on the war and patient remi- 
 nisced on the Spanish war. 
 
 MN/MCW 
 
 January 30. 
 
 Patient's fiancee, Mrs. Driscoll, visited. Says patient is to be married 
 on the nth. Is much upset about patient's disregard for rnoney. She 
 anticipates quarrels on the subject after they are married. Said the $0.50 
 visitor gave him on way to work he spent, saving only. $0.05 and expected 
 her to give him money to go to work on next day. 
 MN/MCW 
 
 February 5. 
 
 Patient's fiancee's brothers called on. They are willing to help if the 
 sister asks them to help, but feel that patient should handle his own afifairs. 
 
 Impression: Fair-minded but disgusted with their sister and what has 
 been going on between her and the patient for some time. 
 MN/MCW 
 
 February 6. 
 
 Patient's fiancee, Mrs. Driscoll. to hospital. In an upset condition 
 bcrause patient had struck her daughter. Thinks she canngt marry 
 
APPENDIX A 579 
 
 1918 
 
 patient and that it is best for her to have an abortion. Feels that if 
 patient continues to spend money as he does now that they will soon be 
 in debt if they are married. Patient advised not to marry if she feels 
 that way and told of agencies that can help her if she does not marry. 
 MN/MCW 
 
 February 6. 
 
 Employer, Mr. Hyde, seen. Employer stated that patient was a good 
 worker and that he would see that he received a raise. The raise would 
 be $0.02 an hour, giving patient $0.33 an hour. 
 
 February 8. 
 
 Cooperative Work Shop, Miss Manson, telephoned to. Promised to 
 consider the case and have visitor get Mrs. Driscoll some work. 
 
 February 9. 
 
 Visitor called on Mrs. Driscoll. Mrs. Driscoll stated that patient had 
 been very kind to her and her daughter and they would be married at eight 
 o'clock on the nth. 
 
 February 11. 
 
 Visitor attends ivedding at St. Francis' Church and gives patient check 
 for $11, wedding fee. 
 MN/MCW 
 
 February 13. 
 
 Cooperative Work Shop, Miss Manson, telephones that patient has 
 received work. 
 
 February 13. 
 
 A worker in training takes her washing to patient's wife. 
 
 February 20. 
 
 Visitor called. Patient's wife stated that her brothers had not helped 
 her out on this month's rent, but that she and patient were saving so that 
 they could pay it soon. Patient's wife promises to go to the Lying-in 
 Hospital to-morrow. 
 
 March 2. 
 
 Patient's zmfe brings in Steamfitters' Union papers to be filled out 
 by administrator. 
 
 March 6. 
 
 Papers filled out by Dr. Phillips, stating patient treated here for 
 neurosyphilis and under treatment since Jan. 21st. 
 MN/MCW 
 
 March 16, 
 
 Wife in. Stated that patient is 2nd in charge of his room. That he 
 and foreman like each other very much, 
 
 MN/MCW 
 
 March 25. 
 
 Cooperative Work Shop, Miss Manson, telephoned to. States patient's 
 wife has been in 3 times for work; does not work well, but she improves 
 each time. She has asked for work for her husband's mother. Visitor 
 stated what she knows about patient's mother. 
 MN/MCW 
 
 April 10. 
 
 Patient in for treatment. Patient stated that he is feeling better and 
 that family are now living at 5 York Terrace, Chelsea. Have 5 rooms, 
 
58o 
 
 APPENDIX A 
 
 1918 
 
 electric lights and steam heat, for which they pay $20 a month. Rent is 
 really $35 but they do the janitor's work for the balance. Patient states 
 that he earns about $16.50. He could make more money, but gets tired and 
 therefore does little or no overtime work for which he would get 1J/2 extra. 
 Patient hopes soon to be able to return to steamfitting, but promises not 
 to do this until the doctor feels it is the wisest and best thing to do. 
 Patient stated that wife will not go to the Lying-in Hospital. She will 
 either go to St. Catherine's Hospital or be confined at home. 
 
 Visitor has urged patient's wife to go to the Lying-in Hospital, but 
 she has many friends who have been to St. Catherine's and she can be 
 confined by a Catholic doctor. Patient's wife is persistent in this in spite 
 of the fact that Miss Dean, Supt. of the Lying-in Hospital, says she might 
 have a Catholic priest called in if she so wished. 
 
 Patient stated that they had had no help from wife's brothers and 
 that they were not looking for it and did not want it. Said that they v,^ere 
 planning to visit them some time, but that they felt that since the brothers 
 owned autos they could take the initiative. Patient working and improving 
 and shows no mental disorder and they are both capable of making their 
 own plans. Patient reports regularly for treatment. $11 to be collected. 
 MN/MCW 
 
 May I. 
 
 Patient in for treatment. Gave visitor $1 on $11 owed for wedding 
 fee. Patient very much pleased with new apartment, but feels they will 
 have to move before another winter as the boilers are not sufficient to give 
 enough heat to the entire building. Patient claims that his wife has the 
 money. He does not know what she does with it, but he is constantly 
 after her to pay the visitor back. He says she is pretty stingy and said 
 he had to pay for 2 treatments in order to get the extra $1 so that we 
 could start in paying visitor. Will try to bring more soon. 
 
 May 10. 
 
 Patient in. Paid balance of $11.02. 
 
 May 13. 
 
 Patient's zvifc in. Patient's wife delighted with new apartments. Feels 
 now that as soon as a few more dishes, etc., are obtained she can invite her 
 relatives to come and see her. They have none of them been to see her 
 since she was married. She wants to have everything fixed up and then 
 invite them. H they refuse, well and good; she won't bother them any 
 more. She seems very proud of the fact that she has never asked them for 
 money since she was married. Informant is 6 months pregnant, but as yet 
 has not felt any life. Has an appointment with a private doctor who will 
 confine patient at St. Catherine's. Will let visitor know results. Liformant 
 does not believe she is pregnant. Informant is anxious that husband ob- 
 tain work in some other department, as she feels that working in the base- 
 ment is not good for him. She says that he gets very, very tired. As yet 
 they have received no money from the Steamfitters' Union and seem to 
 feel that now they may not. Informant has some money saved up toward 
 confinement expenses, but promises to bring in money for visitor. Visitor 
 urged upon her the importance of this, stating that she probably would 
 have less money rather than more later on. 
 MN/MMM 
 
 May 13. 
 
 Patient to clinic. Patient is anxious to obtain new work. He feels 
 that dampness where he is working does not agree with him. Visitor 
 
APPENDIX A 581 
 
 1918 
 
 refers him to Mr. Shackley of the Y. M. C. A. and gives him notes to 
 
 Mr. Young, Library Bureau, and to Mr. Nason, Simplex Company, 
 
 Danvers. 
 
 June I. 
 
 Case closed: Patient has shown no mental symptoms and seems well 
 pleased, industrious, and able to obtain a new job whenever he wishes to. 
 His wife is expecting confinement soon, has money saved up to see her 
 through, and is insistent upon having a private Catholic doctor and refuses 
 to go to B. L. I. or in fact to any hospital. 
 
 Patient reports regularly for treatment and is told to let visitor know 
 if he gets into difficulties. 
 MN 
 
582 
 
 APPENDIX A 
 
 Case 89 
 PSYCHOPATHIC HOSPITAL 
 
 SOCIAL SERVICE 
 NUMBER 293s 
 FILE NUMBER 1 1 201 
 
 0. P. D. NUMBER NAME Joseph Fangillo * 
 
 RESIDENCE 28 Central Ave., Arlington 
 Correspondent Mrs. Theresa Fangillo 
 
 Sex M Age 42 Color 
 
 Civil condition M Place and pate of birth 
 
 Religion C 3/4/1876 
 
 Time in Boston Life Occupation Bookkeeper 
 
 Previous addresses Long St., Mat- In Mass. Life In U. S. 
 
 tapan 
 
 When known to social service 1/28/19 
 
 When discharged from social service 
 
 Reason for being known to social service History 
 
 Report from confidential exchange No record 
 
 Name of father Henry C. (deceased) 
 
 Address 
 
 Name of mother Nell Bonelli (deceased) 
 
 Address 
 
 Name of spouse Theresa Costelli 
 
 Address 28 Central Ave., Arlington 
 
 Names and ages of children or siblings 
 
 W 
 Boston, 
 
 Life 
 
 Children : 
 John— 13 
 Emma — 4J^ 
 
 Admitted to house I, 1/24/19; 
 
 II, 2/24/19; III, 4/9/19 
 Discharged 1,2/13/19; 11,4/5/19; 
 
 III, s/8/19 
 
 Siblings : 
 
 Mrs. Bonelli — about 50 
 
 Theresa — about 45 
 
 Antonio — about 47 
 
 Mrs. Cavalaro 
 
 Mrs. Mardini 
 Authority I Vol., II Vol., Ill 
 
 Vol. 
 Admitted to O. P. D. 
 
 Recovered 
 Unimproved 
 
 Diagnosis I. Manic Depressive Condition I. 
 II. Psychasthenia De- II. 
 
 pressed 
 III. Psychasthenia 
 Social symptoms Date 3/1/19 
 
 Unemployment 
 Industrial decline 
 Worry 
 Social diagnosis Disease Date 3/1/19 
 
 * All names ttsed in this record are fictitious. In this case an unusually detailed 
 record was kept, as it was one of a group of cases included in a study of the psy- 
 chopathic employee in industrv. 
 
APPENDIX A 583 
 
 PSYCHOPATHIC HOSPITAL 
 
 SOCIAL SERVICE 
 CASE NO. 2935 
 
 FILE NO. II20I NAME Joseph Fangillo 
 
 ADDRESSES 
 Patient's telephone: 
 
 Can be reached at Arlington 2640 
 
 Mrs. Giordani, 
 
 28 Central Avenue, 
 
 Arlington, Mass. 
 Family Physician: 
 
 Dr. Sullivan 
 
 Arlington 1786 
 Patient's sister: 
 
 Mrs. Bonelli, 
 
 97 Main St., 
 
 Boston. 
 Patient's brother: 
 
 Antonio Fangillo, 
 
 Bradbury, Vt. 
 Patient's sister: 
 
 Mrs. Cavalaro 
 
 Hamilton St., 
 
 Chelsea, Mass. 
 Patient's cousin: Place of employment: 
 
 Nicholas Tosi, 60 Manhattan St., 
 
 930 Hamberg St., Boston, Mass. 
 
 Dorchester, Mass. 
 
 Tel. Dorchester 946-W 
 Wife's sister: 
 
 Mrs. Jennie Riley, 
 
 43 How^ley St., 
 
 Roslindale, Mass. 
 Patient's wife's another: (Can be reached by telephone of 
 
 Mrs. Costelli, neighbor in same house — Beach 
 
 10 Victoria St., 1459-M) 
 
 Boston, Mass. 
 Wife's sister: 
 
 Bertha Costelli, 
 
 10 Victoria St., 
 
 Boston, Mass. 
 Patient's sister: 
 
 Mrs. Mardini, 
 
 Cedar St., 
 
 Cambridge, Mass. 
 Patient's sister: 
 
 Theresa Fangillo 
 
 Lives with her sister, Mrs. Mardini. 
 
5^4 
 
 APPENDIX A 
 
 PSYCHOPATHIC HOSPITAL 
 
 SOCIAL SERVICE 
 CASE NO. 2935 
 
 FILE NO. II20I NAME Joseph Fangillo 
 
 SUMMARY 
 
 1919 
 
 February 12. 
 Social: 
 
 Patient is a man of 42 — born in Boston of Italian parents. He com- 
 pleted a 3-year high school course at 15, and then took a year of advanced 
 work there, after which he completed a business course of 6 months. 
 
 He then did various kinds of office work, followed by bookkeeping. 
 He was a bookkeeper for the Stratton Piano Company, Boston, for 16 
 years, starting at low wages and working up to $35 a week. 
 
 After being for 2 months in 191 1 at the Boston State Hospital, he 
 spent 2 summers on a small farm in Bradbury, Mass., which he has partial 
 use of for ^2^ a year. Then for a year he was manager at the Marko 
 Cafe. For the past 3 years he has been one of three partners in a liquor 
 concern which proved fairly successful, each member clearing $1,000 a year 
 in addition to his salary. Patient withdrew from this work before Christ- 
 mas, 1918, and has been without a position since. 
 
 Patient is married, having a son, 13, in high school, and a daughter, 
 4^, at home. Family rents a 4-room flat in Arlington for $14 a month. 
 The rooms are on the first floor and sunny, neat, and comfortably fur- 
 nished, and there is a fair-sized garden. 
 
 Physical: 
 
 Patient's mother died of spinal meningitis. Otherwise the family 
 history is not of interest, except perhaps the fact that patient's brother had 
 a breakdown 15 years ago similar to patient's. 
 
 As a child patient had typhoid and diphtheria, and 2 accidents. In 
 one he was run over and his legs were in a plaster cast for 9 months. 
 There are no results now. In the other his head was hit. 
 
 He is of strong build and is in good physical condition at present. He 
 has worn glasses since 19 years of age, his eyes having troubled him more 
 than usual of late. They have been treated only by an optometrist who 
 says his vision is low but perfect with lenses. The 'Wassermanns of his 
 blood and spinal fluid are negative. He admits gonorrhea and soft chancre 
 years ago for which he had treatment. 
 
 Mental: 
 
 Patient was a good student at school. He was graduated from a 
 3-year course at high school at 15, and then took a 4th year there followed 
 by a business course of 6 months. 
 
APPENDIX A 585 
 
 I919 
 
 His work at the Stratton Piano Company was responsible work, and 
 patient had the ability to keep the position until 6 years ago. He has 
 always been inclined to worry, however, and about 10 years ago developed 
 a sex phobia, becoming afraid even to meet women on the street. This 
 worried him excessively. He has always been especially fond of outdoor 
 sports and of reading both fiction and books on economics. His wife had 
 urged him to mix more with others although he has not been especially 
 seclusive. 
 
 In 191 1 he became nervous and fearful, and at the advice of his private 
 physician left work and went voluntarily to the Boston State Hospital 
 where he was given a diagnosis of psychasthenia. While there he had 
 hydrotherapeutic treatment. After 2 months' care there, he was discharged 
 and went to work on his farm oil and on for 2 or 3 years. 
 
 Patient has always been of even disposition, not moody, enjoying com- 
 panj-, though being somewhat quiet. He enjoys his home, children, and 
 reading. He is not sensitive or irritable. He has always been inclined 
 to worry. 
 
 Both patient and the Stratton Piano Company agreed that he was 
 unable to return to them. Patient was unhappy while in the liquor busi- 
 ness. He found the work and the environment uncongenial. After with- 
 drawing from this in December, 1918, he became worried and apprehensive 
 about the future and felt some former fears return. He attempted to keep 
 his self-control through walks of 10 to 15 miles, but was unsuccessful, 
 became depressed and hypochondriacal. He came to this hospital as a 
 voluntary patient. 
 
 RESULTS 
 
 February 12 to May 12. 
 Social: 
 
 There has been no income, but patient's wife says most of the $500 
 saved remains, as she and the children spend about half of the time living 
 with her mother, who apparently stands most of the expense during the 
 visits. Her mother lives in the East End, Boston, and is supported by a 
 son and daughter, both single. 
 
 Patient's wife tried work a few nights, dipping chocolates at $1 for 
 3 hours in a candy factory, but was readily persuaded of the inadvisability 
 of this. She has devoted a large part of her time to visiting patient at 
 the hospital and taking him out for walks. 
 
 When patient was last discharged from the hospital, she took Emma 
 and patient to their little farm in Bradbury, but returned to her mother's 
 on his re-admission to the hospital. She has considerable understanding 
 of patient's condition and, though somewhat worried about the future, is 
 making a very brave fight and is always cheerful in the presence of 
 patient. 
 
 Physical: 
 
 Patient has continued well physically. His eyes have not yet been 
 examined by an ophthalmologist. 
 
 Mental: 
 
 Patient was discharged from the hospital 2/13/19 much improved, and 
 visited his brother on a farm in Bradbury, Vt. He got along well for a 
 
586 
 
 APPENDIX A 
 
 1919 
 
 week, but after an idle Sunday his fears returned and he was readmitted 
 to the hospital 2/24/19. He seemed worse after this second admission, but 
 pulled himself together sufficiently to try his farm at Bradbury, being 
 discharged from the hospital 4/5/19. He worked there outdoors a few 
 days when his old sex phobia returned, and he was so discouraged about 
 this that he returned to the hospital, readmitted 4/9/19. All through his 
 stay at the Psychopathic he has worked hard on the wards, pleading con- 
 stantly for hard work. 
 
 His chief fear all spring has been that prohibition will not be put into 
 effect, and that therefore he has lost out by giving up his liquor business. 
 Although he can reason with himself that he is fortunate at all events to 
 be out of the liquor business, this fear still possesses him so much that 
 he dreads reading the newspapers. In the last few weeks, however, this 
 fear has decreased considerably, and he feels that he has it pretty well 
 under control. 
 
 He is very anxious to get well and repeatedly says he will do anything 
 in his power to do so. He frequently aslcs whether visitor thinks he will 
 ever get well. 
 
 On 5/8/19 patient was discharged to the Middlesex State Hospital as 
 a voluntary patient, Dr. Lawson, his examiner, feeling that he would do 
 much better there with the increased facilities for recreation and team- 
 work outdoors. 
 
 May 12 to September 30. 
 Social: 
 
 Patient remained at Middlesex until July 14 when he went to live at 
 his camp in Bradbury. His wife and children preceded him there by a 
 few weeks, patient visiting them often during his stay at Middlesex. 
 Patient's wife has canned a quantity of vegetables for the winter. Her 
 family have been frequent visitors to the camp and have brought them 
 food for the family. Patient plans to move back to Arlington about 
 October i, the rent having been paid all along by his wife's relatives 
 who feel very kindly toward patient as do his relatives also. Both patient's 
 family and his wife's family are superior Italian people of ambition and 
 thrift. Patient's mother-in-law has a large household to cook for, as her 
 single son and daughter, both working, and a married daughter, son-in-law, 
 and their two children live with her, and in addition the patient's wife and 
 children are frequent visitors. 
 
 Patient is one of six siblings. The oldest, a sister with whom patient 
 lived several years before his marriage, has several grown children able 
 to support the family without her husband's assistance, who is now a semi- 
 invalid. A brother is on a farm in Brayton, Vt., and two of his sisters 
 live together, one of them married, the other working. 
 
 Patient has done his own farm work this summer as well as hiring 
 out to neighboring farmers frequently. John has begun his second year 
 at high school in Arlington and Emma was sent to school for a few days, 
 but is now kept home for a week or two until the family canning is finished 
 at camp and the family move to Arlington for the winter. 
 
 Physical: 
 
 Patient is in excellent physical condition as a result of outdoor work. 
 
 Mental: 
 
 Patient improved considerably at Middlesex, doing six hours pick-and- 
 shovel work there a day most of the time and farm work at his camp 
 
APPENDIX A 587 
 
 week-ends. Early in August efforts were made to get him into the employ 
 of the Gray Motor Company, Dorchester, in the fall, but the employment 
 manager has found no vacancy. The Schuleman Paper Box Factory in 
 the East End, which prides itself especially on its humane handling of its 
 employees and where another patient is apparently very happily placed, 
 stated early in September they would be glad to interview patient. As a 
 result, patient came down from camp a few days ago to visit Schuleman's. 
 They agreed to take patient on any time but patient feels that though they 
 are most considerate the chances for advancement are not large. Patient 
 says he knows "beggars can't be choosers" but says "I would like some 
 place where I could begin work and work hard if I felt that I could learn 
 some useful trade or where I could be sure of advancement provided of 
 course I merited it." This indicates a desire to plan for the future which 
 he has not manifested before. 
 
 Patient reports that occasionally he has "fear spells" but much less 
 frequently and of shorter duration. He is full of hope for the future and 
 sure he will be entirely well after getting into new work. His eyes look 
 very bright now instead of apathetic. 
 
 September 30 to December 12. 
 Social: 
 
 Early in October patient's family moved to Arlington for the winter 
 but still visited the farm frequently week-ends. The children are in school. 
 Patient remained in the country until the end of November picking apples 
 and coming to market in Boston frequently. The family has on hand quite 
 a little fruit for the winter and patient earned most of the expenses of 
 the summer by his farm work. His wife remains very philosophical. 
 
 While in the liquor business, $300 was borrowed from patient, and a 
 brother owes him $700, and a brother-in-law $200. He hopes to be paid 
 some of this soon. He has two $1,000 semi-endowment life insurance 
 policies. Patient's wife returned to candy dipping this fall at $1.25 for 
 three hours in the evening, planning to stop when patient is regularly 
 employed. 
 
 Efforts have been made to find patient suitable work through the 
 Y. M. C. A., State Employment Office, Bureau for Returning Soldiers and 
 Sailors, and Bryant & Stratton's. He applied definitely for clerical posi- 
 tions at the Riverside Book Shop and at Schuleman Paper Box Factory, 
 Stratton Piano Company have no openings for patient. 
 
 Physical: 
 
 Patient's eyes have not been examined as Dr. Jacobs advises no 
 examination for the present. 
 
 Mental: 
 
 Dr. Jacobs agreed to see patient because doing research in psycho- 
 neuroses, and saw patient early in October. He felt patient's diagnosis 
 was between manic depressive depressed and psychasthenia or a combina- 
 tion of both, but that patient was rapidly recovering and soon would be in 
 as good shape as after his attack several years ago. Every three months 
 or so he should report to some psychiatrist to make sure he is not over- 
 working. He says there is no reason why patient should have to try work 
 different from his former clerical work but em.phasizes the necessity of 
 patient's having a hobby. His fears are so slight now that they can be 
 disregarded. Patient gives the credit of getting well to his wife. He has 
 been a little afraid of attempting bookkeeping again but has been per- 
 suaded to do so. 
 
588 APPENDIX A 
 
 The Riverside Book Shop felt they could not consider patient, as the 
 work was especially nerve-racking, there being only women among the 
 customers and help and books being behind. They also felt that patient 
 must be rusty at bookkeeping as he had not done any in five years. 
 
 The Schuleman Paper Box Factory was ready to consider patient for 
 clerical work but patient felt the chances for advancement were not great 
 enough. When he was finally convinced of the desirability of the job, the 
 job was no longer open. 
 
 December 12, 1919, to March 12, 1920. 
 Social: 
 
 Patient and his family spent a few days at Christmas with her rela- 
 tives. The children received about $35 in Christmas gifts and patient $25 
 from his farmer friend, James. His brother has paid back $50 but no 
 other debts have been paid him. His wife is still working at candy 
 dipping at $1.25 for three hours. The children were sick at the end of 
 January, John with influenza and Emma with stomach trouble, and patient's 
 wife was tired out at this time. She still keeps up good courage. The 
 relations with the landlady have been a little strained but not markedly so. 
 
 Patient did not get a job until February 11, when he has since held a 
 temporary position as bookkeeper at $25 a week. Many agencies assisted 
 in helping to look for suitable work for patient but clerical openings for 
 men have been exceedingly scarce, especially without stenography and type- 
 writing. 
 
 Physical: 
 
 Patient had a slight cold but has otherwise been well. 
 
 Mental: 
 
 Patient looked up many openings on his own initiative as well as 
 those suggested by agencies and visitor. On patient's part the following 
 were reasons for not taking the jobs offered: too much responsibility, and 
 not enough chance for advancement. He kept up good courage although 
 admitting more and more discouragement at not being able to get a job. 
 He admits he feels much better since working, and feels sure he will be 
 perfectly well when a permanent position presents itself, efforts to obtain 
 which are now being made. 
 
 HISTORY 
 
 January 29. 
 
 Patient seen on ward. 
 
 Impression : pleasant, intelligent, good insight into condition. 
 
 Patient says that in his family his brother had a "nervous breakdown" 
 15 years ago, which seemed similar to patient's present trouble. Brother 
 was worried, broke down ; went "up country" where he recovered. Patient 
 did well at school, going through High School and finishing a commercial 
 course in 6 months. He finished the two courses in as short a time as 
 possible because he had little money. He had his commercial training at 
 the Comer Commercial School, Somerville, now out of existence. 
 
 Patient has worked as private secretary and for 16 years as book- 
 keeper in the Stratton Piano Company, a very good position of responsi- 
 bility and from which he has recently been given a good recommendation. 
 
APPENDIX A 589 
 
 I919 
 
 When he went to the Boston State Hospital in 191 1 they would not re- 
 employ him at the Stratton Piano Company on his return. 
 
 He stayed out of work for 2 or 3 years, and for one year was manager 
 of the Marko Cafe, and for 3 years was in the liquor business from which 
 he retired in 1918. The business was fairly successful, each of the three 
 partners making $1,000 a year besides their salary. Patient retired because 
 he disliked the business and because he felt it would be better to get 
 started in another position some time before prohibition comes in July, 
 
 Patient seems to be happily married. His wife has ingenuity and a 
 happy disposition. Of his children, John, 13, is in the high school. 
 Emma, 4^^, is at home. 
 
 Patient likes to be among people, but he is particularly fond of reading 
 both fiction and books on economics. His wife has urged him to mix 
 more with others and he realizes that one is better mentally when not 
 alone too much. He is particularly fond of outdoor sports, likes farming, 
 walking, etc. He and his wife go out together occasionally in the evening; 
 he seems to have several friends. 
 
 Patient says he had children's diseases. At the age of 9 he was run 
 over across his body and in a plaster cast for 9 months. He believes he 
 has no serious results of the accident. Patient has suffered from neuritis 
 for some time. His eyes also have troubled him. He has been to several 
 doctors for treatment, among them being Dr. Baker from the Patton 
 Building. He has been under medical care of Dr. Francis. 
 
 Patient says that at the time of his going to the Boston State Hospital 
 he was run down physically and nervously. He went voluntarily and 
 seemed to improve under the treatment of the baths he was given. After 
 leaving there he could not return to his former position and so for 2 or 3 
 years he lived "up country," renting 2 or 3 rooms and being given all the 
 land he wanted to farm. He improved here and he seemed stronger until 
 suddenly about 2 or 3 weeks ago he felt a "fear spell" come on him ; things 
 worried him which he was unable to drive from his mind. He felt that 
 he had made a mistake in leaving the liquor business ; that he was not well, 
 etc. He realized that he had to fight this off' and for three days he had 
 been taking long walks, sometimes for 18 or 20 miles a day. He suc- 
 ceeded in driving it off but in 2 days it returned again. He could not sleep, 
 but felt he had to be up walking all the time ; but even while walking he 
 could not keep himself from worrying. He became discouraged, intro- 
 spective, and disappointed. He went to Dr. Sampson for advice, asking if 
 it were not possible for him to come here. The doctor agreed and patient 
 wanted to come immediately on Thursday, January 25. The doctor per- 
 suaded him, however, to wait until morning. He came here voluntarily 
 without telling his wife or children where he was going. 
 
 At present he does not sleep well, but says he is feeling stronger and 
 says he is much better able to control his thoughts and keep himself from 
 worrying. His main desire now is to get strong so that he can be able 
 to take a position, preferably not in the bookkeeping line because of his 
 eyes. 
 
 His wife said that if he is not better she will break up the home and 
 go to live with her mother or go to work herself, but he feels that he can 
 take a good position when the opportunity comes. 
 
 January 28. 
 
 Neighbor, Mrs. Giordani (28 Central Avenue, Arlington) telephoned 
 to. Informant lives in flat above patient's family and has known patient 
 
590 APPENDIX A 
 
 several years. She says that since leaving Boston State Hospital in 191 1 
 patient has been "fine" until about 6 weeks ago when he said that he felt 
 nervous and that the "same trouble was coming on" again. He was told 
 to mix in more with others and thus he would feel better. He did this ; 
 he continued to be nervous, however — he could not keep quiet and seemed 
 to have to keep going all the time. He was a little irritable. 
 
 Informant believes patient does not drink. He has complained at 
 times of his eyes. He has always been quiet — has always been pleasant. 
 She does not know that patient has been sensitive or that he has been 
 fearful of enemies or suspicious of friends. 
 
 January 29. 
 
 Present illness: 
 
 Previous to patient's attack in 191 1 he had been complaining of neu- 
 ritis in his wrist. For this he took medicine. He stayed home for a week 
 but found even at the end of that time that he could not return to work. 
 He was advised by Dr. Francis to go to Boston State Hospital, where he 
 did go voluntarily ; remaining two months. While there he was given 
 baths, which patient considered most satisfactory treatment. While still 
 at hospital informant used to take him out to walk and would occasionally 
 take him home to spend Sunday. Upon his return home he could not work 
 (even had not his former position been filled). Informant believes he was 
 run down physically at the time. The succeeding summer he spent "up 
 country" on a friend's farm, where he dug and worked outdoors, and 
 where his condition improved. He and informant spent the next winter 
 at patient's sister's home. The following summer he spent again at the 
 farm and in the autumn of that year he returned to work for the first time 
 in two or three years. 
 
 Informant feels that the three years patient spent in liquor company 
 have been a contributing factor in his second attack. This business 
 brought him into contact with a much less desirable class of men than he 
 had known when a bookkeeper, the environment about his place of work 
 was not pleasant, and patient did not, moreover, like the liquor business. 
 For some time he had been considering withdrawing from the company 
 and finally did witlidraw just before Christmas, 1918. This business worry 
 has been the only matter over which patient need have felt trouble; he had 
 nothing at home to cause him worry. 
 
 Patient intended to get into some other form of employment, but on 
 a night after Christmas a "spell" similar to one in 191 1 returned, which, 
 according to patient, was much less severe than in 191 1. After three days 
 it wore away, for patient said he was resolved to resist it and fight it off. 
 In 2 days, however, it returned, to wear away again. On Wednesday, 
 January 22, patient felt well in daytime but was worse at night ; on 
 Thursday night he hardly slept at all and he decided to come here for care 
 at this hospital. 
 
 Informant denies hallucinations, delusions, or fears in patient. She 
 says his mind, even at the present time, has always been clear and normal. 
 Patient's nerves alone need some sort of treatment. Informant feels that 
 patient has improved while being here and that in two or three weeks he 
 will be well enough to return home. 
 
 February i. 
 
 Dr. Lazi'soji, patient's examiner at hospital, consulted. Stated that 
 patient has insight. Informant has not gone into his sex history, but does 
 
APPENDIX A 591 
 
 1919 
 
 not feel that the reasons for his leaving Stratton Piano Company are of 
 vital significance in his condition. Patient's prognosis is good. Patient 
 has initiative and can himself state what work is best for him. 
 
 February 3. 
 
 Patient seen on zvard. Stated that a friend of his has a farm in 
 Bradbury, Mass. For the use of a few rooms there patient pays $25 a 
 year. He has gone up there several summers in succession. Patient has 
 between $500 and $600 left. Has known his wife since she was 7 or 8 
 years old. "Went with her" about 10 years. For details of patient's work 
 see "Industrial History" enclosed. 
 
 February 4. 
 
 Patient's wife seen at hospital. States that she is of a worrying nature 
 — trying to look on the bright side. Both her children have stomach 
 trouble from time to time. Her family doctor is Dr. Sullivan of Arling- 
 ton. Treats them from time to time for gastritis. Patient's wife often 
 takes the children to her mother's for the week-end, opposite Station 2, 
 East End. Informant's father is dead and her mother is supported by a 
 son and daughter who live with her. 
 
 February 12. 
 
 Place of employment, Stratton Piano Company, 288 Bagley St., Mr. 
 Dawson and his father seen. 
 
 March 15. 
 
 Dr. Malcolm, Optometrist, Rice Building, telephoned to. Informant 
 stated that he has treated patient for several years, the last time being 
 December 16, 1918. At that time his vision with compound lenses in both 
 eyes was perfect (20/20) though without lenses was 15/20 in each eye. 
 Sees no reason why patient could not do any kind of work he pleased as 
 far as his eyes are concerned. Stated that patient's lenses should be 
 changed about once a year, though he would like to see patient soon as 
 he had added a little to patient's prescription on December 16 for near 
 work and would like to know how this affected patient. 
 
 May 24. 
 
 Patient's mother-in-lazv, Mrs. Costelli, 10 Victoria St., Boston, visited. 
 Sister-in-law, Bertha Costelli, also seen. 
 
 Impression of Mrs. Costelli : Looks intelligent, kindly, and healthy, 
 but speaks almost no English. 
 
 Impression of Bertha Costelli : Intelligent, warm-hearted, and ex- 
 ceedingly interested in patient and his wife. 
 
 Impression of home : Exceedingly neat and well furnished, up three 
 flights. The street is a blind alley consisting of tenements crowded closely 
 together. 
 
 Mrs. Costelli cooks for ten people including patient's wife and child. 
 Bertha Costelli and her brother, both of whom are single, and a married 
 sister with her husband and two children. Patient's wife is always afraid of 
 intruding. Informants do not feel that she is, however. Bertha Costelli 
 stating that the Italians are more sympathetic with their friends in trouble 
 than other races. 
 
 Both patient and his wife are splendid people and devoted to one 
 another. Informants see no reason why patient should worry. Bertha 
 regrets that her mother has always worked, having started at the age of 6 
 on a farm in Italy and refusing to rest now. 
 
592 APPENDIX A 
 
 1919 
 May 24. 
 
 Patient's older sister, Mrs. Bonelli, gy Main St, visited. 
 
 Impression : Informant is an intelligent, refined Italian, devoted to her 
 family and to patient. 
 
 Impresbion of home : Very neat and well furnished, on the first floor 
 of a tenement house at the better end of Alain St. 
 
 Patient has always been studious, ambitious, and conscientious. Patient 
 was with informant 4 years before his marriage 15 years ago. He pre- 
 ferred being with informant to living with his mother. Informant sees 
 patient and his family often. At bookkeeping he worked much overtime 
 and toward the last wore 2 and 3 pairs of glasses at a time. Informant 
 ascribes his first illness to overwork. She thinks that now he is in better 
 physical condition than when he broke down 6 years ago. 
 
 All the relatives on both sides are very sympathetic with patient. 
 Patient has always made friends easily and had many. Informant would 
 do her share financially if help was needed, but patient's wife's family are 
 aiding at present. 
 
 Informant is the oldest child, followed by Antonio who has a farm 
 in Brayton, Vt., and has been recently married. Patient is next followed 
 by a single sister who lives with the youngest, Mrs. Mardini, Cedar St., 
 Cambridge, Mass. Patient has not been overly religious. 
 
 Informant's husband has not worked in the past 2 years. He was 
 formerly a laborer and insisted on giving his children a good education. 
 Visitor saw one daughter who is a High School graduate and attended 
 Bennett's Business School. 
 
 January 29. 
 
 Dr. Francis, E. Boston 488-lV, telephoned to. Informant says cause 
 of patient's trouble is that he went "sexually wrong" about 10 years ago. 
 Informant would not make more definite statement over telephone except 
 to say that patient was abnormally sexually excitable, — if he saw a female 
 approach on the street he would have to cut down a side street, so strong 
 was his sexual instinct. He brooded and worried over this until it became 
 a mania with him and this was the sole cause of his having to leave the 
 Stratton Piano Company where he had a good position. He was at the 
 Boston State Hospital for a short time and has been better in recent years. 
 
 Patient used to be cheerful and optimistic before marriage. Infor- 
 mant says his married life has been only fairly happy, and that recently 
 patient has had great financial worry. His trouble dates from his mar- 
 riage. In recent years patient has grown coarse and vulgar, contrary to 
 his former personality. Informant feels that the fact that patient had to 
 "rough it" while associated with liquor business was a good thing for him. 
 
 Informant says that patient has complained of nervous trouble, having 
 "wandering pains" over body. Informant titled this "neuritis" or "neur- 
 asthenia," but believes the pains were psychogenic. 
 
 Informant says patient did not have syphilis, but that his worry over 
 his sexual desire is cause of his nervous condition. 
 
 January 29. 
 
 IVife interviewed at hospital. 
 
 Impression : Pleasant, intelligent, self-possessed. Seems to be co- 
 operative, yet at times noncommittal, perhaps desiring to shield patient. 
 
APPENDIX A 593 
 
 1919 
 
 Family History: 
 
 Grandparents : Unknown to informant. 
 
 Mother : Died at 75 probably of pneumonia — bright, cheerful, of ex- 
 cellent disposition. 
 Siblings : 
 
 1. Sister, Mrs. Bonelli, 97 Main St., Boston. 
 
 About 50 years old. Is well and has several children. 
 
 2. Sister, Theresa, about 47. Unmarried. 
 
 Works in box factory. When 3 or 4 years old she had spinal 
 meningitis, as a result of which she lost the sight of one eye 
 and became quite deaf in both ears. 
 
 3. Brother, 47. Married. No children. Is well and works in 
 
 Brayton, Vt., on a farm. 
 
 4. Patient. 
 
 5. Sister, Mrs. Cavalaro, Hamilton St., Chelsea. Mass. 
 
 6. Sister, Mrs. Mardini, Cedar St., Cambridge, Mass. 
 
 Married. Well; good disposition. 
 Informant knows of no constitutional disease, nor of any mental or 
 nervous trouble in family. Family is normal. 
 
 Personal History: 
 
 Developmental : Not known to informant. 
 
 Educational : 
 
 Patient graduated from High School (which was then composed 
 of 3 grades) at 15. Being too small to take a position he spent 
 next year in the "advanced course." He then went to Comer's 
 Commercial School. He seems to have been noticeably bright in 
 school. 
 
 Economic : 
 
 Patient's work at Stratton Piano Company satisfactory to all con- 
 cerned. 
 
 Marital : 
 
 Married 15 years. Lived previously on Long St., Mattapan. Has 
 two children: 
 
 Boy> 13 — ist year High School ^ Both children are well and 
 Girl, 4j4 — fond of dancing ] bright in intellect. 
 
 Habits : 
 
 Patient is not a drinker. He takes only an occasional glass of 
 liquor. Is only moderate smoker. No drugs. Informant knows 
 of no infectious blood disease. 
 
 Personality : 
 
 Even disposition, not moody. Is fond of company and enjoys 
 people. He has friends in to call and he and informant go out 
 together not infrequently. Is quiet, however ; likes to be home 
 with his children and likes constantly to read. Is not sensitive nor 
 suspicious. Is not hot-tempered nor irritable. Patient has always 
 been rather inclined to worry. 
 
 Medical : 
 Informant knows of no serious illnesses. Patient has been at no 
 other hospital beside this except Boston State Hospital. He has 
 been under care of Dr. Francis for several years. No fainting 
 attacks. 
 
594 APPENDIX A 
 
 ACTION TAKEN 
 1919 
 February i. 
 
 Patient seen on ward. Anxious to remain another week to get a hold 
 on himself. Thinks he will be much better ofif after his stay here and after 
 he gets to work. Says he worries when not working. Is anxious to do 
 any sort of work whatsoever. He had his eyes examined as recently as a 
 few weeks ago by Dr. Malcolm and had his lenses changed. 
 
 February 3. 
 
 Patient seen on ward. Will stay several days longer. 
 
 February 7. 
 
 Neiucomb's Ink Co., Mr. Pierce, employment manager, telephoned to 
 regarding possible opening for patient. Stated that he had a position 
 which would involve general picking up about the place^ which might do 
 for patient. Asked that patient be sent to him. 
 
 February 8. 
 
 Patient and zvife sent tvith note from Social Service to Newcomb's Ink 
 Company. On his return patient stated that Mr. Pierce had not been 
 aware that the position was already filled by one of the foremen. 
 
 February 8. 
 
 Netvconib's Ink Company, employment ma)iagcr Mr. Pierce, telephoned 
 that without his knowledge the position had been filled by a foreman. 
 
 February 10. 
 
 Patient seen on ward. Stated that he would like to visit his brother 
 on a farm in Brayton, Vt. 
 
 February 11. 
 
 Newcomb's Ink Company, employment manager Mr. Pierce, telephoned 
 to. He has no openings but will let Social Service know if he has a little 
 later. 
 
 February 12. 
 
 Patient seen on zvard. Stated that his brother is to call for him 
 2/15/19 and take him to the farm of this brother's fiancee in Brayton, Vt. 
 Patient has felt better since contemplating this. Social Service agreed to 
 think this plan over and talk it over with Dr. Lawson. 
 
 February 12. 
 
 Dr. Lazvson, patient's examiner at hospital, seen. Thinks plan a good 
 idea. Would like to see employer, Mr. Dawson, regarding patient's sex 
 tendencies. Patient has not spoken of this to informant. 
 
 February 12. 
 
 Patient's wife seen. Took patient out for about two hours to-day as 
 she has done for a number of days. 
 
 February 13. 
 
 Patient discharged to-day from hospital as he suddenly decided he had 
 sufficient grip on himself to make the plunge now. He will go in a day 
 or two to the farm of his brother. Patient's wife agreed to let Social 
 
APPENDIX A 595 
 
 Service know how patient gets along. After a few weeks there patient 
 plans to return to Boston and would like Social Service to look for a job 
 for patient in the meantime. 
 
 February 25. 
 
 Patient's wife telephoned that she visited patient 2/22/19. Found him 
 doing fairly well though he still has "fear spells" at times. He is working 
 hard all day. Has not yet planned on date to return to Boston. Will 
 telephone when she has further news of patient.. 
 
 February 25. 
 
 Patient was readmitted to hospital yesterday, this fact not being known 
 to Social Service or patient's wife at the time of her telephone message. 
 
 February 25. 
 
 Patient's wife later visited patient. She was somewhat worried over 
 patient's apparent relapse, but is hopeful of a good recovery, and puts 
 forward a cheerful face to patient. 
 
 February 25. 
 
 Patient seen on ward. Somewhat depressed and disappointed that 
 work has not cured him. Is determined to put forth every effort to get 
 well, but is doubtful whether he will recover. Spent the time in Vermont 
 in doing farm work, cutting ice, hauling wood, etc. On Sunday 2/23/19 
 patient was idle and had time to worry considerably, and yesterday he was 
 too nervous and excited to work. His brother told him he was a "fool" 
 to return to the hospital and urged patient to "stick it out," but patient felt 
 he could not. 
 
 February 25. 
 
 Dr. Lawson, examiner of patient, seen. Stated that she will go into 
 patient's sex history this time. 
 
 March 3. 
 
 Dr. Lawson, patient's examiner, seen. Patient is very depressed to-day 
 and is having hydrotherapeutic treatment. Informant has talked with 
 patient about sex matters. Patient gives no history of anything of the sort 
 disturbing him in several years. 
 
 March 7. 
 
 Patient seen on ward — very depressed to-day ; easily weakening. 
 Knows he should not worry about giving up the liquor business, but has 
 an idea that prohibition may not be put into effect. Realizes fully that the 
 liquor business did not agree with him. Also realizes that his present 
 worry is inconsistent. Has a fear of being sent to the State Hospital. 
 Reassured patient on this point. He is "pining" for good hard work. 
 
 March 7. 
 
 Superintendent of Nurses, Miss Murray, seen and urged to give pa- 
 tient more work on the wards. 
 
 March 10. 
 
 Patient's zvife seen dt hospital — looking more tired than usual. Stated 
 that for the past week she has been working nights at a chocolate factory 
 on Bar St., dipping chocolates at the rate of $1.00 for each night of three 
 
596 APPENDIX A 
 
 hours, 7 to 10. She was anxious to earn car fares in this way and was 
 getting lonesome at home. 
 
 Social Service pointed out other sides to the question ; namely, that 
 patient would resent her working now whether or not he finds it out until 
 later, and that her children need her at home, especially as she visits 
 patient at the hospital daily. Also urged against it from the point of view 
 of her own health. Suggested that she think the matter over. She stated 
 she now felt she would not return to work. When asked the name of the 
 firm, she would give no further details than to state that only a few 
 employees work there. Informant did not seem at her ease. Social Serv- 
 ice made an appointment to visit at her home 3/12/19 in the morning, and 
 she and Emma will be at home. Emma is now staying with wife's sister, 
 Mrs. Riley, 43 Howley St., Roslindale. 
 
 Later, when Social Service saw informant on the ward, informant 
 beckoned in uneasy manner to her to state that she hoped Social Service 
 was not going to visit the neighbors. Social Service stated that they haa 
 no intention of visiting neighbors now. 
 
 March 10. _ 
 
 Patient's examiner, Dr. IVarren, consulted. Stated that in his esti- 
 mation patient can do any kind of work ; is strong physically and could 
 stand indoor work. Informant is willing for patient to leave the hospital 
 at any time he wants to ; the sooner patient starts to work the better. In- 
 formant does not know what patient's vision is and says patient does not 
 know what he fears during his "fear spells." 
 
 March 10. 
 
 Patient talked with on zvard — very depressed; still afraid he did not 
 do the right thing in leaving the liquor business, and that perhaps he 
 should not have settled to the disadvantage of his partners, even though 
 they had previously robbed him. Does not like to think of leaving the 
 hospital soon, as he is afraid lie might attempt to make away with himself. 
 Assured patient that he could not expect to be entirely well until after 
 getting to work. 
 
 March 12. 
 
 Home visited. 
 
 Impression of home: Very neat, sunny, well-furnished rooms; four 
 in number besides pantry, on first floor of a frame house. Situation on a 
 high hill in Arlington, five minutes' walk from Grant College. 
 
 Patient's wife and Emma at home. Patient's wife visited patient 
 yesterday and found him exceedingly depressed. Her courage was good 
 until then, but she has been considerably worried in the last twenty-four 
 hours. Tears came into her eyes easily during the visit. She insisted on 
 serving a little luncheon to visitor, which was well prepared and nicely 
 served. 
 
 Landlady dropped in for a few minutes, a very intelligent, kind, 
 neighborly person, evidently knowing the details of patient's illness. 
 
 Emma obviously has adenoids, and docs not look exceedingly well. 
 She seems bright but quite restless, a very affectionate and winning child. 
 
 Patient's wife has given up her work at the factory. She would hate 
 to have to give up her present home, but does not see any necessity of it 
 for several months at least. The rent is $14.00. Family has lived in this 
 house five years — landlady occupying the second floor. Patient's wife left 
 with visitor to go to hospital. 
 
APPENDIX A 597 
 
 1919 
 
 March 12. 
 
 Newcomb's Ink Co. visited. Mr. Pierce out. Was shown through 
 factory by Miss Martin, his office assistant, and by one of the foremen, 
 Mr. Gordon. Both stated that they felt sure Mr. Pierce would take 
 patient if he could make room for him, unless he had some plan of his 
 own to the contrary. 
 
 The factory is very well lighted and roomy, and the atmosphere is 
 kindly. Miss Martin will let Social Service know in case Mr. Pierce can 
 fit patient in soon. 
 
 March 12. 
 
 Patient seen on ward. Seemed very cheerful. 
 
 March 14. 
 
 Patient seen running down the steps from one floor to another of the 
 hospital. His face was beaming and he stated that he is feeling very well 
 to-day. His wife brought his former partner in, with whom patient 
 settled one or two matters on his mind. He has been cleaning windows 
 with the attendants to-day and has spent a good part of the day doing this. 
 Willingly agreed that work was good for him. 
 
 March 24. 
 
 Patient's wife seen at hospital. Informant says patient was still de- 
 pressed yesterday and does not feel equal to getting out or seeing an 
 employer. Visitor asked wife to urge patient to go out for a walk. 
 
 March 25. 
 
 A. F. Gainshoro's employment manager, Cambridge, telephoned to. 
 Informant stated that they are not in need of anything but skilled ma- 
 chinists. He suggested telephoning to the Federal Steel Trades Cor- 
 poration. 
 
 March 25. 
 
 Federal Steel Trades Corporation, 83 Aubiirndale St., employment 
 manager Miss Fiske telephoned to. Informant stated that openings have 
 been very few and she has no suggestions at unskilled or clerical positions. 
 
 March 25. 
 
 Patient's examiner, Dr. Warren, telephoned to. Informant stated that 
 he still feels patient should soon return to work, and that he has stressed 
 this whenever he talked to patient. Informant has not talked much with 
 patient recently, but will do so soon. 
 
 April 5. 
 
 Patient discharged to wife and O. P. D. 
 
 April 9. 
 
 Patient admitted to house as voluntary. 
 
 Aprilio. 
 
 Patienfs wife seen at hospital. She was disappointed that patient has 
 not been able to hold his own away from the hospital, but feels that a 
 longer time here will eventually set him on his feet. 
 
598 APPENDIX A 
 
 1919 
 April II. 
 
 Patient interviewed on ward. He is discouraged over the fact that his 
 fears return as soon as he leaves the hospital. He clings constantly to the 
 hope that his disease will be cured eventually. He tries to keep his 
 thoughts ofif of himself, and forces himself to read the newspaper, although 
 in so doing he reads the news concerning "Prohibition," and concerning 
 the fact that the new law may possibly not go into effect after all. This 
 worries him, as he feels remorse over the fact that he may have made a 
 mistake in retiring from the liquor business. He is anxious for work and 
 for reading material. 
 
 April 15. 
 
 Four current magazines sent up to patient. 
 
 April 15. 
 
 Patient's wife seen at hospital. She goes walking with him every day 
 and feels that he is slowly improving. She is buoyant and full of encour- 
 agement which patient seems to appreciate. 
 
 April 17. 
 
 Patient's wife seen at hospital while she was waiting to take patient 
 to walk. \i in the near future patient is considering leaving the hospital 
 again, she will let visitor know. 
 
 April 21. 
 
 Patient seen on zvard. He was pleased with the magazines. Said he 
 read eagerly every word of them. 
 
 April 22. 
 
 Patient and wife seoi on leaving hospital for a walk and told of the 
 return of Miss May, former visitor. 
 
 April 24. 
 
 Patient and is.nfc reported to visitor before going out for a walk. 
 She takes patient walking several hours a day now. He says this is the 
 only time he enjoys during the day, as it is the only time he is free from 
 fear spells, even when working at the hospital. He still cleans windows 
 daily. 
 
 April 28. 
 
 Patient seen on zvard. He is much improved though still fearful re- 
 garding prohibition. He reads the papers daily in an effort to throw off 
 this fear. The farmer on the land on which patient's camp is located in 
 Bradbury has written urging patient and family to move out. He will get 
 the ground plowed and all ready for patient. Patient likes the idea and 
 thinks his wife will go up soon to see about this. Visitor urged that wife 
 do this 3/30/19 and that patient get to work there soon. 
 
 April 28. 
 
 Patient's examiner, Dr. Laivson, consulted. Informant stated that she 
 has not talked with patient in several days, but that a week ago she advised 
 his going to another hospital, such as Middlesex, to get into a more suit- 
 able atmosphere. At such a hospital she feels there is more opportunity 
 for exercise, recreation, and work with "gangs." She does not consider 
 patient in fit condition to work in the community as yet. She had hoped 
 patient would act on this recommendation himself. 
 
APPENDIX A 599 
 
 1919 
 
 May I. 
 
 Patient and his wife talked with visitor before going out for a walk. 
 Dr. Lawson, patient's examiner, has advised his care at Middlesex and told 
 patient she would see Dr. Lang about this. Patient thinks it would be a 
 good thing, as he could do outdoor work under supervision, and he hopes 
 he will be allowed there to frequently visit his country home, Bradbury, 
 near by. 
 
 The farm patient visits consist of 20 acres belonging to an Italian 
 who has a frame house there divided up for seven families which he rents 
 to patient and others, all of whom grew up together. Patient pays $25 
 rent a year, having the use of 2 rooms. He can plow all the land he wants. 
 Patient would consider also being discharged from the Psychopathic Hos- 
 pital and going to Bradbury, reporting frequently to the O. P. D. Visitor 
 agreed to talk with the doctors about this. Patient says very emphatically 
 that he will do anything in his power to get well. 
 
 May 3. 
 
 Patien. seen starting out for a walk with his wife. He is still hesitant 
 about going to Middlesex, stating that he is not sure they will keep him 
 outdoors sufficiently. Visitor told him she would write the Social Service 
 worker there, and that as Dr. Lawson had told him he would work there 
 outdoors a great deal, there was no ground for hesitation. Patient agreed 
 to decide by 5/5/19. 
 
 May 8. _ 
 
 Patient and his zvife talked zvith in the morning. His wife told him to 
 do whatever he thought best ; but he has been considerably hesitant. He 
 had been advised by some one to report to the Middlesex Clinic at the 
 Homeopathic Hospital 5/6/19, where he could personally ask the super- 
 intendent what the chances of outdoor work were. He did not go there, 
 however, as he decided to try longer walks daily, his wife reporting to the 
 Psychopathic early in the morning. 
 
 Visitor assured patient that Dr. Lawson did not approve of his making 
 plans of his own at present. Patient agreed that she was right, and 
 decided to take a trip to Middlesex to-day with his wife to ask the super- 
 intendent about the nature of his care should he stay at Middlesex. 
 
 Patient's wife stated that for a number of weeks she and the children 
 have been living with her mother at 10 Victoria Street. Her expenses 
 have been light, consisting of rent in Arlington and occasional food at her 
 mother's, besides carfares. She said most of the $500 was still left but 
 would not be definite. 
 
 Patient agreed to stay at Middlesex if conditions seemed satisfactory. 
 Later he was admitted to Middlesex as a voluntary patient. 
 
 May 13. 
 
 Patient's^ wife telephones that she visited patient as recently as 5/12/19 
 and found him very contented. He has not yet been put at outdoor work 
 but the weather has not been suitable. Superintendent said he would have 
 to know patient better to decide whether he could let patient of¥ for fre- 
 quent visits to his farm in Bradbury. 
 
 Patient's wife has received a long blank to be filled out regarding 
 patient's mental history. Visitor agreed to help her in filling out the blank. 
 
600 APPENDIX A 
 
 1919 
 May 16. 
 
 Patient's wife reported to hospital with a blank to be filled out. As 
 she is going to Aliddlesex to-morrow, visitor advised that she take the blank 
 with her to be filled out at Middlesex. She has taken the children with 
 her this afternoon for a week-end in Bradbury but is returning to Boston 
 after that. 
 
 May 23. 
 
 Patient's wife telephoned that she found patient doing fairly well when 
 she saw him 5/18/19. She is going up to the country again to-day, planning 
 to stay until the end of next week. John will continue to attend school, 
 living with his grandmother. 
 
 May 24._ 
 
 Patient's mother-in-laiv, Mrs. Costelli, 10 Victoria St., Boston, visited. 
 Informant invited visitor to supper, but visitor had already eaten. Her 
 daughter, Bertha Costelli, says that Emma needs her tonsils removed 
 because she has great difficulty at night in breathing. Bertha's single 
 brother has just paid patient's rent in Arlington and Bertha expects to pay 
 the rent a little later, as informants do not want patient to give up his 
 home yet. They are not discouraged about patient, although Mrs. Costelli 
 has lost some weight worrying about him. 
 
 June 2. 
 
 Patient sent a friendly letter by visitor. 
 
 June 19. 
 
 Patient heard from. The letter was written at his camp in Bradbury 
 where he was spending Saturday and Sunday. He says he is much im- 
 proved although still bothered with those "fear spells" at times. He was 
 planning to return to Middlesex from the camp. His stay at Middlesex 
 is more satisfactory than at the Psychopathic, as he can work outdoors 
 with pick and shovel and keep busy with other indoor work. 
 
 Patient's wife is due in Boston on the 25th to attend John's graduation 
 in Junior High School. 
 
 June 30. 
 
 Patient's zvifc reported to visitor at the hospital. A letter to another 
 patient named Fangillo had been forwarded from the Psychopathic Hos- 
 pital to patient's sister on Main Street for patient early in June. Patient's 
 sister had been busy and neglected to forward the letter to patient. Patient 
 had just heard from hospital asking that the letter be returned. Patient's 
 wife came in at once this morning to straighten out the matter. She is 
 looking well and says she feels well. Patient is constantly improving and 
 is spending the week-ends at their camp in Bradbury. He works six hours 
 a day with pick and shovel at Middlesex and sleeps very well. He is now 
 in the parole ward. 
 
 Informant's relatives visit her at the camp occasionally and before 
 long her mother as well as her married sister will stay for some time at 
 the camp. Her relatives bring her food and patient has planted quite a 
 few vegetables which will be maturing before long. Her money is holding 
 out very well and she says she has nothing to worry about. She has not 
 attended to Emma's tonsils and adenoids, claiming that she has been too 
 busy. In spite of visitor's arguments to the contrary she seemed to think 
 this matter should have to be put off until later in the summer or fall. 
 
APPENDIX A 60I 
 
 Emma will attend school in the fall. Informant agreed to keep visitor 
 closely informed as to patient's progress. She has jokingly told patient 
 that the next thing he would worry about would be his future work. 
 Patient told her that he would ask advice from the Psychopathic Hospital 
 when he was ready to work and that he was sure work could be found for 
 him at which he could keep well. 
 
 June 26. 
 
 Patient's wife heard from. Letter states that she is too busy to come 
 to town for her son's graduation and states that her husband is improving 
 though still worrying somewhat. 
 
 July 8. 
 
 Patient written to. Letter was sent to reassure patient. 
 
 July 29. 
 
 Patient heard from. Letter states that he was discharged from the 
 hospital on the I4tli of July and that he is feeling much better though still 
 "very nervous and irritable." He is busy with his garden and in the past 
 two weeks has put in thirty hours' work for the neighboring farmers. 
 He expects to stay there until November i, doing work for the farmers 
 whenever it is available. He expects to improve rapidly now and sug- 
 gests that visitor may be able to help him in selecting a line of work later. 
 He has not decided what line of work to take up yet. The family are well. 
 
 August 7. 
 
 Gray Motor Company, Dorciiester, employment manager, Mr. J. San- 
 born, written to. Letter asks whether informant could place patient in the 
 fall, stating that patient would be willing to start at any type of work, but 
 would aim to work toward clerical work or a combination of clerical and 
 physical work. 
 
 August 13. 
 
 Patient's wife telephoned. She came to town to do some errands, 
 coming with a friend by automobile. Patient is doing very well. He 
 sleeps fairly well but not yet perfectly. He takes fishing trips and enjoys 
 the farming. When he left the Boston State Hospital the doctors warned 
 him not to leave the country too soon. Informant plans to come to Boston 
 by October i, probably starting Emma in for a month of school at 
 Bradbury. However, informant may possibly come to Boston earlier, if 
 patient is well enough to come, spending the week-ends at the camp. 
 
 August 13. 
 
 Jackson's employment manager, Mr. Broivn, visited. Informant 
 states that he has but few men on the clerical force and that all the 
 vacancies are filled. 
 
 August 18. 
 
 Gray Motor Company telephoned to. In the absence of Mr. Sanborn, 
 chief ot the education department, word was left for him to telephone 
 visitor regarding patient. 
 
 August 21. 
 
 Gray Motor Company, employment manager, Mr. Sanborn, heard from. 
 Letter states that visitor's letter of August 8 has been held up pending 
 
602 APPENDIX A 
 
 1919 
 
 their decision concerning patient. At present, they are completely filled 
 up ; but if a vacancy occurs whereby they can use him to advantage they 
 will let visitor know. 
 
 September 4. 
 
 Patient zmttcn to. Letter asks patient whether he is ready to start in 
 at work at any time visitor has suitable position. 
 
 September 9. 
 
 Schuleman Paper Box Factory visited. Visitor attended the "Shop 
 Committee Meeting" which is held every week, all the foremen and execu- 
 tives being present to discuss their needs and grievances. Two weeks 
 before visitor had gone through the factory. There are about 250 em- 
 ployees and the firm prides itself on the fact that they all feel like "one big 
 family." The foremen are called by their first names. Obviously the 
 employees are treated very considerately and they seem unusually happy. 
 Mr. Jones, superintendent, stated he would be glad to have a talk with 
 patient and place him to best advantage in the factory, though he is not 
 sure that the work will lead to clerical work. Mr. Chase, efficiency expert, 
 and Miss Macpherson, nurse, were also talked to about patient. They are 
 all interested in another patient from the Psychopathic Social Service, 
 John Flynn, who has been there two weeks and is giving the greatest 
 satisfaction. 
 
 September 10. 
 
 Patient zvritten to. Letter describes the factory of Schuleman's and 
 suggests that patient come to Boston soon to see about an opening there 
 even though he may not be ready to stay on in Boston as yet. 
 
 Note: 
 
 The firm is glad to take employees known to reliable social agencies 
 as they consider that as good as knowing their families. In so far as 
 possible, they employ neighborhood people because the families are acces- 
 sible. 
 
 September 11. 
 
 Patient's wife telephoned. She is in town to-day and to-morrow, start- 
 ing Emma in at school. The family expect to stay at camp three weeks 
 longer. Patient will answer visitor's letter soon. He is doing pretty well. 
 Informant will telephone again to-morrow as she can hardly hear where 
 she is to-day. 
 
 September 16. 
 
 Letters to patient, addressed Bradbury, Mass., returned unclaimed. 
 They were remailed to patient to Box 13, R. F. D., Bradbury, Mass, 
 
 September 19. 
 
 Patient writes that he has just heard from visitor. He will be at the 
 hospital on September 22 in the morning. He would come in to-day, but 
 his potatoes are rotting in the ground and he has about thirty bushels to 
 dig immediately. John is going to high school. Emma went to school for 
 a few days, but is now at the camp for about a week until things are in 
 shape for the winter. 
 
APPENDIX A 603 
 
 1919 
 September 22. 
 
 Patient reported to visitor in the morning, haviirg jllst come down 
 from camp. He looked better physically and decidedly improved nerv- 
 ously. His eyes were bright and he was full of hope for the future. He 
 occasionally has "fear spells," but he gets over them rapidly and he thinks 
 that when he is at work they will vanish entirely. He has been doing 
 farm work for several of the farmers in the vicinity as well as at his own 
 camp. At present, patient's wife and his mother are at the camp putting 
 up tomatoes. His son John would rather live at home in Arlington than 
 with his grandmother. Yesterday he was out to the camp and returned 
 last night to stay in Arlington. He gets his own meals and the landlady 
 keeps an eye on him. Patient is sure he gets into no mischief and says 
 he is a thoroughly reliable boy. 
 
 Patient is ambitious to undertake work which gives promise of ad- 
 vancement. Visitor talked with him about the opening at Schuleman's 
 which in many ways appealed to him. He agreed to go down to the plant 
 at once and interview Mr. Jones, superintendent. He is planning to return 
 to camp this afternoon and will let visitor know result of his interview 
 either by letter or telephone. 
 
 September 24. 
 
 Patient writes that he had a nice talk at the Schuleman Paper Box 
 Factory with Mr. Jones and Mr. Chase (efficiency expert) and was shown 
 over the factory. Mr. Jones said patient could begin work any time, 
 starting with at least $16. Patient has thought the matter over carefully 
 and feels that though the people there are all very nice the chances of 
 advancement do not look especially bright. He says, "I would like some 
 place where I could begin work and work hard if I felt that I could learn 
 some useful trade or where I could be sure of advancement, provided, of 
 course, I merited it." At the factory apparently the most he could aspire 
 to was to be a "machine man." Patient asked for visitor's advice, stating 
 that though he knows "beggars cannot be choosers," he does not want to 
 make a false start and have to change again in a short time. 
 
 September 24. 
 
 Gray Motor Company, Dorchester, employment department, telephoned 
 to. The employment manager, Mr. Sanborn, is away for a few days, 
 
 September 27. 
 
 Patient written to, stating that visitor would give him more definite 
 advice about his work in two or three days. 
 
 September 29. 
 
 Gray Motor Company, Mr. Sanborn, employment manager, telephoned 
 to. Informant states that there is no opening there for patient. 
 
 September 30. 
 
 Prospective employer, Schuleman Paper Box Factory, visited. By in- 
 vitation, visitor addressed the Shop Committee Meeting on the subject of 
 mental hygiene of industry, explaining her work at the Psychopathic 
 Hospital in particular. The superintendent, Mr. Jones, stated that he 
 would employ any patient visitor sent to him and if there was no opening 
 he would "make one." He was interested in talking with patient the 
 other day. Informant had in mind clerical work for patient to advance to 
 and thinks patient could very soon be placed at such work there, as there is 
 
604 APPENDIX A 
 
 an opening now. It is informant's custom, however, to have every office 
 employee advance from the factory force. He did not tell patient about 
 the prospect of clerical work, however. Visitor agreed to let patient know 
 just what the probable opportunity was and to get in touch with informant 
 again. The nurse, Miss MacPherson, states that should opportunities, for 
 any reason, at the factory seem limited to patient, there is always a chance 
 of his advancing from the paper box factory to the Schuleman Candy 
 Factory, where there is a large clerical force. 
 
 September 30. 
 
 Patient written- to, giving the result of the interview at Schuleman's 
 this morning and stating that, though visitor did not want to force patient 
 to consider this opening, she felt the opportunities of advancement were 
 very good and the atmosphere there especially suited to patient. Her letter 
 explained the chances of advancement to the Schuleman Candy Factory 
 from the paper box factory. 
 
 October 7. 
 
 Patient zvrites that he has heard from visitor, but has not yet come to 
 a decision. He is very anxious to get to work soon, saying, "I certainly 
 feel the position I am in at present." Patient would come in October 6, 
 but he has promised a farmer to pick apples until October 8. Patient will 
 come to see visitor October 8. 
 
 October 8. 
 
 Patient reported to visitor in the morning, bringing with him a satchel 
 full of apples for visitor from the farm. His wife plans to come to 
 Arlington to stay on October 13, but patient plans to follow her a few days 
 later unless he has a detinite jol) in town before that. He is still unde- 
 cided about the kind of work he should undertake, feeling that possibly 
 indoor work will be too confining, and that his eyes might not permit of 
 confining work. He stated that he would be glad to see Dr. Jacobs this 
 afternoon for advice about his work and tliat he would be glad to see 
 the employment manager at the Cole Rubber Company relative to possible 
 employment there later, visitor explaining that the employment department 
 is especially good there. Patient took with him a letter of introduction 
 from visitor. 
 
 Patient says that when his mother died she left about $1,000, of which 
 she gave $600 to patient's sister who is blind in one eye, the other siblings 
 receiving about $200 each. As a matter of fact, most of them owed 
 patient's mother at that time so that the full amount of $200 per person 
 was not available. Patient loaned his share to help out and $80 is still 
 due him from this time from a brother-in-law. Patient's brother Antonio, 
 in Brayton, Vt., wrote patient's wife shortly after Antonio's marriage this 
 summer about his marriage. Patient's wife was too busy to write at that 
 time and Antonio has not written patient since. Patient feels friendly 
 toward all of his relatives, but apparently cited these instances to explain 
 that often others were more considerate of one than one's own relatives. 
 Patient feels especially grateful to his friend "Henry" who owns the farm 
 where patient has been all summer. It is not clear how much money 
 patient still has on hand, but he says that he paid most of his expenses this 
 summer from the work he did on the farm. He has on hand a large 
 amount of fruit for the winter. 
 
 Patient still has occasional "fears," especially when not busy, but sa.vy 
 they are very mild. 
 
APPENDIX A 605 
 
 1919 
 October 8. 
 
 Cole Rubber Company, assistant employment maitager, Mr. Carlton, 
 telephoned to, who stated there is only one vacancy in the clerical depart- 
 ment now, which is for a man who is accustomed to figuring costs. There 
 are only three or four laboring jobs open, which are all excessively heavy. 
 Informant would be glad, however, to talk with patient relative to future 
 employment. 
 
 October 8. 
 
 Patient reported to the hospital in the afternoon to see Dr. Jacobs. 
 Dr. Jacobs states that there really is no "medical problem" as far as patient 
 is concerned. In other words, patient's diagnosis is probably something 
 between manic depressive and psychasthenia or a combination of both, but 
 patient is rapidly recovering. He will soon be in as good condition as 
 after his attack of years ago. Every three months or so he should report 
 to some psychiatrist to make sure that patient is not overworking. Dr. 
 Jacobs feels that there is no reason why patient should have to try work 
 different from his former clerical work and that patient could now hold a 
 responsible clerical position. Patient should have a "hobby," as recreation 
 is quite essential for him. In the past, when at clerical work, patient had 
 practically no recreation. Patient's fears are so slight now that they can 
 practically be disregarded. 
 
 October 8. 
 
 Schuleman Paper Box Factory, Superintendent, Mr. Jones, telephoned 
 to, who stated that there is temporarily no work open for patient in the 
 office as another patient from the Psychopathic Hospital, Martin O'Connor, 
 is, for a time, doing clerical work there. However informant feels that 
 before long he will need further help and says that at almost any time he 
 could arrange things to take patient on. It was mutually agreed between 
 informant and visitor that patient look around for other openings and if 
 patient was not successful, informant would make place for him at 
 Schuleman's. 
 
 October 8. 
 
 Patient reported to visitor that Mr. Carlton at Cole's was very nice to 
 him this morning but stated frankly that there was no opening now and 
 took patient's name, agreeing to let patient know should an opening turn 
 up. Patient had a very satisfactory interview with Dr. Jacobs. Patient 
 says he is not as sure as Dr. Jacobs that he can go ahead and do book- 
 keeping right away, but as Dr. Jacobs says he can, he will try to believe it 
 himself. Visitor agreed to look into other openings which would be dis- 
 tinctly clerical and to let patient know if a good opening was found before 
 he plans to return to Arlington. Patient's wife has said she would gladly 
 go to work to supplement the income this winter, but visitor assured 
 patient this would undoubtedly not be necessary. Patient left the hospital 
 considerably relieved by Dr. Jacobs' advice. 
 
 October 14. 
 
 Psychopathic Hospital Staff, Dr. Jacobs, states that patient's eye con- 
 dition should not be attended to now, as patient would probably not like 
 any glasses ordered now. Patient will probably have another breakdown 
 in about five years. 
 
 October 16. 
 
 Patient's wife telephoned stating that she has bee'n in Arlington all 
 week, but goes to camp for the week-end to-morrow. Patient will probably 
 
6o6 APPENDIX A 
 
 1919 . . . . . 
 
 remain at the camp as long as weather permits until a definite openmg is 
 found for him. The family are well. 
 
 October 23. 
 
 Patient left some apples for visitor at the hospital in her absence. 
 
 October 30. 
 
 Patient's zurife telephoned that patient will probably return from the 
 farm the first of next week to stay. As to-day is a school holiday in 
 Arlington, informant and the children will go to the camp for the week- 
 end. Visitor stated that several openings had been looked into for patient, 
 but that visitor delayed about writing patient until the right opening pre- 
 sented itself. Informant agreed to have patient get in touch with visitor 
 the first of next week. 
 
 November i. 
 
 Federal Employment OMce, 4 Cherry St., registrar, Mr. Brown, tele- 
 phoned to, regarding clerical openings for patient. Visitor had personally 
 interviewed informant during the week regarding openings and had tele- 
 phoned several times since. There have been no suitable openings for 
 patient. 
 
 November 5. 
 
 Patient's wife telephoned that as the weather has been so pleasant 
 patient will remain in the country until next week. Informant prefers to 
 wait until next spring about Emma's tonsils, but agreed to speak to Emma's 
 school teacher about this. 
 
 November 17. 
 
 Patient's imfe telephoned that patient is still in the country and will 
 remain there for a few days more unless visitor sends for him. He no 
 longer talks of himself, but is planning for the future. He is busy packing 
 and shipping apples. Informant is now housecleaning. She seemed 
 pleased to know that the hospital feels she has done a great deal toward 
 patient's recovery and assured visitor that her family as well as the hos- 
 pital had done a great deal also. 
 
 November 17. 
 
 Y.M.C.A. Employment OMce, Mr. Grafton, telephoned to. Infor- 
 mant will keep patient in mind for a clerical position. The coal strike has 
 temporarily pulled down business so that openings are few. Informant 
 asked to have patient drop in to see him when next in town. 
 
 November 24. 
 
 Federal Employment Office, 4 Cherry St., registrar, Mr. Brown, visited, 
 who had no suitable openings for patient. 
 
 November 28. 
 
 Patient reported to visitor. He came to town to stay on November 26. 
 Patient has been busy bringing apples to town with "Henry," the farmer 
 at whose farm patient stays. They came to market from three to five 
 times a week. Patient is now ready and anxious to get to work, but a 
 little fearful of clerical work. His face clouded somewhat at the mention 
 of clerical work, patient asking visitor whether she thought he could safely 
 
APPENDIX A 607 
 
 1919 
 
 do clerical work. He is insistent that he shall never have a recurrence 
 of his disease. Visitor reminded him of Dr. Jacobs' advice about his work. 
 
 His wife has been working since she came to town this fall at a candy 
 factory in the East End, near her mother's home. She dips chocolates 
 from 6:4s to 9:45 P. M. daily at $1.25 for three hours. She did likewise 
 in the late spring before coming to the camp, but did not tell patient about 
 this imtil during the summer. Patient asked visitor definitely not to tell 
 his wife he had spoken of this. Visitor told patient that his wife had told 
 visitor about her working early in the spring and that now she would 
 doubtless speak of it when visitor called. Patient's wife says she would 
 miss work now if she stopped as she enjoys the companionship of the 
 women there. Financially the family is getting along "O. K." though 
 patient does not know the exact amount left, as his wife manages. He 
 plans to collect about $300 due him from individuals who borrowed from 
 him when he was in the liquor business, and he says his brother-in-law 
 still owes him about $200 from his mother's estate, which he will also try 
 to collect. Patient loaned his brother Antonio about $700 several years 
 ago. At one time patient paid Antonio's board at the rate of $7 a week, 
 giving him from $2 to $3 a week besides. Patient is glad he laid in a 
 supply of clothes a year ago considering the cost of living now. He has 
 always provided in advance when possible. 
 
 Patient's wife and children are not insured, but patient carries two 
 semi-endowment policies under the National Life Insurance Company. In 
 case of death a thousand dollars is due from each of them, but before that 
 time, if he lives a number of years, a few hundred dollars is payable in 
 addition to patient. 
 
 Patient plans to join either the Arlington or Boston Y. M. C. A. and 
 will look at once into the possibilities. He is determined to have exercise 
 and recreation to keep him well. Patient was given a number of letters 
 of introduction to the Y. M. C. A. Employment Bureau and the State 
 Public Employment Office, where he expects to report to-morrow morning. 
 Patient understands that clerical openings are scarce for men at present 
 and is very glad to have Mr. Boylston, Bureau for Returning Soldiers and 
 Sailors, keep him in mind for suitable clerical openings. 
 
 Patient says he is feeling better all the time and finds he is best when 
 working hardest. Only occasionally does he have "fears," but he is able 
 to control them. 
 
 November 28. 
 
 F. M. C. A. Employment Bureau, Mr. Grafton, telephoned to. In- 
 formant knows of no clerical openings now. 
 
 November 28. 
 
 Federal Employment Office, 4 Cherry St., Mr. Brown, telephoned to. 
 Informant knows of no clerical openings now. 
 
 November 28. 
 
 Bureau for Returning Soldiers and Sailors, Mr. Boylston, telephoned 
 to. Informant knows of no clerical openings for patient now, but hopes 
 to have some soon and will let visitor know when he has a suitable opening 
 for patient. He does have openings from time to time into which the 
 discharged soldiers do not fit. 
 
 December i. 
 
 Y. M. C. A. Employment Bureau, Mr. Grafton, telephoned to. In- 
 formant sent patient to apply on November 30 at J. K. Hodge's Hay, Grain, 
 
6o8 APPENDIX A 
 
 1919 
 
 & Seed store in Chelsea, where there was a vacancy at office work at $18. 
 Patient has not reported to informant since. Informant referred to 
 patient as a "nice chap." 
 
 December 2. 
 
 Patient telephoned that he had been trying to reach visitor for the last 
 twenty-four hours to report. Mr. Brown, of the Federal Employment 
 Office, took patient's name and asked him to report in a few days. Mr. 
 Grafton of the Y. M. C. A. took patient's name and said he would let 
 patient know when he had a suitable opening for him. The only openings 
 the Y. M. C. A. had were suitable really for boys. Patient agreed to report 
 to-morrow again and visitor agreed to get in touch with the Bureau for 
 Returning Soldiers and Sailors. 
 
 December 3. 
 
 Patient telephoned, stating that he plans to go to the Federal Employ- 
 ment Office this afternoon. He is watching the advertisements in the 
 papers and looking about somewhat. 
 
 December 3. 
 
 Federal Employment Office, 4 Cherry St., Mr. Brown, telephoned to, 
 who knows of no openings for patient to-day. Patient reported to in- 
 formant this morning and will report again to-morrow morning. 
 
 December 3. 
 
 Jackson Commercial School, Mr. Ware, visited, who spoke of an open- 
 ing at the Riverside Book Shop. Miss Martin there is looking for a first- 
 class bookkeeper to straighten out the accounts now handled by two 
 women, who together are paid $45 a week. Miss Martin would probably 
 pay patient $30 a week. Patient should apply at once, stating that he 
 heard of the opening through a friend. Informant could not recommend 
 patient as he does not know him. 
 
 December 3. 
 
 Patient's home visited as no response was received by telephone. 
 Patient was home taking care of Emma and George Giordani. Patient's 
 wife went to the Arlington Theatre to the movies, and John, on returning 
 from school, did likewise. Patient felt he could not leave the house until 
 his wife returned, and telephoned the Riverside Book Shop to see whether 
 • he ought to apply this afternoon. Miss Martin's sister answered the 
 phone, stating that Miss Martin was leaving for New York to-night. 
 Patient gave visitor's name, which she said she did not know, and asked 
 patient to write her his experience. Patient's wife then returned home 
 and went with visitor to the street car. Visitor agreed to get in touch 
 with the Riverside Book Shop soon. 
 
 December 4. 
 
 Riverside Book Shop, Miss Martin, visited. She at once asked whether 
 patient had been a patient at the Psychopathic Hospital and then said she 
 had troubles enough of her own without employing someone from there. 
 Visitor then talked brieily on the subject of the prevalence of psychiatric 
 conditions and need of treatment. Informant was then attentive and 
 agreed to look up patient's references, although, she explained, she con- 
 sidered the work "nerve-racking" as all the customers were women and 
 all of the help, except one, were women and the books were behind. 
 
APPENDIX A 609 
 
 1919 
 
 Informant felt also inclined to think that patient must be rusty in book- 
 keeping if he had done none in five years. Informant is leaving for 
 New York this morning and will not be back until next week. 
 
 December 4. 
 
 Stratton Piano Company, Office Salesman, Mr. Blair, visited as visitor 
 was passing by. Mr. Dawson was not noticed until almost the end of the 
 interview and visitor did not remember Mr. Dawson's name so could not 
 ask for him. Informant stated that patient's work was first-class and that 
 patient was confidential clerk, only one man being over him. Patient 
 knew all that was going on in the office. Informant knows of no openings 
 in the piano line now, but thinks patient's experience would serve him 
 equally well in the lines of furniture or installment work. The firm would 
 give patient an excellent recommendation at any time. 
 
 December 4. 
 
 Patient seen at the Federal Employment Office, 4 Cherry St., Mr. 
 Brown had no opening for patient then. Patient expects to join the 
 Y. M. C. A. as soon as he is working. There is a swimming tank there 
 but none in the Arlington Y. M. C. A. Patient is reporting to the Y. M. 
 C. A. Employment Bureau, Mr. Grafton, this afternoon, and visitor agreed 
 to look into the openings at the Y. M. C. U. 
 
 December 4. 
 
 Y. M. C. U. Employment Bureau, Mr. Howland, visited. The bureau 
 places only non-union men and fills no factory or laboring positions. 
 Informant will be glad to see what he can do to find a suitable position 
 for patient and visitor agreed to send patient in to-morrow morning. 
 Informant states that though clerical openings are not abundant they are 
 to be had. 
 
 December 4. 
 
 Patient's home telephoned to, leaving word for patient to report to 
 the Y. M. C. U. to-morrow morning. 
 
 December 5. 
 
 Jackson Commercial School, Employment Office, Mr. Ware, telephoned 
 to, reporting developments on the Riverside Book Shop. Informant sug- 
 gests getting in touch with Miss Martin early next week again. 
 
 December 5. 
 
 Y. M. C. U. Employment Bureau, Mr. Hoivland, telephoned to, who 
 was favorably impressed by patient. Informant says he is sure he can 
 find a suitable opening for patient soon. Patient is willing to do selling 
 or clerical work. 
 
 December 8. 
 
 Riverside Book Shop, Miss Martin, telephoned to. She is sure that she 
 could not take patient on. 
 
 December 8. 
 
 Bureau for Returning Soldiers and Sailors telephoned to. Mr. Boyls- 
 ton has left, but his successor, Mr. Max, suggested that patient might find 
 an opening at Henley & Coolidge, Accounts Engineers, 350 Rice Building, 
 
6lO APPENDIX A 
 
 1919 
 
 as this firm has been advertising for bookkeepers and the bureau has sent 
 one or two candidates. Informant agreed further to keep patient in mind 
 for an opening. 
 
 December 8. 
 
 Patient's wife telephoned to, asking patient to telephone visitor to- 
 morrow morning. 
 
 December 8. 
 
 Patient written to, suggesting the opening at Henley & Coolidge. 
 
 December 9. 
 
 Patient telephoned that none of the agencies have found an opening 
 for him yet. The Y. ]\I. C. A. sent him to a garage at Freeman Square, 
 Chelsea, where a bookkeeper was needed, but they really wanted only a 
 boy for a job. 
 
 December 10. 
 
 Patient telephoned to. He has found no suitable openings, but expects 
 to through the help of the agencies interested in him. If he needs advice 
 during the visitor's absence until January 2, he will get in touch with the 
 Social Service or Dr. Jacobs. When visitor complimented him on his 
 success in getting well he said his wife deserved all the credit. Patient 
 expects to sell two pianos by Christmas, netting him about $75. 
 
 December 20. 
 
 Patient was mailed a Christmas card. 
 
 1920 
 January 2. 
 
 Patient's wife telephoned to. Patient is planning to see visitor soon. 
 Informant, patient, and the children were with her family several days at 
 Christmas time. Patient has not yet found work, but is not discouraged 
 
 January 3. 
 
 Patient reported to visitor, bringing a two-pound box of candy as a 
 Christmas gift, which his sister had given him. She works at Young, Cobb 
 & Sanborn and each year gives patient candy. Patient's wife is still work- 
 ing. Patient has made the rounds of the various employment agencies, 
 having added the Commercial Reference Association and the International 
 Reference Association. The only definite positions offered him have been 
 through the Y. M. C. A. One of these positions was suitable only for a 
 young fellow ; the other is pending, a position as ledger clerk at $25 a week 
 at Hudson Shoe Polish factory in Mattapan. Patient has applied there and 
 telephoned regarding the opening several times, but each time has been told 
 that no decision has been made. Patient will telephone soon. The last 
 few days patient has felt somewhat discouraged, but has been able to con- 
 tinDl Eiimself. He has not sold the pianos as yet, as the purchasers find that 
 they are twice as expensive as they thought. 
 
 The children received a total of about $35 for Christmas from rela- 
 tives and patient received $25 from his friend Henry on the farm. Patient's 
 brother has paid him $50 of what he owes. Patient agreed to telephone 
 visitor soon and plans to continue consulting the employment agencies. 
 Mr. Brown of the Federal Employment Office has shown the most interest 
 ia him, but he has had no suitable openings. 
 
APPENDIX A 6ll 
 
 1920 
 January 3. 
 
 Jackson Commercial School, Mr. Ware, telephoned to. Informant 
 knows of no openings for patient now, stating that there are less clerical 
 openings for men now than there were last fall. Informant would be glad 
 to help out at any time he can. 
 
 January 3. 
 
 Hudson Brothers, Mattapan. telephoned to. Employment Manager, 
 Mr. Beers, was out and person answering, apparently in the superintend- 
 ent's office, would give no information about the firm, but suggested getting 
 in touch with Mr. Beers. 
 
 January 5. 
 
 Patient telephoned. He is willing to have visitor use her judgment 
 about consulting Hudson's. 
 
 January 5. 
 
 A fornvcr Mattapan A. C. worker states that the Mattapan A. C. con- 
 siders Hudson's factory a very poor place to work. The employees are 
 underpaid and the girls working there are looked upon as hardly respect- 
 able by other working girls. 
 
 January 7. 
 
 Y. M.C. A. Employment Bureau, Mr. Grafton, telephoned to. In- 
 formant states that the outlook in the office line is bad. It is hard to fit 
 patient in other than clerical position because he has had no experience. 
 Informant will keep patient in mind, however, and try to place him. 
 
 January 7. 
 
 Federal Employment Office, Mr. Brown, telephoned to. Informant 
 offered patient two jobs, both of which patient felt were too far away. 
 It is not the fault of either informant or patient that former has not 
 realized before that patient would consider other than clerical work. He 
 will continue to keep patient in mind, looking out for both clerical and 
 other openings. 
 
 January 7. 
 
 Hudson Brothers, Manufacturers of Shoe Polish, Mattat^an, visited at 
 2 :3o p. M. The employment manager, Mr. Beers, was out. The telephone 
 girl asked whether visitor would see some one else, but when visitor said 
 she would see the superintendent, was informed that Mr. Beers was also 
 superintendent. The advertising manager spoke to visitor, but said he 
 could do nothing about the opening for patient as this was up to Mr. Beers. 
 Visitor asked to be shown over the factory, but the advertising mapagei;- 
 stated that no visitors were allowed as the process was, secret.. 
 
 January 7. 
 
 Bureau for Returning Soldiers- and Sailors, Clerical Department, Mr. 
 Max, visited. Informant would be glad to talk with patient and try to 
 place him. He seemed more than willing to advise visitor regarding cler- 
 ical openings, 
 
 January 7. 
 
 Patient telebhoned to in the evening, asking him to report to Mr. Max, 
 to-morrow morning. Patient had not found any openings. 
 
6l2 APPENDIX A 
 
 1920 
 January 
 
 Patient telephoned that he reported to the Federal Employment Office, 
 4 Cherry St., this morning. Mr. Brown told him that though there was 
 labor trouble at Root's patient might find an opening there. Patient ap- 
 plied at Root's and the employment manager, Mr. Fielding, told him to 
 come in again the next morning. Patient asked visitor's advice, but visitor 
 advised against the firm as paying poorly and not giving much promise of 
 advancement for patient. Patient finds it difficult to go all over town 
 looking for a job. He has not reported to Mr. Max, but will do so at 
 once. He answered an advertisement in the Globe to-day at a team firm 
 as ledger and trial balance clerk. 
 
 January 9. 
 
 Patient telephoned that he reported to Mr. Max yesterday, who was 
 ready to send patient to the Loyal Shoe Company but on finding patient 
 was not an ex-service man felt he could do nothing for patient. Visitor 
 agreed to get in touch with Mr. Max again. 
 
 January 9. 
 
 Bureau for Returning Soldiers and Sailors, Mr. Max, telephoned to. 
 Informant did not fully understand visitor's work as predecessor, Mr. 
 Boylston, did not explain it to him. In only rare instances has informant's 
 bureau placed men not ex-service. If patient is interested in a job as chief 
 accountant at the International Optical Company, Lexington, informant 
 would be glad to get in touch with the employment manager there, Mr. 
 Bates, as informant has no service man willing to go out of town to take 
 the job. 
 
 January 10. 
 
 Patient telephoned to, explaining the opening at Lexington. Patient 
 agreed to talk it over with his wife and report later. 
 
 January 10. 
 
 Patient telephoned that he feels the opening would be too responsible 
 at Lexington and he does not care to break down again. In order to live 
 away from his family he feels he would have to earn quite a large salary. 
 He agreed that there is no harm done in looking into the opening, by cor- 
 respondence, at least, and thinks the same opening is offered through the 
 Federal Employment Office. Patient is getting discouraged about not find- 
 ing work. 
 
 January 10. 
 
 Federal Employment Office, Mr. Brown, telephoned to. Informant 
 has no openings to-day except the one at the International Optical Company, 
 Lexington. Informant does not blame patient for not being interested in 
 the opening for the reasons patient gave. 
 
 January 10. 
 
 Y.M. C.A. Employment Office, Mr. Grafton, telephoned to. The only 
 opening this morning is one as a bookkeeper at $20 on St. Charles Street. 
 Informant knows no further details about it, but feels patient would not 
 consider it as he keeps saying he cannot accept less than $25. 
 
 January 12. 
 
 Jackson Commercial School, Mr. Ware, visited. Informant states that 
 there are no openings suitable for patient as all of them combine sten- 
 ography and bookkeeping. 
 
APPENDIX A 613 
 
 1920 
 January 12. 
 
 Women's Educational Association, Appointment Bureau, Miss Black, 
 visited for possible suggestions about patient. Informant suggests Wood 
 & Berry Service, 60 Eagle St. ; both Miss Wood and Miss Berry were for- 
 merly connected with the U. S. Employment Service. 
 
 January 12. 
 
 Wood &■ Berry, 60 Eagle St., Miss Berry, visited. Informant states 
 that clerical openings for men are very scarce, but suggested the Under- 
 wood Motor Company, Sawyer St., and the City Gas Corporation, as both 
 employing large numbers of male clerks. The latter has taken on night 
 men lately as business is so heavy. 
 
 January 12. 
 
 City Gas Corporation, North Street, Chief of Collection Division, 
 Henry McMillan, visited. No men are employed in the clerical department 
 and there are now no vacancies in the collection department, though men 
 are working in the collection department day and night. Their pay begins 
 at $19.50. _ Informant would be glad to put patient's name on the waiting 
 list if patient cares to come in to see informant. Suggested the book- 
 keeping department on Victoria St. as a possibility. 
 
 January 12. 
 
 City Gas Corporation, 52 Victoria St., Chief of the Bookkeeping Divi- 
 sion, Mr. Grant, visited. Informant states that there are no openings now, 
 but he employs about 50 men at bookkeeping and accountancy. The firm is 
 apt to promote from below but will be glad to see that patient is put on 
 the mailing list. 
 
 January 12. 
 
 Patient visited at his home. His son John was at home reading and 
 seemed a bright, manly fellow. Patient's wife was out. Patient feels that 
 the landlady has not been quite as cordial to the family since their present 
 misfortune, but admits that relations are not very strained, as the landlady's 
 daughter still practices on patient's piano and patient feels free to use land- 
 lady's telephone. 
 
 Patient is discouraged at having so much difficulty in finding work, but 
 realizes that many others are in a similar predicament. He grits his teeth 
 in an effort to drive away any fears and has been fairly sucessful. He 
 feels better after talking with his wife or visitor. He agreed to go to the 
 Cole Rubber Company to-morrow morning ready to accept any kind of 
 work. He is anxious to get to work more to have his mind occupied than 
 to get immediate income. Work out of town, such as ice-cutting, he would 
 find very dreary. He admitted the futility of work such as elevator work, 
 hovvever, as he would be no better off on leaving the job than he was on 
 beginning it. To-day patient answered an advertisement in the Globe by 
 writing a rubber company who wanted men to learn the business, starting 
 at %2'i. He applied at Reed's, who needed salesmen, but said 125 applicants 
 applied, most of whom had to be turned away. Patient was not among the 
 first so was not successful. He applied at another place which was adver- 
 tised in the Globe, but on application found that the place had been filled 
 and that about 20 men had applied. 
 
 John cooked visitor some coffee and patient served some Italian 
 "ravioli," and custard pie, all nicely cooked. 
 
6l4 APPENDIX A 
 
 1920 
 January 13. 
 
 Patient telephoned that he applied at the Cole Rubber Company this 
 morning, but Mr. Carlton there told him that there were no openings. 
 Patient plans to visit the City Gas Corporation this afternoon. 
 
 January 15. 
 
 Schuleman Paper Box Factory, nurse Miss MacPhcrson, telephoned 
 to. Visitor explained that patient had not considered an opening there a 
 few months ago because at the time the opportunities there seemed limited 
 to him. In the meantime the patient has had an opportunity to look about 
 considerably and he would be interested to consider an opening there now. 
 Informant agreed to see the superintendent, Mr. Jones, about this. 
 
 January 15. 
 
 Patient telephoned and was interested to hear of a possible opening 
 at Schuleman's, though he evidently still felt he might have made a mistake 
 in not making further efforts to get a place at Root's, asking visitor 
 whether the Schuleman opportunity was as good as Root's. 
 
 January 16. 
 
 Patient telephoned that he is home this morning as his wife has lum- 
 bago. 
 
 January 16. 
 
 Schuleman Paper Box Company, nurse. Miss MacPhcrson, telephoned 
 that both she and Mr. Jones remember patient well and liked him but that 
 there is no opening this week. Possibly there will be an opening next 
 week and informant will let visitor know if there is. 
 
 January 17. 
 
 Patient telephoned — somewhat discouraged because he has found no 
 openings. He would like to go to his friend Henry in the country in 
 Bradbury to help him chop wood and to consult him regarding openings 
 in automobile factories as Henry is in close touch with some automobile 
 men. Patient feels he cannot leave his children alone at night while his 
 wife is working. 
 
 January 19. 
 
 Patient telephoned that at Ring's Service Bureau this morning he was 
 told that the John Meredith Company at Milton would take on a number 
 of new men for general factory work. Patient would like to look into 
 this opening and agreed to telephone an hour later after visitor had got in 
 touch with the firm. 
 
 January 19. 
 
 John Meredith Company, Printing and Lithographing Inks, factory, 
 Milton, telephoned to. Superintendent Guili, who hires the factory 
 help, stated that he will take on a number of new men if of the right sort; 
 that is, having common sense and with good physical strength. The firm 
 manufactures printing ink and the processes are easy to learn. The pay 
 is 52 cents an hour for a 48-hour week. On certain processes after two 
 months the pay is 70 cents an hour. Mr. Guili is not in charge of the 
 office help but connected visitor with Mr. Mills. 
 
 Mr. Mills, Chief of the office force, telephoned to. Informant states 
 that he has a number of men in his department earning varying salaries 
 
APPENDIX A 615 
 
 1920 
 
 depending on the responsibilities. He has no openings now, but will be 
 glad to talk with patient and keep him on his list. Should patient want 
 to begin at factory work, he would be glad to try and have him advance to 
 office work when there was an opening if patient were suitable. Visitor 
 agreed to have patient ask for Mr. Mills, on arrival in Milton to-day. Mr. 
 Mills states that commuting would be too hard on patient and that it is 
 somewhat difficult to find a boarding place and very difficult to find a place 
 for a family. 
 
 January 19. 
 
 Patient telephoned and seemed interested in the possibilities at Milton. 
 The family have a friend in Needham with whom either he or the family 
 could probably live if it was hard to locate in Milton. Patient agreed to 
 go out to see Mr. Mills at once. Patient did not look into the International 
 Optical Company, but frankly feels the work there would have been too 
 responsible. 
 
 January 20. 
 
 Patient telephoned that he had his usual luck at the John Meredith 
 Company yesterday. At the factory applicants were talked to in a group 
 and told frankly that the work was very trying as they would have to work 
 with all kinds of acids, and with dyes which would color the employee the 
 same as the tint of the dye. Patient says the smell was "awful" and that 
 he could never stand it or the change of shifts. The plant runs on a three- 
 shift basis and patient would have to vary in his shift 8-4, or 4-12 or 12-8. 
 There is only a late afternoon train besides the i :45, so patient took earlier 
 train, though he was unable thereby to see Mr. Mills, who was away for 
 luncheon. Patient saw Mr. Jackson, assistant manager with the John 
 Rider Company yesterday afternoon. He gave patient the name of a 
 public accountant who might need an assistant. Mr. Jackson is the brother 
 of the man who was in charge of the business school patient formerly 
 attended. Patient will look up that opening to-day. 
 
 January 20. 
 
 Cole Rubber Company, Employment Manager, Mr. Carlton, sat next to 
 visitor at a dinner of the Boston Employment Managers' Association, and 
 stated that though the factory needs female help it has no openings for 
 male help now. There are, however, a number of men doing clerical work 
 there. 
 
 January 21. 
 
 Schuleman Paper Box Factory, nurse. Miss MacPherson, telephoned 
 to, who said she plans to see superintendent, Mr. Jones, about an opening 
 for patient this morning. 
 
 January 21. 
 
 Underwood Motor Company, Sawyer St., Employment Manager, Mr. 
 Johnson, telephoned to. Informant says there are no openings there for 
 clerks and that he has the problem of fitting three of his present book- 
 keepers into general work as they are putting in bookkeeping machines. 
 Informant volunteered to talk with patient about his work. Visitor agreed 
 to send patient to him. 
 
 January 21. 
 
 Jackson Commercial School, Mr. Ware, telephoned to, who stated that 
 the openings for male clerks grow scarcer and that informant is solicitous 
 
6l6 APPENDIX A 
 
 1920 
 
 about being able to place some of his students who will be ready in a few 
 
 months. If patient has any openings at all he had better take them. 
 
 January 21. 
 
 ■Patient telephoned that yesterday afternoon he applied at Fletcher & 
 Lothian, Public Accountants, to whom Mr. Jackson referred him. Mr. 
 Fletcher was out, but patient saw his partner, who talked with patient and 
 asked whether patient was willing to leave Boston occasionally for six or 
 seven days to make a trip with the public accountants. Patient told him 
 he was willing to travel and agreed to come in on January 24 to see Mr. 
 Fletcher. Patient plans to ask Mr. Jackson to telephone Mr. Fletcher on 
 January 24 regarding patient's qualifications. 
 
 January 21. 
 
 Patient telephoned that he had a pleasant interview with Mr. Johnson 
 of the Underwood Motor Company, but there is no opening there now. 
 Mr. Johnson took patient's name and agreed to let him know if any suitable 
 openings developed. Patient plans to visit Mr. Jackson this afternoon and 
 asked visitor what she thought about his visiting the Gray factory. Visitor 
 explained that the turnover was so small at Gray's that there was but 
 little chance of an opening, but that if an additional visit does not tire him 
 there is no harm done by applying. 
 
 January 21. 
 
 Y. M. C.A. Employment Office, Mr. Grafton, telephoned to. Al- 
 though clerical openings are scarce for men, informant has a few such 
 openings right along. The only thing now which would be possible for 
 patient is as an assistant to a public accountant. Informant says that 
 work is quite strenuous at times and dull other times. Patient might find 
 work a strain at the beginning of the year, the busiest time. Informant 
 has two such openings, but has had them some time and does not know 
 whether they have been filled. They are : John J. Seavey, 36 Main St., and 
 Gerry & Co., 38 East St. Each of these pay from $5 to $6 a day with half 
 pay when laid off. 
 
 January 22. 
 
 Patient telephoned and agreed to look up the positions as assistant to 
 public accountant at once. He will then make the usual rounds of the 
 employment offices. 
 
 January 22. 
 
 Schuleman Paper Box Factory, nurse, Miss MacPherson, telephoned 
 that both the superintendent, Mr. Jones, and she say there are no openings 
 there now. Both informant and Mr. Jones are very sorry as they remem- 
 ber patient well most pleasantly. Perhaps in a few weeks there would be 
 an opening. Mr. Wells, employment manager at the Schuleman Confec- 
 tionery Factory, is laying off help at present. 
 
 January 22. 
 
 Madison Razor Company, Employment Manager, Mr. Mahoney, tele- 
 phoned to. He states that there are no openings in the plant for men at 
 present. He says clerical openings are scarce for men, but he does not 
 know why. 
 
 January 23. 
 
 Patient telephoned that he applied to the public accountant,, Mr. Bates, 
 but that there is no opening there now. They were nice to patient there. 
 
APPENDIX A 617 
 
 1920 
 
 Patient is keeping up his courage pretty well, but his wife is beginning 
 
 to get discouraged. 
 
 January 23. 
 
 }'. M. C. U. Employment Office, Mr. Hou.'land, visited. Informant said 
 Stratton Piano Company gave patient a good recommendation, but that the 
 tirm said patient's doctor had said he could not stand his former type of 
 work again. Informant is willing, however, to abide by the advice of the 
 Psychopathic Hospital. Because of patient's age and also because of scar- 
 city of positions in general, informant has not been able to place patient, 
 but suggested that visitor visit the National Baking Corporation, Mr. 
 Lowney, Manager, who asked informant to have a crippled soldier placed 
 there. This soldier has been doing very well. Informant suggested that 
 visitor get in direct touch herself, as Mr. Lowney generally asks informant 
 for a "hustler." 
 
 January 23. 
 
 Federal Employment Office, Mr. Browti. visited. He will continue to 
 try to place patient, but agrees with visitor that the best chance to place 
 patient probably will be through interesting some employer in him per- 
 sonally, as otherwise patient's age usually stands in the way. Informant 
 has allowed patient to look over the cards containing the requests from the 
 employers so that patient will be convinced informant is doing everything 
 possible for him. 
 
 January 24. 
 
 Patient telephoned that he did not go around visiting the other public 
 accountant, but applied at Ring's Service Bureau and the Y. ]\I. C. A., also 
 to his friend Mr. Jackson who will get in touch with Mr. Fletcher soon. 
 Mr. Jackson advised patient to send out some form letters to several public 
 accountants applying for positions, which patient will do Sunday. Visitor 
 advised patient to get some work shovelling snow if he was finding the 
 strain of looking for a permanent position discouraging him. Patient 
 seemed inclined, however, to continue his search. Visitor asked whether 
 patient would be willing to consider work in Lawrence and he said he 
 would. 
 
 January 26. 
 
 General Anderson Craig, Lawrence, Mass., mill owner, written to, 
 reminding him that he offered to let visitor see some of the Lawrence mills 
 some time and asking whether visitor could do so within a few days, stating 
 that she would like to talk over possible openings for patient. 
 
 January 26. 
 
 Patient telephoned that he had just telephoned his friend, Mr. Jackson, 
 who will get in touch with Mr. Fletcher about 11 o'clock this morning. 
 Patient sent out letters to six public accountants whose names and ad- 
 dresses he secured from the telephone book. He will make the usual 
 rounds of employment agencies to-day. 
 
 January 26. 
 
 Y.M.C.U. Employment Office, Mr. Howland, telephoned to. In his 
 absence word was left that there did not seem to be any opening at the 
 National Baking Corporation for patient. 
 
 January 27. 
 
 Patient telephoned that he has answered an advertisement of the Jen- 
 kins Graphophone Company, Dalton, Conn., for general factory work. 
 
6l8 APPENDIX A 
 
 1920 
 
 The Federal Employment Office had an opening for patient to consider 
 l»ut it required detailed knowledge of the income tax, which patient said 
 he has not kept abreast. He has received three replies to his letters to 
 public. accountants, all stating that they need no men. 
 
 January 2y. 
 
 &ene'ral Atiiers'on Craig, mill owner, telephoned that he could arrange- 
 for visitor to see the mills any time this week. He is coming to Boston 
 to-m©rrow and will meet visitor at 4 130 to discuss the plans of the next day. 
 
 Janwary 27. 
 
 ■Howland Business School, 9 Center St., Employment Office, Mr. Fen- 
 ton, visited. Visitor explained that one of his former students in her 
 employ had suggested that he might be willing to advise visitor regarding 
 clerical openings for men. He stated that though clerical openings for 
 males had been exceedingly scarce for the last six weeks, they have been 
 on tiie increase and he feels that the high water mark of replacing men by 
 women has been reached and that firms are now putting on men in place 
 of women. He suggested as firms frequently inquiring for help. Burton 
 Tire Company, International Optical Company, Gleason Company, and 
 Lowell, Johnson & Co., public accountants. 
 
 January 28. 
 
 Patient telephoned that there was an advertisement in tl e Globe this 
 morning for a grocery warehouse man on East Street. From the address 
 patient thinks the firm is Sullivan's. Patient's brother-in-law works for 
 Sullivan's, so patient will look into the opening through him. Patient 
 agreed to look into some of the openings that Howland Business School 
 had suggested and visitor agreed to write the International Optical Com- 
 pany herself as she knows Miss Henderson in the employment department. 
 Patient said he would be willing to move to Lexington if the chances of 
 advancement were good there. Patient seemed interested in hearing about 
 visitor's plan to go to Lawrence. 
 
 January 28. 
 
 International Optical Company, Employment Department, Miss Hen- 
 derson, zvritten to, asking whether there would be any opening for patient 
 there and what the living conditions for families are in Lexington. 
 
 January 30. 
 
 Patient telephoned that he was home most of yesterday as John is ill, 
 having the grippe. He is better, but Emma is sick to-day. If she does not 
 respond to home treatment, patient will call in doctor. Patient received 
 one further reply from his letters to accountants which stated that there 
 was no question but what patient was experienced but that there were more 
 highly trained people available for this accountant's purpose. Patient will 
 try to get in touch with firms that visitor suggested on January 28. 
 
 January 31. 
 
 Patient telephoned that he has a slight cold but that the children are 
 better. He has received a reply from Dalton, Conn., stating that they 
 cannot place him anywhere. At this point patient said he certainly had 
 "bad luck" and "everything seems to go hard." Last night he came home 
 and told his wife he at last was sure he had a job. Yesterday Mr. Brown 
 of the Federal Employment Office put him in touch with an opening as a 
 
APPENDIX A 619 
 
 1920 
 
 bookkeeper for the Dean Blacking & Staining Company at $25 a week. 
 This morning patient telephoned the firm and was told that they had 
 settled everything with their present bookkeeper so that a new one was not 
 needed. Patient is afraid his age was against him and that the explana- 
 tion given is not the real one. He promised to rest up this week-end from 
 his cold^ 
 
 January 31. 
 
 Federal Employment OMce, Mr. Brown, telephoned to, who agreed to 
 let visitor know later what the real situation at Dean's was. 
 
 February 2. 
 
 Patient telephoned that Mr. Fletcher has not yet returned from Provi- 
 dence. Patient's family are feeling better. They called in their doctor for 
 Emma, whose stomach was affected, though she did not have influenza. 
 Patient's wife has a slight cold and patient is still about the same. He 
 plans to stay home to-day. He is answering two advertisements in yester- 
 day's Globe. 
 
 February 2. 
 
 Y. M. C. A. Employment Bureau, Mr. Grafton, telephoned to. In- 
 formant states that patient's "appearance and name queer him." Informant 
 has sent him out on at least a half dozen openings and though they did not 
 take on patient they did, however, take on some one else. He cited Hud- 
 son's as an example. 
 
 February 2. 
 
 Y.M.C.A. secretary, Mr. Doyle, telephoned to, who knows of a tem- 
 porary position for a man to do chiefly bookkeeping at Union Square, 
 Chelsea. He will telephone to get the present situation there and report 
 later to visitor. He volunteered that for some unknown reason it is harder 
 for a man out of a job to get a job than for a man who has a job to get 
 another one. 
 
 February 2. 
 
 Y.M.C.A. secretary, Mr. Doyle, telephoned that he has just got in 
 touch with the Lambert Real Estate & Insurance Company, Chelsea, and 
 finds that the position is still vacant. About three weeks ago the firm 
 asked informant to find a man to hold the position for a few weeks. 
 Informant sent a man who filled the position very satisfactorily, but has 
 just left for a permanent position. Although this work is nominally tem- 
 porary, the firm is a large and growing one, and if patient fits in well, 
 informant thinks there might be permanent work there. At all events, if 
 patient takes the position he could make it clear that he might have to 
 leave at any time for permanent work. Informant could reach neither 
 Mr. Lambert nor Mr. Hudson, but left word at the office about patient. 
 Visitor agreed to send patient in to the firm to-morrow to apply for the 
 position. 
 
 February 2. 
 
 Patient telephoned to, telling him of the opening at the Lambert Real 
 Estate & Insurance Company. He agreed to apply first thing to-morrow. 
 
 'February 3. 
 
 Patient telephoned that he applied at Lambert's, but Mr. Lambert said 
 a young man was to apply in a day or so whom he would like to interview 
 
620 APPENDIX A 
 
 1920 
 
 before deciding anything. . It will take two or three days before Mr. Lam- 
 bert decides. 
 
 February 3. 
 
 Y. M.C.A., Mr. Doyle, telephoned to, who says that on the face of it 
 it looks as if Mr. Lambert was not favorably impressed by patient. In- 
 formant will ask a man under whom patient would work directly at Lam- 
 bert's details about the situation at Lambert's, as this man lives at the 
 Y.M.C.A. 
 
 February 4. 
 
 Patient telephoned that he will make the usual rounds to-day. He 
 heard from Mr. Jackson that Mr. Fletcher does not need any men now. 
 
 February 4. 
 
 Johnston-Abbott Mills, Chief Inspector, Mr. Fabian (visitor's brother- 
 in-law) written to, asking him for advice as to possible openings in Law- 
 rence for patient. 
 
 February 4. 
 
 Boston University, Vocational Department, Mr. Warren seen by 
 chance in the evening. He came over to visitor and asked whether patient 
 had a job as yet. He suggested that it would be a good plan for patient 
 to report to him so that informant could have him definitely on the waiting 
 list for an opening. 
 
 February 5. 
 
 International Optical Co., Lexington, heard from. Letter stated that 
 at present the only clerical openings for patient would be in the Traffic 
 Department at $20 and a probable one in the Shipping Department at 
 $18, both of which informant thinks wcnild not attract a man of patient's 
 experience. If he is an Italian, that miglit liar Iiim from office positions 
 other than in workshops. An application blank was enclosed and infor- 
 mant states that possibly a better opening in the offices may later occur, of 
 which visitor will be advised. 
 
 February 5. 
 
 Patient written to, asking him to report to Boston University, Mr. 
 Warren, and telling him of the reply from Lexington. Patient has sent the 
 application blank and visitor stated that she was writing to the Interna- 
 tional Optical Company telling them that doubtless patient would consider 
 an opening such as the one in the Traffic Department if promised definite 
 advancement. 
 
 February 5. 
 
 biternational Optical Company, Lexington, Miss Henderson written to, 
 stating that patient would be glad to make the trip to Lexington if there 
 should be a good opening or if the opening in the Traffic Department gave 
 promise of advancement. The letter asked that patient be kept on the 
 waiting list. 
 
 February 6. 
 
 Patient telephoned. He has not received visitor's letter. He will go 
 to Boston University to-day and to Wood & Berry, which he did not get 
 around to as yet. His wife is feeling the strain of the children's illness. 
 F.mma is not vet un and around. 
 
APPENDIX A 621 
 
 1920 
 February 6. 
 
 y. M. C. A. Secretary, Mr. Doyle, telephoned to, who. forgot to inquire 
 about the Chelsea opening but will telephone Mr. Lambert and report to 
 visitor later. 
 
 February 7. 
 
 Patient telephoned. He went to see Mr. Warren at Boston University 
 yesterday and had a long talk with him. Mr. Warren advised him to apply 
 at the Harvard Coal Company, Mr. Marsh, regarding an opening there as 
 a bookkeeper. Patient applied, but Mr. Marsh was not there all day, but 
 to-day patient found him in. Mr. Marsh was at first very enthusiastic and 
 thought patient could do the work, but later on, finding patient could not 
 do typewriting, said he would have to interview three or four others first, 
 
 February 7. 
 
 Boston University, Mr. Warren, seen at Mr. Jenkins' class for employ- 
 ment managers, Boston University. He told visitor that there was a 
 strong probability that one of the professors at the University would take 
 patient on for temporary work and that informant would get in touch with 
 patient about this on February 9. 
 
 February 9. 
 
 Patient telephoned and was advised to get in touch with Mr. Warren, 
 Boston University, at once regarding the possible temporary opening. 
 
 February 9. 
 
 Y. M. C. A. secretary, Mr. Doyle, telephoned that he has got in touch 
 with Mr. Lambert of the Lambert Real Estate Company, who says he has 
 not interviewed patient and could not find out who has. The opening is 
 still there and Mr. Lambert would be glad to consider patient if he can 
 do the work. 
 
 February 9. 
 
 Boston University, Mr. Warren, telephoned to, who states that the 
 temporary opening at Boston University has been taken by a "young fellow 
 just out of high school." Informant would be perfectly willing to have 
 patient consider the opening in Chelsea. 
 
 February 9. 
 
 Patient written to, asking him to apply at Lambert's and telling him 
 that the opening at Boston University had been filled. 
 
 February 9. 
 
 Patient telephoned to in the evening, asking him to get in touch with 
 Mr. Lambert to-morrow morning. 
 
 February 10. 
 
 Patient telephoned that he interviewed Mr. Lambert this morning and 
 is to begin work there to-morrow morning. Mr. Lambert asked patient 
 very few personal questions and told patient there would be a couple of 
 weeks' work. He asked patient whether he was looking around for better 
 opportunities and patient said he was. Patient was afraid if he put his 
 salary too high he would not get the job so he gave $25.00 as his price and 
 Mr. Lambert said "All right, if I have to pay that, I will." Patient seems 
 pleased that he has a definite opening and agreed to get in touch with 
 
622 APPENDIX A 
 
 1920 
 
 visitor soon to let her know how he likes it. He agreed to let the various 
 agencies to which he applied for work know that he is terhporarily em- 
 ployed, but that he is still looking about for better opportunities. 
 
 February 11. 
 
 Johnston-Abbott Mills, Chief Inspector, Mr. Fabian, writes that he saw 
 his employment manager, Mr. John Durand, on February 9, who says he 
 is taking on men right along and advises that patient call at his office so 
 that he may talk with him and find out for what work he is adapted. 
 Lawrence is not an unattractive city for a factory worker and but few of 
 the workers need to pay carfare. 
 
 February 11. 
 
 Johnston-Abbott Mills, Chief Inspector, Mr. Fabian, in'ritten to, stating 
 that visitor would let him know in about two weeks what patient's plans 
 are and suggesting that possibly at that time patient would be glad to see 
 Mr. Durand. 
 
 February 14. 
 
 Patient's wife telephoned that patient asked her to let visitor know 
 that he liked his work very much and that he is "feeling good" and says 
 the work is "pretty easy." His hours are 9 to 5 and Saturdays until one. 
 Emma is well now and expects to return to school on February 16. Dr. 
 Sullivan said Emma had had a bilious attack which she occasionally has 
 about a week. He has advised about Emma's diet, and of a number of 
 things Emma will not eat, such as cereals, and she has just begun to drink 
 milk. The doctor says that her enlarged tonsils should be removed soon. 
 Visitor urged her to take Emma to a hospital O. P. D. soon to make an ap- 
 pointment for tonsillectomy, as otherwise it might be difficult to make one 
 before summer. Informant agreed to do this. Patient's wife is well now. 
 Her back bothered her for a few days as she had strained it by some 
 heavy lifting. Informant agreed to ask patient to telephone visitor on 
 February 16 at noon. 
 
 February 14. 
 
 International Optical Company, Lexington, Employment and Service 
 Department, Miss Henderson, writes that patient's application and visitor's 
 letter have been received. Informant hopes to be able to find some work 
 for patient and will keep him in mind, letting him know if she has an 
 opening which she thinks patient would like. 
 
 February 16. 
 
 Patient telephoned at noon. He likes his present work which he says 
 "is easy enough," there being "nothing complicated" about it. His boss is 
 the head bookkeeper, Mrs. Judson. When asked how he gets along with 
 her he replied, "I can get along with anybody," and that he pretends he 
 doesn't know anything and does things her way. He is catching up with 
 past bookkeeping as far back as last July which has been poorly done by 
 his predecessors. There seems to be no question of permanent work and 
 he says he sees about ten days more ahead. He asked visitor to get in 
 touch with Boston University again, and to look into openings recently 
 advertised, one at the Federal Furniture Company, 356 Benton St., and the 
 other at Dunton-Bcrry's. 
 
 His wife begins work to-night, intending to keep at it until he has a 
 permanent job. For the present, patient feels that she is better off there 
 
APPENDIX A 623 
 
 1920 
 
 than not working as it distracts her mind from somewhat strained relations 
 
 with the landlady. 
 
 February 16. 
 
 Federal Furniture Company, 356 Benton St., telephoned to. The man 
 who does the hiring stated that the firm is a credit house needing a book- 
 keeper, but a younger man than patient, as all the office force is young. He 
 added, "They do all the work I want them to." 
 
 February 16. 
 
 Dunton-Berry's Department Store telephoned to. The employment 
 manager was out, but the head bookkeeper, Mr. Hathaway, stated that he 
 has an opening for an assistant auditor at $35.00. Considerable bookkeep- 
 ing experience and a man of much common sense is required. There are 
 about 40 applicants and informant will have to decide on them soon. 
 Patient should send in a formal application. 
 
 February 17. 
 
 Patient telephoned to and agreed to write Dunton-Berry's to-day re- 
 garding the opening in the bookkeeping department. 
 
 February 19. 
 
 Patient mritten to, suggesting that he take a half day off to apply for 
 clerical opening at Allison's and enclosing a letter of introduction to the 
 office manager there. 
 
 February 24. 
 
 Patient's zvife telephoned that patient would telephone visitor at noon. 
 Informant would like to live in North Beverly as she has friends of her 
 girlhood living there. H patient should work in Beverly he would first 
 commute from Boston before the family moved. They are all well. 
 
 February 24. 
 
 Patient telephoned stating that he will ask for a day off to look into 
 openings at the Allison Manufacturing Company and the Johnston-Abbott 
 Shops. Visitor agreed to mail patient a letter of introduction to the 
 Johnston-Abbott shops. 
 
 Patient is sure his present work is temporary, lasting only a few days 
 more, as the head bookkeeper practically said that this morning. Patient's 
 job has been to catch up with her past bookkeeping. She has been careless, 
 has let things slide, and does not fully understand her work. She has not 
 made a trial balance for the last eight months. Patient has liked the work, 
 however, and has felt well except that he has not slept very well. He is 
 sure that when he has a permanent job he will be O. K. 
 
 February 24. 
 
 Johnston-Abbott Shops, Chief Inspector, Mr. Doyle, "Written to, stating 
 that patient would apply soon to Mr. Durand. 
 
 February 26. 
 
 Patient telephoned that as he has to take off an hour to-morrow morn- 
 ing to complete a piano deal, he will not visit Lawrence and Beverly until 
 March i. Yesterday he arranged for his landlady to purchase a piano at 
 the Hotel Bellingham as a result of an advertisement he saw in the paper. 
 
624 APPENDIX A 
 
 1920 
 
 This deal will give patient $20 commission. Patient is not yet sure when 
 the work will terminate but says it may any time. 
 
 February 2"]. 
 
 Boston University, Mr. Warren, seen at Mr. Jenkin's class for employ- 
 ment managers. He knows of no opening for patient and admits that 
 patient's age is much against him. Apparently no opening can be expected 
 from this source. 
 
 March i. 
 
 Patient telephoned early in the afternoon that he had spent the morn- 
 ing in Beverly at the Allison Manufacturing Co., but due to the present 
 difficulties in transportation, could not reach Lawrence the same day. It 
 is too late, however, to return to his work in Chelsea to-day. 
 
 This morning he waited one hour and a half for the office manager, 
 Mr. Van Horn, who told patient he would look over various clerical posi- 
 tions to see whether patient would fit in. As most of the bookkeeping is 
 done by girls, there would be no opportunity at bookkeeping. He was well 
 impressed by patient's desire to live in Beverly and be permanent with the 
 firm. He asked patient what salary he would require and patient said he 
 would start at $25 if there was every opportunity for advancement; 
 Mr. Van Horn assured patient that no employee was hired at Allison's 
 without the idea of promotion in mind, and that the firm would not con- 
 sider paying patient less than $25. 
 
 Patient suggested that visitor write a letter to ]\lr. Van Horn, who 
 had asked patient to get in touch with him in about a week or ten days if 
 patient had not heard from him. 
 
 When patient announced that he was not reporting to work this morn- 
 ing, the head bookkeeper was quite afraid that patient was leaving and felt 
 much relieved that his absence was only temporary. Patient feels that he 
 has given her a number of valuable suggestions for her bookkeeping, and 
 that there is still a number of days' work there for patient. Patient seldom 
 sees Mr. Lambert and apparently is responsible only to the head book- 
 keeper. 
 
 Patient plans to visit Lawrence soon, but would prefer to live in 
 Beverly as his summer camp would be so near by. 
 
 March 2. 
 
 Allison Manufacturing Company, Manager, Mr. Van Horn, written to, 
 asking him to let visitor know what he decides about patient, and assuring 
 him that patient is ready for responsible work. 
 
 March 6. 
 
 Johnston-Abbott Shops, Chief Inspector, Mr. Doyle, writes that he 
 spoke to Mr. Durand about patient and hopes patient gets a good job there. 
 Some of the jobs are good and some seem hard to informant. 
 
 March 8. 
 
 Patient telephoned that he has not heard from the Allison Mfg. Co. 
 
 March 9. 
 
 Patient written to, reassuring him about Allison's and urging him to 
 go to the Johnston-Abbott Shops at once. 
 
 March 11. 
 
 Patient telephoned that he sees several weeks ahead of work where he 
 is, and suggested visitor's writing to Allison's to-day. He was very dis- 
 
APPENDIX A 625 
 
 1920 
 
 appointed not hearing from Allison's. He thinks they may be waiting for 
 his letter to decide on his merits. He plans to install new bookkeeping 
 methods where he is. He will write Beverly to-day and visit Lawrence 
 soon. 
 
 March 12. 
 
 Patient telephoned that he is very discouraged, having received a letter 
 yesterday from Allison's, stating that there are no openings now suitable 
 for patient, but if there are later, they will let patient know. Patient feels 
 that other men with only half his ability are getting jobs without difficulty. 
 (Patient apologizes for his conceit.) He wonders whether knowledge that 
 he has been at the Psychopathic Hospital on the part of employers has 
 anything to do with it, as he feels Allison's was so enthusiastic when he 
 saw them ten days ago. Visitor reminded him that Allison's knew of his 
 relations with the hospital at the time. His wife is not interested in Law- 
 rence as she knew so many people in Beverly. Patient will, however, go to 
 Lawrence this morning. He is already in the North Station and has for- 
 gotten to take visitor's letter with him. 
 
 March 11. 
 
 Allison Mfg. Co., Office Manager, Mr. Van Horn, written to, asking 
 why patient was not taken on. 
 
 March 15. 
 
 Patient telephoned that he was much disappointed with his visit in 
 Lawrence. He waited a long time for Mr. Durand who had only night 
 work as a machinist to offer patient. This patient refused though wages 
 were not discussed. Patient asked for Mr. Doyle as head office man, who 
 was not so identified, but patient was referred to Mrs. Mahoney in charge 
 of the clerks figuring the payroll. She told patient she had only young 
 girls and boys at $15 and $16. Later patient talked with the head book- 
 keeper, Mr. Hinton, who said most of the bookkeeping was done in Boston. 
 Patient was not impressed favorably by the place, as even the office looked 
 dirty and the young employees complained of the poor pay. 
 
 On returning to Boston patient applied to the Federal Employment 
 Office and asked to be kept on the list. In his last letter to Boston Uni- 
 versity patient asked to be kept on their lists and visitor agreed to remind 
 Boston University of this. 
 
 Patient feels it very much easier for visitor to advise than for him to 
 carry out the advice, but says he tells himself he must keep up his courage. 
 He wjll continue to look around for permanent positions as will visitor also. 
 
 March 17. 
 
 Allison Mfg. Co., Office Manager, Mr. Van Horn, writes that he could 
 not now_ employ patient "in whom we are mutually interested" as there are 
 no openings in the accounting division and the bookkeeping is done entirely 
 by women. Informant wrote patient recently stating that there was no 
 position now to "capitalize his previous experience" but that he would be 
 kept on the waiting list until the situation became better defined. 
 
 March 18. 
 
 Johnston- Abbott Shops, Chief Inspector, Mr. Doyle, written to, ex- 
 plaining that patient's interview with Mr. Durand was not very satisfactory 
 to patient and asking informant to keep patient in mind should any suitable 
 openings appear soon. 
 
626 APPENDIX A 
 
 1920 
 
 March 25. 
 
 Patient telephoned to ask visitor if there was any news regarding 
 future openings. April i he plans to balance the books at Lambert's and 
 says there may be more work there after that. When his work is finished 
 there, he plans to go to the country a day or two, and will stop off via 
 Allison's on his return home. "What's worth having is worth going after." 
 He will tell Mr. Van Horn at Allison's that he will gladly start in any- 
 where in the firm. Patient inquired for Mr. Warren at Boston University. 
 Patient has done nothing about membership in the Y. M. C. A. because un- 
 settled as to location. He plans to drop his membership in the Elks which 
 he never enjoyed and which costs him $12 annually. He feels it too ex- 
 pensive to play with the Elks. In two or three weeks he plans to go week- 
 ends to his camp. 
 
 March 26. 
 
 Boston University, Vocational Department, Mr. Warren, visited. In- 
 formant had an opening at the B. D. Cole Leather Company, 80 North 
 Street, where Mr. Kelsey is looking for a bookkeeper at $25. Informant 
 has sent over about six candidates, none of whom were accepted. One at 
 $25 was too inexperienced and one at $30 was too expensive, but in- 
 formant does not know what the drawback was with the others. If patient 
 applies he can say he heard of the opening through Boston University. 
 
 March 26. 
 
 Patient zvritten to, advising him to look into the opening at the B. D. 
 Cole Leather Company at once and report back to visitor. 
 
 April I. 
 
 Y. M. C. A., Mr. Doyle, telephoned to, who stated that he could quite 
 easily find out from patient's employer how satisfactory his work is, and 
 that he will make such inquiries soon. 
 
 April I. 
 
 Boston University, Vocational Department, Mr. Warren, telephoned to, 
 who stated that it was more to the point for visitor to telephone the B. D. 
 Cole Leather Company than for informant as visitor knew patient so much 
 better. Visitor agreed to do so. 
 
 April I. 
 
 Patient writes that he has made several unsuccessful attempts to tele- 
 phone visitor. On March 29 he called on Mr. Kelsey at the B. D. Cole 
 Company who was very busy and talked with patient but a few minutes. 
 Patient says "he was rather favorably impressed with me and gave me an 
 application blank to fill out." Mr. Kelsey did not explain the position in 
 detail. Patient thinks firm is "a very nice one" to work for. Patient 
 thinks if Mr. Warren of B. U. would telephone Mr. Kelsey it might help 
 to get him the position. 
 
 April I. 
 
 B. D. Cole Leather Company, 80 North Street, Bookkeeping Dcpf.. 
 Mr. Kelsey, visited at 11 a. m. 
 
 Impression : Keen business man, human interest probably secondary to 
 business. 
 
 Informant asked visitor her interest in patient. He is considering 
 patient among two or three other candidates, but said patient did not im- 
 
APPENDIX A 627 
 
 1920 
 
 press him very favorably. He v^^ould not explain this further than to say 
 he felt patient might leave for the liquor business at any time prohibition 
 took a turn and that informant preferred a younger candidate. In favor 
 of patient he spoke of his neat handwriting. It is difficult novi^ to get good 
 material as bookkeepers though plenty of poor help is available. The 
 position is for a m,an to work in as understudy to the head bookkeeper. 
 His work would be to connect up between the factory and the office and 
 the candidate would have to learn both the factory and office bookkeeping 
 methods as well as have eight or nine men under him. Informant agreed 
 to send for patient if he decided to consider him. 
 
 April I. 
 
 Federal Employment Office, 4 Cherry St., visited. There is no open- 
 ing for patient. 
 
 April 2. 
 
 Patient written to, explaining the result of the visit to the B. D. Cole 
 Leather Company and advising patient not to expect the opening there 
 though he can keep it in the back of his mind. Letter advised patient to 
 visit Allison's soon with regard to future employment. 
 
 April 6. 
 
 Patient telephoned his wife is a little discouraged about his not having 
 steady work but she does not say much. Patient will telephone Mr. Kelsey 
 of the B. D. Cole Leather Company to-morrow to see if there are any 
 chances there and will write Allison's that he plans to visit on April 12. 
 Patient's wife has intended to make an appointment at the Children's Hos- 
 pital for the removal of Emma's tonsils and patient will urge her to do so 
 soon. 
 
 April 7. 
 
 Federal Employment Office, 4 Cherry Street, Mr. Brown, visited, who 
 has no openings for patient as a bookkeeper. Prospects in this line have 
 not improved. 
 
 April 8._ 
 
 Allison Mfg. Co., Office Manager, Mr. Van Horn, written to. explain- 
 ing that patient would visit on April 12 and that he would be willing to 
 start in at any time in any line there, as he was especially interested in 
 the firm because of its promise of advancement. Letter asked that in- 
 formant put patient in touch with the employment department if informant 
 had no openings himself. 
 
 April 8._ 
 
 Patient written to, explaining that visitor was writing Allison's. 
 
 April 9. 
 
 Y. M. C. A., Mr. Doyle, ^ telephoned,^ stating that patient has adapted 
 himself very well to conditions, according to patient's employer, and has 
 helped tide over the situation very well. Patient's work there will soon be 
 finished and informant will keep patient in mind for a similar opening. 
 
 April 12. 
 
 Patient reported to visitor at 11:30, stating that his plans had been 
 changed somewhat. In yesterday's Globe he saw an advertisement for 
 
628 APPENDIX A 
 
 1920 
 
 various types of help at the Standard Drug Company, among them ac- 
 countants and bookkeepers. He decided therefore to apply there the first 
 thing in the morning, and waited with a "seething mob" from 8 A. m. until 
 10:30 before he was seen. The employment manager had him fill out an 
 application blank and then told patient that undoubtedly they could fit him _ 
 into the organization and that the man patient should see would not be in 
 until to-morrow. The employment manager said he would look up patient's 
 references in the meantime. Patient put down as his minimum salary 
 $27.50 per week. Patient seemed quite enthusiastic over the interview 
 there. He plans to go at once to apply at Allison's this afternoon. He 
 spent the week-end on his little farm and his farmer friend Henry told 
 patient of an opening at $4 a day to clear the woods on the estate of the 
 millionaire, Henderson, near Lexington, which would last until the summer, 
 n no definite opening materializes in a week when patient expects the posi- 
 tion at Lambert's to end. patient will take this job in the woods, as he does 
 not want to be idle at all especially considering the high cost of living. 
 Patient's wife cleaned up at the camp preparatory to living there for the 
 summer. The family expect to go to camp again next week-end when 
 patient will do his plowing. Patient says he feels pretty well but still 
 sleeps only fairly well, waking up early and then only dozing for the rest 
 of the morning. 
 
 Patient is sure his present employer will give him a good reference 
 and when patient lecently called up Mr. Stratton of the Stratton Piano 
 Company relative to the sale of a piano, patient was reassured by Mr. 
 Stratton that he would give patient a good reference at any time. Patient 
 stated that it was difficult to reach visitor by telephone especially since 
 there is no booth in his office. He will, however, let visitor know the results 
 of his applications at Allison's and the Standard Drug Company. He 
 telephoned the B. D. Cole Leather Company a few days ago and Mr. Kel- 
 sey said he had filled the position that morning. Patient then asked Mr. 
 Kelsey why patient had not been selected, adding that perhaps patient was 
 asking state secrets. Mr. Kelsey did say it was not because of patient's 
 age but would give no further reply. Visitor agreed with patient that the 
 position at clearing the woods would be good in case no further opening 
 was at hand as patient said he would feel free to leave it at any time. 
 
 April 20. 
 
 Patient's former employer, Lambert Real Estate Co., telephoned to. 
 Patient left there on April 17. The clerk volunteered that patient had done 
 very good work and that they thought he was going to work at Allison's 
 and live at his camp. 
 
 April 20. 
 
 Patient's zvife telephoned to. Patient went out to Lexington to-day to 
 look up Allison's and will be home to-night. Visitor left word for patient 
 to write at once or telephone regarding his work plans. Further details 
 could not be discussed over the telephone. 
 
 April 22. 
 
 Patient's zvife telephoned. A week ago patient was told at Allison's 
 to report April 20 as the firm thought they could then place him in the 
 stockroom. He planned to return home the evening of April 20 for his 
 work clothes if put to work, but nothing has been heard from him. It_ is 
 probably about a half hour's ride from his camp to Allison's, from which 
 he planned to comniute. loformant's plans will depend upon how well 
 
APPENDIX A 629 
 
 1920 
 
 patient likes Allison's if he is working there. She will try to get news of 
 patient for visitor as soon as possible. 
 
 lApril 26. 
 
 Patient reported to visitor, stating that he is well and busy, but that 
 he still has vague fears at times, which he, however, has been able to con- 
 trol. His wife is still working, and his wife's sister is still helping some- 
 what financially. For example, she visited patient's camp last week-end, 
 bringing out a good supply of food, and paying patient's son's transporta- 
 tion. Patient hopes to pay her back later. 
 
 Patient asked visitor's advice about his work. The last two times he 
 applied at Allison's, word was sent to him from Mr. Van Horn that he 
 was too busy to see patient, and that he should report back in a week. 
 Patient wondered therefore if that was the real explanation or whether 
 the firm has no interest in patient. 
 
 The Standard Drug Company, where he reported again to-day, said 
 that patient's name is on the waiting list. They have selected no clerks 
 or bookkeepers as yet, this being up to the department heads. 
 
 Mr. Lambert has sent for patient, asking patient what salary he would 
 require to do the work he did temporarily as a permanent job. The present 
 bookkeeper has already become nervous on the job since patient left, 
 because she finds it beyond her ability to keep the books straight. Patient 
 stated $35 as his salary and said to visitor if no other opening was avail- 
 able, he would take it, but he feels it is a "nerve-racking" job. The em- 
 ployer keeps one book where three are really necessary, hence making the 
 bookkeeping complicated. Three books, though simpler, would entail extra 
 work which the employer is unwilling to pay for. Complications come in 
 through the fact that there are really three different funds to account for 
 and the employer is constantly borrowing from one fund for another. If 
 patient took the job, he fears he would need to start on overtime, but visi- 
 tor firmly said he could not do this, and if overtime is necessary must have 
 assistants. The present bookkeeper Mr. Lambert plans to shift into other 
 work in the office. Patient wonders how she would feel toward patient's 
 keeping her position. He suggested to Mr. Lambert that both Mr. 
 Lambert and the insurance man spend too much time in the office, and 
 that if patient took the position he thought he could undertake some of 
 their office work, such as answering general questions about real estate, 
 and making appointments for interested parties with his employer. Mr. 
 Lambert will decide by noon of April 28 whether he can pay patient the 
 salary of $35 or not. 
 
 Patient would prefer working for some large firm such as Allison's, 
 as he feels a smaller firm can offer only a less secure job. After visitor's 
 telephoning Allison's, patient agreed to get in touch with visitor late to- 
 morrow morning. 
 
 April 26. 
 
 Allison Mfg. Company, Lexington, OMce Manager, Mr. Van Horn, 
 telephoned to, and stated that patient had reported the situation correctly 
 to visitor, and that informant is very sorry he has been too busy to spend 
 the hour required to see whether patient would fit into the stockroom. He 
 is not willing to have patient take another position without informant's 
 looking into the possibilities at Allison's, however. Informant agreed to 
 telephone visitor to-morrow at 4 o'clock what the situation is. 
 
 April 27. 
 
 Patient telephoned late in the afternoon, and agreed to do so again 
 to-morrow morning as Allison's had not been heard from. 
 
630 APPENDIX A 
 
 1920 
 April 28. 
 
 Allison Mfg. Co., Lexington, OfUce Manager, Mr. Van Horn, tele- 
 phoned to at 10:30 A. M. Informant apologized for not telephoning visitor 
 yesterday. He had the memorandum on his desk and had done the pre- 
 liminary work ; namely, to see where patient would fit in. 
 
 At present there is no clerical opening for patient, but he can definitely 
 be taken on in the stockroom giving out orders. _ This work is largely 
 physical and is paid at an hourly rate, where patient would earn about 
 $20 a week. Holidays and Sundays as well as vacations are not paid 
 for. Informant would keep patient in mind while he worked in the stock- 
 room for advancement to clerical work either in the stockroom or else- 
 where. They are hard pressed now in the stockroom for clerical help but 
 informant has not been able to "sell" patient to them for clerical work 
 because of his age. Informant is confident, however, that clerical work 
 will develop for patient later when his abilities are recognized in spite of 
 his years. 
 
 Visitor stated that unless she notified informant to the contrary, patient 
 would report to him on April 30. Informant said that at that time he 
 would introduce patient to the employment department and arrange for 
 patient to begin work on May 3. At first informant suggested that if 
 patient had a good opening at Lambert's, he had better take it, but when 
 visitor spoke of patient's fear of only temporary work there, informant 
 admitted that at Allison's permanency could be expected. 
 
 April 28. 
 
 Patient telephoned and seemed somewhat depressed at the salary 
 ofifered to start with at Allison's. Visitor reminded him that he could 
 hardly have a better person than Mr. Van Horn interested in him, and 
 pointed out the advantageous features of Allison's. Patient will telephone 
 Lambert's about 12:30 to-day and will telephone visitor to-morrow morning. 
 Patient himself will be allowed time by Lambert's to make a decision. 
 Visitor told patient it was up to him to make the final decision. 
 
 April 29. 
 
 Patient telephoned, much discouraged. Mr. Lambert had telephoned 
 to patient's brother-in-law in patient's absence yesterday that he could not 
 meet patient's figure. Patient feels Allison's should offer him more as a 
 starting figure (in fact, Mr. Van Horn told him he could expect a minimum 
 of $25), and that the promise of advancement there is not definite enough. 
 He is wondering whether he should telephone Mr. Lambert, but finally 
 decided he would later. As Mr. Lambert had said he would be v/illing to 
 pay $1,000 more a year, patient does not understand why he is "balking at 
 $35 a week." He thinks all there is for him to do is to make the rounds 
 of the employment ofliccs. Visitor tried to assure him that the hardest 
 part of his task was surely finished ; namely, that he had gone the rounds 
 of the employment offices and now had a good employer interested in him 
 and that he could hardly hope to find a better firm than Allison's. 
 
 Visitor suggested that patient come out to talk with Dr. Jacobs. He 
 first said he would gain nothing, and spoke in the tone of a spoiled child. 
 When visitor reminded him that Dr. Jacobs was the doctor to sanction 
 responsible work for him, he admitted he could lose nothing by coming, 
 out to see Dr. Jacobs and would do so. 
 
 April 29. 
 
 Patient reported at 3 p. m. to see Dr. Jacobs. Visitor first discussed 
 the case with Dr. Jacobs, who felt that patient could rightly be discouraged 
 
APPENDIX A 631 
 
 1920 
 
 with an ofifer of only $20 a week. After seeing patient, the doctor reported 
 to visitor that patient is in very good condition, apparently now having full 
 control of any fears. He is a typical psychasthenic, being introspective, 
 overconscientious, hesitant about making decisions, and lacking self-confi- 
 dence. Dr. Jacobs says patient's present problem to decide would be hard 
 for a normal healthy person, and that if patient were not somewhat worried 
 over prospects, considering his age, his judgment could be questioned. He 
 told patient that he did not know the merits of the Allison opening, but 
 that it likely was a good proposition for the summer at least. 
 
 Patient reported to visitor that he could get Dr. Jacobs' point of view; 
 namely, that he must use "mental suggestions" to himself, but that it was 
 harder to carry out than others realized. He will go to Allison's to-morrow 
 morning and look into the situation for himself. If the promise of ad- 
 vancement is definite enough, he will take the position. He will write 
 visitor to-morrow evening before going to camp for the week-end. He 
 feels considerably worried about the support of his family as he hates to 
 have his wife working, or his relatives assisting. 
 
 He telephoned Mr. Lambert this morning but found him out, but does 
 not plan to telephone again as patient says "I have forgotten all about that 
 place now," evidently considering the deal closed there. 
 
 May 3. 
 
 Patient writes that he is to start in at the Allison Company on May 3, 
 beginning in the stockroom, stating that "Mr. Van Horn promises to see 
 that I get proper advancement if deserving of it." 
 
 May 3. 
 
 Patient written to, stating that visitor feels he has made a wise choice, 
 expressing the need of recreation, and asking him to report frequently 
 regarding the progress of his work. 
 
632 APPENDIX A 
 
 Case 94 
 PSYCHOPATHIC HOSPITAL 
 
 SOCIAL SERVICE 
 NUMBERS 562 
 
 FILE NUMBER 5720 NAME Harriet Nelson Farmer* 
 
 0. p. D. NUMBER 3838 
 
 Residence 44 Stevens St., Roxbury. 
 
 Correspondent Mother, Frances Ordway Farmer, at above address. 
 Sex F Age 28 Color W 
 
 Civil condition S Place and date of birth England, 
 
 Religion Protestant 1887 
 
 Occupation Compositor (typeset- 
 ter) 
 Time IN Boston 22 yrs. In Mass. 22yrs. In U. S. 22yrs. 
 
 Previous addresses 
 
 107 Downing Street, Boston 
 
 63 Revere Street, Boston 
 When know^n to social service 11/30/15; 3/12/18; 6/9/19 
 When discharged from social service 12/31/17; 4/24/18 
 Reason for being known to social service Supervision 
 Report from confidential exchange No record 
 
 Name of father Henry (deceased) 
 
 Address 
 
 Name of mother Frances 
 
 Address 44 Stevens St., Roxbury 
 
 Name of spouse 
 
 Address 
 
 Names and ages of children or siblings 
 
 Frederick (died in infancy) 
 
 Florence, 34 
 
 Benjamin, 32 
 
 Bernard, 30 
 
 Patient, 28 
 
 Admitted to house 10/31/15 Authority Chap. 174 
 
 Discharged 12/8/15 Admitted to o. r. d. 1/19/16 
 
 Diagnosis Condition Unchanged 
 
 Not insane — not feeble-minded 
 
 (Psychopathic Personality) 
 Social Symptoms Date 3/1/16 
 
 Inebriety 
 
 Fabrication 
 
 Lying 
 
 Suicidal attempt 
 
 Non-support of mother 
 
 Insufficient wage 
 
 Friendlessness 
 Social Diagnosis Date 3/1/16 
 
 Vitia (Bad Habits) + Morbi (Disease) 
 
 * All names used in this record are fictitious. 
 
APPENDIX A 633 
 
 PSYCHOPATHIC HOSPITAL 
 
 SOCIAL SERVICE 
 
 NO. S-562 NAME Harriet Nelson Farmer 
 
 ADDRESSES 
 Patient: 
 
 Gordon Home, 
 
 55 Dix Street. 
 Relatives: 
 
 Mother, Mrs. Frances Ordway Farmer, 
 
 44 Stevens St., Roxbury. 
 
 Sister, Florence Farmer, 
 44 Stevens St., Roxbury. 
 
 Employer, Miss Nancy Stowell, Charles St, 
 
 Brother, Benjamin Farmer, 
 Newton St., Nashua, N. H. 
 
 Brother, Bernard Farmer, 
 Dover, Mass. 
 
 Minister, Mr. Young, Channing Church, 
 Day St., Roxbury. 
 Residence, York St., Roxbury. 
 
 PSYCHOPATHIC HOSPITAL 
 
 SOCIAL SERVICE 
 
 NO. S-562 NAME Harriet Nelson Farmer 
 
 EXPENSE SHEET 
 
 Expenditures 
 12/24/15 Tie for Christmas. . .$ .25 
 1/26/15 Material for sewing 
 
 (for another patient) 1.29 
 
 2/19/16 Theater tickets 1.50 
 
 4/5/16 Theater tickets i.oo 
 
 4/6/16 Bath spray 59 
 
 4/8/16 Out-of-work pay 50 
 
 $5.13 
 
634 APPENDIX A 
 
 PSYCHOPATHIC HOSPITAL 
 
 SOCIAL SERVICE 
 
 NO. S-562 NAME Harriet Nelson Farmer 
 
 SUMMARY 
 1916 
 
 January 30. 
 Social History: 
 
 Patient is an English woman of 28, who has lived in the United States 
 22 years ; in Boston 22 years. She has a sister, aged 34, and two brothers, 
 32 and 30 years of age. Patient was eight years old when her mother 
 separated from her father because he was found to be maintaining another 
 wife and family in the city. Children were boarded about a year by a 
 children's agency until the mother, who was and still is an invalid, gained 
 strength to reestablish the home. Family were then supported by two 
 older children. Several years ago both brothers married and left patient 
 and sister to support the mother. In April, 1914, the mother was unable 
 to keep up her housework and the home was broken up. Patient lived in 
 lodging houses in the West End and sister and mother with a married 
 brother. A year later, April, 1915, patient was asked by mother and sister 
 to keep house with them, but she refused to go home to live until June, 
 1915, when she was unable to support herself on her low wages. Financial 
 struggle of the family has always been great. Patient did not contribute 
 after leaving home and only $2 a week when she returned. 
 
 The mother is a frail woman, able to get about only on crutches. She 
 is religious, generous, and open-hearted. The sister has worked in the 
 same dressmaking establishment for many years. She is an earnest, up- 
 right, and matter-of-fact woman of excellent character. The older brother 
 who lives in Nashua has a wife and two young boys. The brother in 
 Dover has a wife and a daughter aged ij^. He is a machinist and ir- 
 regularly employed. Several years ago he was discharged from one firm 
 for attempting to steal money from the safe. The family are all willing to 
 do whatever they can for patient and the mother especially is fond of her. 
 They are discouraged al)OUt her. They reprove her little and allow her to 
 have her own waj- because they arc afraid of her tales of abuse. 
 
 The mother and sister have two rooms, a bath and a kitchen in a 
 house on a pleasant, quiet residence street of Dorchester. 
 
 Patient went to school in Boston through the grammar grades. 
 
 Up to a year ago patient had been a typesetter in the same place for 
 eleven years and earned $12 a week. Since then she has worked in two 
 candy factories for $5 a week. Previously she worked in an office and a 
 laundry, a short time in each. Patient has about $50 savings. 
 
 She is an ardent Episcopalian, though she was brought up a Unitarian. 
 
 When the home was first broken up, a woman prominent in the Boston 
 school department was interested in the family and became guardian to 
 
APPENDIX A 635 
 
 1916 
 
 the children. For the past two years St. James Church with the aid of 
 
 York House has tried to supervise and guide patient. 
 
 Physical History: 
 
 Patient had normal birth and development, with exception of walking 
 a little late. She had measles in childhood, diphtheria at five, and several 
 attacks of appendicitis (no operation). Patient wears glasses. She has 
 some headaches. Her teeth are in bad condition. She is subject to neu- 
 ralgia. Examination here shows a poorly nourished condition. Question 
 of anemia. Wassermann test, blood serum negative. 
 
 In appearance, she is short and slight, and is usually pale. She is the 
 wiry type with normal endurance. 
 
 Father died in Westboro State Hospital of general paralysis. Mother 
 is an invalid and has had spinal curvature from childhood. About twenty 
 years ago she was treated for syphilis contracted from patient's father. 
 Heredity otherwise negative or unknown. 
 
 Mental History: 
 
 Patient was an average scholar. She reads much good literature, Les 
 Miserables and other classics. For the past two years patient has been 
 excessively alcoholic, drinking alone in her own room and going several 
 times to priest, or York House workers, under the influence of liquor. 
 She has been untruthful and unreliable, telling many things about mis- 
 treatment by her family which have no basis in fact. She has told scan- 
 dalous stories about the Episcopal priest to whom she confessed and about 
 the other church members. She has fabricated stories of attentions of 
 men. For a time, an unattractive young man paid her attention, but he 
 soon let her alone. Patient talks constantly and is aggressive toward 
 people with whom she comes in contact. Girls in church club would not 
 come if she were to be there. She is lazy, slovenly, and thoughtless. At 
 home, she leaves all the housework to her mother and sister, and expects 
 them to sew and wash for her as well. She stays in bed late. Patient and 
 sister are uncongenial, but patient is fond of mother. She is depressed 
 at menstrual periods. 
 
 A short time before admission, she had put her name and address into 
 a package of peanuts while working in a candy factory. As a result, she 
 entered into correspondence with a man in Springfield whom she decided 
 to marry. He turned out to be 65. Patient showed much disappointment 
 at the outcome of this affair. 
 
 Patient was sent to this hospital after an attempt at suicide. On this 
 day, nothing unusual had been noticed in patient's behavior. She had 
 never threatened suicide, and had not shown great depression. After going 
 to town that morning, she lunched with her mother, who then went to her 
 room to rest. A few hours later the mother was notified that patient had 
 taken Paris green, and had gone immediately to a doctor's ofifice. She was 
 taken to the City Hospital, and from there was sent here for observation. 
 Patient said she had bought the Paris green for an insecticide and took it 
 because she felt discouraged with her own life and her mother's physical 
 condition. 
 
 In typesetting patient was fair, but was considered physically not fitted 
 for the work. She was laid ofif from monotype with the introduction of 
 more linotype machinery. 
 
 In other places of employment she was liked and considered good. 
 Each place she left for a better place. 
 
 Examination here shows her to grade 15 years plus on the Point Scale 
 and 125^ years on the Binet. 
 
636 APPENDIX A 
 
 1916 
 
 Diagnosis: Not Insane — Not Feeble-minded (Psychopathic Person- 
 ality). 
 
 November 30. 
 Recommendations in regard to : 
 
 Social Condition: Patient should be kept away from her own home 
 except for visits. Her family should be made to understand and tolerate 
 her peculiarities. 
 
 Keep her supplied with interesting handwork. Send to theater occa- 
 sionally and try to have her be with girls her own age through living with 
 them and through church clubs. 
 
 Next season try to arrange for night high school or some industrial 
 class. Suggest books and keep patient supplied with list of free lectures. 
 
 Physical Condition: Regularity of meals and a proper diet should be 
 arranged. Encourage daily bathing. 
 
 Further medical care at a general hospital ( ? of anemia) is recom- 
 mended. Teeth should be filled. 
 
 Mental Condition: Encourage and commend patient in all her efforts. 
 
 Congenial work should be found and signs of mental or "physical 
 fatigue watched for. 
 
 Patient should report to Out-Patient Department monthly in the begin- 
 ning. Special attention should be given to any depression lest it lead to 
 drinking. Patient's complaints and difficulties with family should be mini- 
 mized and her friendly attitude maintained. 
 
 SUMMARY OF RESULTS IN SIX MONTHS 
 
 April 5. 
 Social: 
 
 Since leaving the hospital, patient has lived at the Gordon House in a 
 double room. Every Saturday afternoon and Sunday she has spent at 
 home and last two months she has been staying over night. Occasionally 
 she has spent the day at her brother's in Dover. For two months she has 
 been giving her mother 50 cents or $1 weekly. She takes her dainties often. 
 She has put about $10 in the bank. 
 
 From December 28 to March 11 patient worked at piece work in a 
 factory where the work was irregular and where she could earn a maxi- 
 mum of about $7.50 a week. On March 11 patient started time work in 
 another factory where she pasted labels and packed bottles for $6 a week 
 with advance in wage later. This work was uncongenial to her and on 
 April 24 she found a position in her old trade of typesetting at $8. 
 
 Evenings patient stays in, usually either reading or sewing. She has 
 been with her sister to a church entertainment, to the theater, and some 
 public meetings. Occasionally she goes to the Settlement House forum 
 meetings. 
 
 In the House the girls like her and come into her room evenings. 
 They have spreads and very jolly times. In February her roommate, a 
 blind girl to whom she was devoted, left, and she had a young Polish girl 
 until Slay, when she has been alone. At work, she has made some girl 
 friends. 
 
APPENDIX A 637 
 
 1916 
 
 In January patient joined her people's Unitarian Church, but she has 
 attended only comparatively few times. She went to the Episcopal Church 
 fairly regularly for four months without telling her family, but now goes 
 less often. 
 
 Physical: 
 
 On discharge, patient was referred to the Massachusetts General Hos- 
 pital with a question of anemia. She was in the hospital from December 
 13 to 17 and was found to be not anemic. She has had her teeth cleaned 
 and some fillings done at the Harvard Dental School at times when she has 
 been out of work. She has reported monthly to the Out-Patient Depart- 
 ment. 
 
 Patient eats two meals at the House, and usually fruit and cocoa at 
 night. Luncheon she takes with her to work. 
 
 Patient walked to and from work a distance of about three miles in 
 her first two places. Now she walks occasionally though it is about five 
 miles. At present work she sits on a high stool, but stands from choice 
 some of the time. She goes to bed earlj^ particularly when work has been 
 physically fatiguing. A bath spray has facilitated daily bathing. 
 
 Patient had difficulty with menstruation and has been to consult Dr. 
 Green, a woman physician at the hospital, about it. 
 
 Mental: 
 
 There has been no evidence of patient's telling lies or elaborate fabri- 
 cations. She exaggerates her own good efforts in everything she does and 
 gives accounts of her excellent conduct. There has been no open conflict 
 between her sister and herself. Patient has not been drinking, nor has she 
 mentioned suicide. 
 
 She has appeared to be happy and fairly contented except for her 
 desire to stay at home over Saturday nights. This had not been allowed 
 for several months because patient would stay in bed late and impose 
 on the family. Her mother's invalidism worries her and often she gets 
 discouraged or sad over it. 
 
 Her last roommate was a rather stupid and ill-mannered girl and 
 patient took much pleasure in training her manners and habits. 
 
 Patient has shown herself to be very generous. She was glad to make 
 two garments for another patient known to visitor and she has made 
 several presents for visitor. She is good with handwork of all sorts and 
 enjoys spending her time this way. 
 
 When discouraged and blue she had two long talks with the Chief of 
 StaflF. 
 HA/C 
 
 PSYCHOPATHIC HOSPITAL 
 
 SOCIAL SERVICE 
 
 NO. 8-562 NAME Harriet Nelson Farmer 
 
 HISTORY 
 1915 
 December 3. 
 
 Patient's story: Patient gives following places of employment: 
 
 1. T. S. Davis, 180 Young St., office work. Left for better wages. 
 
 2. One year 1904-5 — Charter Hill Laundry. Laundry work. (Place 
 burned.) Left because work was too hard. 
 
638 
 
 APPENDIX A 
 
 I915 
 
 ' 3. Nine years to November, 19:4 — Sampson Press. Left with intro- 
 duction of a new machine requiring fewer girls. 
 
 4. December, 1914 — G. I. Eaves, candy work. Left because rush sea- 
 son was over. 
 
 5. February, 1914-October, 1915 — Tyson Brand Co., Cross St., Cam- 
 bridge, packing. Left because employees were rough and wages low. 
 $'.50 a week. 
 
 Schools were as follows : 
 
 r. James B. Baker School (Grammar School), finished 1904. 
 
 2. East Boston High School (night), 1905. 
 
 3. Dixon's Commercial School (night), 1905, complete course. 
 
 Patient has always lived with her family until August, 1914, when they 
 broke up because of mother's ill health. She has a married brother, 
 Arthur, aged 32, living on Newton St., Nashua, N. H. Of his wife patient 
 is fond and feels at home there. He has two boys. Another brother, 
 Bernard, is married and has one girl and lives in Dover. Patient does not 
 know his wife well nor feel at home with her. They have asked her to 
 come and stay there when she leaves here, but she is anxious to go to 
 work. "I think I might go insane if I stay out of work nuch longer." 
 Patient and her sister Florence are not congenial. Sister is "older and 
 more set in her ways" into which she tries to draw patient. Sister goes 
 out and takes an interest in suffrage and such things while patient prefers 
 to be at home and quiet. 
 
 Since family broke up housekeeping patient has lived in lodging houses, 
 first at 107 Downing St. Room was $3 and when she took a $2.50 one in 
 the same house it was ill-kept and had Ijugs and vermin. On September 18, 
 1914, she moved to 63 Revere St., where she stayed until June, 1915. At 
 that time she returned to her family (mother and sister) who started to 
 keep house. 
 
 Patient's family are Unitarians. She was confirmed in Christ 
 Church, East Boston. The minister there. Rev. Y. K. Elden, has since left, 
 but she keeps in close touch by correspondence with Mrs. Elden. Patient 
 has been going to St. James Church, Cambridge St., for a little over a year. 
 Confessions she has made to Father Cramer and ha^i confidence in him 
 until lately. When she confessed drinking he sent her to see Miss Kendall 
 at York House, but patient did not feel she could enter there. She has 
 seen Miss Kendall a good deal and trusted her. Has since heard that Miss 
 Kendall said she was "mentally deranged" and this has hurt patient's feel- 
 ings. Father Cramer told her she must do exactly as he said if he was to 
 help her, but patient was unwilling to do this. At one time Father Cramer 
 sent an immoral girl of 16 to her for advice. Patient thinks he must have 
 had confidence in her to do such a thing. Lately, however, he has prom- 
 ised to see her, and has not done so, and said he went to Roxbury and 
 found no one home, when in reality he saw her mother and upset her 
 terribly. Her confession he used in his sermon. After the latter incident, 
 she made up a lot of things to confess just to see whether he would tell 
 them, and he did. Patient will discontinue connection with this church. 
 She feels she ought to go to the LTnitarian Church because Mr. Young, the 
 pastor, is taking an interest in her and offering to help. She cannot believe 
 their doctrines nor be satisfied with the service. 
 
 Patient goes out about two nights a week. The other nights she goes 
 to bed 8 or earlier. She gets up about 6. Always she sleeps well and has 
 a normal appetite. When she had a room, she cooked her own meals there, 
 and on Sundays, when she went to see her mother at her brother's, they 
 filled a travelling bag with home-cooked things for her. From August, 
 
APPENDIX A 639 
 
 1915 
 
 1914, to May, 1915, patient took a glass of port wine ($1 a quart) a day to 
 brace herself. She took raw eggs also. She found the wine made her 
 nervous so she stopped it. Had one glass a few days before admission. 
 She has no desire for it. 
 
 Patient averaged two books a week as well as all the books for which 
 she set up type. She reads good books, naming as examples Last Days 
 of Pompeii and Gilbert Parker's novels. She owns a number. Em- 
 broidery she likes to do and makes all her own clothes, mostly by hand, 
 and trims her hats. 
 
 She likes to be alone and has never made any girl friends with the 
 ' exception of Miss Kendall of York House. For six months in 1914 she 
 knew Karl Cauldwell and was engaged to him, but he left town and wrote 
 he would not see her again. Afterward, she found out he was not a good 
 sort so has not cared that he went away. She had the friendship of Frank 
 Illington, who in September, 1914, went away to study for Roman Catholic 
 priesthood. He left his books to her. He was a fine, good young man. 
 At one time patient belonged to the Girls' Friendly Society but dropped out 
 because the meetings ceased to interest her. She never mixed with girls 
 at St. James Church because she thought them two-faced. She would like 
 industrial classes where work with the hands is done, but she does not care 
 for dancing or exercise. Says she is a good girl. 
 
 Patient does not want to live away from home, but realizes it is better 
 since she worries too much over her mother's suffering. She would want 
 to go home every week. 
 HA/C 
 
 December 2. 
 
 Employer, Mr. D. I. Stern, Snpt. of Sampson Press, seen at Cambridge 
 St., Dorchester. No exact record kept of patient, but informant remem- 
 bered her well. He had always taken an interest in her because he felt 
 that she was delicate and that she was not suited to factory work. Exact 
 dates of employment not kept. Informant thought she had been there for 
 about five or six years. She was a compositor and set up and also cor- 
 rected type. For the first few years she was in piece work and may have 
 been paid from $7 to $17 per week, depending upon her speed. Later that 
 system was abolished and for about a year she was a "weekly worker," 
 and received $12 per week. The hours are from 7 :20 to 5 with an hour 
 for luncheon and every Saturday afternoon off. Patient was quite inter- 
 mittent in her work. No record was kept of that either. Patient worked 
 in a large, light, well-ventilated, clean room with about 75 other workers, 
 men and women. The visitor saw this room and the processes used by 
 the patient. There is no heavy lifting in the work. The patient selected 
 type and arranged it in "sticks," these in turn being placed in a long pan. 
 After the proof had been read it was returned to her. She then cor- 
 rected_ any mistakes in setting up the type. Each worker sits on a high 
 stool in front of a slanting desk arrangement on which the type is de- 
 posited. Theonly element of strain seemed to be that of remaining seated 
 most of the time. A fair degree of skill is required in composition. The 
 worker must have a good knowledge of the English language and be able 
 to spell and punctuate fairly accurately. Patient was a fair worker, but 
 "not distinguished" in speed or accuracy. She reached "about the middle 
 mark" in efficiency. _ The informant thought her chief fault "lack of pep 
 and steam." He said she did not seem to have physical energy. She was 
 fairly attentive to her work and was not "a gad-about." 
 
 At the time when the piece-work system was abandoned a great many 
 girls were dropped. In the natural course of events patient would also 
 
640 
 
 APPENDIX A 
 
 1915 
 
 have been dropped because she was not particularly valuable, but when she 
 told him that there was financial trouble at home and that "it was up to 
 her" he let her stay on as a weekly worker. He felt that the work was 
 too great a strain upon her and told her that she ought to get some kind 
 of work in a private family and some place where she could be out of 
 doors. She looked anemic. Informant heard that there was one member 
 of the family who caused a lot of trouble and in addition there was illness. 
 Patient was often out because of sickness. 
 
 She was always quiet and tractable, but if anything annoyed her she 
 "got up and acted like a normal person." Informant thought that she was 
 very proud and that she would take all trouble on her own shoulders and 
 never give way under it. At one time she gave all the financial assistance 
 that was given to her family. Her eyesight was poor and she had occa- 
 sional treatment for it. Patient's work showed no deterioration. Patient 
 resigned to take another kind of position. Informant would not care to 
 take her back because she was not suited to the work, and was not par- 
 ticularly efficient. 
 
 Informant confirmed his own memory by talking with Mr. Quinn, 
 patient's foreman, who gave a very similar report. 
 
 Impression : Unusually intelligent and understanding man, obviously 
 interested in the welfare of his employees. 
 MBS/C 
 
 December 3. 
 
 Teacher, Miss Neide, seen at James B. Baker School, Roxbury. She 
 did not have patient, but had had her l^rother, Benjamin, in her class. On 
 her recommendation. Miss Neide's brothers, "The Three Neides," took 
 Benjamin to work in their confectionery concern. He was there several 
 jears and it was finally discovered that he liad been taking supplies for 
 some time. He stole from the safe the last thing. The queer part was 
 that he seemed to have no sense of the wrong of it. They all thought he 
 might be "not responsible." 
 HA/C 
 
 York House Matron, Miss Kendall, who has known patient about two 
 yearSj seen. Patient has l^een to her, to Miss Hunt, another matron, often. 
 She has never had a sensible conversation with patient. She is most 
 erratic, talks at great length aliout the men she intends to marry, or about 
 injuries which various people have done her. Nothing that she says can 
 be relied upon for she tells a different story to everyone. For example, 
 she told Miss Kendall not to see her mother, because mother is a Unitarian. 
 Mother was very cordial to Miss Kendall. She is very bold and boastful 
 about her drinking. Has said she drank as much as two quarts of port 
 wine in one night. She usually drinks alone. Has been seen under the 
 influence of liquor though not actually drunk. She seldom takes anything 
 without immediately going to one of the priests of St. James' about it. 
 
 Patient told the story of her father having contracted syphilis and 
 having died in Westboro State Hospital. One maternal aunt was insane. 
 Father disappeared at one time for several weeks. When he returned he 
 gave mother syphilis. She soon found he had a wife and five children by 
 the name of Farmers, living in the West End. Mother is now suffering 
 from syphilis and tuberculosis. After death of father, patient and brothers 
 and sisters were placed in home, patient going to Home for Orphan Chil- 
 dren. Miss Kendall has not had the opportunity to verify these stories. 
 
 Patient has said a good deal about having men in her room and Miss 
 Kendall has thought her to be immoral. Karl Cauldwell was a diseased- 
 looking man; his face was covered with sores. 
 
APPENDIX A 641 
 
 In packing peanuts, patient put her name into a package. In Septem- 
 ber she had a letter from a man in Springfield who had bought the peanuts. 
 She corresponded several weeks with him and then told Miss Kendall she 
 wanted to marry him. Associated Charities in Springfield found he was 
 about 60 and had a wife and children, and was somewhat "oflf" on the_ sub- 
 ject of women. Patient saw this letter from the Associated Charities a 
 few days before she took poison. She had often said before that she 
 would do so, but in an offhand way. 
 
 At home patient is troublesome. She stays out very late several nights 
 a week and is quarrelsome. 
 HA/C 
 
 December 4. 
 
 Guardian, Miss George, of Public Schools, high school teacher, 
 says she was made guardian of patient and other children when father 
 died. She has known the family 25 years. When they first came to her 
 attention through the children at school, they were underfed and it was 
 found the family had been living on stale bread and water for several days. 
 
 Patient has never been a help to her family in a financial nor any 
 other way. She should not go home now because she is too great a care 
 and worry to her mother and sister. Mother has been sick all of 25 years 
 Miss George has known her. 
 
 Patient graduated from grammar school at 17. Was a scholar below 
 average. 
 
 HA/C 
 
 December 4. 
 
 Father Superior and Father Cramer of St. James' Church (Episcopal) 
 seen. Patient has been known to them about two years, and was at that 
 time drinking heavily. She has never been seen when she was unable to 
 walk, but oftentimes was markedly under the influence of liquor and very 
 unsteady on her feet. She has denied immoral sex conduct and they have 
 no reason to believe she has been immoral. She has a "diabolical" and 
 malicious way of starting and spreading scandal. She will tell one tale to 
 one person and another to some one else. Among the parishioners, she is 
 talkative and always ready to make friends. She is not bold. The girls 
 of the church will have nothing to do with her because of her conduct, 
 and have completely frozen her out. If she came to meetings, they would 
 not. 
 
 The priests feel that sex is the basis of the whole matter. If she had 
 married when younger she probably would have been comparatively nor- 
 mal. At one time last winter, Karl Cauldwell kept company with her and 
 they were engaged. He was an uninteresting, somewhat slow young man, 
 but not objectionable or bad. During the time patient kept company, she 
 was a normal individual. He soon discovered what she was like and dis- 
 appeared. Patient has been much worse since that, in February, 1915. 
 Otherwise, her conduct has not shown any fluctuations. 
 
 Patient has taken her transfer letter from the church so is no longer 
 a member of their parish. 
 
 Impressions : Father Cramer is a young man, probably looks younger 
 than his years. 
 
 Father Superior did most of the talking and gave general statements 
 chiefly. Interview was in the church, where the two fathers were on duty 
 for hearing confessions. 
 HA/C 
 
642 
 
 APPENDIX A 
 
 1915 
 December 6. 
 
 Landlady seen at 63 Revere St. Patient roomed there as stated and 
 was recommended bv Frank lUington. She had not known patient drank, 
 until after patient had gone and Mr. IlHngton returned. He mentioned it 
 and she then remembered smelling liquor on patient's breath once. In 
 the beginning she was friendly with some church girls, but later had a 
 falling out and asked landlady not to let them go to her room. Patient 
 never made friends with other lodgers. "There are twelve rooms, two or 
 three let to middle-aged men, and most rooms let for many years to same 
 persons." Landlady never heard of her going out with men nor did she 
 observe her coming home with any. She never had any in her room. 
 Patient was out after twelve some nights when she went home and also 
 she always went home on Saturday for Sunday. Other nights patient 
 stayed home and sewed. She does this well. 
 
 Patient was a good lodger and always paid her rent ($2 a week) 
 promptly and made no trouble. Landlady would not take her back now 
 she knows she drinks. She had thought her queer because she talked so 
 much, mostly about her disagreements with church people. 
 
 Landlady and her husband, old people, have lived in this place for 
 years and have good old furniture and china and very homelike rooms of 
 their own. 
 
 Impression: Unusually honest, frank, and dependable old lady. A 
 well run, respectable house. 
 
 December 6. ^^ 
 
 Employer, Mr. Ra-vson, Mgr. T. S. Davis & Co., "Money to Loan,' 
 seen at his office, 180 Young St., Boston. Says he was there when patient 
 was there for about six months in 1904. She did sirnple clerical work and 
 some bookkeeping and informant can remember nothing except that patient 
 was satisfactory and left for better wages in a laundry. 
 
 Impression: A middle-aged man of refined appearance and manner. 
 
 December 6. 
 
 Employer, Miss Ingham, in charge of packing room at G. L Evans & 
 Co., "Utopian Chocolates," seen at 98 Vernon St., Boston. She says pa- 
 tient worked under her several months, from September, 1914. through the 
 Christmas rush season, and was entirely satisfactory, always on hand 
 promptly. Informant knew patient was a church memljer and other women 
 working there also lived near patient in South End and went to St. James. 
 The women here arc all Americans. Patient might be reemployed after 
 the rush season, but informant thinks it would not be wise for patient to 
 work there during the rush. Patient wrot« to informant _ several times 
 since leaving, but informant has not answered or seen patient. _ 
 
 Impression : Young, but mature American woman, refined in appear- 
 ance, manner, and speech, well dressed and of vigorous build. 
 
 Factory : Only the office seen. This was very neat and there were two 
 other women of refined appearance. 
 
 December 6. 
 
 Employer, Mr. L S. Henderson, Supt., Tyson Brand Co., salted nuts, 
 etc., seen at the factory. Cross St., Cambridge. He says patient was one 
 of the first to apply on opening of new factory last February. She \vas 
 entirely satisfactory and was especially prompt at work. She did packing 
 at a bench with Americans though there are some Italians. She earned 
 $5.50 per week and might have had piece work if she had stayed and 
 earned as much as $7.00 a week. He noticed particularly that she took no 
 notice of the men about the factory as many women do. He would re- 
 employ patient at any time. 
 
APPENDIX A 643 
 
 1915 
 
 Impression : A young man of refined appearance and manners. 
 
 Factory : A new brick building, very well lighted, in neighborhood of 
 other factories. 
 AEL/C 
 
 December 7. 
 
 Sister Florence seen, in town after work by appointment. Patient's 
 conduct has been the greatest trial to sister and mother. She talks so fast 
 and so much it makes her mother nervous. She is superior and will never 
 take any advice from them. Her connection with a different church is 
 partly responsible because she has acted independently in this respect. She 
 thinks she can in all others. She is stubborn. 
 
 Sister believes she drank a good deal with people whom she visited 
 in South End. 
 
 Patient had a better chance than any of other children. She was the 
 only one who graduated from grammar school. She was not petted and 
 spoiled because she was the youngest. In money matters she is brighter 
 than her sister, being quicker to add up her figures to get results. 
 
 Sister has worked years for Miss Nancy Stowell. Her physical health 
 is not as good as patient's. 
 
 Impression : Open-minded, practical, and thoroughly sympathetic. She 
 is a young woman of small stature and a somewhat nervous manner. 
 HA/C 
 
 December 8. 
 
 Family's minister, Mr. Young, Channing Church, seen. He says that 
 the family feel that patient has gained nothing through her connection 
 with St. James Church, and that it would be better if she discontinues 
 going there any more. No matter what there was to be done at home, 
 or how sick her mother was, patient always dropped everything to attend 
 services. She was told that she must go every week. 
 
 The remainder of the Paris green was found in patient's trunk. She 
 has very few clothes. 
 
 Sister Florence works for Nancy Stowell, dressmaker, on Charles St. 
 Miss Stowell is very good about calling sister to the telephone. 
 
 Impression: Reliable, earnest man of about 35 years of age. 
 HA/C 
 
 December 17. 
 
 School report received. 
 HA/C 
 
 December 2;^. 
 
 Dixon's Commercial School reports no record of patient. 
 HA/C 
 
 1916 
 January 21. 
 
 State Board of Insanity telephoned to. They have no record of father, 
 James Farmer. 
 MPC/C 
 
 January 21. 
 
 Patient's mother seen at home. Says that patient has always had her 
 own way ever since she was a child; that she has had more opportunities 
 and used them less than any other member of the family. Patient is only 
 member of the family who went through the Grammar School. Patient 
 was very ill during the voyage from England and has never been strong 
 since, although she was a very healthy baby. Informant's husband, from 
 whom she was separated, has been dead for 12 years. They have always 
 
644 APPENDIX A 
 
 1916 
 
 had all they could do to get along. Patient always told people that she 
 "slaved" at housework, l3Ut informant says that she never did any at all, 
 not even to helping with the coal for the fire, etc. As informant has for 
 many years been a cripple (six operations, one knee removed) she has not 
 been able to do heavy work. 
 
 Five years ago they had to give up their home for a time during 
 operation on informant's legs. The same thing has occurred a number of 
 times since, the last time about a year ago. At one time when informant 
 was "flat on her back" patient locked the door, went out saying that she 
 would kill herself. Instead she went to her brother's, where she stayed 
 for two weeks. At another time a year ago last October she and her sister 
 went to look for a flat. Informant thought that she was able to have her 
 own home again and that patient would live with them again. While they 
 were out patient told her sister that she would never live with her family 
 again. Patient and her sister never got along together. Informant blames 
 patient who always expected her sister to do everything for her and who 
 never did anything in return. Patient's brother never liked her. 
 
 While patient was living away from home she used to bring her wash- 
 ing home for her mother to do. She never did it herself. Informant says 
 that her clothes were always in a disgracefully dirty condition ; that it was 
 too hard work for her to do again. Informant says that patient always 
 talks a lot about being fond of her, but she does not show it much in her 
 actions. Says that patient talks too much anyway. She used to make up 
 stories about unkind things informant's friends said to her. 
 
 Informant thinks that Father Cramer allowed patient too much free- 
 dom ; that if he had been more strict with her she would not have done so 
 many foolish things. Informant says that patient got in with a poor lot 
 of girls at St. James Church. 
 
 Informant says that when patient came home to live with them, as she 
 did for a while, she spends all Sunday morning in bed, leaves the room 
 where she sleeps (the "front" room) in an untidy state, and does not help 
 with any of the work. Patient's sister gives $5 per week to informant 
 who pays $3 for rent and makes the rest do. Patient's sister makes all 
 her own clothes and in the past has made many of patient's. Patient 
 thinks that she ought to make hers all the time. 
 
 Patient went out at all hours even when she lived at home and never 
 told her family where she was going. They never knew where she spent 
 her time unless she happened to mention it rather casually. 
 
 Impression : A very delicate old lady who cannot walk without 
 crutches and then with great difficulty. She seems to be quite passive as 
 though completely worn out with the whole situation with which she 
 obviously feels unable to cope. She appeared convincing and aroused con- 
 siderable sympathy. 
 HA/C 
 
 January 22. 
 
 J'ttal Statistics OiHce gives following record of father: Died Novem- 
 ber 5, 1904, at Westboro State Hospital. Cause, General Paralysis. Resi- 
 dent of Boston, age 46. Inmate i year and 2 months at Westboro State 
 Hospital. 
 FJC/C 
 
 January 27. 
 
 Children's Home Society telephoned to. Patient and family are not 
 known to them as was stated by sister in medical history in house record. 
 
APPENDIX A 645 
 
 1916 
 
 March 27. 
 
 Mother seen. During the time that the patient lived at home, from 
 June, 1915, until admission to the hospital, she paid in her $5 wages to her 
 mother. ]\Iother gave her $1 for spending money, used $3 and put aside 
 $1 for patient's clothes. Patient later found out that her mother had saved 
 $8 and was very disagreeable about it. She asked for it several times and 
 said she saw no reason why she could not take care of her own money, 
 so that mother gave it to her. She did not tell the family that she had any 
 money saved. They all went to Nashua, N. H., to visit during patient's 
 and her sister's two weeks' vacation and patient's sister-in-law found patient 
 very difficult to deal with. She was disagreeable and lazy and impudent. 
 While there she wrote often to the old man, Mr. Radnor, with whom she 
 used to play cards about every week when she lived in the West End. She 
 also wrote long letters to Father Cramer. 
 
 At one time patient was a member of the Girls' Friendly Society, but 
 she had a quarrel with the leader (Christ Church, East Boston) and gave 
 it up. Patient is apt to like people very well and talk about them all the 
 time for a short time and later turn against them. 
 HA/C 
 
 Sister Edith seen by House Historian. See medical record for history. 
 HA/C 
 
 ACTION TAKEN 
 December 2. 
 
 Employer, Sampson Press, would not be willing to take patient back 
 as he considers her unfit for factory work. 
 
 MBS/C 
 
 December 3. 
 
 Miss Kendall, York House, is willing to take patient into the Gales St. 
 House to live until she can find work. She feels that St. James Church 
 people should not let their responsibility end here. Though it seems best 
 for patient to drop her connection with that church, they ought to stand 
 expense of sending her away, if necessary. 
 HA/C 
 
 December 4. 
 
 Miss Kendall says there is room at the Roxbury House, if patient 
 should decide to go there for six months. It would probably be the best 
 plan. 
 HA/C 
 
 December 6. 
 
 Family's minister, Mr. Young of Channing Church (Unitarian), tele- 
 phones. He has expected to take up the care of patient when she leaves. 
 The family (mother and sister) are unwilling that patient should go to 
 York House. They are anxious to have her sever connections with the 
 Episcopal Church for reasons which Mr. Young cannot give by telephone. 
 His plan is to place patient at the Gordon House of Working Girls. While 
 she works in the day time, she should have some training business course 
 at Y. W. C. A. at night as well as club or class work one or two evenings. 
 He knows several workers at this house, whom he will interest in patient. 
 He would like visitor to keep in touch with patient also. 
 
 Mr. Young feels that institutional restraint of such a girl who has been 
 allowed so much freedom, will only make her rebellious and produce no 
 results. 
 HA/C 
 
646 
 
 APPENDIX A 
 
 191S 
 December 7. 
 
 Family's minister, Mr. Young, telephones that he will be able to ar- 
 range for patient to live at Gordon House, 44 Dix St. 
 HA/C 
 
 Mr. Young seen. He has been talking with Mrs. Dickinson, head of 
 the House, and she will take an interest in patient. Miss Taylor of Canter- 
 bury Church will do what she can for her and take a friendly interest in 
 her. Neither one of these people will be able to take definite and com- 
 plete supervision of patient, and Mr. Young feels that he will not be able 
 to do so himself. 
 
 He will, however, see the patient frequently and will naturally get the 
 point of view of the family because he sees them often. He will be able 
 to report to visitor anything which arises in patient's situation. He will 
 pay for patient's board ten days or two weeks, but feels that she should 
 have work by that time. He hopes that a definite schedule can be arranged 
 for patient, so that she will have each evening planned for. He would 
 suggest her taking some training, such as secretarial, at an evening school. 
 
 He would be glad to get some clothes for her so that she will not be 
 ashamed when meeting the other girls at the House. 
 
 Patient taken to Gordon House and Mrs. Dickinson seen. Patient will 
 go to-morrow morning to the Massachusetts General Hospital, Out- Patient 
 Department, Female Medical Clinic, for a thorough examination. There 
 is a question of anemia and tuberculosis. 
 HA/C 
 
 December 10. 
 
 Patient writes. She returns to Massachusetts General Hospital for 
 examination to-day. Girls at Gordon House are not allowed out over night. 
 See letter. 
 HA/C 
 
 December 11. 
 
 Massachusetts General Hospital, Social Sen-ice, Miss Davis, telephones 
 that patient's lungs are negative, but that she has a severe anemia. Dr. 
 Dawson advises patient going into the House for a few days. Patient is 
 reluctant to do this as she says she is devoted to her roommate and does 
 not want to leave her. Sister is at Out-Patient Department with patient 
 and she saj-s patient will stay. 
 
 Case will be transferred to House Social Service so that visitor may 
 have reports directly. 
 
 Patient and sister telephoned. Patient did not want to enter hospital 
 to-day and Dr. Young says he is not sure of a bed for Monday ,12/13. 
 Patient promises to go to Miss Davis on that date and enter hospital if 
 possible. First asked to be treated by private physician. 
 HA/C 
 
 December 13. 
 
 Patient writes. See letter. 
 HA/C 
 
 December 14. 
 
 Massachusetts General Hospital, Miss Davis, telephoned to. Patient 
 was admitted yesterday. 
 
 Minister, Mr. Young, and Mrs. Dickinson telephoned to. Arranged 
 for patient to return to Gordon House on her discharge from Massachu- 
 setts General Hospital. 
 HA/C 
 
APPENDIX A 647 
 
 1915 
 December 17. 
 
 Sister Florence seen in town by appointment. Patient is being dis- 
 charged to-day and she will take her to Gordon House. Sister does not 
 favor any domestic training for she thinks patient's place is at home if she 
 can behave properly. For some time she has talked of stenography, but 
 when aunt took a book to her she did not follow up the work by herself. 
 
 They like to have patient at home Sundays. She makes mother nerv- 
 ous because she talks so fast and so much, but they are both fond of 
 patient and ready to do all they can to help her. 
 HA/C 
 
 December 18. 
 
 Massachusetts General Hospital, Social Service, telephones that patient 
 is not anemic and can go to work. She needs no diet. 
 
 Patient seen at hospital. Is always able to find work for herself. 
 Miss Taylor, Canterbury Church, saw her at Massachusetts General Hos- 
 pital and said she might be able to get her into a private printing place. 
 Patient wants to follow her printing trade, as she is used to it. 
 
 Patient intends to go home only a half day Sundays because the atti- 
 tude at home wears on her. Her mother continually gives her good advice 
 and harps on the past. They are "too strict." She cannot take off her 
 dress and put on a kimono to rest until it is time to go to bed. She 
 cannot have company because it wears on her mother. They are con- 
 tinually suspicious of her conduct. 
 
 Last night she stayed at home because she went out to get her things. 
 They would not let her sleep on the cot in the parlor where she used to 
 sleep, but had to share her mother's bed, so that all three were in the same 
 room. Patient said nothing and does not know the reason for this except 
 that they may not have trusted her to be alone. 
 
 At Gordon House, patient likes her roommate ever so much and her 
 room too. 
 
 Sent patient to Harvard Dental School to have teeth examined. She 
 will look for work Monday. 
 HA/C 
 
 December 23. 
 
 Patient writes. See letter and Christmas card. 
 
 Patient telephones. Hopes to get work in Newman's, 465 Denver St., 
 at typesetting. Wages $12 a week. There is no vacancy now, but she is 
 promised the next opportunity. 
 
 She will go to her own dentist. Dr. Day, Davis Square, Dorchester, 
 who used to do work half price, since the Dental School is closed for 
 vacation. 
 HA/C 
 
 December 27. 
 
 Patient telephones. She goes to work to-morrow at piece work in 
 Dalton Fastener Co., 42 Belle Ave., Cambridge (near Kendall Square). 
 Her first week's wages will have to go to the Mercantile Agency. Girls 
 earn from $6-$i2, according to their ability and skill. Hours are 7:30-5 ^30 
 and patient can have her breakfast at Gordon House and take her lunch. 
 
 Patient says she had a happier Christmas than for some time. "We 
 never had happiness in the home before." She stayed all night there. 
 Patient tells of going to Beacon Hill Christmas Eve to hear the carols. 
 She went to Charles St. Jail- and was much, interested in that. 
 HA/C 
 
648 
 
 APPENDIX A 
 
 1915 
 
 December 31. 
 
 Patient vurites. See letter. 
 HA/C 
 
 1916 
 
 January 10 to January 17. 
 
 Patient writes. Asks to be allowed to go home Saturdays for over 
 night. She writes she has joined the Unitarian Church. See letters. 
 HA/C 
 
 January 17. 
 
 Patient sends diet for past week by request. 
 HA/C 
 
 Monday : 
 
 
 
 
 
 BREAKFAST 
 
 LUNCH 
 
 DINNER 
 
 EVENING 
 
 LUNCH 
 
 Wheatena 
 
 Thin egg sandwich 
 
 Cold sliced ham 
 
 Cocoa 
 
 
 Salt fish hash 
 
 Sponge cake 
 
 Boiled cabbage 
 
 Apples 
 
 
 Cup of coffee 
 
 Blueberry cake 
 
 Boiled carrots 
 
 Oat. cr. 
 
 
 
 Apple 
 
 Mashed potatoes 
 
 Beef tea 
 
 Uneedas 
 
 
 Tuesday: 
 
 
 
 
 
 BREAKFAST 
 
 LUNCH 
 
 DINNER 
 
 EVENING 
 
 LUNCH 
 
 Oatmeal 
 
 Ham sandwich 
 
 Boiled cod and 
 
 Cocoa 
 
 
 Fried eggs 
 
 Doughnut 
 
 cream sauce 
 
 Oxtail soup 
 
 Mashed potatoes 
 
 Apple 
 
 Boiled onions 
 
 Uneedas 
 
 
 Coffee 
 
 
 Boiled potatoes 
 Apple tapioca 
 
 
 
 Wednesday : 
 
 
 
 
 
 BREAKFAST 
 
 LUNCH 
 
 DINNER 
 
 EVENING 
 
 LUNCH 
 
 Wheatena 
 
 Deviled ham sand- 
 
 Roast beef 
 
 Cocoa 
 
 
 Slice of salt 
 
 wich 
 
 Boiled lima beans 
 
 Oat. cr. 
 
 
 chipped beef 
 
 Half slice cake 
 
 Carrots 
 
 Uneedas 
 
 
 (tissue) 
 
 Apple 
 
 Boiled potatoes 
 
 Beef tea 
 
 
 Baked potatoes 
 
 
 Chocolate blanc 
 
 
 
 Raised biscuit 
 
 
 mange 
 
 
 
 Coffee 
 
 
 
 
 
 Thursday: 
 
 
 
 
 
 BREAKFAST 
 
 LUNCH 
 
 DINNER 
 
 EVENING 
 
 LUNCH 
 
 Corn meal 
 
 Roast beef sand- 
 
 Beef stew 
 
 Cocoa 
 
 
 Salt fish 
 
 wich 
 
 Cream pie 
 
 Oat. cr. 
 
 
 Fried potatoes 
 
 Half slice cake 
 
 Bread and butter 
 
 Uneedas 
 
 
 Raised biscuit 
 
 I cookie 
 
 
 Beef tea 
 
 
 Coffee 
 
 Cocoa 
 Apple 
 
 
 Apples 
 
 
 Friday : 
 
 
 
 
 
 BREAKFAST 
 
 LUNCH 
 
 DINNER 
 
 EVENING 
 
 LUNCH 
 
 Wheatena 
 
 Meat pie 
 
 Fried fish 
 
 Cocoa 
 
 
 3 slices bacon 
 
 Tea 
 
 Mashed potatoes 
 
 Oat. cr. 
 
 
 2 baked potatoes 
 
 
 Corn 
 
 Uneedas 
 
 
 Coffee 
 
 
 Bread pudding 
 
 Beef tea 
 Apples 
 Wash, pie 
 
 
 Saturday: 
 
 
 
 
 
 BREAKFAST 
 
 LUNCH 
 
 DINNER 
 
 EVENING 
 
 LUNCH 
 
 Hash 
 
 Sliced ham 
 
 Baked beans 
 
 Cocoa 
 
 
 Muffin 
 
 Baked potatoes 
 
 Piccalilli 
 
 Oat. cr. 
 
 
 Coffee 
 
 Tea 
 
 Bread and butter 
 Tea 
 
 Uneedas 
 Beef tea 
 Macaroons 
 
 
 Sunday: 
 
 
 
 
 
 BREAKFAST 
 
 LUNCH 
 
 DINNER 
 
 EVENING 
 
 LUNCH 
 
 Fish cakes 
 
 Tea 
 
 Canned cherries 
 
 Cocoa 
 
 
 Beans 
 
 Roast stuffed pork 
 
 Bread and butter 
 
 Beef tea 
 
 
 Brown bread 
 
 Pickles 
 
 Cake 
 
 Oat. cr. 
 
 
 Coffee 
 
 Bread and butter 
 
 Cocoa 
 
 Uneedas 
 
 
 
 Potatoes 
 
 
 Frankfurters and 
 
 
 Squash pie 
 
 
 bread 
 Orange 
 
 
 $1.37 was spent extra for food. 
 HA/C 
 
APPENDIX A 649 
 
 1916 
 January 18. 
 
 Mrs. Dickinson, Gordon House, telephoned to. She says patient is 
 doing well. She takes an interest in the life at the House, enjoys the other 
 girls, and has given no trouble in any way. 
 
 Mrs. Dickinson would be willing for her to go home Saturday if 
 visitor arranges it. 
 HA/C 
 
 January 19. 
 
 Patient seen at hospital. Reported at evening clinic to Dr. Hatch. 
 She is happy and says she is doing her best. Drinking she never thinks of. 
 
 The life at the House is great fun. The girls always come into 
 patient's room toward the end of the evening and leave things to eat, 
 apples, cocoa. Patient spends her evenings sewing. She mends her room- 
 mate's clothes as well as her own and she has been doing some crocheting 
 and embroidery for the nurse of the House, who is engaged. Mr. Young's 
 church is to have a Fair, and she is making things for that as a surprise. 
 She seldom goes out evenings though she went once to moving pictures. 
 Sundays she goes home in the morning and returns in the afternoon. She 
 washes her own shirtwaists at home, but her other clothes are done at the 
 House and included in the board. Patient and her mother are devoted to 
 one another and get on peaceably. Sister treats her better now, but patient 
 has no fondness for her. Patient took her roommate, Fannie, home with 
 her last Sunday and the family liked her. 
 
 Patient walks to and from work to Kendall Sq., Cambridge. She 
 sleeps with windows open and eats heartily. 
 
 Work has been irregular. The largest wage made was some over 
 $7, but it has been nearer $5 usually. There are many types of work and 
 different machines and patient will make an effort to get on a machine 
 with which she can earn most. 
 
 The foreman, Mr. James, is good to her, and when she complained he 
 shifted her. This week, work has been slack because the firm is starting 
 a new department next week. The old girls say one is seldom laid off, so 
 patient will try it out another week. She can earn 80 cents for the other 
 days this week. The board at Gordon House is $4. Patient owes Mr. 
 Young $4 and the House $2 from a week she was not working (Mr. 
 Young only paid the first two weeks). Patient has plenty of clothes. 
 Mr. Young offered her more, but she did not need them. She still has 
 some savings, but she does not wish to spend them for current expenses. 
 
 Patient is anxious to learn linotype because that was what put her out 
 of work at the Sampson Press when she was setting type by hand. She 
 thinks she cannot afford to go to a school for it this year. 
 
 Patient tells of a young man, whom she passes every morning going 
 to work, asking her to meet him some night. She used to pass him when 
 she worked at Tyson Brand and so she speaks to him. She does not 
 intend to go out with him. Recently, she met Karl Cauldwell and he 
 walked home with her. He offered to "keep company" with her again, but 
 she "threw him over." 
 
 Patient seems happy, looks well, and is very friendly toward visitor. 
 HA/C 
 
 January 21. 
 
 Minister, Mr. Young, telephoned to. He thinks patient is doing well 
 and has not been drinking. She is not really self-supporting yet. He was 
 surprised and pleased to have her join the church. 
 HA/C 
 
650 APPENDIX A 
 
 1916 
 
 January 21 
 
 Patient's mother seen at home. Informant thinks that patient gets 
 along with sister somewhat better than previously, but notices no other 
 change in her actions or attitude. Visitor asked informant about having 
 patient return to her home to spend Saturday nights. Informant is willing 
 to have her, but seems to feel that it may not be for patient's best good, 
 as she thinks that patient is making the necessity of being at home in order 
 to go to church an excuse to escape the early rising necessary at 
 Gordon House. Informant says that patient can get to Church Sunday 
 morning from where she is, that she did it last Sunday with her room- 
 mate whom she took to dinner at her home. Informant says that on day 
 patient wrote to previous visitor (i/i) she spent the night at home and 
 did not go to church the next morning, but read in bed. Informant thinks 
 that patient will impose upon previous visitor unless she is most careful. 
 Informant fears that patient will be most disagreeable to her if she finds 
 out what informant has said. Informant is so tired of having fusses that 
 she does not give a word of advice to patient now — whenever she does 
 patient is ugly to her. 
 
 Informant suggests that if it is decided to be wise for patient to go 
 home Saturday nights, it would be advisable to make it conditioned upon 
 her attending church Sunday mornings, and in order not to make the 
 patient angry at her family, to have the information obtained from Mr. 
 Young, the minister. Informant says that patient cannot fool him. Patient 
 joined the Unitarian Church the first Sunday of January, for which her 
 mother is glad. Thinks it may do something toward keeping her with the 
 family. 
 
 Informant says that patient .should live as she is now with people and 
 under rule ; that otherwise she will become untidy again and will bring bad 
 girls into her room. She thinks that if patient complains to visitor about 
 conditions as she has at home that visitor should not pay too much atten- 
 tion to her, but should insist that she live with a roommate. 
 
 Informant says that patient was doing fairly well until last week when 
 she made only $5 l)ecause the machine broke down and there was not 
 enough work to do. Says that patient was discouraged Sunday. In- 
 formant thinks patient should try to get a position as monotype corrector 
 as that is her trade. 
 
 Patient has never contributed to support of family, and does not con- 
 sider the extra trouble it makes when she visits them, either in the matter 
 of expense or work. 
 
 Informant is evidently rather afraid of patient and anxious not to 
 displease her. 
 MBS 
 
 January 21. 
 
 Patient and mother written that she is not to go home Saturdays for 
 the present. 
 HA/C 
 
 January 24. 
 
 Patient writes. See letter. 
 
 Patient telephones she is out of work for a day or so. Will go to 
 Harvard Dental School this morning. 
 
 Linotype School sends literature. Evening course $50. 
 
 Patient seen at hospital. Is to go back to work 1/26 and to-morrow 
 will have more work done on her teeth and will spend extra time mending. 
 
APPENDIX A 651 
 
 1916 
 
 She made $4.40 last week and the foreman has promised to put her 
 on a good machine when she goes back. She likes it so well there that 
 she hates to leave and will give the place further trial. Mr. James urged 
 her to stay on. 
 
 Patient wants to go home Saturday nights because it means such an 
 early rising and such a hurry to get out to Roxbury in time for church 
 Sundays. She stayed at home Friday night because she and sister went to 
 an entertainment at Church. 
 
 Patient is very friendly indeed and assures visitor she wants to make 
 as little trouble as possible. 
 
 Patient wants to go to Linotype School when she gets well established 
 in work. 
 
 January 25. 
 
 Patient writes and asks to be allowed to help and do some sewing for 
 visitor. See letter. 
 
 Patient written to, asking her to make two chemises for another 
 patient. 
 HA/C 
 
 February 9. 
 
 Patient zvrites, 1/26 and 29, 2/5 and 9, and telephones 2/5. She is en- 
 thusiastic about her work, to which she went back 1/27. She made $1.75 
 and $1.80 for the first two days and over $7 for the past week. _ She 
 expects to have all back board paid by 2/20. She has some neuralgia of 
 the gums and if it is not improved in a few days, she will take time off 
 to have her teeth seen to. Her roommate, Fannie, has been very sick and 
 patient had to wait on her. Now she is away for a few weeks' rest. 
 
 February 9. 
 
 Patient writes, "It may seem strange to many people that my mother's 
 illness should make such an impression on me, but it does. I am the 
 youngest and think a whole lot of my mother, but instead of going out 
 and seeing her enjoy life, I have to see her a cripple holding back her pain 
 and trying to be happy. ... I am sorry I was so bad, but I will be good 
 always now to make up for it." 
 
 See letters. 
 HA/C 
 
 February 9. 
 
 Matron of Gordon House, Mrs. Dickinson, seen. She likes patient 
 and thinks she is doing her very best. No indications that she has been 
 drinking. The other girls like her, as she is always bright and jolly. 
 Informant thinks she is happy there. She has a very lovely roommate, a 
 blind girl, to whom she is devoted, and at present she is feeling pretty 
 lonely, as the roommate has gone away to the country for two weeks. 
 Informant chose this girl for patient's roommate, as she felt she would be 
 a good influence. 
 
 Patient is orderly about picking up her things but the room is apt to 
 be in need of dusting, but informant makes allowances for this as patient 
 has to go off so early to work. Leaves the house at seven and does not 
 come back till almost six. 
 
 The factory where she works is being enlarged and temporarily a 
 good many people are working only part time. Last week patient worked 
 only a few days and did not earn enough to pay her board. When she 
 works full time she makes only about $8 at piece work. She is somewhat 
 
652 APPENDIX A 
 
 1916 
 
 discouraged, and very restless when out of work. Talks of changing to 
 Gillette Razor Factory, but Mrs. Dickinson is urging hei to stick it out 
 here in hopes that she will soon have regular full-time employment. 
 
 Informant feels she is devoted to her mother, but cannot get on well 
 with her sister. Has told informant that she never could live with her. 
 Informant thinks that probably patient teases sister, who retaliates. 
 
 There are no clubs or classes in Gordon House to which she can 
 belong. There is a Friday Night Forum to discuss social questions, but 
 patient has not attended. She does not go out evenings to movies, only 
 occasionally for a few minutes to do an errand. Does not go with any 
 former friends, but seems contented to be with her roommate, and sews 
 a good deal. 
 EB/C ■• 
 
 February 12. 
 
 Patient seen at hospital. Brought visitor a guest towel and face cloth 
 which she had made as a present. Last week made $8 and was idle part 
 of two half days. She would have made more, but was slow on account 
 of a small injury to the tip of a finger. 
 
 Patient is lonely with roommate away. 
 HA/C 
 
 February 15. 
 
 Patient writes. Is going to a suffrage meeting with sister and a friend 
 to-night. See letter. 
 
 February 21. 
 
 Patient and sister sent theater tickets to "It Pays to Advertise" to- 
 night. 
 HA/C 
 
 March 9. 
 
 Patient writes often. See letters. 
 HA/C 
 
 March 10. 
 
 Patient seen at hospital. This week has been a bad one at work. 
 They were laid off more than two hours one day, ij/^ the next, and patient 
 made only 24 cents this morning. Patient is discouraged and would like to 
 change to a firm that can give steady work. 
 
 Patient made two chemises by hand for another patient, made neatly 
 and well. 
 
 Mr. Steadman, Delle Ink Co., telephoned to. He will see patient to-day 
 and if she is good will start her there. She would make $6 a week for 
 about two weeks and then go on to piece work at zzVi per cent over regu- 
 lar piece work prices which would gradually be reduced until in about four 
 or five weeks she would be at a regular rate. If she is good with her 
 hands she might later work into piece work that gives $10 to $13 a week. 
 HA/C 
 
 March 13. 
 
 Patient's employer, Dalton Fastener Co., Mr. James, seen at factory. 
 Belle Ave., Cambridge (near Central Sq.). Says patient returned to fac- 
 tory on 3/10/16 after employees had been dismissed early to tell him she 
 had obtained other work, but he had gone, so she sent letter which he 
 received next day. Patient was entirely satisfactory as a worker and got 
 on well with other employees. She made about $9 a week on piece 
 work, which is on ball and socket fasteners for automobile tops, tending 
 machines, sorting and packing. Informant would reemploy patient when- 
 ever they need help. She might make as high as $16 a week on piece work. 
 
APPENDIX A 653 
 
 1916 
 
 Impression : A young man of intelligent appearance and kindly manner, 
 apparently genuinely interested in the welfare of his employees. 
 
 Impression of Factory : Visitor was shown room where patient 
 worked. A large, very bright room, not crowded with machinery or 
 workers, but exceedingly noisy. Factory is a new one. Workers can eat 
 lunch in room where they work, for which tables are cleared and ma- 
 chinery is stopped for an hour. Women employed are Americans. 
 AEL/C 
 
 March 21. 
 
 Patient writes about every other day. She says she likes her work 
 and is receiving $6 a week for the first two weeks. Hours are 7 :30-i2 ; 
 12:45-5:30, or 9^ hours a day, and 7:30-1, or 5^ hours, Saturdays; total, 
 51^ hours a week. She is labelling and packing bottles. The work can 
 be done faster standing. Stools are provided, but patient stands. 
 
 All patient's back board and two weeks' board advanced by Mr. Young 
 was paid 3/6/16. Patient saved the money which would have gone to 
 carfares and bought an attractive blue corduroy coat for about $5. Pa- 
 tient will keep an account book of all week's wages and expenditures. 
 Board is now $4. 
 
 Patient now has a new roommate, Nancy Bornstein (also a patient. 
 File No. 7246), who is under the care of Miss Stella Farrell, Massachusetts 
 General Hospital Social Service. She is a great trial to patient who is try- 
 ing to train her in manners, cleanliness, and industry. Nancy's diagnosis 
 is Not Insane (Moron — Hysteria). Patient goes with her to see Miss 
 Farrell. 
 
 Last week at visitor's suggestion patient offered her mother $1 which 
 was refused. See letter of 3/20/16 from patient. 
 HA/C 
 
 March 27. 
 
 Massachusetts General Hospital Social Service, Miss Farrell, tele- 
 phones about patient's roommate who is under her supervision. Nancy is 
 under Dr. Fenmore's care at Massachusetts General Hospital nerve clinic. 
 She is to stay on as long as possible at Gordon House. 
 
 Patient writes. See letters. 
 
 Mother seen at home. Patient has been in church very little in Rox- 
 bury, about three or four times, and mother suspects that she continues to 
 go to St. James. When she used to go there she made friends with a girl 
 who had an illegitimate child, and this child was boarded out with people 
 who drank. Mother suspects that patient continues to see this girl, because 
 she asked her sister about making a dress for a baby two years old. 
 Patient was godmother to this child. 
 
 Patient wishes to stay at home Saturday nights and sometimes talks 
 about going home to live. Mother is very unwilling to say that she does 
 not want her at home, but it is evident that the patient is a trial to them. 
 She stays in bed late and does not go to church and does a great deal of 
 washing and odd jobs about the house which leaves a good deal of dis- 
 order. She once said she was staying at Gordon House as a punishment. 
 Mother does not wish to take money from the patient, because in the past 
 she has "thrown it up at them" for doing so. She does not want to be 
 under any obligation to the patient. In regard to the incident about the 
 tea mentioned in her letter of 3/20, mother says that she off-ered to pay 
 for the tea from the beginning. 
 
 Mother thinks that the patient's present roommate is not good for her. 
 
654 
 
 APPENDIX A 
 
 1916 
 
 She always has taken things hard and thinks too much about this girl. 
 Thinks patient has improved somewhat, especially in her talk, which used 
 to be profane and disagreeable. Mother thinks that the visitor has a good 
 deal of influence over the patient, but that patient "puts on" a great deal 
 of her own goodness. 
 HA/C 
 
 March 28. 
 
 Sister Florence met in town. She feels as mother does about the 
 money, but is willing to have patient give $1 a week if it is necessary. 
 
 Patient told her employer at Dalton Fastener Co. that she could not 
 support her invalid mother on what she earned. She is always misrepre- 
 senting family situations to sister's friends. Patient and her brother Ber- 
 nard never got along together and sister is much amused at patient's pre- 
 tending to take such an interest in him. 
 
 Sister will let visitor know the first time patient mentions the money 
 she gives her mother. 
 
 Patient seen at Gordon House. Though 7 130 she is ready for bed. 
 She gets so tired standing at work that she usually goes to bed or reads 
 after dinner. Patient bathes once a week at home and will not use the 
 tub here because everyone uses it. 
 
 Patient does not go out evenings, both she and her roommate say. 
 Nancy relates the fun which they have together evenings, eating oranges 
 and joking. Nancy is apparently fond of patient and an admirer. She 
 says "Harriet is smart." Patient is crocheting a large door mat out of 
 heavy string. She is also making a complicated work bag. Patient has a 
 library card and reads a good deal. The gas light is at one side and gives 
 a poor light. 
 
 Patient goes to church every Sunday at some Episcopal church and has 
 been to St. James several times. If she is allowed to go home Saturday 
 nights, she will go to the Unitarian Church, but she does '..ot take much 
 interest in it. Patient begs to be allowed to go home Saturdays. She 
 speaks of living at home later; says one feels freer as to hours and all. 
 
 Patient continues on time work at $6 a week (third week) but the fore- 
 lady praised her work. She has talked to Hilda Tibbets (also a patient 
 here) and asks if she can do anything for her as she has noticed that no 
 one talks to her. 
 HA/C 
 
 March 30. 
 
 Mother writes. See letter and copy of answer. Visitor suggests pa- 
 tient go home Saturdays for a trial. 
 HA/C 
 
 March 31. 
 
 Patient zvrites. See two letters. 
 
 Patient telephones to say she does not want to appear at a staflF meeting 
 of N. E. Hospital Social Workers' Association, but finally agrees. Patient 
 will start staying at home Saturday nights. 
 
 Gordon House, Miss Dickinson, telephoned to about Saturday arrange- 
 ment. Patient is in almost every evening or else comes in very early. 
 HA/C 
 
 April 3. 
 
 Employer, Mr. Stcadman. Dclle Ink Co.. telephoned to. Patient is 
 doing average work and though it is usually customary for new workers to 
 stay six weeks on time work he will allow her to try piece work next week. 
 
APPENDIX A 655 
 
 1916 
 
 Patient writes 3/30, 3/31, 4/3. See letters. She gave ner mother 50 
 cents this week. 
 
 Patient called at hospital this evening and left a present for visitor — • 
 crocheted slippers which she had made herself. 
 HA/C 
 
 April 4. 
 
 Patient's roommate writes. See letter. 
 HA/C 
 
 April 5. 
 
 Patient seen. She gave visitor her gold cross and chain because now 
 she is a Unitarian she cannot wear it. 
 
 Patient presented at a clinic at the Massachusetts General Hospital 
 meeting of N. E. Hospital Social Workers' Association. When asked to 
 tell about her experiences she gave a very direct and clear account of how 
 discouraged she had been before taking poison, of how much it meant to 
 her to have someone take an interest and encourage her as the hospital 
 people had, how the life and jolly times at Gordon House had made her 
 happy. 
 
 Patient and her roommate given tickets to see "Grumpy." . 
 HA/C 
 
 April 7. 
 
 Patient and her roommate write. See letters. 
 HA/C 
 
 Mother writes that patient gave her 50 cents last week. See letter. 
 HA/C 
 
 April 10. 
 
 Patient writes that she has lost her gold watch, the gift of her mother. 
 She is much discouraged with everything. 
 
 Patient telephoned to. 
 HA/C 
 
 April 12. 
 
 Patient seen by Chief of Staff, Dr. Adler. He reports that she recog- 
 nizes that her depression comes in six-month periods. She is now passing 
 through the period — the previous one came in the fall when she took poison. 
 She has no appetite, sleeps poorly, is disgusted with work and discouraged 
 with everything. She is apt to go back to drink. 
 
 Patient seen. She wants to get back into printing trade. She cannot 
 take much interest in ink work. 
 
 A shower spray was sent patient last week and she bathes twice a day 
 now. 
 HA/C 
 
 April 17. 
 
 Patient writes to-day and 4/14. See letters. 
 HA/C 
 
 April 20. 
 
 Patient telephoned to every day. Her appetite is better. So far sug- 
 gestions for work have been unsuccessful. She stayed out of Delle's this 
 morning to go to two places for work. Patient's watch was found 4/16 
 at church. 
 
656 APPENDIX A 
 
 1916 
 
 Mr. Norton of Sampson Press seen. They cannot take patient back 
 because she was second or third rate worker, her attendance was very 
 irregular, and they have no opening. 
 
 Mother seen at home. Visitor had alread)^ explained to sister by tele- 
 phone last week that this is a critical time with patient. Mother seems to 
 be a whiney individual. She repeats a good deal of past history in great 
 detail. 
 
 Sister sat up until midnight last Saturday trimming a hat for patient 
 to wear to church. She never came until after church. 
 
 Patient was at home over yesterday's holiday. 
 HA/C 
 
 April 22. 
 
 Patient seen at hospital. She feels encouraged about her work because 
 she made $7 at piece work, even though there was a holiday. She will 
 continue at least one week more. Then she may stop and try to find 
 printing or some kind of work at which she can sit. The standing is diffi- 
 cult at Delle's. Patient has enough money in the bank to pay her own 
 board while out of work. She cannot remember the exact amount. 
 
 Her roommate is more restless and queer of late so that patient has not 
 had the proper amount of sleep. At midnight she got up and tried to go off 
 so that patient had to call the matron. 
 
 Patient's appetite is good now and she has almost no desire for drink. 
 
 She has made two tea aprons for another patient and done them well. 
 HA/C 
 
 April 26. 
 
 Patient has written and telephoned tzvice. She has secured work at 
 Doherty's, 181 Norfolk Ave., hours 7 :30-5 -.30. Thinks the pay will be $7 
 or $8 per week. She sets type for menus for hotels. She only worked 
 until 3 :30 to-day. Patient seems very happy over her new work, is much 
 interested, and "the day simply flies." 
 MC/C 
 
 April 28. 
 
 Patient seen at Gordon House. She was tired and had a headache, and 
 she went to bed early. She had had a tooth extracted. Nancy has refused 
 to speak to her for several days. 
 MC/C 
 
 April 28. 
 
 Gordon House, Mrs. Dickinson seen. She has decided that Nancy can- 
 not stay at the House any longer and she is waiting to hear from Miss 
 Farrell. They all like patient very much. She does not think it is best for 
 oatient to have the care of Nancy. 
 MC/C 
 
 May 2. 
 
 Patient seen. At patient's invitation, visitor and patient attended re- 
 cital at Jacob Sleeper Hall given by Curry School of Expression. 
 MC/C 
 
 May 5. 
 
 Patient seen at visitor's residence. She walks to her work every day 
 now. She has to stay until 4:30 on Saturday afternoons, but will not have 
 to do this in the summer. 
 MC/C 
 
 May 8. _ ■ . 
 
 Patient writes. See letter. 
 MC/C 
 
APPENDIX A 657 
 
 1916 
 
 May 8. 
 
 Patient telephones. She is worrying for fear she will have to go home 
 to live. Says she has been "thirsty all day and drinks a large quantity of 
 water." 
 MC/C 
 
 May 12. 
 
 Patient writes. See letter. 
 MC/C 
 
 May IS- 
 
 Gordon House, Mrs. Dickinson, telephoned to. Nancy came back to 
 the House for the night only. Miss Farrell said Nancy had no place to go 
 so Mrs. Dickinson gave her the room for two days and a night. She did 
 not see patient at dinner so she probably left immediately after she 
 came home. 
 MC/C 
 
 May 15. 
 
 Patient telephones. She is at her mother's and wants to stay all night 
 because she is angry because Nancy came back to room with her. She 
 understood that she was to have a new roommate. Visitor advised patient 
 to go back to the Settlement House. 
 
 Patient telephones later that she has decided to return and is on her 
 way there now. 
 MC/C 
 
 May 28. 
 
 Patient telephones that she fainted at work yesterday because of men- 
 struation. She is at home and resting to-day. 
 MC/C 
 
 Patient telephones and writes often. See letters. She likes her work 
 and has made friends with girls at the shop. 
 HA/C 
 
 May 29. 
 
 Patient writes details of a medical nature. See letter. She has crav- 
 ing for drink and takes vinegar and water, lemon and limes, and anything 
 she can think of. 
 
 She goes out to supper occasionally. 
 HA/C 
 
 May 31. 
 
 Patient writes and telephones. She tried to work Monday S/29, but 
 had to leave in early afternoon. 
 HA/C 
 
 June 2. 
 
 Patient seen at hospital. She is anxious to live at home now. She 
 feels dissatisfied with the food at Gordon House because it is too salty and 
 makes her thirsty. Visitor urged against going home, but left decision 
 pending. 
 
 Patient gives her mother $1 a week; earns $8. She goes on the car 
 now. She is able to save, out of the remaining $7, $2.40. 
 
 Patient says she is going out with a man older than herself. The 
 affair is a serious one though patient has not yet decided to marry him. 
 From everything she can hear, he is a good sort. She refuses further 
 details on the ground that her previous affair with Karl Cauldwell was 
 broken up by interference from other people, 
 HA/C 
 
658 
 
 APPENDIX A 
 
 1916 
 June 5. 
 
 Patient writes that she has decided not to go home to live. This week- 
 end she thought her mother and sister were very severe and strict with her. 
 See letter. 
 HA/C 
 
 June 6. 
 
 Matron, Gordon House, Mrs. Dickinson, seen. Food is not salty. 
 They always have fresh meat and fish and only occasionally ham. At 
 dinner they have potatoes and two vegetables, or one vegetable and lettuce. 
 Matron has found that patient exaggerates and cannot be depended upon 
 to keep strictly to the truth. Illustrations given seemed to have discrep- 
 ancy of detail rather than entire false basis. 
 
 There is no one to room with patient at present, but matron will have 
 it in mind to put some one with her when she can. Patient is well liked 
 Ijy the girls, is friendly, agreeable to every one, and seems well behaved. 
 She is in most of the time, but goes home to dinner occasionally on week 
 nights. 
 HA/C 
 
 June 8. 
 
 Patient reported at hospital. Was seen by Dr. Green and given advice 
 about menstrual period. 
 
 Dr. Wilson had a long talk with patient and says he thinks she is fairly 
 contented ; that there is nothing to the love affair. Patient is doing well. 
 HA/C 
 
 June 10. 
 
 Patient writes and telephones. She has a chance to work three even- 
 ings a week in a store in Kensington, but is advised not to do so, because 
 of extra wear. 
 
 She has given up the young man by going off and leaving him looking 
 in a store window. He wanted to give her a dog for which she had no 
 place. 
 HA/C 
 
 June 13. 
 
 Patient writes. 
 HA/C 
 
 June 23. 
 
 Patient zvrites and telephones often. She went to Y. ]\I. C. A. Enter- 
 tainment one night with Henry Elkins, whom she knew at Sampson Press. 
 He is a widower who is going to be married again next month. 
 
 Patient is writing short stories, a sample of which shows very word}^ 
 and flowery style with a romantic and imaginative background. 
 HA/C 
 
 June 23. 
 
 Minister, Mr. Young, telephones to inquire how patient is doing. He 
 advises strongly that patient and family both be urged against patient's 
 ever going home to live. 
 HA/C 
 
 June 23. 
 
 Patient seen at hospital. She wanted to explain to visitor about fellow 
 employees who are not altogether agreeable with her. Patient and Martha 
 Wilson, who soon leaves to be married, are the only Protestants. Since 
 the other girls found this out, they have gone cut of their way to be dis- 
 agreeable and troublesome ; for example, patient will just get her hand full 
 of type and be seated on her stool, when they decide to get certain trays 
 
APPENDIX A 659 
 
 1916 
 
 under her stool, so that she has to get down. They 'kick her standing box 
 to the other side of the room whenever they get a chance. Patient will do 
 her best to stand it and report to visitor before leaving. 
 HA/C 
 
 July 3I-. 
 
 Patient seen often in past month. She continues to write and telephone 
 often. See letters. She has one friend, James V., who lives across the 
 street from hospital. She "picked him up" through the window while she 
 was on Ward V. Went out to suppers, several dances, and to ride with 
 three or four different men, but would not tell visitor about them. 
 
 Patient once brought up question of going home to live, but after two 
 days' consideration decided against it. Mother and sister have been in 
 Dover part of month and patient went there for week-ends. 
 
 August 15. 
 
 Patient seen and writes often. James V. went to Bloomington, 111., to 
 work two days ago and patient has been quite blue ever since. She takes 
 no interest in the other men and is going to give them up entirely. One 
 made improper advances to her by saying something and patient will not 
 have anything to do with him. Had a long talk with patient On this sub- 
 ject, but could get no definite accovmt from her of her own affairs. She 
 has never been "immoral" — her mother would put her out if she were, she 
 says. 
 
 Patient is found to have pinworms. She reported to O. P. D., Dr. 
 Samuejs, who prescribed for her. 
 
 Employer, Mr. Simpson, a foreman at Doherfy Printers, seen. He says 
 patient's work is good. She has not shown any special discouragement 
 (patient wrote she thought he saw her crying). He was not planning on 
 giving her a vacation, but if visitor thinks she needs one he will arrange it. 
 Employer is not given name of visitor or hospital, nor did he ask. Patient 
 was not seen. 
 
 Impression : Intelligent young man who is kind and sympathetic. 
 HA/C 
 
 August 17. 
 
 Mother writes, saying that patient seems to be getting restless and talks 
 ©f going home to live and she fears that as soon as visitor leaves patient 
 will disarrange things. 
 
 Patient taken to dinner. A Mrs. Davis asked her to live with her. 
 Patient would have the use of the kitchen and better meals. Room rent 
 would be free. Mrs. Davis is an old friend as well as a fellow employee 
 at Dalton Fastener Co. Patient also brings up the question of going home 
 to live, but promised visitor to make no such change during her absence 
 nor to talk about it to her mother. 
 
 Patient told of opportunity to go to Hampton Rest the first week in 
 September and thinks that she would prefer to go to her brother's in Dover. 
 She will write him and find out whether he can have her. 
 HA/C 
 
 August 26. 
 
 _ Matron, Mrs. Thom-pson, Gordon House, seen. She was surprised that 
 patient complained of waiting on table because she has never seen her do it, 
 although patient is supposed to do her share. She has not spoken of it 
 because weather has been so warm and patient has s_eemed so tired. Patient 
 
66o APPENDIX A 
 
 1916 
 
 seems worried and unhappy, probably because she would like to be at home, 
 
 but has decided to abide by the doctor's advice to stay away. 
 
 Patient is to have a roommate, beginning to-night. 
 MW/C 
 
 August 26. 
 
 Patient telephoned to at i :30. She has decided to go to her brother's 
 in Dover for her vacation. She sounded happy and seemed pleased at being 
 called up. 
 
 Hampton Rest written to, saying patient will not take their place. 
 MW/C 
 
 August 31- . . 
 
 Patient called at hospital in evening and asked advice about moving 
 from Gordon House. She is dissatisfied and says the new matron is too 
 strict. She has asked her repeatedly to wait on table, has not had a place 
 set for her when patient returned after a week-end at home, and told her 
 new roommate that patient has spells of depression. Patient thought of 
 taking her things home this week-end and living there after her vacation 
 until a new place can be found. Visitor advised leaving things as they are 
 and staying at the Gordon House until INIiss Bemis returns and new .ar- 
 rangements can be made. Patient promised to abide by this and went away 
 happy. 
 MW/C 
 
 September 30. 
 
 Patient seen two or three times and writes and telephones often. See 
 letters. At first she wished to move on return from her vacation at her 
 brother's in Dover ; she had a new roommate and was content to stay on. 
 Roommate, Frances Caldwell, is a Church Home girl of 18, young, attrac- 
 tive, and not undesirable or bad. Patient is very superstitious and believed 
 what a fortune teller told her, interpreting that brother, Benjamin, was 
 working against her particularly with mother. She writes she intends to 
 make over her insurance to visitor. 
 
 Patient had one crying spell at work before menstruation period. Has 
 been to Out-Patient Department and given treatment by Dr. Samuels for 
 pinworms. 
 
 Patient has taken an account book and will keep track of her expenses. 
 Is interested in doing so. 
 
 Room visited and patient keeps it cozy and pleasant. 
 HA/C 
 
 October 31. 
 
 Mother visited 10/6. She does not want patient's financial assistance 
 of $1 because she is apt to throw it up to her that she gives money. Per- 
 suaded to continue taking it. Patient does not go to Unitarian Church. 
 When she comes home, she is as disagreeable and vulgar as ever. 
 
 Patient seen three or four times. Moved 10/21 to the Inman House, 
 taking her roommate, Frances Caldwell, with her. Became dissatisfied with 
 new matron, Mrs. Thompson. Roommate was hot-tempered and saucy and 
 wanted to leave. Before going patient had a talk with matron who felt 
 more kindly disposed toward her. Patient has several young men with 
 whom she goes out to dinner and she claims she is not at the house many 
 times a week. 10/24 patient was disagreeable and sullen over telephone and 
 said she was going out on the streets. Wrote next day apologizing. Patient 
 telephones and writes often. See letters. 
 
APPENDIX A 66l 
 
 1916 
 
 Matron, Mrs. Thompson, seen. She has nothing to say against patient 
 and thinks she is a nice girl. They had a good talk before patient left. 
 Patient was not absent from meals that she noticed. 
 HA/C 
 
 November 30. 
 
 Patient seen twice, writes and telephones often. Has made several 
 things for patients' Christmas tree, crochet baby sacks and slippers. 
 
 Patient is going to evening dental clinic at Boston Dispensary, referred 
 by visitor. Was out of work a day at menses. 
 
 She complains of their third roommate, a nurse, who is not sociable 
 and who they think tries to annoy them and be inconsiderate. Patient does 
 not make friends with the others in the house and goes out evenings a good 
 deal with men, coming in early. The boys' living club similar to this gave 
 a party to the girls which patient seemed to enjoy. 
 
 Middle of month patient was determined to go home to live and would 
 not promise visitor not to move. Three hours later telephoned she would 
 stay where she was. Patient became angry at family and said she did not 
 intend to go in to see them again, at least will not sleep there any more. 
 See letters. 
 
 Former friend. Miss Simpson, governess of Mrs. M. C. Saunders' chil- 
 dren, telephones to inquire for patient and says she expects to go to see her. 
 She used to know her at St. James Church and had lost track of her until 
 recently hearing of her coming to the hospital. 
 
 Mother writes patient brings her washing home and it is too much for 
 her to do. (Laundry is not done at this house.) See letters. 
 HA/C 
 
 December 30. 
 
 Patient seen, telephones and writes. Has contributed 3 or 4 presents 
 to the Christmas tree and takes much interest in doing so. The settlement 
 club at Ferris Memorial, to which visitor referred patient, has not been 
 active. Once patient went and it was a Jewish holiday and no others were 
 there and last time only two or three, so that she is discouraged with it. 
 
 Patient was referred to Miss Harriet Martin (Boston Society for Care 
 of Girls) for one of the new Girls' Protective Leagues. These are to be 
 made from clubs already established, but Miss Martin will keep patient in 
 mind. Patient has been to church with Miss Simpson. Is now going fre- 
 quently to Episcopal Church. 
 
 December 31. 
 
 Patient seen three or four times. At end of month had a large and 
 serious abscess in her tooth which gave her much pain and kept her from 
 work a week. Spent a good deal of time at home. 
 
 Patient has a laundress and does not take washing home to mother. 
 
 See letters. 
 HA/C 
 
 1917 
 January 31. 
 
 Patient seen a number of times. Patient became dissatisfied with In- 
 man House because Matron, Mrs. Sawtelle, was not considerate of her 
 when she was sick, because she did not like the third roommate, and be- 
 cause Frances Caldwell moved to her sister's. Effort was made to have 
 patient return to Gordon House, but they refused to take her back but 
 would give no reason, i/ii — After staying home three days patient moved 
 to Warrenton St. Y. W. C. A. She has been very enthusiastic about it since. 
 
662 APPENDIX A 
 
 I917 
 
 Patient knows several girls from Gordon House who room there. Patient 
 introduced them to visitor and they seemed nice, wholesome working 
 women, friendly toward patient. 
 
 Patient was out of work half a week with the abscess. 1/8 she went 
 to Massachusetts General Hospital Out-Patient Department for advice in 
 treatment of worms and was given medicine. 
 
 Mother wrote 1/8, fearing patient was planning to move home. See 
 letter. 
 HA/C 
 
 February 28. 
 
 Patient seen. Writes often ; see letters. 2/12 patient wrote "best of 
 friends must part" and "I will not trouble you any more." Interview 
 brought out fact that because patient was told over telephone that visitor 
 was "out" she thought visitor did not wish to hear from her. Episode was 
 smoothed over. 
 
 In past six weeks patient has not been going to church much. Is urged 
 but does not wish to. Later writes she goes to Catholic Church at noons. 
 
 Patient made a chemise for a sick patient and called for another girl 
 patient here to direct her to Y. W. C A. 
 
 Friend, James V., who lives on Granville Road, is ill with mastoid and 
 patient is quite upset over it. She has known him over a year, claiming to 
 have picked him up while a patient in Ward V. They have been around 
 together a good deal when he is in town. Patient tells of many invitations 
 to go out with men, 
 HA/C 
 
 March 31. 
 
 Patient seen four times and writes. See letters. 3/4 patient wrote she 
 was through with visitor and visitor did not go until 3/6 to see her. She 
 continued to think she was abused in the telephone service, her chief grudge 
 being that she could not reverse a business call because visitor was out. 
 Thinks visitor could call her oftener. During month, patient has telephoned 
 very little. Relationship continues strained through the month over tele- 
 phone controversy, which patient insists is putting her down. She cites 
 every instance when visitor said she was in a hurry or was out and enlarges 
 on it. 
 
 Went with patient to see Mr. Mittelman, Vicar of St. Matthew's 
 Church, and patient promises to go again and has already been to several 
 services. 
 
 At work patient had $1 raise in pay with only two or three others in 
 the shop, making $9 wage. She is saving money. 
 
 First of month Beftha Greenwood (also Social Service case) went to 
 live across from patient. She had previously lived at Y. W. C. A. and old 
 girls said horrid things about her so patient was snubbed for speaking to 
 her. This lasted about ten days and is still a factor with patient's room- 
 mate, who now seldom speaks to her. Patient takes some pride in having 
 befriended Bertha, who tells to patient untrue things about visitor and to 
 visitor things which patient does not do. 
 
 April 30. 
 
 Patient seen three times. Early in month she talked of moving to a 
 private family, but decided against it of her own accord. Reported that a 
 girl in the house had offered her liquor last month. 
 
 After present of an Easter lily, patient was friendly and like herself 
 until 4/24 she. came unexpectedly in the evening and stayed labours. She 
 was cross and sullen at first and would not look up. She criticized visitor 
 
APPENDIX A 663 
 
 1917 
 
 and was very disagreeable. Later became jolly and chatty. Seemed to 
 have come just to "let off steam" at some one and possibly to get a reaction 
 from visitor, but visitor let her talk. She does not see brother, Bernard, 
 now and plans not to visit there week-ends as she used to because she thinks 
 he talks against her and dislikes her visits. Has not seen him since 3/25 
 at her mother's. 
 
 Patient says that last week she has taken a glass of porter every night 
 (pays 5 cents for it). This week she has not taken it. She goes out and 
 drinks it alone because it makes her sleep better. She has been restless and 
 sleepless lately and has a loss of appetite. Patient promises not to drink 
 at least to 4/30. 
 
 She is very discouraged and thinks visitor is only interested in order to 
 find something on her to put her awa}^. Has an idea which cannot be dis- 
 pelled that visitor is a probation officer (view shared by Bertha Green- 
 wood). Thinks she is followed by detectives because she has met the same 
 man several successive mornings on the way to work. Another man was 
 seen at Y. W. corner on several nights. 
 
 Patient was seen by Dr. Samuels, Out-Patient Department, 4/28, and 
 had in the meanwhile written she would not drink again. 4/6 patient visits 
 mother regularly on Sundays, but remains only 30 or 40 minutes and refuses 
 to stay to meals. Patient v/as in a very disagreeable mood on last visit 4/1 
 and talked incessantly about quarrels with different girls at Y. W. C. A. 
 Mother has not received_ any financial aid from patient since Christmas. 
 For past two months patient has been cool and indifferent toward mother 
 and sister. The sister usually met patient on way to business, but has not 
 seen her during the past week. Both mother and sister are worried over 
 the estrangement. 
 HA/C 
 
 May 31. 
 
 Patient seen 3 times. Was rather disagreeable 5/19 but the next day 
 wentto Marshfield Hills with visitor to see Fern Linnwood (also a Social 
 Service case), a blind woman who was formerly her roommate. Patient is 
 really devoted to her and suggests spending her vacation at the same house. 
 Patient has been on excellent terms with visitor ever since. Does not put 
 much trust in Bertha Greenwood, and sees as little of her as possible, but 
 rooming across from her this is difficult to accomplish. 
 
 Patient would like to know if mother really needs her contribution. 
 She would gladly give it, but has a feeling it is not wanted. 
 HA/C 
 
 June I5._ 
 
 Patient seen twice. It is arranged that she will go 6/24 to Marshfield 
 Hills with Fern Linnwood for her vacation at the rate of $7 a week. 
 Patient has promised to room at the Y. W. C. A. during visitor's absence. 
 The istof the month she insisted that she should live in a private family 
 and while efforts were being made to find one patient changed her mind. 
 She wrote that she realized if she came home tired she would make no 
 effort to get proper food. See this and other letters. 
 
 Patient is friendly and responsive to visitor. 
 HA/C 
 
 July 5- 
 
 Patient seen at hospital. Patient says that she does not feel that her 
 week's holiday rested her as much as it ought to have. Since coming back 
 she has had a headache almost continually. She is quite sure this is from 
 her eyes. She says she is going to see Dr. Nelson, an oculist on Irving 
 
664 
 
 APPENDIX A 
 
 1917 
 
 Avenue, about them. Visitor urged her to go to the Bennett St. Dispensary 
 and not spend so much money. She is skeptical of dispensaries. Patient 
 says she may take three weeks' holiday soon, as work is slack and she feels 
 the need of more rest. She would like to stay in her room and sleep and 
 rest. She went to a dance Monday night at Nantasket with her young man 
 friend. He is continually coming to see her and wanting her to go out 
 with him. She finds him rather tiresome. 
 SPE/C 
 
 July 20. 
 
 Patient seen at work, 292 Nottingham Ave. Patient says the principal 
 reason that she wanted to change her room was because her roommate was 
 away and it was quite likely that a transient would be put with her. They 
 are often brought in in the middle of the night and they are quite often 
 girls that you cannot trust at all. Patient says that she has a nice room 
 at the Y. W. C. A. and would hate to give it up as she feels as if it was 
 quite like home. Says she will wait till Miss Bemis comes back and talks 
 it over with her. Patient said she had spent a very happy Sunday with 
 Fern Linnwood, a Social Service case. Patient seems to take a great in- 
 terest in Bertha Greenwood and plans different things to keep her from 
 getting into trouble. Patient did not seem as depressed as letter had 
 indicated. 
 HA/C 
 
 Matron, Y. W. C. A., Mrs. Denecn, seen at 68 Warrenton St. Informant 
 says as far as she knows patient has been going to her work and doing 
 perfectly well in every way. A certain crowd of girls in the house were 
 very noisy on Sunday, but there was no drinking. She knew patient was 
 not in this crowd as she was away. Informant says she did not ask patient 
 if she had been drinking as she does not know who it was. Informant 
 thinks patient is very apt to exaggerate small incidents. 
 
 July 21. 
 
 Letter received from patient. See letter. 
 SPE/C 
 
 August 2. 
 
 Patient writes, asking advice in regard to medical examination. Family 
 are anxious to have her see physician. Patient insists on woman physician. 
 MRW/C 
 
 August 6. 
 
 Neiv England Hospital, O.P.D., telephoned to. Dr. Zcaring reports 
 no evening clinics. 
 
 August 7. 
 
 Dr. Margaret K. Dcniing telephoned to at 56 Chenowcth Road. Dr. 
 Denying will see patient any Wednesday evening on her way home from 
 work between 5-6:30 p. M. Will accept visitor's recommendation as to what 
 fee should be. 
 
 Patient visited at Y. W. C. A. Patient very communicative and friendly. 
 Talks much. Physical symptoms gone into. Nothing apparent save painful 
 and too frequent menstruation with its accompanying depression. Patient 
 thinks mother unnecessarily worried. Agrees to see Dr. Deming Wednes- 
 day evening, August 15, and give her frank history. Is rooming at present 
 with Bertha Greenwood because she did not like transient who was 
 put into her room. Hot weather created desire for drink, but claims she 
 took nothing. 
 MRW/C 
 
APPENDIX A 665 
 
 1917 
 August 8. 
 
 Dr. Deming telephoned to. 
 MRW/C 
 
 August 13. 
 
 Letter written to patient. 
 
 Social summary sent to Dr. Margaret Deming. 
 MRW/C 
 
 August 14. 
 
 Patient telephones in much disturbed condition because she has been 
 told that Miss Bemis is not returning and feels that hospital has been 
 trying to deceive her. Her point of view is that if the hospital lies to her 
 in one thing it cannot be trusted in any. Situation finally explained after 
 10 or 15 minutes' conversation. Patient asks visitor to write Mrs. Deneen 
 to see if it can be arranged for her to have a single room. Complains of 
 being much upset by frequent arrival of transients. 
 MRW/C 
 
 August 15. • 
 
 Letter written to Mrs. Deneen, Y. W. C. A. 
 MRW/C 
 
 August 15. 
 
 Telephoned to Dr. Margaret K. Deming, 56 Chenoweth Road. Dr. 
 Deming reports that she gave a_ full physical examination to patient last 
 evening and fiods her lungs and heart negative. Patient eight pounds under 
 weight. Dr. Deming considers that the pain experienced at the menstrual 
 periods is due largely to her generally run-down physical condition. Has 
 given her a tonic and is to see her again on September 5. If patient then 
 continues to have much pain, Dr. Deming will give a local examination. 
 Finds no evidence of any tubercular bone condition. Feels that patient is 
 much relieved to learn this and also to know that her heart is normal. 
 Patient paid Dr. Deming two dollars for the visit. 
 MRW/L 
 
 August 17. 
 
 Letter received from patient. See letter. 
 MRW/L 
 
 August 17. ... 
 
 Letter written to patient, urging her to follow Dr. Deming's directions 
 conscientiously. 
 MRW/L 
 
 August 17. 
 
 Letter written to Mrs. Deneen, Y. W. C. A., 68 Warrenton St., asking 
 her, if possible, to arrange for patient to have a room by herself. 
 MRW/L 
 
 August 20. 
 
 Letter from patient, stating that she is going to take a week off to rest. 
 Liked Dr. Deming and is willing to do what she has advised. Is contented 
 at the Y. W. C. A., although she still has occasionally longings to be with 
 her own people. Dr. Deming has advised against this at present. 
 MRW/L 
 
 August 21. 
 
 Patient seen at hospital. Mrs. Deneen has given patient a room by her- 
 self and she feels much better. Is resting this week, getting up late and 
 going away for day trips. Agrees to see Dr. Dixon about her glasses soon. 
 MRW/L 
 
666 APPENDIX A 
 
 1917 
 
 August 23. 
 
 Letter from patient. 
 MRW/L 
 
 August 29. 
 
 Letter from patient. Seemed depressed. 
 
 Letter to patient. 
 MRW/L 
 
 September i. 
 
 Letter from patient. 
 MRW/L 
 
 September 4. 
 
 Letter from patient. 
 MRW/L 
 
 September 5. 
 
 Letter to patient. 
 MRW/L 
 
 September 12. 
 
 Patient seen at work during noon hour. Patient looked well and ap- 
 peared in good spirits. Talked about several young men friends, especially 
 about one named Young, whom she refused to say where she had met. 
 SPE/L 
 
 September 19. 
 
 Patient seen at hospital. Patient appeared extremely "blue," played 
 with her hands in a nervous way and cried. She said th?t she dreaded 
 having the operation, but she supposed if it really would help her she would 
 be willing to go through with it. 
 
 Since she broke off with her friend, Young, she says a well-dressed 
 man has been v»-atching her on the street corner and making remarks to he.'. 
 She has a feeling that this man may be a detective placed there by Young. 
 
 Patient saw Dr. Harmon and after talking with him she appeared 
 somewhat cheered. 
 SPE/L 
 
 September 25. 
 
 Patient seen at hospital. Patient brought hat and shoes to be given 
 away. She appeared in a much more cheerful mood since last seen in spite 
 of the fact that a great family friend, whom she called uncle, had just died. 
 SPE/L 
 
 September 27. 
 
 Dr. Simpson telephoned to. Informant said that the treatment that 
 patient needed would only keep her in the hospital two or three days 
 After that she should have a week or two of convalescent care. Informant 
 recommended patient going to the Massachusetts General Hospital, the 
 Women's Free Hospital, or the New England Hospital. 
 SPE/L 
 
 Patient seen at noon. Is willing to go to Massachusetts General Hos- 
 pital for slight operation recommended by Dr. Simpson. She is very loath 
 to go to a convalescent home for a week after, but finally consents to go to 
 the country to board. 
 
 She enjoys her single room at the Y. W. C. A. Her family are now 
 treating her very well and she goes several times a week to see her mother. 
 She has not been going out with the boys any during the summer. Has lost 
 interest in such matters. 
 
APPENDIX A 667 
 
 Patient is entirely friendly and is in good spirits with the exception of 
 believing that the matron, Mrs. Deneen, is not kindly disposed toward her. 
 
 Foreman, Mr. Simpson, seen at Dohertj', Printers. It will be best for 
 patient to be away the week of 10/15. He cannot readily spare her for this 
 time, but is willing to do so in this case of sickness. 
 HA/L 
 
 October 13. 
 
 Patieyit ivrites several times, last two letters saying she has decided not 
 to go to the Massachusetts General Hospital for the operation, as she has 
 gotten the impression from a friend that this operation is a reflection upon 
 her "character and her good name" and will "go against her" when she is 
 married. Patient says that she intends to be married soon. 
 
 Patient seen at noon. Consents to go to the hospital when nature of 
 operation is explained. Ingram Stone wishes her to be married soon. He 
 is a man of 35, unmarried, and well able to support her. She ha^ known 
 him since her discharge from this hospital in 1915. Refused to introduce 
 him to visitor. 
 HA/L 
 
 October 15. 
 
 Patient entered the Massachusetts General Hospital. 
 HA/L 
 
 October 16. 
 
 Mother seen at home. Patient has come in to see her every two weeks 
 or month since last January. Last July she paid $1 for two or three 
 weeks, but has not done so at any other time since January, 1917. She has 
 taken no meals at the house with the exception of one breakfast. She has 
 been fairly agreeable and not particularly troublesome. ^Mother seems to 
 have a better conception of patient's needs and changeableness than previ- 
 ously, and to accept it as part of her character. 
 HA/L 
 
 Patient seen three or four times, and writes. October 15-21 patient 
 was in the jMassachusetts General Hospital for a slight gynecological opera- 
 tion. She paid $ig out of her own money for this. From Oct. 21-26 she 
 was at home, going Oct. 26 to IMarshfield Hills (Country Week paying 
 fares), to spend the week-end with another patient, Fern Linnwood, a blind 
 woman, formerly patient's roommate. She stayed only until the next day 
 because of a disagreement with the boarding women. Fern later wrote a 
 disagreeable letter, which has estranged patient from her. See letter. 
 
 Brother Bernard's wife had him arrested for abuse and non-support, 
 and he was in jail a night in the end of October. Patient has been much 
 upset over this. Agreement was made out of Court, and they are living 
 together again. 
 
 Patient says that in the summer she went into Ukrane's Cafe, Pember- 
 ton Square, and ordered a drink. The waiter was a long time bringing it, 
 and patient saw one speak to another, became suspicious that visitor had 
 posted them not to serve her, but to get the police, and left hurriedly. 
 She will not go back, and still thinks that visitor was in there to tell them. 
 
 Patiejit and Bertha Greenwood (another Social Service case) go sev- 
 eral nights a week to a Soldiers' Mission on Isham Street. 
 
 November 15. 
 
 Patient's mother seen. She says that when patient was with them 
 everything went well. jMother was given some army knitting to do, from 
 which she is earning $2.30. They find it very hard to make both ends meet. 
 
668 APPENDIX A 
 
 1917 . . ... 
 
 especially as Florence's sewing season is dull, and living higher. Mother is 
 
 not so well lately, and has pains in the side more often. 
 
 Patient seen four or five times, writes and telephones. Before Thanks- 
 giving she drank something a couple of times, but did not tell visitor until 
 two weeks later. She is most anxious to keep from it and will turn to 
 some other visitor if she needs assistance in doing so. 
 
 She crocheted at the Mission, and was criticized by one of the men, so 
 that she left. Patient has since been asked by the Matron, Mrs. Mentor, to 
 return. She goes Saturday and Sunday evenings usually. Last Saturday 
 she went with another girl to Underwood Chapel and stayed to Sunday 
 School. Has not been to St. Matthew's church for several months, and no 
 one has visited her from there, so that she thinks that she is not missed. 
 
 For the past two weeks, patient has been around evenings with Fannie 
 Olson, who rooms across from her. She is a girl known to Miss Yonger, 
 a social worker in the State House. Patient is afraid that she steals, so 
 she will not go around the shops with her. They go to the INIission and 
 Underwood Chapel. 
 HMA/A 
 
 November 15. 
 
 Patient's mother seen. She will write the Social Service if patient ever 
 tries to move home, or makes any definite trouble. She is sometimes dis- 
 agreeable to them, and on several occasions has spoken to Florence on the 
 street. Her attitude is about as usual. 
 
 Brother Bernard now lives in Dover, Mass., to be nearer his employer, 
 Introit Dillingham Electric Co.. 
 
 See letters. 
 HA/S 
 
 December 31. 
 
 Case closed. Patient is doing well, 
 HA/S 
 
 1918 
 January 7. 
 
 Rev. Mr. Mittelman seen at St. Matthew's Church, Emmons St. Visi- 
 tor tells informant that patient had not been going to St. Matthew's Church 
 lately, but had been going to Underwood Chapel instead. Visitor asked 
 informant if he would call on patient and get her interested in some organ- 
 ization. Informant did not remember patient's name, or know that she was 
 a member of his church. He said he would be glad to do all he could for 
 her. It was made known to informant that patient was a closed case to 
 the hospital. 
 SPE/S 
 
 March 12. 
 
 .Case reopened. Patient seen at hospital, said she was still living at 
 Y. W. C. A., 68 Warrington St., but that she was very anxious to move. 
 She is in debt to Y. W. C. A. for back room and board to the extent of $16 
 or $17, and would like to have arrangement made by which she could pay 
 off this debt by paying $1 per week. Said she had between $40 and $50 in 
 the bank, but did not want to take any money out as she was afraid she 
 would never be able to save any more. Said she had become very intimate 
 with a girl named Fannie Olson, who also lived at Y. W. C. A. Patient felt 
 that this girl had bad influence over her. The girl steals, and spends a great 
 deal of money for clothes. Patient tries to dress as well as Faimie Olson 
 and consequently spends all her money for clothes. It was in this way that 
 
APPENDIX A 669 
 
 igi8 
 
 patient ran u£ bill at Y. W. C. A., as, instead of paying for board and room, 
 she spent the money for clothes. 
 
 Patient seemed anxious to get a furnished room and take her meals 
 out; thought it would be better for her to live alone, for when she lived 
 with other girls she always got into difficulties. Said she had a married 
 brother, Benjamin Farmer, living in North Dunning. She has always gotten 
 along with him, although recently she has seen very little of him._ Did not 
 know whether they would consider giving her a home. Would like visitor 
 to see them and will send visitor the exact address. Patient will stay at 
 Y. W. C. A. until March 16. Is still working for Doherty Printers, 292 
 Nottingham Avenue, Boston, earning $10 a week. 
 MBH/H 
 
 Patient said she did not feel very well ; had had a continuous cold all 
 winter; said she was still subject to crying spells. 
 MBH/H 
 
 March 13. 
 
 Mrs. Dawson, Matron of Y. W. C. A., telephoned to. Said patient was 
 a nice, quiet girl who gave no trouble in the house. Keeps to herself a 
 great deal and has few friends in the house, although she is liked by every- 
 one. To informant's knowledge, patient has not been drinking, and has 
 been home a great deal, and has had several crying spells. Thought patient 
 was in good condition physically, aside from a hard cold, which she had 
 had all winter. 
 
 Informant said that patient and Fannie Olson had been very intimate, 
 but quarreled about a month ago when a man who had been going with 
 patient transferred his affections to Fannie. Patient and Fannie have not 
 spoken since. Informant said Fannie was a very nice girl and did not 
 believe patient's stories that Fannie stole could be true. Nothing had 
 been taken from the house, and if Fannie was inclined to steal she would 
 have excellent opportunity at the house. 
 
 Informant said that patient owed Y. W. C. A. a little over $16. Visitor 
 asked if patient could pay this back in installments of $1 a week, to which 
 informant readily agreed. Visitor told informant that patient was consider- 
 ing moving and informant was sorry to hear this, as she had enjoyed 
 having patient in the house. 
 MBH/H 
 
 March 14. 
 
 Sec letter from patient. 
 
 March 14. 
 
 Inman House telephoned to. House is closing 3/30/18. 
 
 Gordon House telephoned to. Said they would not consider giving 
 patient a room, as she had caused so much trouble when she was there 
 formerly. 
 MBH/H 
 
 March 15. 
 
 Patient telephoned to. Said she had decided to stay at Y. W. C. A. 
 Told her that arrangement had been made with Mrs. Dawson by which 
 patient could pay $1 a week on her back board. Patient agrees to do this 
 and said she would begin March 16. Said she liked living at Y. W. C. A. 
 very much. The only reason she wished to move was because she thought 
 Fannie Olson had bad influence on her. However, she has seen very little 
 of Fannie lately, so did. not feel it was necessary to move in order to get 
 away from her. 
 
670 APPENDIX A 
 
 T919 
 
 Mrs. Deneen, M air on Y. W. C. A., telephoned to. Told her that patient 
 had decided not to move, and that she would begin paying back $1 a week 
 on March 16. Informant said she was glad to have patient stay. 
 MBH/H 
 
 April 24. 
 
 Patient telephoned. Said she had been sick for a few days, but was 
 now back at work. Said everything was going splendidly, both at work 
 and at the Y. W. C. A. Said she was getting along well with the other 
 girls, and seemed to be enjoying life very much. She is paying every week 
 on her back board and now owes only about $10. 
 MBH/H 
 
 April 24. ^ 
 
 Case closed. 
 MBH/H 
 
 June 9. 
 
 Case reopened. Patient interviewed at hospital. She came to talk over 
 her job. She has been working steadily at the same job and living in the 
 same place, but has recently become discouraged because she has had no 
 advancement. She feels that the boss is hard on her and gives her a great 
 deal more difficult and a greater amount of work than he gives to the other 
 girls in the same department who have been there a shorter time and are 
 earning more money. Seems quite depressed and discontented. Says that 
 it is very difficult to get along on her present wage, which is still $10 a 
 week. 
 
 Visitor advises patient to talk things over frankly with her Superin- 
 tendent before giving up the job, asking him what he can do for her and 
 calling to his attention the fact of how long she has been there. Patient 
 promises to do this. 
 EW/MMM 
 
 June II. 
 
 Patient telephones. States that she has talked with her Superintendent 
 who could tell her nothing definite. Promises to see her again on June 14th 
 and let her know the result. 
 EW/MMM 
 
 June 16. 
 
 Patient telephones. Says that the Superintendent was very nice to her 
 and that he could not raise her wages until fall at any rate because the 
 work was slack in the summer and he had to keep down expenses. States 
 that he intended to raise all the girls' wages in the fall and will raise 
 patient's. Meanwhile he gave her $6 surplus and promised to do what he 
 could in this way during the summer, also to lighten her work somewhat. 
 EW/MMM 
 
 June 20. 
 
 Patient telephones. Things have been going fairly well as the Super- 
 intendent has lightened her work considerably and given the harder extra 
 work to the other girls. She has not had overtime work since she spoke to 
 him. She has not quite decided whether she will stay. Visitor advises her 
 not to be precipitous in any case. Patient promises to let visitor know 
 before she changes her job, or if she gets wind of any other position. 
 EW/MMM 
 
Form I 
 
 Name 
 
 Residence 
 
 Correspondent 
 
 Sex 
 
 Civil condition 
 
 Religion 
 
 Time in Boston 
 
 Previous addresses 
 
 APPENDIX B 
 SOCIAL SERVICE FORMS 
 
 PSYCHOPATHIC HOSPITAL 
 
 SOCIAL SERVICE 
 
 XCemoraudiuu Slip 
 
 File number 
 O. P. D. number 
 
 Age Color 
 
 Place and date of birth 
 
 Occupation 
 
 In Mass. Jn U. S. 
 
 Name and address of father 
 
 Name and address of mother 
 
 Name and address of spouse 
 
 Names, addresses, and ages of children or siblings 
 
 Names and addresses of relatives or friends 
 
 Admitted to house 
 
 Discharged 
 
 Diagnosis 
 
 Provisional diagnosis 
 
 Reason for referring to Social Service 
 
 Report from the Confidential Exchange 
 
 Authority 
 
 Admitted to O. P. D. 
 
 Examiner 
 
 Date 
 
 Living conditions previous to admission 
 
 Remarks 
 
 Visitor's name 
 671 
 
672 
 
 APPENDIX B 
 
 Form II 
 
 Name of patient 
 Date 
 
 PSYCHOPATHIC HOSPITAL 
 
 SOCIAL SERVICE 
 
 mqulry Slip 
 
 CHECK WHEN 
 DONE WITH 
 
 INITIALS 
 OF VISITOR 
 
 PERSONS TO BE SEEN 
 (Give full name, address, and relationship to patient here and below) 
 
 PERSONS TO BE TELEPHONED TO 
 
 PERSONS TO BE WRITTEN TO 
 
APPENDIX B 
 
 ^7Z 
 
 Form HI 
 
 PSYCHOPATHIC HOSPITAL 
 
 SOCIAL SERVICE 
 
 Outluie for History 
 
 Date 
 
 Name 
 
 Address 
 
 Age 
 
 Date and place of birth 
 
 Religion 
 
 Civil condition 
 
 Referred to hospital by 
 Brought by 
 Reason for coming 
 History obtained by 
 
 Medical Record : 
 
 Dates of admissions 
 
 Dates of discharges 
 
 Summary of physical examination 
 
 Summary of mental examination 
 
 Summary of intelligence tests 
 
 Conduct on the wards 
 
 Diagnosis 
 
 Prognosis 
 
 Social History; 
 Family: 
 
 Father j 
 
 Mother 
 
 Brothers and sisters ! 
 
 Spouse I 
 
 Children ! 
 
 For each give 
 
 Date and place of marriage 
 Other members of the household 
 Attitude of the family toward patient 
 Relatives 
 
 Address 
 
 Age and date of birth 
 
 Nativity 
 
 Religion 
 
 Time in U. S., in state, in city 
 
 Occupation 
 
 Intelligence 
 
 Character 
 
674 APPENDIX B 
 
 Social History : — Continued 
 
 Friends and References: 
 Friends, neighbors 
 Doctors, lawyers, clergymen 
 Institutions, courts, social agencies 
 Hospitals 
 
 Work: 
 
 {Progress 
 Wages 
 Duration of the position 
 Character of associates 
 
 Recreation: 
 Opportunities 
 Companions 
 
 Schools (in order in which they were attended, with dates) : 
 
 Home and Neighborhood: 
 
 Character of locality (factory, business, tenement, suburban, etc.) 
 
 Character of street ^ 
 
 Character of building 
 
 Character of the home I State as far as possible in specific term. 
 
 (i) furnishings 
 
 (2) neatness and cleanlinessj 
 Income and savings 
 
 Expenses — rent, insurance, benefit societies, etc. 
 Attitude of family toward their income 
 
 Habits of family in regard to eating and sleeping 
 
 Character of patient's bedroom (sleeps alone or with whom) 
 
 Character of patient's food 
 
 P H VS I C A L H I STORY : 
 
 Dcvclopmoital History: 
 
 Full term? Normal delivery? \ 
 
 Prenatal history : 
 
 Work of mother during pregnancy 
 
 Diseases of mother during pregnancy 
 
 Injuries to mother during pregnancy 
 
 Mental strain of mother during pregnancy 
 Birth weight 
 
 Feeding — breast or bottle 
 Age of sitting up 
 Age of first tooth 
 Age of creeping 
 Age of walking 
 Age of talking 
 Age of puberty 
 Illnesses : 
 
 General 
 
 Convulsions 
 
 Injuries 
 
 Hospital c^x^ 
 
APPENDIX B 675 
 
 Physical History : — Continued 
 
 Personal Hygiene: 
 
 Habits of sleeping (hours) 
 Habits of eating 
 Habits of bathing 
 
 Heredity : 
 
 Relationship between parents 
 
 Condition of health and cause of death of — 
 
 Father 
 
 Mother 
 
 Sisters and brothers 
 
 Maternal grandparents 
 
 Paternal grandparents 
 
 Uncles and aunts 
 Tuberculosis, alcoholism, insanity, f eeble-mindedness, epilepsy, or cancer 
 Any mental or physical abnormalities in the family 
 Any exceptional ability in the family 
 
 Physical Efficiency: 
 Lazy or energetic? 
 Frail or robust? 
 How easily fatigued? 
 Susceptibility to pain? 
 
 Mental History : 
 
 Education : 
 
 Age of going to school 
 
 School record 
 
 Grade and age of leaving 
 
 Special t^raining (industrial, commercial, musical, etc.) 
 
 Reading 
 
 Employment: 
 
 Success or failure 
 
 Reasons for resignations or discharges 
 
 Patient's trade 
 
 Work for which patient thinks he is best fitted 
 
 Dispositicin and Character : 
 Likes and dislikes 
 Habits 
 Peculiarities 
 Special abilities 
 
 Attitude of patient toward his family 
 Changes in character 
 Onset of present trouble 
 
 Summary: 
 
 Social history 
 Physical history 
 Mental history 
 
676 APPENDIX B 
 
 Analysis of Social Symptoms 
 
 Social Diagnosis 
 
 Recommendations in Regard to- 
 Social condition 
 Physical condition 
 Mental condition 
 
 II 
 
 History (Interviews) : 
 Patient's Story 
 
 Statements of Others (with impression of informant at the end of each 
 statement) 
 
 III 
 
 Action Taken (Chronological record). 
 
 SiTMMARY OF Results: 
 
 r Social condition 
 At the end of every three months-< Physical condition 
 
 L Mental condition 
 
APPENDIX C 
 LEGISLATION IN RELATION TO MENTAL DISEASE 
 Frankwood E. Williams, M.D. 
 
 When hospitals for the insane were first opened in this country, 
 admission to them was as informal and on the same basis as ad- 
 mission to any other hospital. Provision was made for the com- 
 mitment by courts of those "so furiously mad as to be a danger 
 to the community," but patients who desired admission or those 
 whose friends desired admission for them were admitted freely. 
 
 During the early twenties of the nineteenth century, public in- 
 terest in the care of the insane was aroused and states began to 
 build public hospitals. This interest had come from England, 
 where it had been shown that many of the insane if taken from 
 the almshouses and jails, cages and pens, where many of the 
 poorer were confined and neglected, and treated in proper hos- 
 pitals, might be restored to reason. The object in building the 
 state hospitals, therefore, was to provide this sort of care for those 
 who could not otherwise afiford it. The hospitals were regarded 
 with great favor — ^the "state's greatest charity." It was believed 
 that the earlier a patient could receive treatment the greater was 
 the chance for his recovery and no obstacles, therefore, were put 
 in the way of entrance to the hospital. On the contrary, the 
 friends of patients, and patients themselves, were urged to come 
 to the hospital as soon after the first signs of mental illness as 
 possible; and when they came no question as to admission was 
 raised except the possible one of an unoccupied bed. 
 
 This informality of admission continued, in Massachusetts, for 
 example, for a period of forty-four years, or from the opening of 
 the McLean Hospital in 1818 to 1862 when a law was passed re- 
 quiring "in all cases the evidence and certificate of at least two 
 reputable physicians ... to establish the fact of insanity." 
 
 For some thirty years the hospitals had held the confidence of 
 the community, but in the ten years previous to 1862 there had 
 begun to develop a feeling first of disappointment and then of 
 distrust. The disappointment was more or less warranted as the 
 hospitals had not been able to bring about the happy results the 
 community unfortunately had been led to expect; the distrust at 
 
 677 
 
678 APPENDIX C 
 
 this time was not warranted. Nevertheless, the fear became more 
 or less general that patients were being wrongfully detained in 
 hospitals and driven mad by their associates, that personal liberty 
 was becoming of little consequence, and even that it might be 
 possible to find two physicians who through interested motives 
 might wrongfully certify to insanity, and that a superintendent 
 might be bribed to keep the person in confinement. As a result, 
 legal barriers were year by year built about the hospitals, until by 
 1874 the hospitals were almost completely isolated from the com- 
 munity ; admission to them was a formal legal matter to be decided 
 by court or jury. In consequence, admission was practically im- 
 possible for patients in the early stages of illness and the hospitals 
 became asylums for the care of chronic patients about whose men- 
 tal condition there could be no question, as it was obvious even to 
 lay judges and juries.^ 
 
 As the hospitals became more and more asylums for chronic 
 patients, interest in them on the part of the medical profession 
 lessened and the hospitals became the prey of the politician, posi- 
 tions in the hospitals from ward attendant and nurse to super- 
 intendent becoming the rightful spoils of successful candidates for 
 public office. This situation obtained for many years and still 
 obtains in certain states. 
 
 Legislatures that had been so aroused against the hospitals in 
 1874 had learned by 1882 that they had been badly advised; that 
 it was to the interest neither of the community nor the patient to 
 deny to the patient the only possible help there was for him until 
 such time as his illness had become so chronic that any hope that 
 there might have been in the first place was largely lost. A period 
 of constructive legislation began about this time. Some states still 
 have on their statute books the laws passed in this period of dis- 
 trust, but in the past forty years many of the states have rewritten 
 their "insanity laws" and in this rewriting two main objects have 
 been kept in mind — to remove the hospitals from the field of po- 
 litical spoils and to place them in the hands of reputable physicians 
 whose qualifications are their professional skill and knowledge of 
 the special problems involved ; and to make the hospitals as acces- 
 sible as possible to those who may need them in order that the 
 hospitals may serve their communities effectively. This desire to 
 bring the hospitals back into the communities as dynamic forces in 
 the interest of public health has been greatly increased in the past 
 few years by the knowledge that has come from medical and social 
 
 ^ Legislation for the insane in Massachusetts with particular reference 
 to the voluntary and temporary care laws. By Frankwood E. Williams, 
 M.D. Boston Medical and Surgical Journal, vol. 173, no. 20, Nov. 11, 1915. 
 Publication No. 5 of the Massachusetts Society for Mental Hygiene. 
 
APPENDIX C 679 
 
 investigations showing the relationship that frequently exists be- 
 tween mental disease and defect and asocial conduct and likewise 
 by medical research that has made possible a clearer conception of 
 the nature of mental disease and indicated means by which such 
 disease may be not only cured but avoided. The barriers, there- 
 fore, that had unwisely been built about the hospitals until their 
 usefulness had been largely destroyed are now being rapidly re- 
 moved and the hospitals from being institutions of horror are 
 becoming institutions of hope ; professional skill of a very special 
 kind instead of being locked inert within hospital walls is being 
 brought through out-patient departments and social service depart- 
 ments out into the community where it can be of great service; 
 and the community instead of drawing away in fear is seeking 
 from the hospitals advice both in personal and community matters. 
 
 This development has been slow, although more rapid of recent 
 years, and has developed differently and at a different pace in 
 different states so that one may now find in this country an illus- 
 tration of almost any stage from the more or less completely 
 isolated and politically controlled asylum of the sixties and seven- 
 ties to the most modern type of hospital scientifically equipped and 
 staffed, with its social service and out-patient departments radiat- 
 ing to all points in its locality and its advice sought on many dif- 
 ferent matters. 
 
 In bringing about this accessibility of the hospitals three laws 
 have been found particularly useful. These are known as the 
 Voluntary Care, the Temporary Care, and the Observation Laws. 
 In Massachusetts a fourth law, known as the Boston Police Law, 
 has been found very useful. 
 
 Provision for the reception of voluntary patients in state and 
 private hospitals has been made in the following twenty-nine states : 
 California, Colorado, Connecticut, Georgia, Illinois, Indiana, 
 Kansas, Maine, Maryland, Massachusetts, Michigan, Minnesota, 
 Mississippi, Missouri, New Hampshire, New Jersey, New York, 
 North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode 
 Island, South Carolina, South Dakota, Vermont, Virginia, West 
 Virginia, and Wisconsin. 
 
 The law ususally provides that the patient must sign an appli- 
 cation for admission, that his mental condition must be such that 
 he can understand the nature of this request as well as the need 
 of treatment, and that he must be released on a demand in writing 
 in from three to seven days after such application. In the case of 
 six of these states his request for admission must be accompanied 
 by the certificate of one or two physicians, and in some instances 
 his application must be signed in the presence of a physician. 
 
 Fifteen states and the District of Columbia have laws authoriz- 
 
68o APPENDIX C 
 
 ing commitment for temporary care and observation. They are 
 Connecticut, Illinois, Maine, Massachusetts, Michigan, Minnesota, 
 New Jersey, New York, North Carolina, Oklahoma, Pennsylvania, 
 South Carolina, Tennessee, Washington, and Wisconsin/ 
 
 The best examples of Temporary Care Laws are probably those 
 of Massachusetts, and they may well be used as illustrations here. 
 Aside from the law permitting voluntary admission, Massachusetts 
 has three laws that make it possible for a patient to obtain hospital 
 care and treatment without formal court procedure and a fourth 
 law under which the legal formalities are slight. 
 
 1, Temporary Care Law (Chapter 174, Acts 1915). This law 
 provides that a superintendent may, when requested by a physi- 
 cian, by a member of the board of health or a police officer of a 
 city or town, by an agent of the institutions-registration depart- 
 ment of the city of Boston, or by a member of the district police, 
 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 tre- 
 mens or drunkenness. Such patients are received on application 
 in writing filed at the time of reception of the patient or within 
 twenty-four hours thereafter and must be discharged or com- 
 mitted within ten days unless they make a request for voluntary 
 care. This law is useful both as an emergency law and as an 
 observation law as under it physicians may bring to the hospital 
 for examination and advice patients about whose condition they 
 have reason to be concerned, but whom they do not sufficiently 
 understand to warrant a formal application for commitment as 
 insane or those patients who, although clearly "insane" in a medical 
 sense, are in such an early stage of their illness that a formal 
 commitment would not be possible. Treatment is therefore pro- 
 vided at a time when it is likely to be of greatest help, but which 
 could not be obtained except for the provisions of this law. The 
 value of the law as an aid in restoring health and preventing 
 chronic illness can scarcely be overestimated. 
 
 2. Emergency Laiv (Section 42, Chapter 504, Acts 1909). The 
 superintendent of a hospital may receive and detain, for not more 
 than five days without a court order, any person "certified to be 
 one of violent and dangerous insanity or of other emergency" by 
 two qualified medical examiners. Officers authorized to serve 
 criminal processes, 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 
 
 *Laws controlling commitments to state hospitals for mental diseases, 
 by James V. May, M.D., Menial Hygiene, vol. 5, no. 3, July, 1921. 
 
APPENDIX C 68 1 
 
 received, or for his removal from the hospital. This law makes it 
 unnecessary in an emergency to "arrest" a sick individual as a 
 criminal and confine him in a local jail until such time as it may 
 be possible to bring him before a court for commitment. Courts 
 are frequently not in session at the time an individual becomes ill. 
 When holidays fall at the end or the beginning of the week there 
 may be several days without a session of the court. Through the 
 provisions of this law, the patient may be brought at once to the 
 hospital where he can be properly cared for until such time as the 
 court may convene. 
 
 3. Observation Law (Chapter 145, Acts 1919). A person 
 found by two qualified examiners to be in such mental condition 
 that his commitment to a hospital is necessary for his proper care 
 or observation may be committed to a state hospital for a period 
 of thirty-five days pending the determination of his insanity. This 
 law is particularly useful in legal and criminal proceedings in 
 which the question of mental condition is raised. It is useful also 
 in difficult cases in which more time is needed for a determination 
 of the patient's mental condition than is provided in the Temporary 
 Care Law. 
 
 4. Boston Police Law (Chapter 307, Acts 1910). Under the 
 provisions of this law all persons sufifering 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 Boston Psychopathic Hospital in the 
 same manner in which persons afflicted with other diseases are 
 taken to a general hospital." Cases sufifering from delirium tre- 
 mens 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 insti- 
 tution appropriate in each particular case unless the patient re- 
 covers or is discharged. Chapter 394 of the Acts of 191 1 is com- 
 plementary to the above in that it provides that no person suffering 
 from insanity, mental derangement, delirium, or mental confusion, 
 except delirium tremens or drunkenness, shall, except in an emer- 
 gency, 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 physi- 
 cian and shall be furnished suitable medical care and nursing and 
 shall not be detained for more than twelve hours. In Boston these 
 patients 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 admitted to a state hospital or 
 cared for by relatives or friends. 
 
682 APPENDIX C 
 
 A very considerable use of the voluntary and temporary care 
 laws is made in Massachusetts. In fact, the temporary care laws 
 have very largely determined the legal status of patients admitted 
 to the Boston Psychopathic Hospital. During a period of six 
 years, 6,499 patients, 57.5 per cent of all admissions, were ad- 
 mitted under the "ten-day" temporary care law. Nine thousand 
 and seventy-four, or 80.3 per cent of the total number of admis- 
 sions during the same period, were temporary-care patients of one 
 kind or another. The voluntary patients represented 1 7.6 per cent 
 of the 11,289 patients during the period.^ 
 
 At the request of the Surgeon General of the United States 
 Army, who during the war found embarrassing the lack of uni- 
 formity in the various state commitment laws, the National Com- 
 mittee for Mental Hygiene appointed in 1919 a special committee 
 to make a study of the various state laws and to recommend such 
 provisions as it seemed desirable to incorporate in a modern com- 
 mitment law. The committee was composed of Dr. George M. 
 Kline, Commissioner, Massachusetts State Department of Mental 
 Disease ; Dr. Charles W. Pilgrim, Chairman of the New York 
 State Hospital Commission ; Dr. Owen Copp, Superintendent, 
 Pennsylvania Hospital, Department for Nervous and Mental Dis- 
 eases; Dr. Frank P. Norbury of the Board of Public Welfare 
 Commissioners of Illinois ; and Major Frankwood E. Williams of 
 the Office of the Surgeon General, Washington, D. C. The 
 committee recommended in its report voluntary commitment, tem- 
 porary care, emergency commitment, and commitment for obser- 
 vation. 
 
 * Laws controlling commitments to state hospitals for mental diseases, 
 by James V. Aiay, M.D., Menial Hygiene, vol. 5, no. 3, July, 1921. 
 
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 ilies and The Report of the Philadelphia Intake Committee." 
 Philadelphia, Bureau for Social Research, Seybert Institution, 
 1919. 
 
 Wells, F. L. "Mental Adjustments." New York, D. Appleton & 
 Company, 19 17. 
 
 . "The Status of Clinical Psychology," Mental Hygiene, v. 6, 
 
 pp. 11-22, January, 1922. 
 
 White, William A. "Foundations of Psychiatry." New York 
 and Washington, Nervous and Mental Disease Publishing Com- 
 pany, 1921. 
 
 . "Mechanisms of Character Formation : An Introduction 
 
 to Psychoanalysis." New York, The Macmillan Company, 1916. 
 
 . "The Mental Hygiene of Childhood." Boston, Little, Brown 
 
 & Company, 1919. 
 
698 BIBLIOGRAPHY 
 
 White, William A. "Outlines of Psychiatry," 7th edition. Wash- 
 ington, Nervous and Mental Disease Publishing Company, 1919. 
 
 White, William A., and Jelliffe, S. E. "Diseases of the Nervous 
 System : A Text-book of Neurology and Psychiatry," 2nd edition. 
 Philadelphia, Lea and Febiger. 1917. 
 
 Williams, Frankwood E. "Legislation for the Insane in Massa- 
 chusetts with Particular Reference to the Voluntary and Tem- 
 porary Care Laws," Boston Medical and Surgical Journal, v. 173, 
 pp. y22,-y2,A^ November 11, 191 5. 
 
 . "Mental Hygiene and the College Student," Mental Hygiene, 
 
 V. 5, pp. 283-301, April, 1921. 
 
 . "The State Hospital in Relation to Public Health," Mental 
 
 Hygiene, v. 4, pp. 885-896, October, 1920. 
 
 "Treatment of Mental Patients in the General Hospitals of 
 
 the United States Army," Proceedings of the American Medico- 
 Psychological Association, pp. 271-286, June, 1919. 
 
 Williams, Frankwood E., and Brown, M. W. "Neuropsychiatry 
 and the War : A Bibliography with xA.bstracts." New York, Na- 
 tional Committee for Mental Llygiene, 1918. 
 
 Wolf, Robert B. "Individuality : The Key to Conscious Life Pur- 
 pose," Survey, v. 41, pp. 620-625, February i, 1919. 
 
 . "Making Men Like Their Jobs," System, v. 35, pp. 
 
 34-38, 222-226, January and February, 1919. 
 
 WoRCH, Margaret. "Psychiatric Social Work in a Red Cross Chap- 
 ter," Mental Hygiene, v. 6, No. 2, April, 1922. 
 
 Yerkes, Robert M. "Plow May We Discover Children Who Need 
 Special Care?" Mental Hygiene, v. i, pp. 252-259, April, 1917. 
 
 Yerkes, Robert M., and others. "A Point Scale for Measuring Men- 
 tal Ability." Baltimore, Warwick and York, Incorporated, 191 5. 
 
INDEX 
 
 Aboulia, iii (case 17), 419 
 
 Accident, fear of, 328 (case 87) 
 
 Acquired, 217 
 
 Adaptation, 369 
 
 Adjustment, of inner to outer 
 
 relations, 368 
 Adler, Herman M., 347, 487, 499, 
 
 527, 545 
 Agoraphobia, 142 (case 24) 
 Aid, charitable, 231 
 — financial, 156, 157, 174, 507 
 — in clothing, 337 
 —temporary, 108, 196 
 Alcohol, 237, 253, 446 
 — and epilepsy, 470 
 Alcoholic, 24 (case 4) ; 35 (case 
 
 6) ; 113 (case 18) ; 211 (case 
 
 42) ; 262 (case 62) ; 291 (case 
 
 71); 450 
 Alcoholic deterioration, 263 (case 
 
 62) 
 Alcoholic hallucinations, 250 (case 
 
 59). 
 Alcoholic hallucinosis, 253 (case 
 60); 257 (case 61); 296 (case 
 
 73) ; 471 
 
 Alcoholic jealousy-psychosis, 471 
 Alcoholic psychosis, 245, (case 
 
 58) ; 262 (case 62) ; 470 
 Alcoholism, 109 (case 17) ; 133 
 
 (case 23) ; 217 (case 45) ; 245 
 
 (case 58) ; 267 (case 63) ; 348 
 
 (case 94) ; 446 
 Alienist, 438, 439; (chart) 441; 
 
 443 
 Almshouse, 221 
 Ambition, 126, 156 
 American Association of Hospital 
 
 Social Workers, 555 
 American Psychiatric Association, 
 
 437 
 Antisyphilitic treatment, no (case 
 
 17) ; 204 (case 39) ; 457 
 — during pregnancy, 172 (case 31) 
 Anxiety neuroses, 483 
 Apperception, 9 
 
 x\rmy, 215, 233, 240, 242, 308, 361 
 Arrested, 17, 294, 356 
 Arteriosclerosis, 270 (case 64) 
 Associates, 541, 542 
 Attitude, "Borrow no trouble," 285, 
 
 351 
 Authority, 547 
 — inadequate, 419 
 — public, 31 
 Autobiography, 73 
 
 Bacon, Francis, 384, 420 
 
 Bacon, Roger, 419 
 
 Bad habits. See Vitia, definition 
 
 of, 412 
 Bakunin, 435 
 Barker, Lewellys, F., 552 
 Baths, 2. See also, Hydrother- 
 
 apeutic treatment 
 Beauty, 404 
 Bellevue Hospital, 520 
 Birth control, 357 
 Bismarck, 433 
 Blood tests, 459 
 Bodily disease, 472 
 Bolshevism, 430, 435 
 Bosanquet, Mrs., 539 
 Boston State Hospital, 520 
 Brain disease, 472 
 Brodie, Sir Benjamin, 412 
 Burleigh, Edith N., 520 
 
 Cabot, Richard C, 37^, 423. 5I9, 
 
 522 
 Cannon, Ida M., 382, 521 
 Capitalist, 435 
 Case, "closed," 74, 85, 109, 164, 
 
 191, 214, 254, 300 
 — "intensive," 526, 534 
 — "slight service," 526, 534 
 Character, 397 
 Character-building, 376, 377 
 Character-training, 544 
 Charitable institutions, attitude of, 
 
 213 
 Chorea, 273 (case 65) 
 
 699 
 
yoo 
 
 INDEX 
 
 Clausewitz, 433 
 
 Clinic, dental, 20 
 
 — out-patient, 42 
 
 Clinic manager, 530 
 
 Cocainism, 472 
 
 Commitment, 106 (case 15) 
 
 — for observation, 146, 151 
 
 Committable, 149 (case 26) ; 279 
 
 (case 68) ; 303 (case 75) 
 Community, 367 
 — health of, 459 
 Compensation, 108, 116, 340 
 Concussion, 231 (case 49) 
 Conflict, 12 (case 2) 
 Congenital, 217 (case 45) ; 223 
 
 (case 48) ; 228 (case 48) 
 Consociates, 541 
 Constitutional inferiority, 8 (case 
 
 2) . 
 
 Constitutional psychopathic in- 
 feriority, 24 (case 4) ; 359 
 (case 98) ; 487, 490 
 
 Constitutional psychopathic in- 
 feriors, 497 
 
 Control, of desires, 53 
 
 Convulsions, 104 (case 15) ; 237 
 (case 45) 
 
 Cooperation, 90 
 
 Court, 194, 274, 294 
 
 — contempt of, 194 
 
 Crime, 51, 395, 449 
 
 — disease or vice, 178 (case 33) 
 
 Criminal law, 395 
 
 Criminological system, 249 
 
 Criminology, 51 
 
 Croix dc Guerre, 307 
 
 Crowd, inexperienced, 419 
 
 Custom, force of, 419 
 
 Cyclothymia, 143 (case 25) ; 295 
 (case 73) ; 313 (case 81) ; 477 
 
 Cyclothymic, 338 (case 89) 
 
 Cyclothymic constitution, 21, (case 
 3); 182 (case 25); 235 (case 
 52) ; 318 (case 82) ; 362 (case 
 100) 
 
 Cyclothymic tendency, 69 (case 10) 
 
 Danvers State Hospital, 520 
 
 Darwin, 403 
 
 Davis, Michael M., 521 
 
 Defective delinquent, 487 
 
 Defense reactions, 22 (case 3) ; 30 
 
 (case 5) 
 Delinquency, 8 (case 2) ; ^2 (case 
 
 S) ; 52 (case 8) ; 245 (case 
 
 S8); 489 
 
 Delinquency vs. psychopathy, 14 
 
 (case 2) 
 
 Delinquent, 66 (case 9) 
 
 Dfelirium tremens, 27 (case 6) ; 
 250 (case 59) ; 252 (case 60) ; 
 471 
 
 Delusions, 254 (case 60) 
 
 Dementia, 88 (case 12) ; 271 (case 
 64) ; 298 (case 73) 
 
 — psychological, 473 
 
 Dementia praecox, 7 (case i); 10 
 (case 2) ; 13 (case 2) ; 24 
 (case 4) ; 88 (case 12) ; 108 
 (case 16) ; 115 (case 18) ; 148 
 (case 26) ; 168 (case 31) ; 182 
 (case 35) ; 215 (case 43) ; 216 
 (case 44) ; 224 (case 48) ; 293 
 (case 71) ; 295 (case j:^) ; 300 
 (case 74) ; 308 (cases 77, 78) ; 
 310 (case 79) ; 311 (case 80) ; 
 312 (case 81); 447, 450, 473, 
 496 
 
 — catatonic, 286 (case 70) 
 
 — in feeble-minded person, 448 
 
 — sexuality in, 286, (case 70) 
 
 Dementia simplex, 284 (case 70) 
 
 Dental treatment, 549 
 
 Dental work, 196 (case 38) ; 231 
 (case 49) 
 
 Deportation, 5, 29, 89 
 
 Desertion, 174 (case 32) 
 
 Deteriorate, 477 
 
 Deterioration, 236 (case 53) ; 298 
 (case 7s) ; 473 
 
 Dewey, John, 512 
 
 Diagnosis, change of, 301 (case 75) 
 
 — importance to therapy, 364 (case 
 100) 
 
 Diagnostic decision, 118 
 
 Diary, 319 
 
 Differential diagnosis, 145 
 
 Dipsomania, 253 (case 60) ; 501 
 
 Disappeared, 354 
 
 Disease, definition of. See Morbi, 
 definition of, 411 
 
 — functional, 410 
 
 Draft, 241 
 
 Dragon-slayers, 427 
 
 Dramatis personae, 540 
 
 Drug, 446, 450 
 
 Dual personality, 310 (case 80) 
 
 Dubois, 538 
 
 Eccentric, 374, 2,77, 475 
 Eccentricities, 380, 401 
 Economic point of view, 381, 518 
 
INDEX 
 
 701 
 
 Economic unrest, 498 
 Economics, 369, 384 
 Education, 188, 407 
 Educators, 465 
 Efificiency, 370, zn 
 Emerson, 406 
 
 Empathic index, 17 ; 121 (case 20) ; 
 256 (case 60) ; 269 (case 63) ; 
 
 477 
 Employment managers, clinic for, 
 
 362 
 Employment obtained, 231 
 Engineering Foundation, 499, 531 
 Environment, 369 
 Epilepsies, 237 (case 53) ; 450, 469 
 Epilepsy, 13 (case 2) ; 158 (case 
 
 29) ; ^2)7 (case 53) ; 238 (case 
 
 54) ; 240 (case 55) ; 242 (case 
 _ 57) ; 446, 469 
 Epileptic fugue, 10 (case 2) 
 Epileptic temperament, 469 
 Epileptics, many eminent men, 160 
 
 (case 29) 
 Epileptiform equivalent, 470 
 Erotic, 315 (case 81) 
 Error, causes of, 419 
 Errores, definition of, 411 
 Ethics, 364 
 
 Eugenic researches, 228 
 Eugenists, 465 
 Evil, definition of, 408 
 
 Fabrications, 189, 348, 359 
 Family, 229, 234, 367, 466, 535, 562 
 — unit of interest, 223 
 Family adjustment, 266 (case 62) ; 
 
 328 (case 87) 
 Family agency, 151 
 Family case, 23 (case 4) ; 83 (case 
 
 II) 
 Family conference, 102 
 Family problem, 115 (case 19) ; 
 
 137 (case 24) ; 171, 506, 508 
 Farmer, Gertrude L., 534 
 Feeble-minded, 66 (case 9) ; 103 
 
 (case 15) ; 125 (case 20) ; 148 
 
 (case 26) ; 223 (case 48) ; 227 
 
 (case 48) ; 229 (case 49) ; 
 
 233 (case si); 335 (case 88); 
 
 342 (case 92) ; 449, 487 
 Feeble-mindedness, 84 (case 11) ; 
 
 96 (case 13) ; 97 (case 13) ; 
 
 182 (case 35); 263 (case 62); 
 
 267 (case 63) ; 284 (case 70) ; 
 
 446; 463; 465; (chart) 461; 
 
 463- 519 
 
 Fenton and Schwab, 492 
 Fernald, Walter E., 125, 126, 551 
 "Fit to work," 83 (case 11); 117 
 
 (case 19) 
 Folie a deux, 486 
 Follow-up, 278, 530 
 Forme fruste, 14 (case 2) ; 21 
 
 (case 3) ; 71 (case 10) 
 Foster, Josephine Curtis, 183 
 Fracture, of skull, 233 (case 51) ; 
 
 238 (case 54) 
 Freudian mechanisms, 336 (case 
 
 88); 688 
 Functional, 447 
 
 General paresis, 203 (case 39) ; 
 
 215 (case 43) ; 216 (case 44) ; 
 
 456 
 — 'Costly delay of diagnosis, 203 
 
 (case 39) 
 — "fatal prognosis," 211 (case 42) 
 Glueck, Bernard, 518, 556 
 Gonorrhea 156 (case 28) ; 358 
 
 (case 96) 
 Grail-hunters, 427 
 Great War, 370, 431, 444, 492, 521 
 "Great-man" theory, 498 
 Group, 367, 386 
 Guardian, 285 
 
 Haeckel, Ernst, 403 
 
 Hallucinations, 88 (case 12) ; 263 
 (case 62) ; 305 (case 75) 
 
 — hypnagogic, 115 (case 18) 
 
 Health, of wife and children, 266, 
 268 (case 62) 
 
 Healy, William, 380, 538, 540 
 
 Henderson, L. J., 369 
 
 Hereditary, 217 (case 45) ; 223 
 (case 48) ; 228 (case 48) 
 
 Hereditary taint, 6 (case i) 
 
 Heredity, 36, 39 (case 6) ; iii 
 (case 17) ; 155 (case 28) ; 168 
 (case 31) ; 190 (case 36) ; 217 
 (case 45) ; 228 (case 48) ; 231 
 (case 49) ; 240 (case 54) 
 
 History, 434 
 
 — economic interpretation of, 401, 
 
 ^34 . . 
 
 - — psychopathic interpretation of, 
 
 401 
 Hoboes, 293 
 Hohenzollerns, 433 
 Homeless men, agency for, 177 
 Homosexual, 12 (case 2) ; 51 (case 
 
 8) 
 
702 
 
 INDEX 
 
 Hormones, 378 
 Hospital wards, 513 
 Housekeeping, advice about, 264 
 Hume, David, 404 
 Hydrotherapeutic treatment, 230 
 
 (case 49); 342 (case 91); 549 
 Hygiene, 379 _ 
 — instruction in, 176 
 Hyperkinetic, 224 (case 48) ; 226 
 
 (case 48) 
 Hypersexuality, 25 (case 4) ; 58 
 
 (case 8) ; 355 (case 96) ; 489 
 Hyperthyroidism, T^, (case 10) ; 
 
 2"]^ (case 66) 
 Hypnotism, 516 
 Hypoboulia, 109 (case 17) ; 144 
 
 (case 25) ; 419 
 Hypobulic, 353 (case 95) ; 489 
 Hypochondria, 118 (case 19) 
 Hypophrenia, 464 
 Hypophrenic, 18 (case 3) 
 Hysteria, 72 (case lo) ; 106 (case 
 
 is) ; 143 (case 25) ; 225 (case 
 
 48) ; 242 (case 57) ; 335 (case 
 
 88) ; 483 
 — "mechanisms" of, 118 (case 19) 
 Hysterical, 93 (case 13) 
 Hysterical paralysis, 226 (case 48) 
 
 Idiot, 463 
 
 Ignorance. Sec Errores, definition 
 of, 411 
 
 Illegitimate, 96 (case 13) 
 
 Illegitimate child, 17 (case 3) ; 98 
 (case 14) ; 192 (case 36) ; 216 
 (case 44) : 225 (case 48) ; 273 
 (case 65) ; 276 (case 66) 
 
 Illegitimate children, 87 (case 12) ; 
 189 (case 36) 
 
 Imbecile, 463 
 
 Immigrant, 352 
 
 Immigration, 5 
 
 Indigestion, 195 (case 38) 
 
 Individual, 351, 367, 386, 387, 535 
 
 Individualization, 328, y]7^ 380, 421, 
 544 
 
 Industrial accident, 83, 240, 339 
 
 Industrial Accident Board, 83, 117, 
 
 339; 503 
 Industrial cases, family interests 
 
 in, 506, 510 
 Industrial traumatic neurosis, 115 
 
 (case 19) 
 Inebriety, chronic, 258 (case 61). 
 
 See also Alcoholism 
 
 Infantilism, 24 (case 4) ; 347 (case 
 
 94) 
 
 Influenza psychosis, 277 (case 67) 
 
 Inoculation, 241 (case 56) ; 242 
 (case 57) 
 
 Insanity, 371, 438, 519 
 
 —a legal concept, 284 (case 70) - 
 
 —a legal, not medical unit, 203 
 (case 39) 
 
 Institutional home, voluntary re- 
 sort to, 125 
 
 Interference, 248 
 
 Intolerance for alcohol, post trau- 
 matic, 36 (case 6) 
 
 Investigation, 213, 543 
 
 Involutional psychosis, 284 (case 69) 
 
 Irregular employment, 500 
 
 James. William, 371, 374, 401, 521, 
 
 557 
 Jealousy psychosis, 255 (case 60) ; 
 
 262 (case 62) 
 Jev^rs, 142, 328 
 Job, mottoes from, 429 
 Jobs, lost, 267 
 Judge, 195, 464 
 Jurists, 444 
 
 — cases of interest to, 414 
 Juvenile tabes, 216 (case 45) 
 
 Kellogg, Theodore H., 519 
 Kleptomania, 17 (case 3) ; 144 
 
 (case 25) 
 Kober and Hanson, 154 
 Kraepelin, 474, 487 
 
 Language difficulty, 106 (case ^5) ; 
 
 159 (case 29) ; 357 (case 97) 
 Law, 414 
 
 Law's delay, 87, 565 
 Lawsuits, 294 
 Lawyer, 464 
 Lead poisoning, 178 (case 34) ;i 
 
 231 (case 49) 
 Legal entanglement, evil of, 5^5 
 Legislators, 465, 513 
 Lenin, 435 
 Letters (quoted), 53-56, 67-68, 
 
 125, 176 
 Litigation psychosis, 486 
 Litigia, definition of, 414 
 Lucas, W. P., 521 
 "Lump sum" settlement, 85, 119, 
 
 340 
 
 McMahon, Katherine, 521 
 Maladjustments, 369 < 
 
INDEX 
 
 703 
 
 Malecidal, 427 
 
 Maleducated, 411 
 
 Malthus, 402 
 
 Malthusian, 357 
 
 "Man crazy," 79, (case 10) 
 
 Manhattan State Hospital, 520 
 
 Manic depressive psychosis, 13 
 (case 2) ; 21 (case 3) ; 24 
 (case 4) ; 31 (case 6) ; 142 
 (case 25) ; 216 (case 44) ; 295 
 (case 72) ; 312 (case 81) ; 317 
 (case 82) ; 447, 450, 477, 501 
 
 Mannerisms, 302 (case 75) 
 
 Man's attire, 133 
 
 "Marginal" status, 14 (case 2) 
 
 Marital discord, 162 (case 30) ; 
 194 (case 2,7) 
 
 Marx, 435, 498 
 
 Massachusetts General Hospital, 
 520, 522 
 
 Massachusetts School for the 
 Feeble-minded, 551 
 
 Masturbation, 108 (case 16) ; 302 
 (case 75) ; 352 (case 95) ; 355 
 (case 96) 
 
 Maternity home, 274 
 
 Medical care, 214 
 
 Medical diagnosis, 142, 144, 168, 
 
 313 
 
 Medical schools, 437, 556 
 
 Medical social work, 381, 423, 555 
 
 Medical social worker, 223, 350, 559 
 
 Medical sociology, 556, 558 
 
 Medical treatment, 549 
 
 Medicine, 384, 553 
 
 Melancholia, 143 (case 25) ; 182 
 
 (case 34) 
 Menance, 89 
 
 Meniere's disease, 352 (case 95) 
 Men's Club, 35, 38, 246, 256, 292, 
 
 318, 332, 450, 531 
 Mental disease, 284 (case 70) ; 296 
 
 (case 72) ; 371, 437, 438 
 — alcoholic, 253 (case 60) 
 — faked, 308 (case 78) 
 — orderly diagnosis of, 445 
 — popular prejudice, 270 
 Mental hygiene, 161, 221, 272, 382, 
 
 438, 552 
 — aim of, 374 
 — of industry, 86, 498 
 — national committee for, 372, 521 
 Mental hygiene aide, 559 
 Mental hygiene movement, 521 
 Mental hygiene program, 552 
 Mental rating, 86 (case 11) 
 
 Mental sciences, 368 
 
 Mental tests, 182, 219, 449 
 
 — conditions favorable for, 219 
 
 — impulsive answers, 299 (case 74) 
 
 —irregularity in, 155, 178, 262, 
 (case 62) ; 276 (case 66) 
 
 — limitations of, 220. See also 
 Psychological tests ; Psycho- 
 metric tests 
 
 Milk and Baby Hygiene Associa- 
 tion, 121 
 
 Money raised, 152 
 
 IMonomania, 486 
 
 ]\Iontesquieu, 404 
 
 Montessori, Madam, 504, 551 
 
 Moral, 22 (case 4) ; 249 (case 58) ; 
 357 (case 97) 
 
 — definition of, 14 (case 2) 
 
 Moral defect, 390 
 
 "Moral insanity," 60 (case 8) 
 
 Moral problems, 407 
 
 Moral training, 399 
 
 Moral trouble, 395 
 
 Morals, 512 
 
 Morbi, definition of, 411 
 
 Moron, 172, (case 32) ; 219 (case 
 47) ; 232 (case 50) ; 262 (case 
 62) ; 463, 503 
 
 Morphinism, 267 (case 63) ; 471, 
 472 
 
 Multiplication of evils, 542 
 
 Multiplication vs. summation, 422 
 
 Murder, 238 
 
 — story of seeing, 268 
 
 National Conference of Social 
 Work, 519, 522, 554, 555 
 
 National Research Council, 399 
 
 Navy, 232, 359 
 
 Neglected child, 167 (case 31) 
 
 Nephritis, 359 (case 98) 
 
 Nervous breakdown, 5 (case i) ; 
 484 
 
 Neurasthenia, 5 (case i) ; 143 
 (case 25) :_203 (case 39) ; 483 
 
 Neurologist, clinical, 444 
 
 Neurones, 378 
 
 Neuropsychiatrist, 444, 552 
 
 Neurosyphilis, 203 (case 39); 455; 
 chart, pp. 453-455 
 
 — diffuse. See Syphilis, cere- 
 brospinal 
 
 — prognosis of, 458 
 
 New York School of Social Work, 
 556, 560 
 
704 
 
 INDEX 
 
 New York State Charities Aid 
 
 Association, 520, 526 
 Nietzsche, 425, 433 
 Non-support, 192 (case 27) 
 Nurse, 557 
 
 Observation, 544 
 
 — objective, 545 
 
 Occupation neurosis, 154 (case 27) 
 
 Occupational orbit, 38 
 
 Occupational therapy, 119, 149, 551 
 
 Occupations, classihcation of, 84 
 
 Old age, 472, 473 
 
 — psychoses of, 270 (case 64) 
 
 "On visit," 322 (case 84) 
 
 Order, 431 
 
 — social case analysis, 394, 402. 
 See also Mental disease, order- 
 ly diagnosis of 
 
 Organic, 42 (case 7) ; 447 
 
 Orthopedic, 36 (case 6) 442 
 
 Out-patient, 234; 317 (case 82); 
 328 (case 87); 352 (case 95) 
 
 Out-patient department, 161, 513 
 
 Out-patient service, 512 
 
 "Overt act," 52 (case 8) ; 150 (case 
 26) ; 316 (case 81) 
 
 Paranoia, 247 (case 58) ; 486 
 
 Paranoid, 488 
 
 "Paranoid condition," 307 (case 
 76) 
 
 Paraphrenia, 247 (case 58) ; 294 
 (case 72) ; 475 
 
 Parker, Carleton, 401 
 
 Pass system, 97 
 
 Pathological intoxication, 253 (case 
 60) 
 
 Pathological lying, 490 
 
 Patient's story, quoted, 323-325 
 
 Pennsylvania School for Social 
 Service, 556, 560 
 
 Penuriae, definition of, 415 
 
 "Perioganic," 43 (case 7) ; 114 
 (case 18) 
 
 Permanent Charity Fund, In- 
 corporated, 499 
 
 Personality of worker, 60 
 
 Philanthropist, 277 
 
 Philanthropy, 390 
 
 Philosophical idealism, 424 
 
 Physique, 349 (case 94) 
 
 Placed-out, 129 
 
 Placing-out, 96, 275 
 
 Police, 10 
 
 Political science, 369, 384 
 
 Politics, psychiatric analysis of, 435 
 Pound, Roscoe, 2>^, 385, 563 
 Poverty, 398 
 Practice work, with social cases, 
 
 S6i . 
 Pragmatic, 413 
 Prenatal care, 96 (case 12) ; 164 
 
 (case 30) 
 Preventive medicine, 373, 552 
 Prison psychosis, 486 
 Privacy, no (case 17) 
 "Private," 385, 386 
 Probation, 53 (case 8) ; 66 (case 
 
 9) _; 321 (case 84) 
 Probation system, 79 
 Professional attitude, 547 ' 
 Prognosis, 153 (case 27) ; 306 (case 
 
 75) 
 — persistent social problem, 275 
 
 (case 65) 
 Prohibition, 248, 269 
 Promiscuity, 57 (case 8) ; 70 (case 
 
 10) ; 156 (case 28) ; 353 (case 
 96) 
 
 Prostitute, 53 (case 8) ; 158 (case 
 
 28) ; 342 (case 92) ; 353 (case 
 
 96) 
 Prostitution, 449 
 
 Pseudo-hallucinations, 88 (case 12) 
 Psychasthenia, 339 (case 89) 
 Psychasthenic, 114 (case 18) ; 143 
 
 (case 25) ; 145 (case 25) ; 204 
 
 (case 39) ; 339 (case 89) ; 483 
 Psychiatric examination, 475 
 — negative values of, 222 
 Psychiatric point of view, 60, 79, 
 
 96, 375. 376, 466, 544 
 Psychiatric social cases, 375 
 Psychiatric social work, 23, 87, 90, 
 
 96, 195, 378, 379, 381, 518, S19. 
 
 521, 522, 543, 555 
 — chronology of, 520 
 Psychiatric, social worker, 39, 61, 
 
 116, 216, 223, 313, 350, 382, 503, 
 
 5 IS, 552, 556, 559 
 "Psychiatric touch," 235 (case 52) 
 Psychiatrist, 61, 222, 443, chart, p. 
 
 441 
 Psychiatry, 350, 371, 383, 437, 438, 
 
 443 
 — broad conception of, 446 
 — textbooks on, 445 
 Psychoanalysis, 516 
 Psychoanalyst, 12, 353 
 Psychoanalytic, 336 (case 88) ; 
 
 338 (case 89) 
 
INDEX 
 
 705 
 
 Psychogenic, 88 (case 12) ; 117 
 (case 19) ; 181 (case 34) 
 
 Psychological examination, 146 
 
 — by non-English norms, 147 
 
 Psychological examiner, 553 
 
 Psychological level, 147 
 
 Psychological tests, 84, iii. See 
 also Mental tests; Psycho- 
 metric tests 
 
 Psychologist, 222 
 
 — a scientific person, 553 
 
 — limitations re medical practice, 
 
 331 
 
 Psychology, 369 
 
 Psychometric rating, 118 
 
 Psychometric tests, 9, 65, 178, 220, 
 234, 285. See also Mental 
 tests ; Psychological tests 
 
 Psychoneuroses, 89 (case 12) ; 143 
 (case 25) ; 204 (case 39) ; 483 
 
 Psychoneurosis, 108 (case 16) ; 141 
 (case 24) ; 153 (case 27) ; 180 
 (case 34) ; 193 (case 37) ; 301 
 (case 75); 312 (case 81); 328 
 (case 87) ; 450 
 
 Psychoneurotic, 128 (case 21) ; 137 
 (case 24) ; 195 (case z?) ', 227 
 (case 48) 
 
 Psychopathia sexualis, 22 and 25 
 (case 4) ; 133 and 136 (case 
 ^2) ;.353 (case 96) ; 486, 490 
 
 — congenital, 137 (case 23) 
 
 Psychopathic, 6 (case i) ; 375 
 
 Psychopathic employee, 339 (case 
 
 89) ; 531 
 
 Psychopathic Hospital, 247 
 Psychopathic Hospital social serv- 
 ice, 520, 523, 524 
 Psychopathic husband, 162 (case 
 
 30) 
 
 Psychopathic personality, 8 (case 
 
 2) ; 20 (case 3) ; 24 (case 4) ; 
 
 29 (case 5) ; 30 (case 5) ; 69 
 
 (case 10) ; 122 (case 20) ; 134 
 
 ; 154 (case 28) ; 
 
 ; 189 (case 36) ; 
 
 235 (case 52) ; 
 
 273 (case 65) ; 
 
 347 (case 94) ; 
 
 362 (case 100) ; 
 
 (case 23) 
 
 (case 33) 
 
 (case 48) 
 
 (case 63) 
 
 (case 74) 
 
 (case 96) 
 
 472, 486, 489 
 Psychopathologist, 443 
 Psychopathology, 371, 443 
 Psychopaths, situations dominated 
 
 by, S40 
 Psychosis, acute, 159 (case 29) 
 
 177 
 224 
 267 
 299 
 
 354 
 420, 
 
 Psychosis of the deaf, 99 (case 
 
 14) 
 Psychotherapeutic methods, 143 
 Psychotherapy, 38, 60, 141, 180, 313, 
 
 328, 338, 364; chart, pp. 481, 
 
 484, 514, 515 
 Public, 385, 386, 387 
 Public agency, 229 
 Public care, 97, 106 
 Public charge, 53 (case 8) ; 234 
 
 (case 52) 
 Public education, 532 
 Public health, 272, 552, 558 
 Public health movement, 383 
 Public health nurse, 558 
 Punishment, 546 
 Putnam, James Jackson, 378, 520, 
 
 538 
 Pyorrhea, 263 (case 62) 
 Pyromania, 65 (case 9) 
 
 Quetelet, 376 
 
 Ralph, Georgia C, 534 
 Rationalization, 35, 38 (case 6) ; 
 
 145 (case 25) ; 338 (case 89) ; 
 
 364 (case loo) 
 Ray, Isaac, 554 
 Recidivism, 64 
 Recidivist, 233 (case 51) 
 Reconstruction, 370, 430 
 Red Cross, 493, 522 
 Reeducation, 413 
 Reformation, 413 
 Relation of patient to himself, 44 
 
 (case 7) 
 Relief, 518 _ 
 Religious views, 425 
 Research, 531, 536 
 Resourcelessness. See Penuriae. 
 
 definition of, 415 
 Responsibility, 26, 245, 412, 544 
 Results, summary of, 138-41 (case 
 
 24) ; 169-71 (case 31) 
 Richmond, Mary E., 375, 392, 422, 
 
 538, 540 
 Ross, E. A., 405, 498 
 Rousseau, 402 
 Royce, Josiah, 423, 521 
 Ryther, Margherita, 522 
 
 Sailor, 323, 341 
 
 St. Vincent de Paul, 517 
 
7o6 
 
 INDEX 
 
 Schizophrenia, lo (case 2) ; 108 
 
 (case 16) ; 293 (case 71) ; 301 
 
 (case 75); 313 (case 81); 361, 
 
 (case 100) ; 473 
 
 Schizophrenics, colonies for, 287 
 
 (case 70) 
 School, 322 
 
 School for feeble-minded, 230, 551 
 — waiting list, 221, 224 
 Schopenhauer, 433 
 Schwab and Fenton, 492 
 Seclusive, 108 
 Seguin, 504, 551 
 Self-reliance, advantage of counsel 
 
 vs. possibility of loss of, 341 
 Senile, 472 
 
 Senile dementia, 271 (case 64) 
 Senile psychosis, 279 (case 68) 
 Sense deprivation psychosis, 486 
 Sex experience, infantile, 17 (case 
 
 3) ; 336 (case 88) 
 Sex obsessions, 338 (case 89) ; 
 
 342 (case 91) 
 Sexual impotence, 262 (case 62) 
 Sheffield, Mrs. Ada E., 534 
 Shell-shock, 117 (case 19); 311 
 
 (case 80) ; 492 
 Shell-shock analogue, 42 (case 7) 
 Small, A. W., 404 
 Smith, Adam, 404 
 Smith College, 521, 556 
 Smith College Training School for 
 
 Social Work, 560 
 Sociability, 406 
 Social, 387 
 
 Social adjustment, 486 
 — specialist in, 370 
 Social agencies, 86, 93, i73. 229, 
 
 234. 356 
 — family known to, 24, 234 
 — variety of, 72 
 Social care, 215 
 Social case work, 381, 562 
 Social clinics, 533 
 Social diagnosis, 245 (case 58) ; 
 
 376, 538 
 Social examination, 525, 543 
 Social history. 146, 239, 447, 525 
 Social incurability, 74 (case 10) 
 Social justice, 277 
 Social medicine, 558 
 Social prognosis, 53 
 Social psychiatry, 193, 523, 562 
 Social records, 189, 389, 534, 536 
 Social Science Association, 554 
 Social service, 301 
 
 Social service, contributary to diag- 
 nosis, 294 
 
 — failure, 269 
 
 — function of, 524, 530 
 
 — organization of, 527 
 
 Social summary, 122, 174-176 
 
 Social supervision, 527 
 
 Social symptoms, -141, 193, 258 
 (case 61) ; 356, 528 
 
 Social treatment, 52, 164, 212, 228, 
 259, 304, 313, 318, 437, 525, 
 537. 538, 543 
 
 — record of, 99-102 (case 14) ; 112- 
 113 (case 17) 
 
 Social work, 379, 380, 438, 515, 524, 
 
 543. 553 
 —an art, 554 
 — empty formulae in, 421 
 — relation to medical work, 525 
 — theory of, 367 
 Social worker, 31, 40, 102, 176, 222, 
 
 . 330, 350, 370, 450, 464, 559 
 — limitations re medical practice, 
 
 331 
 — not religious?, 429 
 — practical, 425, 427 
 — splint to the will, 43 (case 7) 
 — task of, 239 
 
 Social workers, psychiatric instruc- 
 tion for, 350 
 — case familiar to, 350 
 Socialism, 435 
 Socialization, problem of, 108 (case 
 
 16) 
 Society, menace to, 52 
 Society for After-Care of Insane 
 
 in England, 520 
 Sociologist, 559 
 Sociology, 367, 369, 556, 558 
 Soldier, 215, 241, 306, 308, 310, 326, 
 
 342, 344 
 Solomon, Harry C, 154, 203, 205, 
 
 207, 216, 449, 455, 502 
 Solomon, Maida H., 502 
 Special class, 230 
 Spencer, Herbert, 368, 498 
 Spheres of influence, 2>7^, 385 
 "Splitting" of personality, 473 
 Spoiled child, 299 (case 74) 
 State care, 372. See also Public 
 
 care 
 State hospital, 122, 271, 299 
 State hospital vs. private boarding 
 
 place, 271 
 Stearns, A. Warren, 531 
 Street-walker, 355 (case q6) 
 
INDEX 
 
 707 
 
 Struggle for existence, 403 
 
 Stuckenburg, 405 
 
 Students, training of, 531 
 
 Sublimation, 108 
 
 Subnormal, 18 (case 3) ; 234 (case 
 
 52) ; 374, 463 
 Suicidal attempt, 99 ; 168 (case 
 
 31) ; 291 (case 71) ; 299 (case 
 
 74) ; 348 (case 94) 
 Suicidal intent, 134 
 Suicide, potentiality of, 479 
 — feigned, 154 
 Summands, 542 
 Summary, 537 
 
 Summary of results, 264-266 
 Summation of evils, 542 
 Summation vs. multiplication, 422 
 Supervision, medical and social, 
 
 293 
 
 "Symptom" catalogue, 258 
 
 Symptoms, 85, 451 
 
 Syphilis, 51 (case 8) ; 72 (case 
 10) ; 99 (case 14) ; 104 (case 
 15) ; 109 (case 17) ; 172 (case 
 31) ; 203 (case 39) ; 217 (case 
 45 ; 218 (case 46) ; 226 (case 
 48) ; 355 (case 96) ; 446, 
 530 
 
 — blood test for, family, 217 (case 
 
 45) 
 — cerebrospinal, 205 (case 40) ; 
 
 211 (case 42) ; 504 
 — congenital, 103 (case 15) ; 168 
 
 (case 31) ; 216 (case 45) 
 — familial, 207 (case 41) 
 • — routine examination of family, 
 
 207 (case 41) 
 — sustained treatment difficult, 212 
 
 (case 42) 
 — tests, 204 (case 39) 
 Syphilitic, 225 (case 48) 
 Syphilitic child, 51 (case 8) 
 Syphilitic parents, 348 (case 94) 
 Syphilitic taint, 227 (case 48) 
 
 Taboparesis, 215 (case 44) 
 
 Taft, Jessie, 556 
 
 Tarde, 498 
 
 Taussig, 380 
 
 Technique, 40, 96, 392, 401, 543, 
 
 562 _ 
 — of social virork, 61 
 Temperament, 511 
 Temperamental, 41 (case 6) ; 74 
 
 (case 10) 
 Temperamental deviations, 401 
 
 Temporary care, committed for, 
 
 160 (case 29) 
 Temporary care law, 41, 252, 256. 
 
 See Appendix C. 
 Therapy, importance of diagnosis 
 
 to, 364 (case 100) 
 — variety as, 349 
 Training, 397, 545 
 — through emotions, 545 
 Transfer, of case, 548 
 Transfers of control, 61 
 Traumatic defect, 231 (case 49) 
 Traumatic hysteria, 117 (case 19) ; 
 
 340 (case 90) ; 341 (case 91) ; 
 
 485 . 
 Traumatic neurosis, 86 (case 11) 
 Traumatic psychosis, 116 (case 19) 
 Treitschke, 433 
 Tremor, 343 (case 92) 
 "Truncate" deficiency, 96 (case 12) 
 Truncated hvpophrenia, 66 (case 
 
 9) 
 Tuberculosis, 358 (case 96) ; 359 
 
 (case 98) 
 
 Tufts, James H., 512 
 
 Vacation, 164 (case 30) 
 Vagrancy, 233 (case 51) ; 294 (case 
 
 72) 
 Valentine, Robert, 499 
 "Vasomotor neurosis," 117 (case 
 
 19) 
 
 Vice, 395 
 
 Visiting housekeeper, 121, 164 
 
 Vitia, definition of, 412 
 
 Voltaire, 425 
 
 Voluntary patient, 6 (case i) ; 83 
 (case 11); 113 (case 18); 142 
 (case 25) ; 179 (case 34) ; 279 
 (case 67) ; 300 (case 74) ; 337 
 (case 89) ; 513 
 
 Wanderer, 352 (case 95) 
 
 Wanderlust, 291 (case 71) 
 
 War, an evil, 430 
 
 Wayward child, 164 (case 31) 
 
 Welfare, 370 
 
 White Slave Traffic Commission of 
 
 Massachusetts, 450, 465 
 Will, lack of, 156. See also Aboulia 
 Williams, Frankwood E. See Ap- 
 pendix C 
 Willisen, 433 
 Wisdom, superficial, 419 
 "Wolf boys," 182 (case 35) 
 Work, interfered with, 267 
 
7o8 
 
 INDEX 
 
 Work, irregular, 155 (case 28) ; 160 
 (case 29) ; 190 (case 36) ; 308 
 (case 78) ; 342 (case 92) ; 352 
 (case 95) 
 
 World War, 67. See also Great War 
 
 Worry, 195 (case 38) 
 — financial, 297 (case 73) 
 
 X-Ray, 242 (case 57) ; 344 
 
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