THE UNIVERSITY OF ILLINOIS LIBRARY ^icawrc*^ Return this 'book on or before the Latest Date stamped below. A charge is made on all overdue books. University of Illinois Library SEP 20 18^^5 JU -3 19S2 m 2 2C0* 27214 SOCIAL ASPECTS OF THE TREATMENT OF THE INSANE Based on a Study of New York Experience JACOB A. GOLDBERG, A. M. SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN THE Faculty of Political Science Columbia University NEW YORK I92I So My Teachers and Friends STEPHEN S. WISE AND SIDNEY E. GOLDSTEIN <^ -ili^GSGG PREFACE The aim in writing this volume was to supply a needed source to which the layman, the social worker, the general practitioner, and others could refer when considering mat- ters pertaining to the treatment of the insane. Many books have been written on various phases of the problem, but, no one of these books answers the purpose in mind. When the writer first became interested in mental hygiene activi- ties, he sought in vain for any one volume or even for several which would give him a comprehensive understand- ing of the questions involved in caring for and treating the insane. The facts and their interpretations, as presented in the following pages, are the result of several years of active and intensive work and study of matters relating to the in- sane. The reason so much emphasis has been placed upon insanity among the Jews is that the material available to the writer dealt largely with this group. In making a study of this kind, the cooperation of many persons is necessary. The thanks of the writer are ex- tended to Dr. M. B. Heyman, Supt. of Manhattan State Hospital, and to Dr. G. A. Smith, Supt. of Central Islip State Hospital, for permission to consult records in their files ; and to Dr. M. S. Gregory, Director Psychopathic Ser- vice, Bellevue Hospital, for similar cooperation. For many valuable suggestions I am indebted, among others, to Drs. J. Smith and M. M. Sherman, psychiatrists of the Free Synagogue Mental Hygiene Clinics; tO' Dr. A. A. Brill, Dr. Bernard Glueck, Dr. H. M. Pollock, Mr. G. H. Hastings, 149] 7 8 PREFACE [150 and particularly to Profs. Franklin H. Giddings and Henry R, Seager. I am above all indebted to Prof. Samuel McCune Lindsay, who has been my guide and friend during the years I have studied at Columbia University, and to Dr. Sidney E. Gold- stein, teacher and friend for many years. Jacob A. Goldberg Columbia University, Jan. 21, 1921. TABLE OF CONTENTS PAGE CHAPTER I History of New York's Policy of Caring for the Insane Introduction 15 Care and Treatment under Commonwealth of New York, 1777 to 1827 16 1830 to 1873 ig 1873 to 1888 26 County Care of Insane • . . 28 State Care, 1889 to 1920 , 30 Reception or Psychopathic Hospitals 38 Hospital Development Commission 44 CHAPTER II Insanity as a Community Problem Cases Studied 48 Incidence of Insanity among Jews 48 In European Countries 48 Insanity in Rural and Urban Districts 50 Jewish Insane in New York City 52 Methods of Committing Patients to State Hospitals 54 Legal Provisions for Commitment 54 Social Workers and Commitment of Patients 57 The Police and Mental Cases 58 Definition of the term "Insanity" 60 Causes of Insanity 62 Heredity 63 Alcohol 66 Syphilis 68 Injuries and Other Causes 69 Contributing Causes 69 Classification of Mental Diseases 69 Marital Condition of Admissions to Bellevue Hospital, Psychopathic Wards 94 Nativity 96 Age Distribution 98 Deportation of Immigrant Insane 99 151] 9 10 TABLE OF CONTENTS [152 PAGE Years Resident in United States loi New Immigration Law and Insanity loi Disposition of Patients 103 Mental Examination of Prisoners 106 Mental Deficiency Law 107 Discharges from Psychopathic Wards 108 Deaths in Psychopathic Wards 109 Summary no CHAPTER III Results of State Hospital Care and Treatment Need and Provisions for Scientific Study of Insanity in Overcrowding in State Hospitals 114 Extension of Observation Period I IS Private Sanatoria and Hospitals 119 Classification of Patients at State Hospitals 120 Occupational Therapy at State Hospitals 121 Readmissions to State Hospitals 126 High Readmission Rates among Jewish Patients 128 Reasons for High Readmission Rates . 130 Movemtnts for Establishment of Jewish Psychopathic Hospitals . 132 Diagnosis of Admissions to State Hospitals 133 Result of One Year of State Hospital Care 134 Follow-up Work in New York City I37 Need for This Form of Service 137 Extent of Follow-up Work in New York 138 Need for Follow-up of Jewish Patients 139 Deaths in State Hospitals 140 Death Rate of Jewish Patients 140 Reasons for Increasing Death Rates 141 Length of Stay in the Hospitals 143 CHAPTER IV A Social Survbv of 786 Admissions to State Hospitals Introduction ^49 The Family of the Insane Patient 150 Single Persons, without Dependents, in State Hospitals, for One Year ^5i Value of Visits to Patients IS3 Attitude of Patients' Relatives toward State Hospitals IS4 Married, Widowed, and Divorced Persons, without Dependents, Remaining in State Hospitals ISS Social Status of Patients who Died in State Hospitals 155 153] TABLE OF CONTENTS II PAGE Single 156 Married 157 Status of Family Following Death of Husband 158 Status of Family Following Death of Wife 159 Social Problems Following Death of Married Patients 160 Death of Aged Married Men 161 Care of Dependent Widows and Orphans 161 Family Problems Following Death of Mothers 165 Widowed 167 Divorced 168 Modification of Marriage and Divorce Laws 168 Parole System of State Hospitals 169 Development of Out-Patient Departments 169 Extent and Effectiveness of Parole System 170 Paroled and Discharged Patients 173 Details of Survey Form 174 Survey of Paroled and Discharged Patients 177 Mental Condition 178 Physical Condition l8o Social Condition 182 Employment of Paroled Patients 182 Financial Relief to Families of Patients 184 Dependent Children Committed to Orphan Asylums 185 Recreational Opportunities 186 CHAPTER V Social Trbatmekt of the Insane Introduction 188 Development of Mental Hygiene Movement 189 Organization and Development of a Mental Hygiene Agency . . 191 Activities of a Mental Hygiene Agency 193 Typical Cases of a Mental Hygiene Agency 195 Cases Studied 196 Manic Depressive Insanity 196 Dementia Praecox 205 Paranoid Condition 214 General Paralysis 219 Arteriosclerosis 220 Mental Deficiency 220 Hysteria 221 Constitutional Psychopathic Inferiority 223 Total Presentation of Twenty-Five Typical Cases 226 12 TABLE OF CONTENTS [154 PAGE CHAPTER VI Recommendations and Conclusion Shortcomings of Social Service 228 Need of a Newer Method of Approach to Problem 229 Mental Hygiene and Childhood 230 Mental Hygiene and Adolescence 232 Mental Hygiene Needs of a Community 235 Mental Hygiene Agencies 236 Convalescent Homes 236 Clinics 236 Workshop for Mental Hygiene Patients 237 Psychopathic Hospital 239 Conclusion 240 LIST OF TABLES FAGB 1. Total Admissions to Psychopathic Wards, New York City . . 54 2. Number of Cases of Alcoholic Insanity 67 3. Psychoses of Admissions 71 4. Age Distribution : General Paralysis 75 5. Disposition of Manic Depressive Insanity Patients 83 6. Age Distribution of Manic Depressive Insanity Patients ... 84 7. Disposition of Cases of Dementia Praecox 88 8. Age Distribution of Dementia Praecox Patients 88 9. Number of Admissions to Bellevue Hospital, Psychopathic Wards 93 10. Marital Condition 95 11. Nativity 97 12. Age Distribution 99 13. Years in United States loi 14. Disposition of Patients 104 15. Diagnosis of Prisoners 106 16. Diagnosis of Discharges 109 17. Diagnosis of Deaths no 18. Overcrowding in the State Hospitals 114 19. Number of Days Spent in Psychopathic Wards of Bellevue Hos- pital Prior to Commitment to State Hospital 117 20. Occupations of Males 123 21. Occupations of Females 124 22. Number of Readmissions to State Hospitals 127 23. Distribution of Certain Psychoses Among Readmissions . . . 129 24. Disposition of Patients by State Hospitals 134 35. Rate of Recovery and Improvement of Patients 135 26. Diagnosis of Patients who Died in State Hospitals 143 27. Duration of Hospital Life of Recovered Cases 144 28. Duration of Hospital Life of Improved and Much Improved Cases 145 29. Duration of Hospital Life of Patients Dying in State Hospitals 147 155] 13 CHAPTER I History of New York's Policy' of Caring for THE Insane I. INTRODUCTION The gradual process of evolution in methods of caring for the insane may be roughly divided into four periods,^ viz : 1. The era of demoniacal exorcism, or of revenge. 2. The chain and dungeon period, or of indifference. 3. The era of asylums for the insane, or of humanitarian- ism and empirical treatment. 4. The era of hospitals planned and organized to meet the needs of the various classes of the insane, including psychopathic hospitals for the acutely insane in cities, and colonies for the chronic and mixed classes of in- sane in the country; or of scientific study, rational treatment and preventive medicine.^ These periods, while distinct in their outline, have not shown any sudden 'break of continuity in the transition from one period to the other. It is difficult, therefore, to fix the time limits of these eras by centuries, and yet we may ap- proximate an historical sequence by assigning the era of demoniacal exorcism to the Middle Ages, the chain and dun- geon era to the 17th and 18th centuries-, and the era of special asylums to the 19th century, while we reserve for the 1 Peterson, Frederick, American Journal of Insanity, vol. Iviii, Nov. 3, 1902, p. 405. ' Van Gieson, Ira, National Conference of Charities and Correction, jgoi, " Public Policy in the Care of the Insane," p. 161. 157I ^5 l6 SOCIAL ASPECTS OF TREATMENT OF INSANE [158 20th century the distinction of introducing more generally into modern civilization the methods of care and treatment based upon scientific study, rational treatment and, above all, preventive medicine. The aim of this study being limited to a consideration of the genesis and development of methods in the social care and treatment of the insane in New York State, and of the social aspects of the problem, it is obvious that a discussion of the era of revenge and of the chain and dungeon period would be largely out of place. II. CARE AND TREATMENT (a) Under Commonwealth of New York, 1777-1821. The first public hospital or asylum in the State of New York, in which the insane received special medical treat- ment, was the New York City Hospital. This institution was incorporated by royal charter bearing date June 13, 1771,^ and a building in pursuance of its objects was begun in 1773, which, unfortunately, was destroyed by fire before completion. The intervention of the Revolutionary War, bringing with it financial embarrassments, delayed the prog- ress O'f the work of contruction, so that, despite pecuniary aid received from the colonial legislature, the edifice was not opened until January, 1791. It was then opened as a general hospital, receiving all cases of disease indiscrimin- ately, and in this way cases of insanity gradually found their way into it.^ The exact date of the reception of the first case cannot be ascertained, although two are reported as admitted in May, 1797.^ Hitherto the insane had been * Peterson, Arthur E., anid Edwards, Geo. W., New York as an Eighteenth Century Municipality, p. 301. * Ordronaux, John, Lunacy Laws of New York, p. 199. * Earle, Pliny, History of the Bloomingdale Asylum for the Insane, 1848, p. 8. 159] HISTORY OF NEW YORK'S POLICY 17 legally classified among disorderly persons/ and were to be disposed of according to the pleasure of the magistrates be- fore whom they were brought, either by being confined, or if strangers, returned to their last legal place of settlement. Meanwhile, as the insane had greatly multiplied in num- bers, and formed an exceptional class whose condition re- quired for its successful treatment such space and isolation as could not be obtained in a general hospital, the governors of the New York Hospital applied to the legislattlre for assistance to enable them to build a separate structure for this class of patients. This was granted themi in i8o6,' through the enactment of " An Act for the 'better and more permanent support of the hospital in the City of New York." It provided that the State of New York should ap- propriate the sum of $12,500 annually for a period of fifty years as a subsidy to the hospital. The new structure was opened in July, 1808.^ No requirements were stipulated at this time as to the admission of insane patients, but in 1809 a law was passed, granting authority to the overseers of the poor of any city or town in the state to contract with the governors of the New York Hospital for the mainten- ance and care of any lunatics chargeable to such city or town.* This act was the initial step taken by the legislature in the recognition of the insane as a special class of diseased persons, requiring medical care and treatment in institutions of a definite character. It also established the principle of its judicial custody over them as wards, to be protected and supervised in their persons as well as in their estates through the agency of its courts and appointed officers. At this period there was no institution to which the * Laws of 1788, chap. 31. ' Laws of 1806, chap. 54. ^ Ordronaux, op. cit., p. 200. * Laws of 1809, chap. 90, sec. 3. 1 8 SOCIAL ASPECTS OF TREA TMENT OF INSANE [ 1 60 criminal insane could be sent, and two cases arose requiring the action of the legislature, the governor not being at that time empowered to grant pardons in such cases. In 1799 one John Pastano was convicted of murder and sen- tenced to be executed. It transpired that the man was in- sane. An appeal was made to the legislature to save him and a law was passed pardoning him, on condition that he be kept in prison until he could be returned to his place of legal residence.^ A similar case arose again in 181 6 and was disposed of in the same way, except that arrangements were to be made by the friends or relatives for care in some " lunatic hospital or asylum." ^ In 181 6 the society of the New York Hospital was again given authority by law to erect a new building. This was opened for use June, 1821, as the Bloomingdale Asylum for the accommodation of in- sane persons, and received a further annuity of $10,000, to be continued like the other to 1866.^ There was no further legislation dealing with the com- mitment and care of the insane until 1827, when a law was passed bearing upon the proper provision for the custody of insane persons in jails, and the responsibility of the next of kin to care for or make proper provision for the care of insane persons.* It might be well to note at this point that ^ Laws of 1800, chap. 3, entitled "An Act to pardon John Pastano for murder." ^ Laws of 1816, chap, 4. 3 Ibid., chap. 203. * Laws of 1827, chap. 294, entitled An Art concerning Lunatics. Sees.. 2, 3 and 4 recite that " no lunatic shall be confined' in any prison, gaol or house of correction, or Ibe confined in the same room with any person charged with, or convicted of, any criminal offense. But he shall be sent to the asylum in New York, or to the County poor-house or almshouse, or other place provided for the reception of lunatics by the county superintendents." Sec. 5 recites that it shall be the duty of the parents or relatives of any lunatic, if able, to support him in such asylum. l6l] HISTORY OF NEW YORK'S POLICY jg during the first half-century of the existence of the com- monwealth, viz., from 1777 to the passage of the above law in 1827, the insane were treated as dangerous persons, and the policy was to protect society against their acts of violence by arresting and incarcerating them in jails and prisons with criminals/ For nearly twenty years, viz., from 1808 to 1827, the State of Nev^r York confined its insane in jails, where they were still treated as criminals and were gienerally chained, as directed by the law of 1788;" in the poor- houses or almshouses, where the chronic insane congregated and were subjected to every possible degree of cruelty and neglect; and in the asylum of the New York Hospital, where they were treated in the most humane manner, by the best class of officers and attendants.^ It was during the next half century, from 1827 tO' 1877, that the policy of the state was steadily in the direction of improving the public care of the insane, and especially of insane poor. (b) iSjo-iS/j. There was a great want felt at this time for state asylums for the insane. The population of the state had grown to almost 2,000,000 and there were as yet no special facilities provided by the state or county authorities for the care of the insane, other than what has been alluded to in regard to the New York Hospital. The need had become so great that Gov. Throop, in his annual message to the legislature of January, 1830, called its atten- tion to the uncared-for condition of the poor and indigent insane. He referred to the privations and neglect to which these persons were subjected under poor-house regulations, and remarked that " no restoration can be hoped for under such circumstances." * Moved by these unanswerable * American Journal of Insanity, July, 1883, pp. 50-51. * Laws of 1788, chap. 31, sec. 6. * Ani^r. Jour, of In^., July, 1886, pp. 61-62. * Assembly Document no. 2, Jan. 7, 1830. [ 20 SOCIAL ASPECTS OF TREATMENT OF INSANE [162 arguments in favor of state intervention, the assembly shortly thereafter adopted a resolution that " the standing committee on charitable institutions do inquire into the pro- priety of making further provision for ameliorating the con- dition of the insane poor." ^ Upon the recommendation of this committee, there was appointed a special committee to investigate the manner in w^hich the hospital in the city of New York and the asylums connected with it, had disbursed the funds received from the state, and to inquire into the necessity of erecting a new establishmient.^ The report of this special committee made March 10, 1831,^ dealt with the causation of insanity, its status in this and other countries, the needs of the insane in the state, and the duty of the state toward them. According to this re- port, there were at that time (1830) 2,695 insane persons, with but one incorporated asylum at Bloomingdale, contain- ing provision for about 200 patients, and one private asylum at Hudson with accommodations for 50 patients. It was optional for the Bloomingdale Asylum under the law of March 24, 1807, to accept pauper patients, and for this reason there was no provision whatever in the state for the comfortable support and proper treatment of the insane poor. During the session of 183 1 a special legislative committee was again appointed upon this subject and a report sub- mitted; but no legislative action was taken. In the same session (1831) Dr. Samuel White, superintendent of the Hudson Lunatic Asylum, applied for a subsidy in aid of his institution.* A special committee on Lunacy Legislation spoke very highly of the Hudson Asylum, and recommended * Assembly Journal, Jan. 29, 1830. * Assembly Document no. 408, April 14, 1830. 3 Ibid., 263, March 10, 1831. * Ibid., 305, April 4, 1831. 163] HISTORY OF NEW YORK'S POLICY 2 1 that county authorities make contracts with Dr. White for the care of the insane but did not advise any subsidy on the part of the state/ In 1832 Gov. Throop in his annual message again reverted to the condition of the pauper insane as one calling for state intervention.- A special comlmiittee was again appointed and reported in favor of making state provision for the in- sane.^ However, no action was taken before the legislature adjourned. In January 1834, Gov. Marcy recalled the matter to the notice of the legislature.* A special committee was again appointed; belief in state provision for the insane was reaffirmed, but no legislation followed.^ In 1835 the same program was essentially repeated, with the same result.^ No action was taken by the legislature to mitigate the existing evils until 1836, when an act was pas- sed authorizing the establishment of the State Lunatic Asylum at Utica.^ This came about at this time largely as a result of a memorial presented toi the legislature by the State Medical Society, asking for the erection of a suitable state asylum for the insane.® The asylum at Utica was opened in 1843 s-'^d was to provide for the transfer of the most suitable cases from the county poor-houses. In 1850 the law governing admission tO' the State Lunatic Asylum 1 Assembly Document 305, April i, 1831. * Ibid., 2, Jan. 3, 1832. ''Ibid., 174, Feb. 28, 1832. *Ibid., 3, Jan. 7, 1834. ^ Ibid., 347, March 29, 1834. ^ Ibid., 167, Jan. 31, 1835. ''Laws of 1836, chap. 82, entitled An Act to authorize the establish- ment of the New York State Lunatic Asylum. * 2Slh Annual Report, Managers of State Lunatic Asylum at Utica, 1867, pp. 50-51. 22 SOCIAL ASPECTS OF TREATMENT OF INSANE [164 was amended so as to restrict the selection of cases, by pro- viding that *' no person in indigent circumstances, not a pauper, shall be admitted into the asylum, unless such per- son shall have become insane within one year next preced- ing such admission, and county judge must take proof of same." ^ County judges had the power to send indigent insane persons brought before them either to the county poor-house or the State Asylum, as in their judgment might be for the l>est interests of all concerned. The county superintendents of the poor committed the pauper class. It was not until 1848 that provision was made for insane criminals, when an act to amend the law regulating county and state prisons was passed, providing that whenever any convict became insane, he was, after examination by the prison inspector, to be transferred to the Utica Asylum. - If at the expiration of his sentence he was still insane, the superintendent of the asylum might return him to the charge of the superintendent of the county whence he came. As a result of the steady increase in the number of insane dis- covered among criminals in the prisons,^ and of the impos- sibility of affording them suitable treatment in the hospitals attached to such institutions, further legislation was enacted in 1855. This represented the first effort toward a more systematic classification of the insane, and toward the es- tablishment of a distinction between criminals and non- criminals in relation to their detention in asylums.* It being found impracticable to carry this project into operation, and as nothing short of a separate institution would suffice for the contemplated purposes, the legislature ' Laws of 1850, chap. 282, sec. 2. * Lazvs of 1848, chap. 294, sec. 96. ^ Ordronaux, op. cit., p. 29. *Laws of 1855, chap. 456, entitled An Act to Provide for Insane Criminals. 165] HISTORY OF NEW YORK'S POLICY 23 passed an act organizing a special asylum in 1858/ The institution thus erected at Auburn for the care of insane con- victs provided accommodations for all the criminal insane of the state until 1892, when the Matteawan institution wasi opened at Fishkill-on-the-Hudson (now Beacon). Reference should be made to the care of the insane in the metropolitan district — the counties of New York and Kings — where the insane in custody of the poor authorities, increased to such an extent that the almshouse and its at- tached hospital, both situated on the grounds of the present Bellevue Hospital, were unable to care properly for those under their care. It was not until 1839, when the insane asylum on Blackwell's Island was opened, that any relief was afforded. This was the first institution of its kind erected by the County of New York, and on June 10, 1839, 197 insane persons were removed to it from the almshouse and hospital." From) time to time additions were made to the Blackwell's Island institution until 1869, when the* authorities sought permission from the legislature to issue bonds for the purpose of laising funds to construct a new insane asylum on Ward's Island.^ This permission was granted and the new institution was opened in 1871 for male patients removed from Blackwell's Island, the latter being retained for women. Pauper lunatics in Kings County, as in other counties, had been kept in the poor-house asylum on the county farm at Flatbush. In 1844 the need of better accommodations for ^ Latvs of 1858, chap. 130, entitled An Act to Organize the State Lunatic Asylum for Insane Convicts, sec. i providing that " The build- ing now being erected on the prison grounds at Auburn shall be known and designated as the State Lunatic Asylum for Insane Convicts." *Oirdronaux, op. cit., pp. 202-203. ' Laws of 1869, chap. 56, sec. i. 24 SOCIAL ASPECTS OF TREA TMENT OF INSANE [ 1 66 this increasing class led to the passage of a law ^ which authorized the county treasurer to raise funds to erect a new insane asylum at Flatbush. The need of additional ac- commodations led to further enabling legislation in 1851,^ 1853,^ 1855/ 1860,^ and 1867.® Accommodations were thus provided for about 600 patients. Like New York and Kings, Monroe County was author- ized in 1863 to provide for all its dependent insane and construct a separate and distinct institution from that of the county poor-house, to be known as the Monroe County Asylum at Rochester/ Of the other coimties in the state, not one made adequate provision for their own insane. There was an increasing disposition on the part of the coun- ties to resume the care of their chronic insane, in many instances, an assumption also of the right of treating acute cases of insanity. This was done by coimty ofHcers who, on the plea of economy, evaded the law relating to the speedy commitment of recent cases to state asylums, and thus con- verted the poor-house asylums into- institutions for the insane.* Despite the establishment of the State Asylum at Utica, the number of insane in almshouses increased steadily, due to the rapid increase in the population of the state. In 1855 the county superintendents of the poor held a convention at the Utica State Asylum in order tO' consider what action they should take to remedy the difficulties they were having in providing for their insane. Their recommendations were ^ Laivs of 1844, chap. 203. * Lazi's of 1851, chap. 351. ^ Laws of 1853, chap. 255. * Laws of 1855, chap. 92. ^ Laivs of i860, chap. 221. * Laws of 1867, chap. 546. ' Laivs of 1863, chap. 82, sees. 1-9 inc. * Ordronaux, op. cist., p. 215. 167] HISTORY OF NEW YORK'S POLICY 2$ that two additional state institutions should be contructed. At the following session of the legislature a bill was in- troduced creating two more asylums; it was favorably re- ported, but the premature adjournment of the legislature arrested its further progress/ At last, mainly through the efforts of Miss Dorothea L. Dix and Dr. Sylvester D. Wil- lard, secretary of the State Medical Society, the legislature in 1864 authorized an investigation by Dr. Willard of the condition of the insane in the state." The report was sub- mitted to the legislature in 1865 and dealt at some length with the appalling condition of the insane in the county in- stitutions, and the crowded condition of the state asylum.^ The result of the report was the establishment of the Willard Asylum for the insane poor O'f the chronic classes,* and the further provision that acute cases were to be sent tO' the Utica State Hospital. After the completion of the Willard Asylum no more chronic cases were to- be sent to the county poor-houses from the Utica institution, but tO' the Willard Asylum instead. The creation of the distinction between acute and chronic cases persisted until it was finally abolished by the State Care Act of 1890. Further steps leading to the establishment of other asylums were being taken, and in 1867 a law was passed authorizing the establishment of the Hudson River Asylum at Poughkeepsie.^ This institution was opened in 1871 for the reception of the so-called acute cases. In 1870 a law ' Hiird, Henry W., Instilutional Care of the Insane, vol. iii, p. no. ' Lazvs of 1864, chap. 418, entitled An Act in relation to insane per- sons in poor-houses, insane asylums and other institutions in the State of New York, the purpose of which was to obtain statistics of the insane. ^Assembly Doc, vol. xix, Session of 1865. * Laws of 1865, chap. 342. s Laws of 1867, chap. 93. 26 SOCIAL ASPECTS OF TREATMENT OF INSANE [i68 was passed establishing a homeopathic asylum at Middle- town, New York/ this being the first attempt in the United States to establish such a hospital. It was erected with the aid of private contributions, and received its first patients in 1874. An act to establish the Buffalo State Asylum for the Insane was passed in April, 1870." This institution was of- ficially opened in November, 1880. (c) 181^-1888. A turning point in the history of lunacy affairs in New York came as the result of the passage of a law in 1873, whereby the office of the State Commissioner in Lunacy was created.^ This law also required that private asylums be licensed.* It was the duty of the Commissioner in Lunacy to examine into the condition of the insane and idiotic, the management and conduct of the asylums and other institutions for their custody,^ and to submit a report to the State Board of Charities. Chapter 571, Laws of 1873, was found to impose ex- ceedingly cumbrous and confused powers upon the Com- missioner in Lunacy. Among other things, although he was a state official, instead of reporting his official acts to the legislature, he was required to render a report to the State Board of Charities, at whose direction only such re- ports could reach the law-making power. Furthermore, in * Laws of 1870, chap. 474. ^ Ibid., cihap. 378. * Laws of 1873, chap. 571, entitled An Act further to define the powers and duties of the Board of State Commissioners of Public Charities, and to change the name of the Board io the State Board of Charities. Sec. 13 created the oflfke of State Commissioner in Lunacy. John Ordronaux, LL.D., professor of medical jurisprudence in the Law School of Columbia College, was appointed to the office. ^ Laws of 1873, chap. 571, sec. 9, requiring that private asylums be licensed by the newly created State Board of Charities. '" Lazvs of 1873, chap. 571, sec. 14. 169] HISTORY OF NEW YORK'S POLICY 27 spite of the fact that the office had been estabhshed to dis- cover and redress wrongs committed in asylums, no method was provided to do this, as reports had to be submitted, as above noted in a round-about and time-consuming manner. These facts soon became so obvious that the next legislature radically altered the powers and duties of the Commissioner in Lunacy.^ This was done by the enactment of a law in 1874,^ based upon recommendations made by the Commis- sioner in Lunacy, John Ordronaux, and the Attorney- General, Daniel Pratt." Section i of this law provided that no person should be committed to or confined as a patient in any asylum public or private, or in any institution, home or retreat for the care and treatment of the insane, except upon the certificate of two physicians, under oath, setting forth the insanity of such person. But no person should be held in confinement in any such asylum for more than five days, unless within that time such certificate be approved by the judge or justice of a court of record of the county or district in which the alleged lunatic resides; and said judge or justice may in- stitute inquiry and take proofs as to any alleged lunacy, before approving or disapproving of such certificate, and may, in his discretion, call a jury in each case to determine the question of lunacy. Section 2 required that " the examining physicians be of re- putable character, graduates of some incorporated medical college, permanent residents of the state and engaged in the actual practice of their profession for at least three years," and such qualifications had to be certified to by a judge of a court of record. Section 3 prohibited any physicians from certifying to the insanity of any person for the purpose of ^ Laws of 1874, chap. 446. * Ibid. ' Report on a codification of the Laws relating to the Insane, with proposed amendments thereto, Senate Doc. 86, Session 1874. 2S SOCIAL ASPECTS OF TREATMENT OF INSANE [170 committing him to an asylum of which the said physician was either superintendent, proprietor, an officer, or a regular professional attendant therein. Previously, county judges or superintendents of the poor had committed patients without the certificates of physi- cians, and up to this time legislation had been considered chiefly with a view to protecting the public against danger- ous persons. In order that the Commissioner in Lunacy might have proper assistance when making any investigation intoi the general management and administration of any asylum, public or private, in which insane persons were detained, a law was passed in 1878,^ providing that " whenever he shall undertake any such investigation, he shall give due notice thereof to the district attorney of the county in which the in- stitution is located, and that it shall be the duty of such dis- trict attorney to appear at such investigation in behalf of the people." On May 13, 1879, a law was passed abolishing the New York State Inebriate Asylum and converting it into the Binghamton Asylum for the Chronic Insane." The latter was opened for the reception of patients of the chronic pauper class from poor-houses in October. 1881. There was no further legislation of imlj>ortance until 1887 ^ when the St. Lawrence State Asylum at Ogdensburg was estab- lished. This institution was opened to receive patients in 1890. III. COUNTY CARE OF INSANE There were at this time seven state and three county asylums for the insane.* Despite this fact, the number of * Laivs of 1878, chap. 47, sec. 2. * Laws of 1879, chap. 280. ' Laws of 1887, chap. 375. * State Commissioner in Lunacy, Annual Report, 1888, p. 99. lyij HISTORY OF NEW YORK'S POLICY 29 insane in almshouses was still as great as in 1869, when the Willard Asylum was opened. The growth of the general population of the state, which in 1890 reached almost 6,000,000/ was so great that the state institutions were in- adequate to meet the demands made upon them. In the meantime the movement on the part of the county authori- ties, which had begun in 1871," for exemption from sending chronic cases to the state institutions, was gradually ex- tended until in 1887 there were 19 counties legally author- ized to maintain this class of dependents. A further indication of the pressure brought to bear to bring about the extension of the system of county care of the insane, was the Act passed in 1888 providing for the support, con- trol and management of the chronic insane in Erie County, through the establishment of a county institution. ' However, objections to the county system were numerous and of great weight. Its greatest fault was the fact that there was no uniformity in the care bestowed upon patients, nor was there any standard of care. Each county asylum was managed by local men, generally without experience or adequate training and with only a limited knowledge of the requirements of such an institution. The asyhims were not under the control of medical men and their management was apt to be governed by considerations of economy rather than of humanity. In consequence of these conditions, as many systems of maiiagiament were evolved as there were * U. S. Census. * Laws of 1871, chap. 713, entitled An Act in relation ersons pending examination as to their in- sanity, to be known as receiving pavilions." ^ No action was taken at this time nor for some years thereafter. It was not until 1900 that a definite recommendation for the erection of a reception hospital was made by the State Charities Aid Association." The plan advocated provided for the accommodation of 600 patients by the erection, in several of the largest cities of the state, of comparatively small reception or psychopathic hospitals as branches of the existing state hospitals. These new institutions were to be designed for the reception and temporary treatment of in- sane patients. The reception hospital for New York City was to be a branch of the Manhattan State Hospital and iake the place of the wards for the insane at Bellevue. Furthermore, the thought was that these newer and better equipped institutions should be prepared to care for (i) excited cases, (2) restless and suicidal cases, (3) quiet cases, (4) private or paying patients. ^^ The State Co-m- mission in Lunacy estimated in 1901 that such a hospital on Manhattan Island should accommodate from 100 to 200 ^ State Com. in Lunacy, Annual Report, 1891, p. 529. 'State Com. in Lunacy, Annual Report, 1900; Report of State Char- ities Aid Association, p. 1054. ' Peterson, Frederick, " New Paths is Psychiatry," Phila. Medical Journal, June 11, 1898; "A Visit to the Newest Psychopathic Hos- pital," Medical News, Jan. 20, 1900; "Some of the PTX)blems of the Alienist," American Journal of Ins., vol. Ivi, no. i, 1899. 40 SOCIAL ASPECTS OF TREATMENT OF INSANE [182 patients, and a similar one in Brooklyn from 50 to 100 patients/ It is quite obvious that because of the large increase in the population of Greater New York ajid the state as a whole, these estimates would now be too low. Reception hospitals in the United States have been in operation for a number of years in Boston, Baltimore, and Ann Arbor, as well as in Albany, as a part of the general hospital.- For smaller cities and towns, these reception or psychopathic hospitals may properly become wards of a general hospital. In a large city like New York, however, with its hundreds of admissions to state hospitals every year, a special institution would have to be created. It is self-evident that the mentally sick should be per- mitted the same rights of treatment for their various illnes- ses as the physically sick, that they should be accorded the same consideration, and that the hospitals of the several cities should be prepared to receive, care for, and intelligently treat them. This means that somewhere in a city there should be wards specially designed and maintained for the receipt, care and treatment, of patients suffering from mental diseases.^ Such wards or hospitals, adequately equipped and properly officered, with organic connections with a large municipal or state hospital, would be the centers where all persons ailing mentally would receive prompt and effective advice and treatment,^ and from which would radiate all efforts at popular instruction in matters ^ State Com. in Lunacy, Annual Report, 1901, p. 31. ' Hurd, op. cit., vol. i, pp. 258, 259. ^ For results of treatment in psychopathic hospital, see "Analysis of Recoveries at the Psychopathic Hospital, Boston," by Thomas H» Haines, in Boston Medical and Surgical Journal, Dec. 31, 1914. Also similar study by E. E. Southard, M.D., Boston Medical and Surgical Journal, Sept. 24, 1914. * White, William A., " Dividing Line between General Hospital and Hospital for the Insane," The Modern Hospital, March 1914." State Com. in Lunacy, Annual Report, 1902, pp. 83-84. 183] HISTORY OF NEW YORK'S POLICY 41 connnected with mental disease. A psychopathic hospital or department, in conjunction with its other functions, should serve as a prophylactic and educational station. Standing in a community on the plane with the general hospital, or other specialized hospital, it emphasizes mental disease as a disease, and should serve as a center to which may come for advice and counsel, those suffering from psychoneuroses and the early stages of mental disease, as easily and freely as they would seek out a general hospital in case of organic illness/ The State Commission in Lunacy, as well as the State Charities Aid Association, both strongly advocated for a number of years the construction of a series of psychopathic hospitals throughout the state for the reception and treat- mient of acute curable cases.' In 1902 a law was passed providing that accommodations be obtained or provided for the observation and treatment of a limited number of in- sane persons.^ A year later a bill to establish a reception hospital for the insane was introduced in the legislature but failed to pass.* The following year (1904) the same bill was introduced and was passed with slight modification.^ * Williams, Frankwood E., " Psychopathic Hospitals and Prophy- laxis," Boston Medical and Surgical Journal, June 24, 1915, pp. 933, 935. * State Com. in Lunacy, Annual Report, 1902, pp. 7, 1027-1029. ^ Lazvs of 1902, chap. 593, providing that " The Commission shall provide accommodations in the City of New York for a hospital to receive a limited number of alleged insane, and insane persons, where skilled observation is necessary in making required pathological and psychopathic research and examination. Admission to the hospital hereby created shall be regulated by the Commission." * State Com. in Lunacy, Annual Report, 1903, p. 956. * Laws of 1904, chap. 760, entitled An Act authorising the City of New York to acquire a site and to lease the sam-e to the state for 4he establishment thereon of a reception hospital for the insane. The hos- pital thus to be erected was to have accommodations for not less than 200 patients, and the sum of Three Hundred Thousand Dollars was to be spent for the erection of the necessary buildings. 42 SOCIAL ASPECTS OF TREATMENT OF INSANE [184 In 1905 an appropriation of $150,000 was made by the legislature toward the erection of the hospital/ and action was taken to obtain cooperation between the State Com- mission in Lunacy and the New York City authorities." A site for the proposed psychopathic or reception hospital was finally acquired by the City of New York, but upon investigation by the Commission in Lunacy it was found that the site was unsuited for the purpose intended for a number of reasons, among them the inaccessibility of the plot, its meagre extent, and its noisy neighbors.^ The State Hospital Commission^ passed a resolution in 1912 referring the consideration of the question of the pyschopathic hospital and the site selected by the city, to a committee consisting of the superintendents of four state hospitals in the metropolitan district and three other mem- bers. ■"* At a meeting held July 24, 1912, a decision was reached to the effect that " it was the sense of this committee that the time is not yet ripe for the establishment of an in- sitution such as proposed, and that therefore, the city be notified that the state is at present unable to proceed with * State Com. in Lunacy, Annual Report, 1905, p. 27. * Ibid., pp. 1093-1094. * State Com. in Lunacy, Annual Report, 1908, pp. 65-66. The site was situated between 725] INSANITY AS A COMMUNITY PROBLEM 53 psychopathic division, and later transferred to their re- latives in the city. The incidence of alcoholism and al- coholic psychoses among Jews, as will be pointed out later, has been considerably less than in almost any other element of the general population of New York, and for this reason, using the Bellevue Hospital fig-ures, the percentage of in- sanity among Jews was 13.72 per cent for 1918-1919; whereas it had reached 16.38 per cent the year previous. The total population of New York City in 191 7 was ap- proximately 5,800,000;^ the total Jewish population about 1,500,000, or 25.8 per cent of the general population, with admission rates to the psychopathic wards of Bellevue His- pital of 16.38 per cent one year and 13.72 per cent the following year. To Bellevue Hospital are brought the insane or alleged insane from the Boroughs of Manhattan and the Bronx only. Kings County Hospital in Brooklyn receives such patients from the Boroughs of Kings and Queens; Rich- mond Borough, with a Jewish population of only 5,000, sends its insane directly to Manhattan State Hospital after examination by two local physicians. A consideration of the total admissions to the psychopathic wards of both Bellevue and Kings County Hospitals for two years, thus including practically the entire city, will give a still better and more accurate index of the occurrence of insanity among the Jews of New York. The total number of ad- missions to Kings County Hospital, psychopathic wards, from September i, 191 7 to August 31, 19 18 was 2,326, of which 392 or 16.85 P^^ cent were Jews. For the following year, September i, 19 18 to August 31, 19 19 the total ad- missions were 2,550, of which 429 or 16.82 per cent were Jews, there being in both years a markedly lower rate of 'Dept. of Health, New York City, estimated the total population on July I, 1917, at 5,737,492, Weekly Bulletin, July 7, 1917, p. 223. 54 SOCIAL ASPECTS OF TREATMENT OF INSANE [196 admissions than the percentage of the total population. For the entire city (exclusive of Richmond, which is practi- cally negligible) Table I indicates the admissions and per- centages : Table i. Total Admissions to the Psychopathic Wards, New York City Year. Bellevue Hospital. Kings Co. Hospital. Total in City. Total Jew. in City. Per cent Total. Jew. Total. Jew. Jew. in City 1917-18 1918-19 6,878 8,25s 1,127 2,326 2.550 392 429 9,204 10,805 1.519 1,562 16.50 14.45 In view of what has been said regarding the unusually large total admissions to Bellevue Hospital for the year 191 8- 1 91 9, it might be advisable to make sufficient allow- ance for the increase over the preceding year by setting the total admissions at about what they were in 191 7-19 18. In any event, the percentage of Jewish admissions for the entire city would not average over 16.5 per cent, which is considerably less than 25.8 per cent, the proportion of Jews in the general population of New York City. III. METHODS OF COMMITTING PATIENTS TO STATE HOSPITALS (a) Legal Provisions for Commitment. The patients admitted to the psychopathic wards of Bellevue Hospital came from various sources, usually being brought there by the special ambulance attached tO' the psychopathic service of the hospital. The transference of the patients toi the hospital is carried out under authority of Section 87, of Article 4, Chapter 27 of the Consolidated Laws known as IC)7] INSANITY AS A COMMUNITY PROBLEM 55 the " Insanity Law " relative to the transfer of alleged in- sane persons to the psychopathic wards of Bellevue His- pital, the law reading as follows : It shall be the duty of such trustees of Bellevue and Allied Hospitals ... to see that the proceedings are taken for the determination of the mental condition of any such person in the boroughs or counties mentioned, who comes under their observation or is reported to them as apparently insane, and, when necessary, to see that proceedings are instituted for the commitment of such person to an institution for the care of the insane; provided that such report is made by any person with whom such alleged person may reside, or at whose house he may be, or by the father, mother, husband, wife, brother, sister, or child of any such person, or next of kin available, or by any duly licensed physician, or by any police officer, or by the representative of any incorporated society doing charit- able or philanthropic work. When the trustees of Bellevue and Allied Hospitals are thus informed of an apparently in- sane person, residing in the boroughs of Manhattan or the Bronx ... it shall be the duty of these authorities ... to send a nurse or a medical examiner in lunacy attached to the psychopathic ward of their institution, or both, to the place where the alleged insane person resides or is to be found. If, in the judgment of the chief resident alienist of the psycho- pathic ward or of the medical examiner thus sent, the person is in immediate need of care and treatment or observation for the purpose of ascertaining his mental condition, he shall be removed to the psychopathic ward for a period not to exceed ten days, and the person or persons most nearly related to him, so far as the same can be readily ascertained by such trustees , . . shall be notified of such removal. This section of the law went into effect March 5, 19 12, when the old law was amended. Prior to the amendment, patients were brought to the psychopathic wards by the police as prisoners, or committed for examination by city 56 SOCIAL ASPECTS OF TREATMENT OF INSANE [igg magistrates. Such procedure greatly aggravated the mental infirmities, which require more tender, skillful and gentle handling than medical and surgical cases. Since this measure has became operative and experienced nurses and a special ambulance are sent for the patients, thus eliminat- ing the police as arresting agents and the court procedures, the number of excited and disturbed patients received in the psychopathic wards has greatly decreased, and straps, handcuffs, and police patrol wagons have been altogether done away with.^ The legal right of the hospital authorities to go into a home and forcibly remove a patient against his own will was questioned for a time by those interested in the matter of personal rights. The opinion of the Corporation Counsel of the City of New York regarding the interpretation of this section is appended.^ The obvious purpose of Section 87 is to sanction and permit the summary removal to the hospitals of alleged insane persons who, by their actions, evince symptoms of insanity, or whose conduct, in the judgment of the medical examiner sent pur- suant to its provisions, is such that it would be dangerous to themselves or to the community to allow them to remain unrestrained or would disturb the public peace, and to afford alleged insane persons, in whose cases these elements of danger or disorder are lacking, opportunity to be heard before de- priving them of their liberty. In this view I am of the opinion and advise that it is not contemplated or required by Section 87 that a person alleged to be insane should be forcibly brought to the hospital, unless such person has acted in a disorderly manner, has committed an overt act, or is apparently an immediate source of danger to himself or to the community, and that in other cases, ' Bellevue and Allied Hospitals, New York City, A. R., 1912, pp. 68-69. 'Ibid., A. R., 1913, p. 64. igg] INSANITY AS A COMMUNITY PROBLEM 57 recourse should be had to that provision of Section 87 which reads : " Whenever in the City of New York an information is laid before a magistrate that a person is apparently insane, the magistrate must issue a warrant directed to the sheriff of the county in which the information is made, or any marshal or policeman in the City of New York, reciting the substance of the information and commanding the officer forthwith to arrest the person alleged to be insane and bring him before the magistrate issuing the warrant." It should be remembered that the procedure of summarily removing a person to the hospital against his will for examination as to his mental condition would seem to de- prive the person of his liberty without due process O'f law, in violation of the fundamental law of the land. However, this section of the statute authorizes this procedure as a police measure, so that whenever there is no element of danger to the individual himself or any danger or distur- bance to the community, it would not be within the purport of the law to bring a patient to the hospital in this summary- manner. This is particularly applicable to the paranoid types of mental disease, which will be discussed in another part of this chapter. (b) Social Workers and Commitment of Patients. In applying the various provisions of the law, if any difference of opinion exists in the family regarding the mental con- dition of the patient or his transfer tO' the hospital for ex- amination, extreme caution must of necessity be exercised in removing him from his residence. When the '' request" comes from a physician or a " representative of an incor- porated society doing charitable or philanthropic work," without the consent of the family or relatives of the patient, it is usually inadvisable and frequently fraught with harm to remove him summarily from his home. 58 SOCIAL ASPECTS OF TREATMENT OF INSANE [200 The ease with which patients may be brought to the hospital might become too great a temptation to social workers and representatives oi charitable organizations to hasten patients to the hospital for examination. While in a number of instances such a method is most desirable and beneficial, many neurotic and borderline patients might be- come greatly upset from the shock incident to such trans- fer. Every effort should always be made to bring the milder cases of mental trouble to the hospital as voluntary patients, or to take them to mental hygiene clinics in order to ascertain their mental condition and the advisability of transferring them to the hospital for further examination. The intent of this section of the law, empowering repre- sentatives of charitable or philanthropic agencies to apply for the mental examination of persons in the psychopathic wards, is altogether a praiseworthy one. However, unless organizations specializing in the care of the mentally sick are specifically called upon, there is, as pointed out above, too much left to the judgment of workers nearly always without training in the observation, care, and understand- ing of mental cases. Several training schools for social workers have realized this fact and are instituting both theoretical and practical courses for the training of psychiatric social workers. (c) The Police and Mental Cases. As a result of much experience it has been found advisable to have a police officer present at the house of the patient when the ambul- ance arrives, especially if the patient is unduly excited and liable to do harm to himself or to others if he should see the ambulance and nurses. The presence of a police officer is also at times necessary when the patient has no friends or relatives residing with him; in such instances the duty of the officer is to take care of the personal effects and pro- perty of the patient after his removal to the hospital. ^Ol] INSANITY AS A COMMUNITY PROBLEM ^q On May 5, 191 9, an amendment to the insanity law pro- vided that in the City of New York the officer commanded by a warrant to arrest a person alleged to be insane must bring him before the magistrate's court out of which the warrant was issued, instead of before the magistrate issu- ing the warrant. Though the number of insane or alleged insane persons thus brought to court is small in comparison with the total number committed, still, with the system of rotating magistrates as it exists in New York City, the apparent difficulty and inadvisability of taking aii insane person to another section of the city than the one in which he lives, is quite obvious/ One of the difficulties experienced by friends and rela- tives as well as by mental hygiene workers of private organ- izations is in having certain patients brought to the hospital without court proceedings. The police department, acting for the Ambulance Board of the city, must be notified when an ambulance is wanted. As a rule a policeman is either asked to telephone for the ambulance or he is at the house when the ambulance calls. The patient, especially if a paranoiac, will speak lucidly and intelligently and the officer frequently accuses the relatives of the patient of attempting to " railroad " the patient to an insane asylum. The same also happens when a hospital interne responds to an am- bulance call, and, not having sufficient experience in the diagnosis of mental diseases, refuses to accept the patient for transfer to the hospital. In a number of cases it is for these reasons a matter of weeks before a person whose relatives realize that a condition of mental abnormality ex- ists, is at last brought to the hospital. Once there, the Commitment Law of the state, probably the most practic- able in the country, preserves the constitutional rights of the individual. It involves little publicity, is not cumber- * Laws of 1919. sec. 87, chap. 380. 6o SOCIAL ASPECTS OF TREATMENT OF INSANE [202 some, and is well safeguarded.^ In other cities in the state the provisions for the care of the insane pending commit- ment have shown many shortcomings, as such persons have been detained in jails and almshouses. In order to correct this evil a law was passed in 1914 authorizing the State Hospital Commission to enforce its requirements as to suitable care for the dependent insane during the time steps are being completed for their commitment to a state hospital.^ This has helped reduce the number of instances where im- proper care is bestowed and within a short time adequate provision for proper care should be found in every county in the state.® There are two methods in which studies of the nature of this work may be made: (i) the statistical method; (2) the case method. It is the purpose to follow both these methods in this study, and it may be well to define the various terms to be used, as well as to present the classifica- tion and give a brief definition and review of the different psychoses and neuroses to be considered. IV. DEFINITION OF TERM "" INSANITY "'' However, before proceeding to the task of setting forth the definitions spoken of, the question of the meaning or connotation of the concept insanity should be settled if pos- sible.* Many attempts have been made to formulate de- finitions of the term, and several are herein presented for consideration. Thus, White ^ states that insanity is not a * State Comm. in Lunacy, A. R., 1890, p. 125. *Laws of 1914, chap. 305. (Incorporated in the Insanity Law as sec. 20.) »S. H. C, 26th A. R., 1913-1914, p. 277. *For a full discussion of the term see article by William A. White on " Underlying Concepts in Mental Hygiene," in Mental Hygiene, Jan., 1917, pp. 7-8. 5 White, William A., Outlines of Psychiatry, 1918, p. 17. 203] INSANITY AS A COMMUNITY PROBLEM 6i disease; it is rather a symbol grouping for a large number of different mental diseases which tend to arrange them- selves with greater or less distinctness into^ circumscribed groups of reaction trends. According to Dercum ^ insanity may be defined as a diseased state in which there is more or less persistent departure from the normal manner of thinking, acting, and feeling. Still another, though kind- red interpretation of the term is offered by Craig " in stat- ing that a person may be considered of unusual mind if from some mental cause : ( i ) he is unable tO' look after himself and his affairs; (2) he is dangerous to himself or tO' others; (3) he interferes with society, i. c, is unable to adjust himself to his surroundings.* Maudsley * wrote that the most prominent pathological characteristic of the in- sane is a complete or almost complete absence of moral feel- ing and moral ideas. A more concise definition is that of- fered by Peterson when he states that " insanity is a mani- festation in language or conduct of disease or defect of the brain." ^ As a scientific term, insanity is falling into disuse and now retains a significance imiainly in a legal sense; like lunacy it seems destined to become obsolete.*^ It would be best to restrict the applicatioii o'f the term to cases in which the mental disorder is of such a nature as to render advisable commitment for treatment or custody to a special institution, or care under trained and expert supervision.^ 1 Dercum, Francis X., A Clinical Manual of Mental Disease, 1914, p. 21. 2 Craig, Maurice, Psychological Medicine, 1905, p. 20, •Mercier, Charles A., Textbook of Insanity and other Mental Diseases, 1914, p. 42. * Maudsley, Henry, Responsibility in Mental Disease, 1874, PP- 171-172. * Church, A. and Peterson F., Nervous and Mental Diseases, 1901, p. 630. •De Fursac and Rosanoff, op,, cit., Introduction, p. xi. ^Peterson, Frederick, Mental Diseases, 1899, P- 603, quotes the noted 62 SOCIAL ASPECTS OF TREATMENT OF INSANE [204 . V. CAUSES OF INSANITY There has been much speculation as to the causes of insanity, though some factors have been definitely deter- mined upon as being responsible for a large proportion of the cases of mental alienation that fill our state hospitals and cost the various communities and states in the country large sums for their care and treatment/ Broadly speaking and with special reference to causation the mental disorders may be divided into two groups : ( i ) Exogenous, or where the causes are chiefly external; (2) Endogenous, where the existence of external causes or of primary tissue changes in. the brain has not been demonstrated. The causes found in this group are internal, the insanity growing, as it were out of the personality." Among causes affecting the first class^ are syphilitic infection, poisons introduced into the body, (as alcohol, cocaine, opium and its derivatives, etc.) or created within the body, and exhaustion. Heredity plays a most important part in the causation of mental disease in the endogenous group. Kraepelin classifies the causes in this class under the divisions of general predisposition and personal predisposition.^ Modern physiological psychology English jurist, Lord Justice Blackburn, who once said while giving evidence before a committee of the House of Commons, " I have read every definition which I could meet with, and never was satisfied with one of them, and have endeavored in vain to make one satisfactory ta myself. I verily believe it is not in human power to do so." Clouston, T. S., Unsoundness of Mind, 191 1, p. i, also emphasizes the difficulty encountered when attempting to give a satisfactory definition of the term. ^ Number of patients on books in New York State Hospitals at close of fiscal year June 30, 1918 : in civil hospitals 37.352 ; in hospitals for the criminal insane 1,420. (S. H. C, 30th A. R., 1917-1918, p. 9.) Total expenditures for the year approximately $11,000,000. Ibid., p. 25. *Hoch, August, "The Manageable Causes of Insanity," Nezv York State Hospitals Bulletin, Sept., 1909, pp. 1-3. See also Thomson, J. Arthur, Heredity, 1908, pp. 263-264, for a discussion of this classi- fication from a somewhat different viewpoint. » Kraepelin, Emil, Psychiatrie, Achte Auflage, i Band, pp. 140-208. 205] INSANITY AS A COMMUNITY PROBLEM 63 emphasizes the fact that there are innumerable phenomena which indicate that the mind operates as a true cause within the structure of the body, and that the reverse relation is also true/ Considering another method of classification, it may be stated that the essential causes of insanity are = heredity, alcoholism, syphilis, and head injuries; and that there are numerous and complex incidental or contributing causes, which in themselves do not suffice to produce in- sanity, but do so only in the presence of an essential cause. Alcohol and head injuries belong to this class also, as do various psychic conditions, common among which are business and domestic troubles, love affairs, death or illness of relatives. Other etiological factors that may be men- tioned are race, age, sex, environment, occupation, marital condition, education, and immigration. - (a) Heredity. In any discussion of insanity the ques- tion of heredity looms up as probably the most important factor.^ An inherited predisposition to mental disorder is found in from 30 to 90 per cent oi cases according tO' dif- ferent authorities.'* This wide variation in percentages is due to the inability to gather such statistics accurately, the lack of cooperation of relatives in obtaining the neces- sary information, and the failure to consider large enough groups in such studies to render them of any statistical ^Ladd, G. W. and Woodworth, R. S., Elements of Physiological Psychology, 1915, pp. 644-646. " De Fursac and Rosanoff, op. cit., pp. 2-20. 'Mercier, Charles A., Crime and Criminals, 1918, sets forth his doc- trine of the causation of insanity, stating that it is due in varying proportions to the two factors of heredity and stress — to the stress of circumstances acting upon an innate constitution ; to varying propor- tions of heredity and environment, p. 225. Mercier, iCharles A., Text- book of Insanity and other Mental Diseases, 1914, pp. 3-4. For opinions similar to the above see 13th A. iR., S. Comm. in Lun., 1900-1901, p. 37. * White, William A., Outlines of Psychiatry, 1918, p. 20. 64 SOCIAL ASPECTS OF TREATMENT OF INSANE [206 value/ In one careful study of a comparatively large num- ber of cases, an investigation by Rosanoff and Orr, the cor- respondence between the actual findings and the theoretical expectation acording to the ^Nlendelian theory, was very close.- However, it is quite apparent that the scientific study of heredity cannot be applied to the diseases of man with as much accuracy as in the vegetable kingdom or among the lower animals. The human race is not open to Mendel's essential methods, and its mere complexity in- volves innumerable differences from lower forms of life.^ Among other things, there is general agreement that the appearance or non-appearance of a characteristic may be in part decided by environmental influences.* Given the op- portunity, certain characters may manifest themselves which without such opportunity must have lain dormant.' Our present-day knowledge of heredity as applied to man is as yet insufficient to permit us to take a definite stand as to the inheritance of psychoses.*' Furthermore, there is ^Church and Peterson, Mental Diseases, p. 637, quote Lunacy Com- mission tables showing that of 136.478 admissions to asylums in England and Wales, heredity influence ascertained in only 20.5 per cent of admissions. "Rosanoff, A. J. and Orr, Florence I., "A Study of Heredity in Insanity in the Light of the Mendelian Theory." Bulletin No. 5, Eugenics Record Oifice, Cold Spring Harbor, N. Y. ' Cowers, Wm. R., " Heredity and Disease," Royal Society of Medicine, 1909, vol. ii, p. 15. *Lugaro, Ernesto, Modern Problems in Psychiatry, 1909 (trans, by D. Orr and R. G. Rows) emphasizes the fact that it is not a rare occurrence to see robust individuals spring from a marriage of weak individ-uals when the conditions of life are favorable, p. 212. *Bateson, W., Mendel's Principles of Heredity, 1909, pp. 303-305- •Davenport, Charles B., Heredity in Relation to Eugenics, 1911, points out in preface to book (p. in) that a large amount of in- vestigation will be required before it will be possible to take a definite stand, and that the advance thus far made is chiefly in getting a better method of study. 207] INSANITY AS A COMMUNITY PROBLEM 65 Still too much speculation in the field of psychiatry as to the origin and course of certain psychoses to make it advisable to accept as final any of a number of theories that have been formulated to date. There is even the feeling among psychiatrists and students of heredity that the psychoses may represent disease processes rather than true heredity,^ or that they represent abnormal variations unfitted for sur- vival in the world as it is at present organized. Thomson, in his well-known volume on *' Heredity," states It should be recognized that man has created around himself a social heritage which often evolves quickly, hurrying and pressing its creator, who cannot always keep pace with it. This is the frequent condition of mental disorder. The attempt to keep pace with the changes in environment — physical, biologi- cal, psychical and social, causes a strain that provokes disease." What is needed in order to determine tne actual bearing of heredity on insanity is the establishment of an organized re- search which would especially make a study of the descen- dents, normal and otherwise, of the insane confined in his- pitals. From the studies already made we know that in- sane patients have had a poor heredity in a greater per- centage of cases than has been the case among normal per- sons. The researches suggested must necessarily extend over a period of years and until they are inaugurated and completed, the more accurate knowledge of the relationship existing between heredity and insanity will remain at least partly unknown.^ ' Myerson, Abraham, "Mental Disease in Families," Mental Hygiene, April, 1919, p. 239. ' Thomson, J. Arthur, Heredity, 1908, p. 253. * During the year ending Sept. 30, 1910, in the New York State Hospitals, in the cases where positive information could be elicited, there was a reported history of insanity in 27 per cent of the male, and 32 per cent of the female patients. (White and Jeliffe, Modern Treat- ment of Mental Disorders, vol. i, p. 812.) 66 SOCIAL ASPECTS OF TREATMENT OF INSANE [208 (b) Alcohol. Another essential cause of insanity is the excessive indulgence in alcohol, which produces the familiar picture of drunkenness, and such excesses if frequently re- peated, are apt sooner or later to produce one or another of the alcoholic psychoses.^ Chronic alcoholic addicts are often of a psychopathic constitution, congenital or ac- quired,- and are characterized by a gradually progressive dementia, with diminished capacity for work, faulty judg- ment, defective memory, moral deterioration, occasional de- lusions, and various nervous symptoimis.^ In a study relating to the use and effect of alcohol in rela- tion to the alcoholic ps3xhoses, it was found that, ( i ) the drink habit leading to alcoholic insanity is usually formed in early life, males acquiring the habit earlier than females; (2) the average duration of the alcoholic habit prior to admission to the hospital for the insane is approximately 22 years among the males and 16 years among the females; (3) the liquors causing alcoholic insanity in New York State are principally whiskey and beer, the former appearing to be the principal factor in the majority of cases ; (4) either regular or periodic drinking may lead to alcoholic insanity, more than three-fourths of the patients observed (464) having been regular drinkers prior to admission; (5) a fixed habit of excessive drinking with frequent intoxica- * Kraepelin pointed out that 10 per cent of the patients in the asylums for the insane in the German Empire were committed on account of mental diseases due to alcohol. In some institutions the number was as high as 30 per cent, and even then these figures did not include numerous cases where alcohol was the exciting cause of the trouble, as in cases of mania, epilepsy and paresis. (Kraepelin, "Duty of the State in the Care of the Insane," trans, by Stewart Paton, Amer. la. of Ins., 1900, p. 236.) 'Jacoby, Geo. W., Unsound Mind, 1918, p. 288. ^Diefendorf, A. Ross, Clinical Psychiatry, 1907, p. 288. i 209] INSANITY AS A COMMUNITY PROBLEM 67 tion precedes the mental breakdown in a great majority of the cases. ^ The spread of the prohibition movement throughout the country during the past decade has resulted, to some ex- tent at least, in the decrease in the number of cases of alcoholic insanity admitted to the New York State Hos- pitals. The following figures indicate the gradual decrease in the percentage of cases of alcoholic insanity annually adimitted from 1909 tO' 1916," and now that the prohibition amendment to the Constitution has become law, a more substantial decrease may naturally be expected to follow. From October i, 1908 to June 30, 1916, 58,011 patients were admitted to New York State hospitals. Table 2. Number of Cases of Alcoholic Insanity All Admissions. Per cent of Total Year. Number. Admissions. Male, Female. Male. Female. 526 546 530 529 535 418 321 255 145 148 173 153 155 137 III 98 15.2 14.7 14.1 14.0 13.5 lO.I 7.8 8.0 4.6 4.4 5.0 4-4 4.2 3-6 2.9 3-2 IQI-J 1916 (9 months). In the year 191 7 there was an increase in the number of first admissions in alcoholic insanity, a total of 549, 437 males and 157 females, or 8.6 per cent of the total first ad- ^ Pollock, Horatio M., State Hospitals Bulletin, Aug., 1915. 'Pollock, Horatio M., "Decline of Alcohol as a Cause of Insanity," Psychiatric Btdletin, vol. xi, Apr., 1917, no. 2, pp. 103-104. b ^ SOCIAL ASPECTS OF TREATMENT OF INSANE [210 missions being classified in this group. The reasons for the marked change in this particular year are not known. ^ For the year ending June 30, 19 18, the percentage of alcoholic cases admitted was 7.3 per cent males, and 3.0 per cent females, the lowest rate since 1909.^ A more marked decrease is expected to follow within the next few years. (c) Syphilis. Syphilis appears as the essential cause of all cases of general paralysis and of cerebral syphilis, as well as of a large proportion of the cases of cerebral arteriosclerosis.^ General paralysis hardly ever develops before from ten to twenty years after the primary syphilitic infection.^ Not counting cases of arteriosclerosis, which are not always of syphilic origin, 19.4 per cent of all male first admissions and 7.0 per cent of all female first ad- missions to the New York State hospitals during a given year, occurred on the basis of syphilis as an essential cause. ^ For the year ending June 30. 1918, the cases of general paralysis which have been gradually increasing in re- cent years, showed a percentage of 13.4 of all first admis- sions.^ It is now a recognized fact that without a previous syphilis there can be no paresis.'^ Syphilis is not a sole factor, however. Only a very small proportion of the persons who are syphilitic develop general paralysis, and •in many, if not almost all cases of general paralysis it has been found that the patient has recently passed through a ^S. H. C, 29th A. R., 1916-1917, p. 407- 2 S. H. C, 30th A. R., p. 285. *De Fursac and Rosanoff, op. cit., pp. 9-10. *Kraepelin, Clinical Psychiatry (trans, by Thomas Johnstone), 1917, p. 41- »S. H. C, 25th A. R., p. 312. "S. H. C, 30th A. R., p. 284. 'Dercum, Clinical Manual, p. 256. 21 1 ] INSANITY AS A COMMUNITY PROBLEM 69 period of mental or other stress, which has seemed to de- termine the onset of the disease/ (d) Injuries and Other Causes. Head injuries are re- sponsible for but a small percentage of the cases admitted to the state hospitals. In 1918 there were only 15 cases thus admitted, 13 being men and 2 women. In 191 7 there were but 18 cases." These cases are far more often brought to general hospitals than to hospitals for the insane for reasons that are sufficiently obvious. (e) Contributing Causes. 'As mentioned above there are a number of contributing causes of insanity which in themselves are not responsible for any large percentage of cases of insanity, but which have, however, become re- cognized as important contributing factors in the causa- tion of insanity. A number of these factors have already been mientioned, and to them may be added bodily diseases ; ^ overwork, rarely a cause in healthy persons ; '^ and the group of physiological factors including puberty, the puerperal state,^ the climacteric and seniHty, all of which are indirect strains to which the organism is subject, by reason of the more or less profound physiological commotions they arouse in the nervous system.® VI. CLASSIFICATION OF MENTAL DISEASES (a) Introduction. There has been much difficulty ex- perienced in constructing a final standard classification of mental diseases, due largely to the question as to whether ^ Mercier, Textbook of Insanity, p. 244. ' S. H. C, 30th A. R, p. 284. ' Mercier, Textbook of Insanity, pp. 21-22. ^ Craig, Maurice, Psychological Medicine, p. 29. 5 See Lugaro, Modern Problems in Psychiatry, pp. 2ys-2'/6', also Mercier, Crime and Criminals, 1918, p. 195 for a discussion of the puerperal state and insanity. *Church and Peterson, Nervous and Mental Diseases, p. 668. 70 SOCIAL ASPECTS OF TREATMENT OF INSANE [212 such classification should be established on an etiological basis, on symptomatology, or from the point of view of pathological anatomy/ Various classifications have been proposed,' but the one followed in this work is the classifica- tion used in the New York State Hospitals and gradually being extended to all the hospitals for the insane in the United States.^ Table 3 follows the classification above alluded to and sets forth the psychoses, neuroses, and other ailments of Jewish admissions to the psychopathic wards of Bellevue Hospital for a period of a year. In order that this study may be intelligible to the layman as well as to the social worker, a brief discussion of the nature, prognosis and treatment of the various psychoses will accompany the con- sideration of the statistics presented. In accounting for the large number of males (673) admitted in comparison to the number of females (454) it should be noted that there are relatively more males in the foreign-bom white popula- tion of the country than in the native-born white population; a ratio of 129.9 males to 100 females for the former com- pared with 102.7 to 100 for the latter.* (b) Senile Psychosis. The senile psychoses, of which there were 16 male and 25 female admissions, are character- ized by a gradually progressive mental deterioration accom- ^Diefendorf, A. Ross, Clinical Psychiatry, pp. 116-117. •White, Outlines of Psychiatry, 1918, p. 19, suggests that the following be used : paranoia and paranoia states ; manic-depressive psychoses ; paresis, dementia praecox, senile and arteriosclerotic psychoses, infec- tion exhaustion psychoses, toxic psychoses, those associated with or- ganic diseases and injury of the brain, symptomatic psychoses, border- line states, and idocy and imbecility. ' I'ide Statistical Manual for the Use of Institutions for the Insane, prepared by the American Medico-Psychological Association and the National Committee for Mental Hygiene (pamp. 40 pp.) 1918. *Insane and Feebleminded in Institutions, Bureau of Census, 1914, p. 27. 213] INSANITY AS A COMMUNITY PROBLEM Table 3. Psychoses of Admissions 71 Diagnosis. Senile Psychosis Arteriosclerosis Organic Nervous Dis General Paralysis General Paralysis, Juv. . . . Lues Cerebral Syphilis Chorea Brain Tumor Cerebral Hemorrhage .... Chronic Alcoholism Intoxication Psychoses . . . Toxic Delirium Heroin Poisoning Infection Exhaustion Manic Depressive Manic Depressive Mixed . Allied to Man. Dep Involution Melancholia . . Dementia Praecox, Para. . Dementia Praecox, Kata. . Dementia Praecox, Hebe . Dementia Praecox, Simple Dementia Praecox, Allied . Paranoid Conditions Epilepsy Psychoneurotic Hysteria Hysterical Episode Constitutional Infer Mental Defective Imbecility Depression Undiff Transitory Confusion Hypomanic Unclassified Not Insane Totals Male. 16 17 12 88 I I 3 I 4 I 17 3 I 2 4 102 35 30 I 44 5 118 21 19 8 32 4 I I 21 26 7 I 3 7 16 Female. 673 25 2 6 II f3 103 54 32 5 34 I 34 18 24 2 14 9 I 9 15 I 17 2 I I 9 454 Total. 41 19 18 99 I I 5 2 4 I 19 3 I 8 17 205 89 62 6 78 6 152 39 43 10 46 4 10 2 30 41 8 18 5 25 1,127 panied by a series of lesions in the central nervous system.^ The most conspicious feature of these cases is a defect of memory, especially for more recent events,- and often an • Dief endorf, p. 369. * Mercier, Textbook of Insanity, p. 309. 72 SOCIAL ASPECTS OF TREATMENT OF INSANE [214 outbreak of ill-temper. The course of the affection is pro- gressive until death. The patients finally become com- pletely demented so that. they are wholly disorientated, con- fused, know no one around them; in fact may not even know their own nam^s.^ The disease is encountered most frequently between sixty and seventy-five years of age ; in- dividuals with a faulty constitutional endowment, worn with hardships, and especially those addicted to excesses, may succumb before sixty. (c) Arteriosclerosis. Arteriosclerosis was the diagnosis in the cases of 17 males and 2 females. This disease is not, as some have thought, always of syphilitic origin or affec- tion,' but may also be brought on by gout, lead poisoning, alcoholism, pulmonary and cardiac conditions.^ Among the physical symptoms are headaches, insomnia, muscular weakness, attacks of faintness or dizziness, epileptiform or apoplectiform seizures. The mental symptoms indicate dim- inished capacity for work, undue fatigability, emotional in- stability and depression; later, forgetfulness and general mental deterioration. The course of the disease in most cases extends over a number of years, even ten or twenty years. The prognosis is unfavorable for recovery, though under favorable conditions, such as rest, freedom from worry or excitement, moderation in eating and drinking, the condition may remain approximately stationary for months or even years.* A study of the New York State Hospital statistics has shown that the senile and arteriosclerotic, as well as the paretic groups, have high rates of first admis- ' White, Outlines of Psychiatry, p. 183. ' De Fursac and Rosanoff, p. 444. * Church and Peterson, p. 195. *De Fursac and Rosanoff, pp. 448, 452. 215] INSANITY AS A COMMUNITY PROBLEM 73 sions and deaths, with low rates of readmissions and dis- charges/ (d) Organic Nervous Diseases. Psychic disorders in- duced by pathologic processes in the brain, such as men- ingitis, tumor, softening, and hemorrhage, are included under the category of organic nervous diseases. Emotional irritability, hallucinations of the various senses, defects of intelligence, and stuporous conditions are common mental manifestations of these processes. Eighteen such cases were admitted, 12 males and 6 females. (e) General Paralysis. Some consideration has already been given to syphilis as a cause of mental disease, and from the figures in Table 3, it is seen that there were 99 cases of general paralysis, 88 males, 11 females and one case of juvenile general paralysis, all of which were a result of syphilis.- About 9 per cent of Jewish admissions were dir- ectly traceable to syphilis as the cause of the mental dis- ease; ^ this includes the juvenile case, which developed years after the primary infection.'* Studies of recent immiigra- tion, that is, prior to 1914, indicate that three-fourths of ^Psychiatric Bulletin, vol. ii, no. iv, Oct., 1917, New York State Hos- pital Statistics. Death rate per 1,000 patients under treatment in prin- cipal groups of psychoses in civil state hospitals for 1918 was as follows : general paralysis 352.8, cerebral arteriosclerosis 340.2, senile 297.2, these being three highest figures. (S. H, C, 30th A. R., p. 312.) ''For a comprehensive and thorough study of general paralysis, vide Kraepelin, " General Paresis," Nervous and Mental Disease Mongo- graphs, series no. 14. •General paralysis constituted 13.4 per cent of all first admissions to the New York State Hospitals for the year ending June 30, 1918. (S. H. C, 30th A. R., p. 284.) * Stokes, John H., The Third Great Plague, 1917, presents a satis- factory discussion of the whole question of syphilis and its effects upon society. See also Vedder, Edward B., Syphilis and Public Health, 1918, iSalmon, Thomas W., "General Paralysis as a Public Health Problem," Amen Jo. of Ins., 1914-1915, pp. 45-50. 74 SOCIAL ASPECTS OF TREATMENT OF INSANE [216 the married men, excepting Jews, among the immigrants left their wives in Europe, and that nearly 85 per cent of all the males of the Slavic and Italian races living in the United States are single or are married men living here apart from their wives. ^ This has resulted in conditions which have a very definite bearing upon the prevalence of venereal diseases." Paresis is relatively more common in cities than in rural districts,^ and yet among Jewish immii- grants who bring their wives with them intending to re- main, but who also congregate in the cities, general paralysis is less prevalent than among the native population.* Paretics are thus diagnosed because they become absent- minded, do not grasp events transpiring about them, mis- take persons and objects, and lose themselves among familiar surroundings.^ An increased tendency to fatigue is frequently among the first symptoms of the disease, the patient finding his ordinary labor very difficult. Paretics seldom have a true realization of their condition. On the contrary, the patients frequently feel healthier than pre- viously, or, at least, they do not appreciate that they have lost all their mental powers. In the patient's behavior there is a noticeable bluntness to the demands of propriety and custom which leads him to exhibitions of tactlessness, lack of restraint and even gross offenses, without his having the least realization thereof. They are careless of appearance, * White and Jelliffe, Modern Treatment of Mental and Nervous Disorders, vol. i, p. 255. 'Kraepelin and other authorities have pointed out that unmarried persons seem to be more prone to paresis than the married. (See Kraepelin, "General Paresis," p. 149.) •Dercum, Clinical Manual, p. 258. * White and Jelliffe, vol. i, p. 255. * Kraepelin, "General Paresis," p. i. 217] INSANITY AS A COMMUNITY PROBLEM 75 have no sense of order or cleanliness, boast obtrusively, and disclose their most intimate affairs/ The disease may be said to be absolutely fatal, and occa- sional alleged cures should be regarded with the greatest skepticism.^ The acute forms of the disease are rapidly fatal, the majority die in from eighteen months to three years, while in a certain few cases the disease process isi very slow and may occupy many years.^ Of the 99 cases admitted, yi, males and 1 1 females were committed to state hospitals; of the remaining male patients 12 were taken home by relatives, one, a well-known actor, was sent to^ a private sanatorium, where he died within a few days, and two died in the psychopathic ward. Table 4 indicates the years during which general paralysis: usually appears, and brings out the fact that about 66 per cent of the cases occur between the ages of 35 and 50 years, the busiest and undoubtedly the most fruitful years of the lives of active men and women. Table 4. Age Distribution : General Paralysis Age. 20-24 25-29 30-34 35-39 - 40-44 45-49 50-54 55-59 60 and OTCT . Totals Male. 2 4 7 17 29 16 7 3 3 88 Female. , Totals. 3 6 II 17 31 17 8 3 3 99 1 Kraepelin, "General Paresis," pp. 3, 12, 15. *Ihid., p. 96. ■•Dercum, Clinical Manual, p. 258, ;76 SOCIAL ASPECTS OF TREATMENT OF INSANE [218 In the treatment of general paralysis, institutional care from the first seems to be pre-eminently essential. The patient is absolutely unable to care for himself and in a great majority of instances the friends are equally unable to care for him. As soon as the diagnosis is made steps should be taken looking towards the appointment of a committee of his person and property or otherwise guarding his business interests, if any; upon investigation such interests show, al- most without fail, evidences of poor management, the result of early manifestations of the dementia/ The economic loss to the State of New York on account of syphilitic mental disease for one year is sufficiently large to compel attention, especially since it is recognized that prompt treatment during the first stages of syphilitic infec- tion would remove the danger of the involvement of the nervous system. Dr. Horatio M. Podlock, statistician of the New York State Hospital Commission, and a very careful and competent student of the subject, has made the follow- ing computations : Cost of maintenance of patients in institutions .... $471,918.72 Loss of earnings of males 4,652,942.35 Loss of earnings of females 273,783.92 Total loss $5,398,644.99 When it is remembered that patients with syphilitic men- tal diseases rarely, if ever, recover and that death occurs on the average within two years of the time of entrance in the hospitals, it would seem that himianitarian considerations alone would impel city and state authorities to do every- thing within their power to check the ravages of syphilis. Moreover, the enormous economic loss due to syphilitic mental diseases furnishes a financial argument that can not well be ignored.^ 'White, Outlines of Psychiatry, pp. 138-139. ' Pollock, " Economic Loss on Account of Syphilitic Mental Diseases," Mental Hygi-ene, Apr., 1918, pp. 277-282. 219] INSANITY AS A COMMUNITY PROBLEM yy (f) Juvenile General Paralysis. Juvenile general par- alysis is usually due to inherited syphilis, though it may have its origin in syphilis acquired in infancy ; compared with the adult form it is of course, rare/ Although but com- paratively few cases of general paralysis in children have been reported, it undoubtedly occurs quite frequently but is usually unrecognized. The possibility of general paralysis should be thought of in all cases of progressive mental im- pairment in children.- The single case referred to in Table 3 was that of an eight year old boy whose mother, still living, had contracted syphilis from the child's father six- teen years prior to admission of the youngster to the hos- pital; the mother was treated with mercury for six years and pronounced cured ; she gave birth to no other children, though she had several miscarriages and re-married on the death of the child's father. The patient was treated with salvarsan for two years, as well as with mercury for many months ; despite the vigorous course O'f treatment the Was- serman tests continued to indicate four plus. At the state hospital staff meeting when this case came up for diagnosis and discussion the question as to whether or not the patient belonged in a state hospital for the insane was considered, but due to the fact that no other institution would receive him, he still remains in the state hospital among adults.* Kraepelin has pointed out that among the cases of juvenile general paralysis oi the female sex coming to his attention, the patients are strikingly often prostitutes.* ^ Dercum, Clinical Manual, p. 259. * White, Outlines of Psychiatry, p. 132. ^ Miller, Henry W. and Achucarro, N., reported a somewhat similar case — that of a boy 12 years of age, illegitimate, mother had syphilis before birth of child but refused to undergo treatment ; also had several miscarriages. {Arner. lo. of Ins., Jan., 1911, pp. 559-5/0.) * Kraepelin, " General Paresis," p. 153. yS SOCIAL ASPECTS OF TREATMENT OF INSANE [220 (g) Lues and Cerebral Syphilis. Lues, another name for syphilis, presented only one case that found its way to the psychopathic ward. There were five cases of cerebral syphilis, 3 males and 2 females. Of the males, one was a married man of 34, who had been treated in several hos- pitals, and whom it became necessary to send to the City Hospital, his mental condition being sufficiently intact to render him a non-committable case.^ The other patient was also a married man, aged 32, who was being kept at home' while receiving the salvarsan treatment at one of the semi- private hospitals.- One of the women, aged 31, single, came from Randall's Island and died in the ward within ten days after admission. The other, a married woman of 46, was taken home by her husband after her mental con- dition had somewhat cleared up. Cerebral syphilis is not so often met with as general paralysis, at least in psychopathic wards or hospitals for the insane. For the year ending June 30, 191 8, there were 913 cases of general paralysis admitted to the New York State Hospitals, and only 49 cases of cerebral syphilis thus admitted.^ This is a grave af- fection; untreated cases progress more or less rapidly with tissue destruction and often a fatal termination. Treat- ment, however, if instituted early, may result in a quick and apparently perfect cure, the treatment being that of syphilis in general.* (h) Chorea. Two cases of chorea were admitted, one ^The City Hospital of the Department of Public Charities of the City of New York receives patients suffering from syphilis in its various forms, and for whom no other provision can be made. *In this study when a patient is readmitted during the year to the psychopathic ward, each admission is considered as though it were a. separate admission. • S. H. C, 30th A. R., p. 410. * De Fursac and Rosanoff, pp. 442-443. 22 1 ] INSANITY AS A COMMUNITY PROBLEM 79 male and one female; the former, a youth of 19 years, arrested, charged with a felony, and sent to the hospital for observation, thereafter being returned to the city prison. The second case was that of a married woman 33 years of age, whom it was necessary to commit to a state hospital. The abnormal mental conditions occurring as a part of chorea have been found to be an immediate cause of de- linquency,^ the coincidence in this single case being instruc- tive. Huntington's chorea, the diagnosis in the second case, usually sets in between the ages of 35 and 50 years. ^ It is a chronic, slowly progressive, incurable affection, mental S3miptoms appearing in almost every case sooner or later, with a weakness of judgment, general dissatisfaction with surroundings, a growing selfishness and irritability being among the earliest symptoms observed.^ Studies of family histories have indicated that every sufferer from this form of chorea had at least one affected parent, the obvious way in which this disease can be eliminated being for those who suffer from it not to have children.* (i) Brain Tumor. In many cases of brain tumor the symptoms are not of a sufficiently pronounced character to render their recognition easy,^ though they are often limited to headache, vomiting, vertigo, optic neuritis, together with certain neurological conditions depending upon which por- tion of the brain is affected. In about two-thirds of all cases mental phenomena are added.* Of the four men ad- ' White and Jelliffe, vol. i, pp. 221-222. *De Fursac and Rosanoff, pp. 360-361. * Hamilton, A. S., "A Report of Twenty-seven Cases of Chronic Progressive Chorea," Amer. lo. of Ins., Jan., 1908, pp. 403-474. * White and Jelliffe, vol. i, pp. 33-34. * Paton, Stevi^art, Psychiatry, p. 458. •Dercum, Clinical Manual, p. 291. 8o SOCIAL ASPECTS OF TREATMENT OF INSANE [222 mitted, all were between 35 and 40 years of age; two were discharged to the custody of relatives, one was committed to a state hospital, and the fourth died on the ward within three days after admission, having been brought to the hos- pital in a moribund condition. (j) Cerebral Hemorrhage. The single case of cerebral hemorrhage was that of a man 43 years of age, who had been struck on the head by a bar of iron while at his work. He left the hospital within a day after admission, and his condition had not fully cleared up months later, especially as it was aggravated by heavy drinking of alcoholic liquors. He was not considered a proper case for commitment. (k) Alcoholkm. The question of alcohoHsm and the problems it creates has been discussed in preceding pages. Many writers have pointed out that Jews contribute but a small percentage of alcoholic psychoses to the total admis- sions to state hospitals.^ Of the 22 admissions for which alcohol was the essential cause, but 3 cases presented an acute alcoholic psychosis, these being the only alcoholics to be subsequently committed to a hospital, one to a private sanatorium, 2 to a state hospital, out of a total of 828 com- mitments," while 5.2 per cent of first admissions for the state as a whole presented alcoholic psychoses.* (1) Narcotic Drug Poisoning. During the past few years the number of cases of narcotic drug poisoning has increased very perceptibly and the nine cases of drug poison- ing including one of toxic delirium, represent only those whom' it was found advisable temporarily to detain in the ^Fishberg, Maurice, The Jews, pp. 273-274, 342-43; Kirby, George H., "Race and Alcoholic Insanity," Jo. Anier. Med. Assn., July i, 1911, pp. 9-11; Swift, H. M., "Insanity and Race," Amer. Jo. of Ins., July, 1913, p. 152. * See table 14, " Disposition of Patients." » S. H. C, 30th A. R., p. 285. 223] INSANITY AS A COMMUNITY PROBLEM gl psychopathic wards. ^ None of these cases required com- mitment to a state hospital though the existence of proper and adequate facilities would have helped materially in the treatment of these and many other patients suffering simil- arly. (m) Infection Exhaustion Psychosis. All factors cap- able of bringing about rapid and profound exliaustion of the organism occur in the etiology of primary mental con- fusion; physical and mental stress, painful and prolonged emotions, but esj^ecially grave somatic affections. The puerperal state, through the exhaustion which it entails as well as through the nutritive disorders and infections by which it is sometimes complicated ; infectious diseases (typhoid, influenza, cholera) ; profuse hemorrhages, etc. are among the causes frequently found in the historj^ of the disease. Out of a total of 13 female cases of infection ex- haustion psychosis, 6 resulted from the puerperal state, 5 from pneumonia, i from chronic cardiac disease, i from blood poisoning. Four male cases were recorded, i re- sulting from pulmonary tuberculosis. 2 from pneumonia, and I from empyema. (n) Manic Depressive Insanity. The largest single group of cases to be admitted was the manic depressive which totaled 356 patients, or about 31 per cent of the total admissions. The term " manic depressive insanity " was introduced by Kraepelin - and is in general use at pre- sent to signify cases in which the attacks present a double characteristic : a tendency towards recover}- witliout in- 'For a discussion of the problem of drug addiction in New York, with special reference to Jewish drug addicts, see Goldberg, Jacob A., The Drug Habit as a Social and Legislative Problem (M. A. thesis, Columbia Univ., 1916). 'Dercum, Clinical Manual, p. 64; also, Kraepelin, Lehrbuch der Psychiatrie. band ii. 82 SOCIAL ASPECTS OF TREATMENT OF INSANE [224 tellectual eiifeeblement and a tendency toward recurrency.^ The principal cause is hereditary taint, and it is noteworthy that this disease is often found in famihes, the constitutional condition as the basis on which it develops appearing to be directly transmitted." From a symptomatic standpoint the attacks are of three types: manic, presenting a flight of ideas, irritability, and motor excitement; depressed, with psychic inhibition, and a painful emotional state associated with indifference; mixed, in which a period of depression and period of excitement alternate, the transition being either sudden or gradual." It has been found that this psychosis occurs more frequently in females than in males,, about in proportion of 2 to i.* Of the cases under con- sideration, the males in this group accounted for 24.8 per cent of the total male admissions, whereas for the females, 41.6 per cent of the admissions were classified as manic depressive insanity. The individual attacks vary in dura- tion from a few days to several months, some attacks, how- ever, being greatly prolonged.^ Recovery from the single attack is the rule, while the likelihood of subsequent attacks is usually presimied to be quite certain. The prognosis of the disease is bad as to ultimate recovery though good for the separate attacks.^ * De Fursac and Rosanoff, p. 293 ; also White and Jelliffe, vol. i, p. 535. 'White, Wm. A., Outlines of Psychiatry, p. 99; Peterson, Frederick, Mental Diseases, 1899, p. 694, holds that hereditary taint is found in 75 per cent and degenerative stigmata in 20 per cent of cases. 'White and Jelliffe, vol. i, pp. 529-589 present a thorough discussion of this psychosis. *Dercum, p. 63. 'A most interesting study of a case of manic depressive insanity lasting for many months is described by Clifford W. Beers in "A Mind that Found Itself," being a detailed story of the attack suffered by Mr. Beers. •Readmissions to the state hospitals are indicated in table 22. 225] INSANITY AS A COMMUNITY PROBLEM 83 In the accompanying table, the manic and depressed cases are not separated, the total admissions having been 102 males, 103 females; of mixed psychoses 35 were males and 54 females. It is often difficult to draw a sharp line between borderline cases, and these have been entered as allied to manic depressive insanity, 30 males and 32 females/ The following table points out the final disposition of the cases in this group. Tabi£ 5. Disposition of M. D. I. Patients Disposition. Male. Female. Totals. 135 II 2 19 159 '5 294 26 Returned to City Prison Discharged 2 34 Totals 167 189 356 These figures, indicating a large number of commitments and but a few discharges, usually of borderline cases or those whom relatives insisted on taking home, help bring to the fore a marked weakness in the system of care and treatment of the insane. Many, if not a majority of these patients would have recovered from the attack if cared for in a psychopathic hospital for a period oi a few weeks. In- stead, they were sent to an overcrowded and undermanned state hospital in which facilities for the treatment of these so-called acute cases are below the necessary minimum. It is because of the lack of an essential link (psychopathic hospital) in the state hospital system that much of the *On the early differential diagnosis between dementia praecox and manic depressive insanity, vide Dercum, Penn. Med. Jo., Aug., 191 7, p. 765. 84 SOCIAL ASPECTS OF TREATMENT OF INSANE [226 overcrowding is due. Given such hospitals in different parts of the state, a marked percentage of the present over- crowded conditions would be eliminated within a short space of time. The distribution of cases of manic depressive insanity ac- cording to age was as follows : Table 6. Age Distribution of M. D. I. Patients Age. Under 15. .. 15-19 20-24 25-29 30-34 35-39 40 and over . Totals Male. 167 Female. Totals. 3 4 7 »S 32 47 39 45 84 32 32 64 20 29 49 23 21 44 35 26 61 356 As in the cases of dementia praecox (Table 8), the out- standing feature of the above figures is the comparative youthfulness of the majority of cases. In this group there is a larger proportion of those over 30 years of age, due to a number of causes, among those being the fact that dementia praecox psychoses develop earlier than manic de- pressive attacks, and also to the fact that many of the more serious stresses in life do not come till after the thirtieth year, heredity and stress being, as aforementioned, the most important causes of manic depressive psychoses. Over 82 per cent of the above cases were under 40 years of age, in the very prime of life, and irrespective of the sadness and misery resulting, the economic loss to society as a result of this must in any event be very large. (o) Involutional Melaiicholm. Involutional melancholia, the diagnosis in t male and 5 female cases, occurs chiefly 227] INSANITY AS A COMMUNITY PROBLEM 85 after forty-five years of age. The ages of the six patients were 42, 45, 53, 54, 56 and 60 years. The causes of this disease are not well known, though a neuropathic heredity has been found in about 60 per cent of the cases. ^ Among the symptoms are anorexia, insomnia, irritability, unwar- ranted pessimism, a tendency to rapid fatigue, with often a marked depression, leading in a number of cases to suicide, unless closely guarded. It was found necessary to commit each of the six patients to a state hospital. (p) Dementia Praecox. Dementia praecox, one of the cormnonest forms of mental disease, is a psychosis essen- tially of the period of puberty and adolescence, character- ized by mental deterioriation tending to progress, though frequently interrupted by remissions. According to Krae- pelin sixty per cent of all cases of dementia praecox begin before the twenty-fifth year, the simple form usually start- ing between the fifteenth and twenty-fifth year, the paranoid form beginning around the end of the second decade, and one-half of the katatonic cases setting in around the twenty- fifth year.^ It is to Kraepelin that much credit belongs for the great interest taken in the subject of dementia praecox in recent years, due to the serious effort on his part to clear up the early confusion.^ There were 212 males and 117 females admitted to the psychopathic wards in one year, the largest number being among the hebephrenic form, of whom 1 18 males and 34 females came to the hospital. The real significance and importance of the cases of dementia praecox from the point of view of hospital expenditures and management especially, may be gathered from the fact that on July i. 191 6, 53.81 per cent of the patients in all the • De Fursac and RosanoflF, p. 324. *Jacoby, Unsound Mind, p. 197. 'Hall, G. Stanley, Adolesceiue, 1908, vol. i, p. 301. 86 SOCIAL ASPECTS OF TREATMENT OF INSANE [228 state hospitals for the insane in New York were diagnosed as dementia praecox, whereas the psychosis that stood next highest was the manic depressive group and the alHed forms thereof, of which there were less than 10 per cent.^ In 191 7 the proportion of dementia praecox cases was 53.8 per cent," and in 1918 it rose to 58.7 per cent." The financial burden which the state must carry in caring for these patients is increasing from year to year, and the need to find a way out is very urgent, since with better care, improved diet and housing conditions, the length of life of these patients in the institutions tends to increase, and thus the percentage of such patients will naturally increase as time goes on. There are many difficulties however, in discovering ways and means of curing or so improving the mental condition of dementia praecox patients that they may safely be dis- charged from custody. To begin with, only the outward manifestations of the disease are known with any degree of accuracy, whereas the causes are almost completely un- known.* It is generally agreed that probably the most im- portant question in contemporary psychiatry is the nature of dementia praecox, that is, the genesis of the disease pro- cess.^ There have been .miany theories advanced as to the cause and nature of the disease. Some have held that heredity is to be regarded as the essential cause of the disorder ; ^ that heredity plays an uncertain role in its ^Psychiatric Bulletin, Oct., 1917. p. 456. » S. H. C, 29th A. R., p. 440. » S. H. C, 30th A. R.. p. 292. *Tanzi, Eugenio. Textbook of Mental Diseases, 1909, pp. 663-665. ^Coriat, Isidor H., " Psychopathology of Dementia Praecox," Amer. Jo. of Ins., Jan., 1917. pp. 670-671 ; Southard, E. E., "A Study of Dementia Praecox," Amer. Jo. of Ins., July. 1910, pp. 124-125. •De Fursac and RosanofF, p. 280. 229] INSANITY AS A COMMUNITY PROBLEM g/ etiology ; ^ that abnormal functions of internal glands are responsible for the disorder; - that dementia praecox is de- pendent upon an auto-intoxication produced by poisons which are elaborated in the sexual organs and which are especially injurious to the brain;" that infectious diseases, especially influenza, may become the starting point of de- mentia praecox.* From the varied and conflicting views it is quite apparent that much still remains to be discovered regarding dementia praecox, though certain more or lesa definite facts concerning the various manifestations of the different forms of the disease have been determined.'^ Parents and relatives of children who' begin to show symptoms of dementia praecox rarely understand the reasons for the apparent laziness, their inability tO' apply themselves to their studies or work, the irritability and failure to join in the games and sports of their fellows.* ^ White, Outlines of Psychiatry, p. 140. ^ Hoch, August, " Precipitating Mental Causes in Dementia Praecox," Amer. Jo. of Ins., Jan., 1914, p. 637; Auer, E. Murray, " Disease of the Glands of internal iSecretion." Amer. Jo. of Ins., Oct., 1914, p. 498. * Taiazi, op. cit., pp. 663-665. quotes Kraepelin on this point ; Tanzi disagrees with this theory. * Paton, Psychiatry, p. 405. * Abbott, E. S., "Meyer's Theory of the Psychogenic Origin of De- mentia Praecox," Amer. Jo. of Ins., July, 191 1, pp. 15-22, makes the observation that causes are multiple, and so diligent search is necessary, not only along psychobiological lines, as advised by Meyer, but in others, including all possible organic changes as well. For a further discussion of Meyer's theory see Psychological Clinic, vol. ii, p. 92 et seq.; Amer. Jo. of Psychology, vol. xxi, p. 395 et seq. •Flexner, Bernard and Baldwin, Roger N., Juvenile Courts and Pro- bation, 1914, pp. 41-42, advise the establishment of psychopathic clinics attached to public schools in order to discover these cases at an early stage of their illness. iMacCurdy, John T., " Psychiatric Clinics in the Schools," Amer. Jo. of Public Health, vol. vi, no. xii, pp. 1265-1270, points out why psychiatric cHnics in the schools may offer reasonable hope of reducing insanity in the latter life of the pupils. Vide Healy, William, The Individual Delinquent, 1915, pp. 66-67. 88 SOCIAL ASPECTS OF TREATMENT OF INSANE [230 The result is that these potential cases of dementia praecox are kept at home until the disease is fully developed and the patience of their relatives is exhausted, when they are brought to the psychopathic ward for commitment to a state hospital. The following figures show the large proportion of the cases that were committed : Table 7. Disposition of Cases of D. P. Disposition. Male. 174 6 4 I 27 Female. Totals. 2 I 9 117 279 4 36 Totals 212 329 It has been computed that dementia praecox involves annual direct and indirect losses to the State of New York of more than $10,000,000.^ This is largely so because these case^ remain in the state hospitals for an average of 16 years, most of them being of wage-earning age. as seen from the figures that follow : Table 8. Age Distribution of D. P. Patients * Pollock, " Dementia Praecox as a Social Problem," Quarterly, Aug., 1918. State Hospital 231] INSANITY AS A COMMUNITY PROBLEM 89 The fact that the recovery rate of dementia praecox patients in state hospitals is very low/ is an additional contributing factor to the high percentage of such cases in institutions, outnumbering, as they do, all other patients put together. Merely to herd these cases in state hospitals is a hopeless task and further steps must be taken either by the state or by private agencies, or by both, to find ways and means of solving the problem of proper and advisable methods to be pursued in the study, care and treatment of this group of the state's charges. (q) Paranoid Cofiditiotis. Paranoia is a chronic pro- gressive psychosis occurring mostly in early adult life, be- tween the ages of 25 and 40 years, characterized by the gradual development of a stable progressive system of de- lusions without marked mental deterioration, clouding of consciousness, or disorder of thought, will or conduct.^ The disease is not common, and constitutes only a small percentage of the cases admitted to insane asylums.^ Men are more often afflicted than women. It develops on a defective constitutional basis, either congenital or acquired, defective heredity existing in a very large percentage of the cases.* The development of the psychosis is often slow and gradual, though it may develop very rapidly, almost suddenly.^ The patient will usually change in dispositicm, • Pollock, "A Statistical View of Mental Disease in the New York State Hospitals" Psychiatric Bulletin, Oct., 191 7. * Diefendorf , op. cit., p. 420. •In 1918 only 4.4 per cent of the patients in the New York State Hospitals were suffering from paranoiac conditions. (S. H. C, 30th A. R., p. 292.) ' Dercum, Clinical Manual, maintains that heredity is responsible in 85 to 90 per cent of cases, (p. 134.) 'A difference of opinion exists as to the rapidity of onset. Thus De Fursac and Rosanoff (p. 287) maintain that the rapid development of the disease is more frequent, whereas Diefendorf (p. 424) holds that go SOCIAL ASPECTS OF TREATMENT OF INSANE [232 become somewhat irritable, grumbling, very suspicious, and easily discontented. There were but 10 such cases ad- mitted, 8 males and 2 females; 7 were taken home by re- latives and 3 committed to state hospitals/ Practically all writers on the subject agree as to the chronicity and in- curability of paranoia ; ^ and though a few recoveries have been reported, a critical examination of these cases hasi resulted in a disagreement as to the diagnosis." (r) Epilepsy and Mental Deficiency. Among the re- mainder of the Jewish cases brought to the psychopathic ward, there were 32 male and 14 female epileptics, and 33 male and 16 female mental defectives of all kinds. Bad heredity is by far the most common and important cause of the above mental conditions, though parental alcoholism and parental syphilis are additional important factors.* Most of the patients of this group were brought to the the onset is very gradual, extending sometimes over years. If the Freudian view is taken, namely, that paranoia is a defense psychosis d'Ctermined by the nature of the painful reminiscences repressed, then the latter viewr must be accepted. Fide Freud, E., Selected Papers on Hysteria and other Psychoneuroses, 1909, pp. 165-174. *Kirby, George H., "Dementia Praecox, Paraphrenia and Paranoia," Amer. Jo. of Ins., vol. Ixxi, p. 359. states that paranoia is the outgrowfth of personal difficulties in the adaptation to the environment of abnorm- ally constituted personalities, and that most of these cases are able to get along in society and their commitment is usually not necessary. • Abbott, E. S., "What is Paranoia," Amer. Jo. of Ins., vol. Ixxi, p. 41. *Bjerre, Paul, History and Practice of Psychoanalysis (pp. 205-246), presents the case of a paranoical system of persecution of ten years standing which he claims was entirely broken up and not a trace of recurrence appeared six years after conclusion of the treatment, which followed the psychoanalytic method and was extended over a long period of time. White, Principles of Psychiatry, p. 97, believes there are possibilities of accomplishing cures by attacking the problem thera- peutically, probably along the Hnes followed by Bjerre. *Tredgold, A. F., Amentia, offers a comprehensive study of this group of cases. 233] INSANITY AS A COMMUNITY PROBLEM gi hospital either because they were sent by the courts for mental examination after arrest for some crime, or be- cause relatives could no longer keep them at home. Only a few of these patients were committed to a state hospital, this step being taken only when they suffered from a psychosis in addition to the other condition'. A majority of them should have been placed in institutions for the epileptic or feebleminded years prior to their arrest or hospital admission.^ However, due to the failure of early diagnosis as well as to the overcrowded institutional con- ditions, these patients have been permitted to wander about the streets, fall into criminal ways, eventually to be sent to jails and prisons instead of to farm or industrial colonies in which they properly belong." Until the state completes a comprehensive plan for the care of all such cases needing custodial or other similar care and treatment, no abatement of hospital and prison admissions of this group can pro- perly be expected. (s) Psychoneuroses. There were 4 cases of psycho- neuroses, few of which find their way to the psychopathic wards and state hospitals, though neuroses constitute one of the most wide-spread forms of disease ; ^ of hysteria i male and 9 female patients, and of hysterical episode i male and I female; of hypomanic i female; of various undifferen- ^Gesell. Arnold, "Mental Hygiene and the Public School," Mental Hygiene, Jan., 1919, pp. 4-10, suggests the means to be employed in public schools in order to pick out those children who are predisposed to mental or nervous conditions. Campbell, C. Macfie, "A City School District and Its Subnormal Children," Mental Hygiene, April, 1918, pp. 232-244, offers suggestions for constructive work with such children. *Glueck, Bernard, "Types of DeHnquent Careers," Mental Hygiene, April, 1917, pp. 171-19S, shows how bad heredity and mental defective- ness may result in delinquent careers. Vide Glueck, "Concerning Prisoners," Mental Hygiene, April, 1918, pp. 177-218. Glueck, Studies in Forensic Psychiatry, 1916. "White and Jelliffe, vol. i, p. 333. 92 SOCIAL ASPECTS OF TREATMENT OF INSANE [234 tiated depressions, i male and 17 females; and of transitory confusion 3 males and 2 females. Eight cases, 7 males and I female were unclassified, due largely to the fact that they left the psychopathic ward in the custody of relatives be- fore the examination could be made or completed. (t) ConstiHUional Inferiority. Constitutional inferior- ity is a term applied to those who show a mildly dwarfed mental endowment with limited attainments and an in- ability to grapple with the problems of everyday life.^ These cases are subject to episodes of excitement and de- pression, often developing paranoid states of a more or less transitory character. They frequently commit crimes and are essentially chronic in character, so far as duration is concerned. Many of them are never admitted to hos- pitals for the insane, but drift into prisons and reforma- tories, or other custodial institutions.^ Their main dif- ficulty seems to be in adjusting themselves to their environ- ment but they cannot be regarded as mentally sick accord- ing to the definition of the code. It is for this reason that so many of them never reach a state hospital, and still in the various institutions to which they are sent they are un- fortunately misunderstood and misjudged — the only solu- tion of the difficulty seeming to be the creation of a special institution for those suffering from constitutional inferior- ity.^ Twenty-five cases admitted to the wards were foimd not to be insane and discharged to their own custody or turned over to police and court officials by whom they had been 'Karpas, Morris J., "Constitutional Inferiority," Jo. Amer. Med. Assn., Dec. 16, 1916, p. 1831, presents an analysis of the concept of constitutional inferiority, especially regarding the method of diagnosis of such cases. * White and JelHffe, vol. i, pp. 846-847. 'Bellevue and Allied Hospitals, Annual Report, 1912, p. 64. 235] INSANITY AS A COMMUNITY PROBLEM 93 brought for mental examination upon order of a court. This completes the analysis from the point of view of diagnosis of the 1,127 Jewish cases admitted to Bellevue Hospital psychopathic wards. What follows immediately considers this group from different angles so that as com- plete a mental picture as possible may be obtained. In this way, it is hoped, the needs of the insane and the respon- sibility of the community towards them may be better un- derstood and realized, and steps taken to alleviate and remedy conditions that should no longer be permitted to exist. Table 9. Number of Admissions Male. Female. Total. 543 130 385 69 454 928 199 Readmissions Totals 673 1,127 It is often difficult to ascertain whether or not certain patients admitted to the psychopathic wards are readmis- sions to these wards. The figures presented in Table g, showing 17.6 per cent readmissions are imdoubtedly low, especially in view of the much higher percentage of read- missions recorded in the state hospitals,^ particularly as re- gards the Jewish patients under consideration. A number of these readmissions were parole cases from the state hospitals; others had been patients in state institutions whose parole period, formerly only six months but now, in s«me instances as long as one year, had expired, thus male- 's. H C, 30th A. R.. p. 278. 94 SOCIAL ASPECTS OF TREATMENT OF INSANE [236 ing it necessary to have them recommitted. The question as to why so large a percentage of cases relapsed after dis- charge from the state hospitals will be considered in detail in another chapter. VII. MARITAL CONDITION In the following table (Table 10) the marital condition of the patients is presented. There were almost twice as many single as married males; whereas, of female patients, there were actually fewer single than married. The large percent- age of single persons amtmg the insane enumerated by the United States Census of 1910, showing 63.5 per cent male and 41.7 per cent female, compared to 60.3 per cent male and 44.5 per cent female in Table 10, should not be inter- preted as indicating that the single are more liable to be- come insane than the married. It means rather, that the in- sane as compared with the normal are less likely to marry. That the percentage of single persons is smaller for fe- males than for males, both among the insane and the general population, is due to the fact that women marry at a younger age than men. The psychoses which are largely responsible for the majority of cases of insanity do not as a rule develop until after the eighteenth year, except in the cases of dementia praecox, hebephrenic form. By this time in many cases, the females are married and for that reason psychoses were found to have developed in an un-< duly large number of young women whose marriage was a matter of but a short time. The added burdens of house- hold care, of gestation, pregnancy, and lactation, have caused the onset of psychoses in persons as to whose good mental condition there was no question prior to marriage ; at least the nearest relatives knew of no mental abnormality, indi- cated or latent. The comparatively large number of married men and 237] INSANITY AS A COMMUNITY PROBLEM 95 women, many of them with dependent children, presents an important social problem. The majority of these patients were between the ages of 20 and 40 years, and the commit- ment of a father or mother to an institution for the insane left a family, in many cases, in straightened circumstances. Table 10. Marital Condition Single Married Widowed . . . . Divorced . . . . Totals Male. 406 234 25 8 673 Female. 190 201 53 10 454 Total. 596 435 78 18 1,127 With but very few exceptions, the social status of nearly all the patients was that of working people whose only source of income was what they themselves earned from week to week, or what relatives contributed out of meagre in- comes. Under such conditions, the commitment of an un- married young man or woman has in many cases meant a reduction in the family income, whereas in cases of mar- ried persons more serious adjustments have to be made, this often being possible only through the financial aid of a social or relief agency. The kind and amount of assistance to be rendered to such families depends on whether the father or the mother has been committed: the number and age of the children, if any; the financial resources of the family, and the assistance to be expected from relatives. Often the most important factor is the matter of the diagnosis of the patient; if a recovery may reasonably be expected within a few weeks or months, emergency assist- ance will usually be sufficient to keep the family together; 96 SOCIAL ASPECTS OF TREATMENT OF INSANE [238 otherwise a more definite program of relief must be outlined and carried out. VIII. NATIVITY In the United States, and esj>ecially in New York State, the question of immigration in relation to insanity presents a problem of great magnitude. Of the total number of in- mates of insane asylums on January i, 1910, according to the enumeration of the Thirteenth Census, 28.8 per cent were whites of foreign birth, and of the persons admitted to such institutions during the year 1910, 25.5 per cent were of this class. ^ Of the total population of the United States in 1 910 the foreign-born whites constituted 14.5 i>er cent." The number of foreign born admitted to the New^ York State Hospitals for the year 191 8 was 44.5 per cent of the total admissions ; those of foreign parentage constituted 59.8 per cent and those of mixed parentage 11. o per cent.* From this it seems that for the country as a whole and for New York State in particular the foreign bom have an unduly large representation in insane asylums. However, it should be remembered that most cases of insanity occur after the eighteenth year, and that the difference in age distribution which exists between the native and foreign- bom parts of the population accounts largely, but not wholly, for the difference in the proportion of insane hos- pital admissions.* ' Insane and Feebleminded in Institutions, U. S. Census, 1914, p. 48. *Ibid., p. 25. »S. H. C, 30th A. R., p. 282. *Rosanoff, A. J., "Some Neglected Phases of Immigration," Amer. Jo. of Ins., July, 1915, p. 47; points out the apparent shortcomings in computing percentages without considering age distribution. '■39] INSANITY AS A COMMUNITY PROBLEM Table ii. Nativity Arabia Austria- Hungary Belgium England France Germany Greece Palestine Persia Roumania Russia Spain Switzerland Turkey Total Native born Totals Male. 127 II I 20 I 24 284 I I 4 476 197 673 Female. "5 I 6 I 15 I I 344 no 454 97 Total. I 242 2 17 2 35 I I I 38 472 I I 6 820 307 1,127 All unusually large number of the immigrants, especially the Jews, settle in the urban districts, more often in the larger cities. It is an established fact that an urban environment brings to the surface neuropathic tendencies of a community far more fully than a rural environment. Considering this factor together with the difference in age distribution, and making some allowance for the heavy stress entailed in the migration and in the subsequent process of adjustment to new conditions and more exacting standards of living, there is found to be but little difference, if any, between the native and foreign-bom parts of the population in the incidence of certified insanity.' Table 11 indicates that 820 or y2.y per cent of the total ' De Fursac and Rosanoff, p. 19. gS SOCIAL ASPECTS OF TREATMENT OF INSANE [240 Jewish admissions under consideration were of foreign birth, and 307 or 27.3 per cent were native bom. Russia contributed more than half of the foreign bom, 284 males and 188 females, a total of 472; from Austria-Hungary came 127 males and 115 females, a total of 242; Roumania contributed a total of 38, Germany 35, England 17, Turkey 6, Belgium 2, France 2, and i each from Arabia, Greece, Palestine, Persia, Spain and Switzerland. The figures of admissions to the psychopathic wards indicate approxi- mately the proportion of Jewish immigration from the vari- ous countries during recent years, especially the last 20 to 30 years prior to 19 14. In view of what has been said on the matter of age distribution among immigrants and the fact that y2.y per cent of admissions in one year were foreign-bom, any seeming disproportion of insanity among Jews in the United States, particularly in New York, where most Jews live, must be discounted.^ The further fact that nearly all Jewish immigrants settle in the cities, especially in the congested sections of the large seaboard communities, should render judgment still more cautious. From all available facts, the only conclusion that can be drawn indicates that there is no greater proneness toward mental disease in the foreign-bom than in the native popula- tion and that the excessive proportion of hospital admissions furnished by the foreign-born is due to other causes. IX. AGE DISTRIBUTION Table 12 indicates the age distribution of the patients ad- mitted. In interpreting the figures it should be remembered that the several chnical groups differ widely with respect to age distribution on admission. The senile and arterioscler- ' U. S. Census, Population, vol. i, p. S 9 I 3 7 5 4 4 2 2 70 9 4 6 13 z Organic Nervous Disease .... I Cerebral Hemorrhage I 14 9 5 36 Infection Exhaustion Psych. - Paranoid Condition 3 s Constitutionally Inferior 6 1 1 Depression Undifferentiated. . Transitory Confusion Unclassified .... 5 7 5 6 Totals '38 208 serious relapse within a short time, with commitment to a state hospital the only alternative. XVII. DEATHS IN PSYCHOPATHIC WARDS Nineteen patients died in tlie psychopathic wards, 13 males and 6 females. A number of these had been trans- ferred from other wards in the hospital in which they had become unmanageable and a disturbance to the other patients in the wards with them. Table 1 7 indicates the cause of death : 1 10 SOCIAL ASPECTS OF TREATMENT OF INSANE [252 Table 17. Diagnosis of Deaths Male. 4 I 2 2 2 I I Female. Totals. 3 7 2 2 Infection Exhaustion Pulmonary Tuberculosis 2 2 Tubercular Meningitis Pleurisy Blood Poisoning Cerebral Spinal Lues I I I I Totals >3 6 19 XVIII. SUMMARY In this chapter the aim has been not merely to present the statistics deaHng with the psychopathic ward admissions, but also thereby to indicate the many needs that must be met ere a more effective policy in dealing with mental cases in New York City and State can be evolved. The problem is not a simple one nor easy of solution, as the mere dif- ficulty in obtaining or agreeing upon an adequate and satis- factory definition as to what constitutes mental alienation or insanity has shown. Psychiatry is of recent origin and the human ills it aims to help and to cure are manifold. Still, with the information already at hand, and the augmen- tation thereof that we may look forward to, it is not too much to ask nor yet to expect that those who are in the service of the state in this particular field shall assist the community not only to return those of unsound mind to a condition of sanity, but shall also take the lead in educating the public to a fuller understanding of the causes, preventa- tives and cures of insanity, as far as available scientific knowledge will permit. CHAPTER III Results of State Hospital Care and Treatment i. need and provisions for scientific study of insanity Scientific observation and experience form the firm founda- tion upon which the whole question of the care of the insane is based. Every step forward — and many steps backward — in the care of the insane are more or less closely related with the medical conceptions regarding the existence and the causes of insanity. It has become more and more the duty of the state to foster scientific investigations in the hospitals for the insane. In this respect psychiatry has long enough been treated as a stepchild. Although our old asylum physicians afford brilliant examples of what can be accomplished with very inadequate means in the attainment of high scientific ideals, the state has only recently recognized that a healthful progress in the care of the insane is not possible without a continuous development of scientific work.^ Thus wrote Kraepelin of the development of experimen- tal and laboratory work and research in his native country, and his words may very properly be applied to conditions as they have existed and still exist with but few exceptions, in the United States. To meet just this problem as well as to centralize research aiming to achieve a better understand- ing and knowledge of the etiology of the various forms of insanity, and likewise to discover cures therefor, the State Hospital Commission (at that time the State Commission in 'Quoted by Drewry, Wm. F., " Care and Condition of the Insane in Virginia," Nafl. Conf. of Char, and Con. Report, igo8, p. 307. 253] 111 112 SOCIAL ASPECTS OF TREATMENT OF INSANE [254 Lunacy) in 1896 organized the Pathological Institute, now known as the Psycliiatric Institute. This agency through its medical officers acts as the standardizing factor in the state hospital system, instructing thq physicians in the several hospitals in the application of a standard classifica- tion of the psychoses, in the organization of the clinical or out-patient service as well as of the staff meetings, in the work of the pathological laboratory, and also in the compila- tion of the medical statistics.^ Though all of this work is important, the institute is greatly hampered because of the lack of a sufficiently large appropriation with which to carry on necessary and extensive investigations, the allotment tO' this division of the state hospital system for the year 19 18 having been only about $28,000,- a smaller amount than was appropriated for this work twenty years ago.* One of the prime necessities for scientific research in the field of mental diseases is a sufficiently large and varied number of patients, presenting many forms of mental alienation, together with a wide range in social status, en- vironment, occupation, nationality, etc. In the New York State Hospitals for the insane there were under treatment on June 30, 191 8, 33,868 patients supported wholly by the state, 3,303 reimbursing patients, and 181 private cases, making a total of 37,352.* probably the largest number of patients under institutional care in any state in the country. Since the thirteen civil state hospitals are located in different 'S. H. C, 30th A. R.. 1918, p. 144- ^ Ibid., p. 267. "Ibid., p. 267. The largest amount appropriated was in 1899, when 136,000 was granted; the largest amount spent was in 1897, $40,058.28. Since then the appropriations as well as the expenditures have been between $20,000 and $30,000 per annum, except in 1900, when $35,155.53 was spent, though only $20,000 was originally appropriated. ♦ S. H. C. 30th A. R.. p. 327- 255] -ST^TE HOSPITAL CARE AND TREATMENT 113 parts of the state, each receiving patients from the district in which it is situated, there is sufficient laboratory material upon which to draw for scientific purposes. Insofar as the factor of different nationaHties represented among the patients is concerned, it might be interesting tO' note that there were almost forty countries which contributed to the insane population of the New York hospitals, though the native-born in these hospitals for the year ending June 30, 1918 were over half of the total, namely 55.5 per cent.'' Considering this wealth of clinical and pathological material, as well as the large number of specialists engaged in the care and treatment of these 37,352 patients, it would seem that much information of a helpful and serviceable nature in effecting recoveries of insane persons should be forth- coming from those associated in the psychiatric, psychologic and pathologic work in the New York State Hospitals. These institutions, rated among the best of their kind in America, have not, however, witnessed the issuance from within their walls of contributions of unusual worth in the field of psychiatry, nor in the other branches, namely, psychology or pathology. This failure has not been alto- gether, if at all, the fault of the psychiatrists and others who should rightfully have been expected to- carry on researches of particular scientific importance. It has rather been due, as pointed out above, to the failure on the part of the state to appropriate sufficient money for the work of the psychia- tric institute, and furthermore, to still another factor — the overcrowding which has existed in the state hospitals for many years, with the concomitant shortage of physicians, nurses, laboratory technicians, attendants, etc. It is to thisi latter problem in particular that practically all hospital superintendents have had to devote much of their time, for 1 S. H. C, 30th A. R., p. 292. 114 SOCIAL ASPECTS OF TREATMENT OF INSANE [256 wkh little extension of building operations during the past few years and with an ever increasing population and a pro- portionate increase in the number of cases of insanity com- mitted to the already overcrowded state hospitals, the prob- lem has become more aggravated each year.^ II. OVERCROWDING The following table indicates the overcrowding of the state hospitals as conditions existed on June 30, 1918.'- Table 18. Overcrowding in the State Hospitals Population June 30, 191 8, Excluding Paroles. Rated Capacity. Overcrowding. Hospitals. No. Per cent. 2,701 884 2,202 5.040 1,281 3,428 4,479 5,327 2,181 1,541 2,285 1,687 2,426 2,400 637 1,700 4,100 950 2,850 3,500 4,250 1,800 1,260 1,950 1,400 2,200 301 247 502 940 331 578 979 1,077 381 281 335 287 226 12.5 38.8 29-5 22.9 34-8 20.3 28.0 Buffalo Central Islip Hudson River Kings Park 25-3 21.2 22.3 17.2 20.5 10.3 St. Lawrence Utica Willard Totals 35,462 28,997 6,465 22.3 There appears but little possibility of lessening the over- ^ Page, Charles Whitney, The Care of the Insane and Hospital Man- agement, 1912; presents a discussion of the method to be followed in choosing a superintendent, his qualifications, duties, his official relation to officers and employees, etc. ' S. H. C, 30th A. R., p. 235. Also Hastings, George A., " Some Essentials of a State Program for Mental Hygiene," State Char. Aid Assn. Publuation, no. 146, pp. 11-14. 257] ^'^^'^E HOSPITAL CARE AND TREATMENT 115 crowded conditions before plans thus far developed by the Hospital Development Commission are carried oiit.'^ Among the more important recommendations of the com- mission are : A new state hospital at Creedmoor ; enlarging, the hospitals in and near New York City; securing a site for a new hospital in the metropolitan district in place of the abandoned Mohansic institution; the establishment of a psychopathic hospital in New York City; completion of a state hospital at Marcy near Utica ; a more orderly method of making appropriations; better planning of institutions, and more preventive and research work." III. EXTENSION OF OBSERVATION PERIOD Still another factor in the overcrowding of the state hos- pitals has been the shortness of the detention period in the observation wards of the municipal institutions. Patientsi brought to the psychopathic wards of Bellevue and other hospitals are not kept there for a sufficient length of time to^ permit those suffering from slight attacks tO' recover prior to their commitment to a state hospital.^ The reasons for this are two- fold; in the first place, the officers of the obser- vation or psychopathic wards, particularly of the largest among them, Bellevue, to which came the cases considered in this work, have for a number of years been facing the same difficulty as the state hospitals, to wit, lack of suffi- cient accommodations. Were it possible to detain a number of the so-called hopeful cases for ten days or more until they had recovered from the attack which caused them to be 1 Survey, Jan. 26, 1918, p. 467, " Crowding in the Insane Hospitals." » S. H. C, 30th A. R., pp. 225-22^. 'Mason, Frank H., " Modern Hospital for the Insane," Daily Consular Reports, Dept. of Commerce and Labor, no. 2264, May 22, 1905; gives an illustrated description of the reception hospital erected by the city of Munich, Germany, for the temporary care and treatment of incipient cases. Dr. Emil Kraepelin was appointed director of this hospital. Il6 SOCIAL ASPECTS OF TREATMENT OF INSANE [258 brought to the psychopathic ward, in the majority of such cases commitment to a state hospital might have been avoided. It is quite apparent that such a plan would in practice amount to a working out of the psychopathic hospital idea within the limited confines of wards in muni- cipal hospitals. xAjiy means employed tO' decrease the crowded conditions of our state hospitals and at the same time aid in the early recovery of a number of patients would be welcomed by all interested in the proper care and treat- ment of the insane. The second reason for the short dura- tion of the observation period lies in that provision of the Insanity Law which reads as follows : " In no case shall any insane person be confined in any other place than a state hospital or duly licensed institution for the insane, for a period longer than ten days."' This of course makes it impossible for any municipal hospital maintaining a psycho- pathic service to detain an insane or alleged insatie person longer than the period of time prescribed in the law, though an extension of this period, if limited to cases indicated, would undoubtedly result in much benefit. Table 19 indicates that 47, or about 6 per cent of the patients were transferred to state hospitals within 24 hours after their arrival in Bellevue Hospital. It should be pointed out, however, that most of these were cases that were out on parole from one of the state hospitals and had been brought to the psychopathic wards of Bellevue Hos- pital for transfer to the institution from which they had been paroled. Among the others were a number whose parole period had expired and who had suffered a recurrent attack, necessitating their re-commitment to the state hos- pital, usually to the one in which they had been previously confined. There were 172 who were transferred within two days, 192 in three days, 129 in four days, giving a total * Oiap. 27 of the Consolidated 'Laws, " The Insanity Law," sec. 87. 259] STATE HOSPITAL CARE AND TREATMENT 117 Table 19. Number of Days Spent in Psychopathic Wards of Bellevue Hospital Prior to Commitment to State Hospital No. of Days. I 2 3 4 5 6 7 8 9 10 Over 10 Totals Manhattan. er cent transferred within four days from the time of admission ; 83 were detained five days, making the percentage 78.8 per cent of the total kept in the psycho- pathic wards less than one-half the maximum time allowed by law. Most of the 1 5 who were kept in the psychopathic wards over ten days were remanded to the hospital by some court for observation and examination, and the ensuing complications resulted in their detention one or more days beyond the ten-day period; the few remaining cases could not be transferred to a state hospital within ten days be- cause of their mental or physical condition, or both. Dr. Henry Maudsley was among the first to propose the erection of an observation hospital for the treatment of in- cipient mental cases in London. The purposes of this hos- pital were to be largely those assigned to psychopathic hos- pitals at the present time. In smaller communities, how- Il8 SOCIAL ASPECTS OF TREATMENT OF INSANE [260 ever, where institutions of large size are unnecessary, psy- chopathic wards in the local general hospitals would often be the means of preventing insanity and accomplishing the early recovery of incipient cases, provided, of course, that the law was changed to allow a longer detention period than is at present prescribed. Among the states making specific mention in their laws of the length of time patients may be kept in observation or psychopathic wards, California provides that the board of supervisors of each city or county must maintain a room or rooms suitable for the detention, care and treatment of alleged insane persons, for a period of not more than twenty days/ The District of Columbia permits the detention of such persons in the government hospital for the insane or in any other hospital for a period not exceeding thirty days." Michigan allows for the detention in au}^ hospital, home or retreat for not more than thirty days, except by special order of the court. ^ In the State of Pennsylvania, persons suffering from mental disorders may be committed for not more than thirty days to the psychopathic wards of hospitals for observation and treatment in the same manner as per- sons are committed to hospitals for the insane ; but persons admitted to these wards who are found insane must be re- gularly committed and removed to a hospital for the insane within thirty days.* Some of the more important advant- ages of such an extended period over the ten days allowed by law in New York State, may be summed up as follows : ^ ^Political Code of California, 1905, as amended by Lazvs of 1909. chap. 65, sec. 2167. ^Revised Statutes of the United States, Act of 1904, 33 Stat. 316. 3 Lazi's of 1909, pp. 16, 185. *Laws of 191 1, chap. 855, sec. 2. ^Briggs, L. Vernon, "What can be done for the Prevention of In- sanity by the Treatment of Incipient Cases in General Hospitals," Amer. Jo. of Ins., April, 191 1, p. 660. 26l] STATE HOSPITAL CARE AND TREATMENT ng 1. The incipient case would have the advantage of im- mediate expert care by members of the hospital staff in every branch of medicine and surgery. 2. He would have the advantage of a large hospital nurs- ing staff instead of attendants. 3. The social considerations after recovery are most im- portant to patients, many of whom would thus be saved from being placed in an insane asylum, IV. PRIVATE SANATORIA AND HOSPITALS There were in the State of New York in 1918 a total of twenty-four private licensed institutions* with a licensed capacity of 1,522 patients. It is these asylums or retreats which serve the purpose of wards in general hospitals, but they are only within the reach of those whose relatives or friends are in a position to pay from $25.00 to $100.00 or more a week. Many incipient cases are discharged as re- covered or improved within a few weeks from these private institutions, in which they have been given much individual attention, more than could possibly be accorded them in the state hospitals. This does not of course mean that the state hospitals are failing to effect cures, but rather that for in- cipient cases some institutions other than state hospitals are at present prepared to render better service, and hence in- crease the ratio of recoveries, because of proportionately larger staffs, better equipment, and less overcrowding. The psychopathic wards or " Pavilion F " of the Albany Hospital are rendering a service that many of the similar institutions throughout the state should be prepared and equipped to give. ' This is a private institution maintained for charitable purposes and those treated there are required * " The Insanity Law," art. 3, sec. 59. ' Mosher, J. M., " The Treatment of Mental Disease in a General Hospital," The Modern Hospital, Nov., 1915. 120 SOCIAL ASPECTS OF TREATMENT OF INSANE [262 to pay or to be paid for by relatives or friends, if they pos- sess the means; the charges include the usual and rather moderate amounts asked for the care of the patients and for the payment of private nurses, if such are found to be neces- sary.^ The development of psychopathic hospitals in the large cities, of psychopathic wards in'general hospitals in the smaller cities of the state, and an extension of the ten-day detention period, would prove to be important elements in the reduction of the number of committed cases, in lessening! the overcrowding of the state hospitals, and in markedly in- creasing the early recovery of incipient cases of mental disorder. V. CLASSIFICATION OF PATIENTS AT STATE HOSPITALS In the preceding chapter it was pointed out that of those admitted to the psychopathic wards of Bellevue Hospital during one year, the following number of patients were committed to state hospitals: Male. Female. Totals. To Manhattan State Hosp. .. To Central Islip S. H To Kings Park S. H 252 184 4 201 147 2 453 331 6 Totals 440 350 790 Upon arriving at the state hospitals, the patients are as a rule sent to the reception wards or buildings, in which they are detained until properly diagnosed and classified. The superintendents of state hospitals have for a long time made 'Mosher, " Need of Early Treatment for Mental Diseases," Amer. Jo. of Ins., Jan., 1909, pp. 501-503; Drury, William F., Evolution of Psychiatry, 1904, p. 42. 263] STATE HOSPITAL CARE AND TREATMENT 121 efforts to promote and carry out a greater uniformity in classification according to age, nationality, education, station in life and diagnosis of those assigned to particular wards/ However, the overcrowding in all the hospitals, the large wards and the insufficiency of the staffs have made it well- nigh impossible to carry out these plans, except insofar as relates to placing patients in wards according to diagnosis, behavior, and the acuteness or chronicity of the ailment. In planning one of the large state hospitals in New York some years ago, the medical superintendent submitted plans which called for a number of cottages, each with a capacity of twenty-live patients, the purpose in mind being to per- mit the classification of the patients along the lines outlined above. When the total outlay for erecting and maintaining such a cottage system was estimated, the amount necessary was found to be far greater than the state had appropriated for the new institution and intended to allow for mainten- ance and upkeep from year to year. The result was that in- stead of erecting separate cottages with accommodations for not more than thirty patients, buildings housing from 125 to 150 patients were erected, with less satisfactory pro- visions for the separation and classification of the different groups in the hospital population. VI. OCCUPATIONAL THERAPY AT STATE HOSPITALS After the assignment of patients to their wards, an at- tempt is made to give them some form of occupation suitable to their particular needs and requirements. Several clas- ses for the reeducation of the patients are maintained in most of the hospitals, though the total number of patients benefiting from such instruction is small. Thus, in 191 8, in the Manhattan State Hospital, with about 5,500 patients in the wards, there were only 1 50 who received instruction ^ State Hospital Quarterly, Aug., 1919, p. 439. 122 SOCIAL ASPECTS OF TREATMENT OF INSANE [264 in the arts and crafts classes/ In a survey made of the Manhattan State Hospital by the New York State Depart- ment of Efficiency and Economy, it was reported that the institution obtained excellent production from the land under cultivation, as well as from the hospital industries. This statement in itself is not sufficient evidence of the efficiency of industrial departments in the hospital, for it fails to take into consideration the number or percentage of inmates employed in these industries, even though it seem- ingly makes allowance for the high per capita production. Mention is made of the fact that of 245 arable acres only 66 acres were under cultivation at the time the study was made.^ The possibility of providing occupational therapy for a larger percentage of the patients under treatment is in- dicated by the experiences of the Bloomingdale Hospital at White Plains, where, with a total of 437 patients in 1918, there was a daily average attendance of 97 patientsi in the departments of occupational therapy, in which a large variety of occupations are taught.^ The marked difference between conditions at the Manhattan State Hospital and the Bloomingdale asylum is due to a number of reasons, among them being the difficulty experienced in trying to educate certain types of mental cases, of which larger numbers are to be found in the state institutions than at Bloomingdale, which proportionately treats a larger number of cases oi manic depressive insanity, and a smaller number of cases of senility, general paralysis, and dementia prae- cox : the lack of a sufficient number of properly trained sup- 'S. H. C, 30th A. R.. p. 201. *McCalmut, M. E., Report of the New York State Dept. of Efficiency and Economy, "Organization and Administration of New York State Hospitals for the Insane," 1915, p. 418. ^Annual Report, Society of the New York Hospital, 1918, pp. 11- 12. 265] STATE HOSPITAL CARE AND TREATMENT 123 ervisors and teachers of trades ; the failure of the state hos- pitals to develop a definite policy regarding the training and education of the patients, and also the large number and variety of trades and occupations represented among the patients in the state institutions. Considering only the 790 patients dealt with in this work, the diversity of employment prior to admission to the state hospitals is evident from the followinsf tables : Table 20. Occupations of Males Actor I Agent 4 Artist I Auctioneer i Author I Baker 2 Barber 2 Bartender ■ i Bookbinder 2 Bookkeeper 8 Brass worker 2 Brushmaker i Butcher 3 Button hole maker i Buttonmaker i Canvasser i Capmaker 3 Caretaker i Carpenter 3 Chauffeur 2 Chemist i Cigar maker 7 Clerk 42 Cutter 9 Deck hand i Designer i Dishwasher i Draughtsman i Driver 5 Electrician 4 Embroiderer 2 Engineer R. R. I Factory hand 3 Farmer I Florist I Furniture maker i Furrier 2 Gasfitter i Grocer 2 Hairworker i Harnessmaker i Hatmaker i Helper i Insurance agent i Interpreter i Ironworker 3 Janitor i Jeweler 2 Junk dealer 2 Laborer Z7 Laundry worker i Letter carrier I Longshoreman 2 Lunchman i Machinist 6 Manager i Manufacturer i Mechanic 2 Mechanical dentist 2 Messenger 1 1 Motorman i Musician 2 Newspaper illustrator i Operator 26 124 SOCIAL ASPECTS OF TREATMENT OF INSANE [266 Packer 4 Painter 9 Paper-box maker 4 Paper roller 1 Peddler 17 Photographer 3 Pipemaker i Plumber i Pocketbook maker 1 Porter i Presser 9 Printer 11 Salesman 32 School pupil 7 Sheet metal maker 2 Shoemaker 4 Singer i Soda dispenser i Soldier 6 Special officer i Stenographer i Storekeeper i Student 3 Street car conductor I Suspendermaker i Tailor 35 Teacher 3 Telegraph operator I Telephone operator I Ticket speculator I Tinsmith 3 Truckman I Upholsterer 3 Watchmaker 2 Waiter 7 Window cleaner 3 No occupation 22 Totals 440 Table 21. Artificial flower maker . . . Bookbinder Bookkeeper I I .. 5 Capmaker i Cashier i Cigar-box maker i Clerk 7 Clothes cleaner i Doll maker i Domestic 8 Dressmaker 11 Envelope maker i Errand girl i Factory hand 4 Glove maker i Housework 185 Interpreter 1 Jewelry dealer i Laundress 2 Leather goods worker i Occupations of Females Milhner 5 Model I Musician 2 Neckwear 2 Needlework i Operator 29 Paper box maker 4 Peddler i Pocketbook maker I Salesgirl 2 School pupil 8 Seamstress 2 Stenographer 13 Teacher, music 3 Waist examiner 4 Waitress i Watchmaker I No occupation 35 Totals 350 The above tables indicating the list of occupations of both 267] STATE HOSPITAL CARE AND TREATMENT 125 males and females show that it would be impossible as weU as impracticable to establish industries within the hospital walls and grounds akin to those in which the patients were engaged prior to commitment. It is quite apparent from a perusal of these lists that there are many trades and oc- cupations which are not listed here, simply because among" the patients considered certain industrial and commercial! activities are not as common as among other people. Thus, among the males, there is to be found but a small number of patients who were employed in the building and mechanical lines, whereas there is a comparatively large number re- presented among the clerks, salesmen, tailors, clothing operators, and kindred or allied trades. The same differ- ence is also found among the females. There were only eight domestics, though a considerable number of the single yotmg women were foreign bom, and a large number in the needle trades. The 185 patients indicated as being engaged in housework represent married women caring for their own households, not leaving their homes to become domestics or servants in the homes of others. The intent and purpose of the discussion of the trades and occupations of the patients will become more apparent in the last chapter of this work, for there thought will be given to ways and means of providing gainful occupation for dis- charged and paroled patients, as well as for those who may under unfavorable circumstances and conditions become so ill mentally as to make their commitment to a state hospital advisable. As pointed out above, the aim has also been to indicate the inadequacy of present accommodations and provisions in the state hospitals for the therapeutic treat- ment of patients through a sufficiently varied and interesting scheme of light occupations. 126 SOCIAL ASPECTS OF TREATMENT OF INSANE [268 VII. READMISSIONS TO STATE HOSPITALS One very important way properly to gauge the efficacy of the care and treatment accorded patients in state hospitals is to consider the proportion of patients that find it neces- sary to return to the hospitals from which they have been discharged or paroled, or taken home by relatives. There are necessarily a number of factors that enter into such a consideration, among them being the over-crowding in the hospitals, the ratio of officers, nurses, and attendants to the number of patients, diagnoses of the patients permitted to leave the hospital, and ease with which patients may be returned to the institutions. Of the 8,700 total admissions to the state hospitals for the year 1918, 6,797 O'^' 7^-^ P^^ cent were first admissions; 1,903, or 21.9 per cent were readmissions.^ There was a marked difference between the readmission rates among the sevettkUiospitals ; the Brooklyn State Hospital had a readmission percentage of only 16.7, largely because of the disproportionate number of senile cases quartered there, whereas there was a percentage of 28.4 of readmissions in the Middletown State Hospital.^ The readmission rates for the two hospitals which figure largely in this study, namely Manhattan and Central Islip State Hospitals, were 18.9 per cent for the former, and 21.4 per cent for the latter. Table 22 indicates the readmissions to the state hospitals of the Jewish patients, who were ad- mitted to these institutions from Bellevue Hospital during the year beginning September i, 191 7 and ending August 31, 1918: > S. H. C, 30th A. R., p. 278. *Ibid., p. 343. 269] STATE HOSPITAL CARE AND TREATMENT 127 Table 22. Number of Readmissions to State Hospitals No. of Admissions. 1 2 3 4 6 7 12 Totals Central Islip, 106 61 13 4 184 99 33 10 5 147 Manhattan. 180 58 13 I 252 127 60 9 2 I I I Kings Park. Totals. s 286 226 123 26 95 19 5 7 I I '• I 440 350 There were 512 first admissions and 278 readmissionsi to the three state hospitals tO' which the patients were com- mitted, showing a readmission rate of 35.2 per cent for the Jewish cases sent to these institutions from Bellevue Hos- pital. This percentage is considerably higher than the rate for the entire state hospital system, and also higher than the rate of readmissioins to^ the Manhattan and Central Islip State Hospitals. In view of these facts, it might be advisable to consider in brief the elements that possibly con- tributed to this greater percentage of readmissions among the group studied in this work. Several reasons have already been assigned for the return of patients to hospitals after they have once been discharged either as recovered or in an improved condition. There are, however, more specific and definite factors that can be held responsible for the high rate of readmissions that have been shown to be prevalent among the Jewish patients ad- mitted to the state hospitals. It has been contended by some students of the subject that the cause of the larger pro- 128 SOCIAL ASPECTS OF TREATMENT OF INSANE [270 portion of readmissions among Jewish patients could be assigned almost entirely to the disproportionate number of certain of the psychoses appearing among these patients, particularly dementia praecox in all its variations, and also the several forms of manic depressive insanity/ (a) High Readmission Rates Among Jewish Patients. In order to find what is probably the cardinal reason for the high readmission rates among the Jewish patients, it will again be necessary to revert to the figures for the state hospitals so as to have a basis upon which to make an ac- curate comparison. For the state as a whole, the per cent distribution among readmissions for the year 19 18 was as follows : for dementia praecox the rate for the entire state was 31.2 p€r cent, with rates of 37.3 per cent for Manhattan State Hospital, and 35.0 per cent for Central Islip State Hospital; for manic depressive readmissions the rate was 36.5 per cent for the state as a whole, 36.6 per cent for Man- hattan State Hospital and 33.1 per cent for Central Islip State Hospital.^ From the percentages presented in Table 23 it is seen that the Jewish patients contributed, in fact, a smaller percentage of readmissions of cases of dementia praecox than either the state as a whole or Manhattan and Central Islip State Hospitals, while they seemingly were responsible for a higher readmission rate among the cases of manic depressive insanity than that which prevailed throughout the state, or in Manhattan and Central Islip State Hospitals. In reference to the latter group, the rate of readmissions to the Manhattan State Hospital for the preceding year, namely 191 7, was likewise 41.8 per cent, identical with the rate of Jewish readmissions for the year 1 918. Table 23 indicates the percentages in summarized form: i;S. H. C, 30th A. R., p. 376, for discussion of readmissions to all state hospitals. *Ihid., p. 294. 271] STATE HOSPITAL CARE AND TREATMENT 129 Table 23. Distribution of Certain Psychoses Among Readmissions Manic Depressive Insanity. Allstate Hospitals- .. Manhattan S»ate Hosp Central Islip S. H.... Jewish cases 36.5 36.6 41.8 Judging from the facts and figures presented above, it is seen that the high rate of readmissions among the Jewish patients as compared with the rate of readmissions to all the state hospitals cannot be ascribed to a higher rate of readmissions among the cases diagnosed as suffering from either dementia praecox or manic depressive insanity. The variation in the percentages of certain psychoses, particul- arly dementia praecox and manic depressive insanity, as shown in the statistics for all the state hospitals for a five year period indicate such a wide divergence,^ that the only safe method that may be pursued in arriving at comparative figures is to take only the percentages for the hospitals to Mrhich the Jewish patients were admitted in large numbers. Following along these lines, the readmission rates to the Manhattan and Central Islip State Hospitals, as shown in Table 23, should be those which alone might properly be used to arrive at a just comparison. Even then, the Jewish patients as already explained, show up favorably when com- pared with the total readmissions, though they have a higher readmission rate among the cases of manic depres- sive insanity. The variation in the basis for diagnosisi among the different hospitals, the marked difference between the reported percentages of certain of the psychoses among the several hospitals, despite the attempts of the staff of the 1 S. H. C, 30th A. R., p. 294. 130 SOCIAL ASPECTS OF TREATMENT OF INSANE [272 Psychiatric Institute to standardize the methods used in arriving at diagnoses for particular groups of cases, indicate that the statistics as thus far presented cannot be taken at full face value, at least insofar as the diagnoses of a large number of cases which may be classified as borderline are concerned. VIII. REASONS FOR HIGH READMISSION RATES The reasons for the higher rate of readmissions among the Jewish patients than among the others committed to the state hospitals are as yet unexplained, though a higher rate of readmissions among those patients diagnosed otherwise than dementia praecox and manic depressive insanity, may in part cover the added percentage of these readmissions. The importance of the question of a higher rate of readmissions! among Jews involves even more fundamental matters than that of distribution of patients according to diagnosis. It again raises the question discussed in another connection, namely, the effect of a proper classification of patients ac- cording to social, racial, language, etc., groups, upon the percentage of recoveries. An indication of some of these difficulties encountered by the staff of workers in the wards is the statement recently made to the writer by a physician in one of the largest state hospitals. He remarked that he had in one of his wards a group of fifty patients whose language was entirely alien to him as well as to the nurses and attendants on the ward. The result was that these patients did not receive the atten- tion that should have been bestowed upon them by the doctor and others in heli>ing them to improve and ultimately to recover. This condition is particularly applicable to the Jewish patients of foreign birth, though the hospital authorities have tried to do all they could to remove such hindrances to the well-being and recovery of the large 273] STATE HOSPITAL CARE AND TREATMENT 131 number of noii-'English speaking charges under their care. The question of agreeable and palatable food is a matter which applies particularly to Jewish patients, most of whom have been brought up in homes where the Jewish dietary- laws are observed, for the eating of food that is not pre- pared according to these laws is more or less obnoxious. The result is tliat patients who understand the difference, among them being a large number of those ultimately paroled or discharged, demand of their relatives that steps be taken leading to their release from custody, often before they are sufficiently recovered to insure against a relapse. In the long run such premature discharges necessitate read- mission to the hospital. Assuming that the reasons for the high readmission rates among the Jewish patients can be ascribed to the causes just outlined, as well as to the fairly large number oif cases of manic depressive insanity that have to be returned to the hospitals, the thought comes to mind that there must be some way or ways of so altering the present methods of dealing with the insane cared for in state institutions, that high readmission rates may be materially reduced. Several methods are obvious from the discussion of the subject, such as introducing into the hospitals physicians and nurses as well as attendants who understand the languages spoken by large groups of patients oi foreign birth ; applying a more thorough and selective classification to all the patients, sup- plying "kosher" kitchens in the hospitals in which large numbers oi Jewish patients are cared for, etc. The im- possibility of doing these several things at the present time because of the overcrowded conditions in the hospitals hag already been touched upon, and nothing can be done along these lines until plans already prepared for the further ex- tension of the facilities of the state hospitals are sufficiently matured to furnish a basis for further suggestion and criti- cism. 132 SOCIAL ASPECTS OF TREATMENT OF INSANE [274 IX. MOVEMENTS FOR ESTABLISHMENT OF JEWISH PSYCHO- PATHIC HOSPITALS Referring particularly to Jewish patients, movements have been set afoot in New York City aiming at the estab- lishment of a hospital for the mentally sick Jews whose diagnosis indicates a prognosis of possible recovery or at least of improvement so marked in both physical and mental conditions, as to render it advisable to care for and treat such patients in an institution resembling in plan and scope the psychopathic hospitals of Boston and Baltimore. Many members of the Jewish community in New York who have given this matter thought seem to agree that such an in- stitution would not only be of much service to those unfor- tunates among the Jews who become mentally unbalanced, but would at the same time effect a higher proportion of cures, reduce the expenditure of state money, and also act as an experimental station for the study of various phases of the problem. The plans for such a hospital have not as yet progressed sufficiently to make it advisable to pass judg- ment upon the matter. However, it is safe to state that any project is worthy when its purpose is to reduce human suf- fering which is involved in the loss of the power to reason and to live the life of a rational being. Mental hygiene agencies have been at work in New York City as well as in different parts of the country for some years past, their activities being almost altogether limited to extra-institu- tional care of those who are either in danger of a mental breakdown or are discharged patients from state or private institutions for the insane. The possibilities for good work inherent in these organizations or societies for the social care of the insane will be dealt with at length in a subsequent chapter. 275] STATE HOSPITAL CARE AND TREATMENT 133 X. DIAGNOSIS OF ADMISSIONS TO STATE HOSPITALS Mention has already been made of the difficulties en- countered in attempting to supply an adequate definition o£ the term " insanity," and of the disagreement among stud- ents of psychiatry regarding a proper scheme or system of classification of the forms of mental alienation. These per- plexities extend to the field of diagnosis of mental cases as well ; in the tables that follow there will be found indica- tions of a marked variance in the number of cases diagnosed and classified under particular divisions, in the ratio' of casesi reported as recovered and improved, etc., even in the statis- tics for two of the largest of the metropolitan hospitals. As long ago as 1874 Maudsley wrote: It would certainly be vastly convenient and would save a world of trouble, if it were possible to draw a hard and fast line, and to declare that all persons who were on one side of it must be sane and all persons who were on the other side of it must be insane. But a very little consideration will show how vain it is to attempt to make such a division. That nature makes no leaps, but passes from one complexion to its opposite by a gradation so gentle that one shades imperceptibly into another, and no one can fix positively the point of transition, is a suffi- ciently trite observation. Nowhere is this more true than in respect to sanity and insanity; it is unavoidable therefore that doubts, disputes, and perplexities should arise in dealing with particular cases.^ Since this statement was originally written psychiatry has advanced in leaps and boimds, and more scientific methods of diagnosis have been evolved; however, the possibility of erring on the part of the individual making and record- ing observations is well known, particularly in the proper interpretation of given facts. The engagement of expertsi ^ Maudsley, Henry, Responsibility in Mental Disease, 1874, pp. 38-39. 134 SOCIAL ASPECTS OF TREATMENT OF INSANE [276 in the diagnosis of mental diseases by both sides in murder cases, and the usual conflicting testimony is a state of affairs which has existed for a long time and doubtless will continue, so long as the standards according to which diag- noses of mental disorders are made, are not sufficiently de- veloped to remove much of the possibility of error of judgment. XI. RESULT OF ONE YEAR OF STATE HOSPITAL CARE It may be affirmed without fear of contradiction that no principle in psychiatry is more firmly established than the fact that early treatment of the insane based upon a correct analysis of the physical and mental conditions is the key to success.^ The figures in the following tables represent in a way the gauge by which we can measure the ability of the state hospital staffs properly to diagnose patients, and of the hospitals to provide the proper standards of care and treat- ment. Table 24. Disposition of Patients by State Hospitals Disposition. Remaining in Hospital . . . Recovered Discharged. . • . Much Imp. and Imp. Disch Unimproved, Discharged.. Died in Hospital Deported to other State. . . Not Insane Totals Central Islip. Manhattan. Tot «J V OS V at CS a a s C4 s Ui S fe s 101 62 127 93 228 21 25 7 10 28 39 41 57 64 96 4 4 10 3 14 18 13 49 27 67 I I I 4 2 I I I 184 147 252 201 436 155 35 105 7 40 5 I 348 * Warner, Chas. G., "Reception, Examination, and Care of New Ad- missions," Amer. Jo. of Ins., 1916-1917, p. 673. ^-^y^ STATE HOSPITAL CARE AND TREATMENT 135 Table 24 indicates the disposition of the patients ad- mitted to the state hospitals, and the result of the care and treatment given to these patients during the period of one year. These figures show that at the end of the first year of care and treatment in the two state hospitals mentioned above, of the total admissions, there were 163 or 49.2 per cent of the patients still under care in Central Islip State Hospital, and 220 or 48.5 per cent in the Manhattan State Hospital. A word should be said at this point regarding the figures for Kings Park State Hospital; the admissions to this institution from Bellevue Hospital are altogether cases which have suffered a relapse and which it is found advisable to return to the institution where they have pre- viously been confined. Also, the number of such patients for the entire year is so small that no dependable statistics can be drawn up. The table that follows points out the rate of recovery and improvement of patients committed to the Central Islip and Manhattan State Hospitals : Table 25. Rate of Recovery and Improvement of Patients State Hospitals. Central lilip Manhattan ■ • Recovered. No. 2546 1017 Per cent of Total Admitted. 1 1.4 2.7 ^ Much Improved and Improved. No. i7-0| »3-9 4-9l 3-8 80 121 Per cent of Total Admitted. 6 4J H iS-7 27.9 24.1 22.6 31.8 27.2 136 SOCIAL ASPECTS OF TREATMENT OF INSANE [278 The general average rate of recovery based on all admis- sions was 19.4 per cent for the year 191 8, the rate for the males being 18.2 per cent and for the females 20.7 per cent.^ From the figures presented above, it is quite evident that the recovery rate for the Jewish patients was unduly small, for while the per cent of the total admissions re- covered for Central Islip was 20.3, for Jewish patients it was only 13.9 per cent; and whereas the rate of recoveries for Manhattan State Hospital for the year 1918 was 15.1 per cent, for the Jewish cases it was only 3.8 per cent, an abnormally low figure. The question naturally arises as to why there should be such a marked discrepancy between the rate of recovery for all patients and the rate for a partic- ular group. Some reasons have already been given, though in connection with the discussion of another phase of the subject. To recapitulate, it might be well to mention the fact that so many O'f the Jewish patients who find their way into the state hospitals do not speak English sufficiently well to per- mit the physicians who care for and treat them in the hospitals to recognize when the patients have recovered. The result is that a number of Jewish patients are dis- charged as improved or much improved, when by the method of classification adopted in the institutions many of them might properly be signed out as recovered. The figures of the improved and much improved cases seem to bear out this statement. The general rate for patients dis- charged, improved and much improved, based on all ad-' missions, was 20.0 in 1918 and 18.6 per cent in 191 7, while the rate for Jewish patients admitted to Central Islip and Manhattan State Hospitals was 24.1 for the former and 27.2 per cent for the latter, for the year 19 18. During this; 'S. H. C, 30th A. R., p. 307. 279] STATE HOSPITAL CARE AND TREATMENT 137 year the general rate for Central Islip was 21.9 per cent, and for Manhattan 21.7 per cent. After making due allow- ance for the larger number of Jewish patients discharged as improved and much improved, there still remains a wide margin between the total rate of recoveries and the small rate for Jewish cases. The fact that Jewish patients da not get along so well as do other patients in state hospitals has already been mentioned and Table 25 brings out this condition more clearly. XII. FOLLOW-UP WORK IN NEW YORK CITY (a) Need for This Form of Service. At this point it might be advisable to consider in brief a problem which has much bearing upon the question of the final disposition of the patients. Little need be said regarding those patients who are suffering from a more or less chronic ailment, necessitating their detention in the institutions. Table 24 brings out that of a total of 784 commitments, 383 or 48.8 per cent of the patients were still in the hos- pitals at the end of one year, with the probability that many would remain inmates of state institutions for many more years, and in some cases even until they died. The patients whom it is necessary to consider in greater detail however, particularly from the point of view of this study, are in- cluded in the recovered, much improved and improved groups. Experience of several years in the work of a mental hygiene agency has conclusively proved to the writer the importance of closely following-up and supervising, patients thus discharged. They required advice and guid- ance in obtaining employment, in being directed intO' new and more suitable occupations, and in making those numerous readjustments which are essential to the mental well-being of former inmates of state hospitals, if relapses are to be prevented and the possibility of the development of a 138 SOCIAL ASPECTS OF TREATMENT OF INSANE [280 chronic mental disorder is to be eliminated. Moreover, the patients should be made to feel that trained psychiatrists and social workers are always available to aid them in their difficulties, whether mental, medical or social. (b) Extent of Follow-up Work in New York. The state, largely through the continued activities of the State Charities Aid Association and its committee on mental hygiene, has come to realize the genuine opportunities for service inherent in a system of after-care work and has accordingly made some provisions along these lines. But to what extent has this been done, and, how much has been accomplished? In view of the possibilities for financial saving alone, not considering at this moment the more humane aspects of the problem, the state has been very lax in failing to provide a sufficiently large corps of workers to follow up discharged and paroled patients and so help to prevent relapses. A very important additional service might be rendered by these workers in spreading educational propaganda where it was most needed, namely, in the families of those who have already suffered a mental break- down. According to the Thirtieth Annual Report of the State Hospital Commission, the number of patients on parole on June 30, 1918, was 1,880;^ this does not of course include those whose parole period of six months had expired. For the large number of patients technically considered as being out on parole there were only thirteen social workers in the service of the state, for whose salaries and main- tenance^ — the only two items in the after-care budget — less than $20,000 was spent, out of a total annual budget of over $8,000,000. The actual accomplishment of this small body of workers was as follows: 3,418 visits to paroled patients, 1 S. H. C, 30th A. R., p. 238. 28 1 ] STATE HOSPITAL CARE AND TREATMENT 139 (an average of less than two visits to each patient on parole) ; 727 visits to other patients outside the hospital ; 1,841 other visits on behalf of patients, and 245 visits in behalf of preventive cases. Situations were obtained for 132 patients from the hospital and for eleven preventive cases/ More recently arrangements have been made by the State Hospital Commission to provide one after-care worker for every 100 patients on parole. Apropos of this welcome addition to the stafif, it is of interest to note that the social service department of the Boston Psychopathic Hospital does not assign more than 20 or 25 patients to each worker. There is no intention to disparage the good work of the follow-up staff of the state hospitals ; it is desired, rather, to point out its inadequacy. The whole situation regarding this particular phase of the problem was well summarized by one of these workers when she stated that she hardly had the time to keep track of the names of those discharged and paroled, much less to serve them. This is probably a some- what extreme statement, though it reflects the state of mind of the follow-up agents who are serving the state in the different hospitals as best they can considering the handicaps under which they labor. (c) Need for Follozv-Up of Jennsh Patients. Table 25 indicates that 63 Jewish patients were discharged as re- covered from the Central Islip and Manhattan State Hos- pitals, that 201 were paroled as much improved and im- proved, and that 2 1 were taken home by relatives in an un- improved condition. This makes a total of 285 patients' who left these institutions during the year to return to their homes and previous environment, with but very little, if any, supervision and follow-up work. If action on the part of the state in appropriating sufficient funds for the 1 S. H. C, 30tih A. R., p. 237. I40 SOCIAL ASPECTS OF TREATMENT OF INSANE [282 establishment of large and well organized social service staffs in the several state hospitals is as slow in materializ- ing as it has been heretofore, the question arises as to wheither it would not bes advisable that some properly officered and equipped Jewish agency assist the state in fol- lowing up and serving these patients, all o^f whom are re- sidents of the City of New York. A further alternative presents itself, namely, that some mental hygiene agency already functioning among Jewish patients, or one to be organized on a much larger scale, be requested by the state hospital authorities to take over the work of rendering social service to the Jewish discharges. Some arrangement might be perfected whereby Jewish social workers and psychia- trists who understand the unique Jewish psychology could assist the state social workers and augment the service and assistance now being rendered. The entire problem of after-care work among Jewish patients is one that should and must in the near future be brought to the serious attention both of the state authorities charged with the proper care of the insane, and of repre- sentatives of Jewish organizations and agencies prepared to render this particular kind of service. In order that the ab- normally high readmission rate prevalent among Jewish patients of state hospitals be materially reduced through timely and adequate mental hygiene service, some such action is imperative. XIII. DEATHS IN STATE HOSPITALS (a) Death Rates of Jewish Patients. Those who are engaged in some form of service in the psychopathic wards of general hospitals to which insane or alleged insane per- sons are brought prior to their commitment, are frequently asked by the friends and relatives of these patients what the possibilities are for the recovery of committed cases. The 283] STATE HOSPITAL CARE AND TREATMENT 141 facts regarding the rate of discharges and recoveries have already been noted. Table 24 shows the number of patients who were otherwise disposed of, particularly those who died in the institutions. Of the total of 784 admissions there were 107 deaths, a death rate equivalent to 13.6 per cent of the admissions; of 436 males admitted during the year, 67 or 15.3 per cent died, and of 348 females admitted in the same period, 40 or 11.5 per cent died. It is at the present time difficult to draw any valid comparisons between the death rate for Jewish admissions and for the total ad- missions to the several state hospitals, this being altogether due to the fact that the statistics prepared for all the patients are based not upon the admissions for the given year, but upon the total number of patients under treatment during the year. Thus, in 19 18, the death rate per 1,000 patients under treatment excluding transfers, which are compara- tively few in number, was 85.5; the male death rate was 98.9, and the female rate 73.5. The one point of com- parison is the higher death rate indicated for males in both groups of figures. (b) Reasons for Increasing Death Rates. Somewhat debatable ground is entered when considering what signi- ficance is to be attached to the fact that the death rate per 1,000 patients under treatment for all the hospitals has been slowly but definitely increasing from year to year, a condition found to exist ever since accurate statistics bear- ing on this phase of hospital care for the insane have been kept. In the year 1897 the total rate, that is, including males and females, was 66.0 per 1,000 patients under treat- ment; in 19 1 7 it had increased to 88.8, with a somewhat lower rate for 1918, namely 85.5. The irrefutable fact is that the death rate has been increasing though the reasons Iherefor are not so obvious. The increasing tendency to send cases of acute mental illness to state hospitals has 142 SOCIAL ASPECTS OF TREATMENT OF INSANE [284 probably contributed to this condition. The ability in re- cent years more readily and accurately to diagnose cases of general paralysis, as well as other psychoses with high death rates, has resulted in the commitment of such cases to state hospitals. For instance, the highest death rates per 1,000 patients under treatment were found among patients suffer- ing with general paralysis, the rate in 191 8 having been 352.8; for cerebral arteriosclerosis the death rate was 340.2' during the same year. Furthermore, up to the last decade oi the nineteenth century many cases of senile psychosisi were housed in county institutions, whereas at present all such cases as reach public institutions are committed to state hospitals. When it is realized that for cases of senile psychosis the death rate per 1,000 patients under treatment in a given year, as in 1918, was 297.2, it is at once seen why the general death rate has increased so much in more recent years. The factors just mentioned have undoubtedly been largely responsible for the increased death rate, though the sum total of their effect upon the statistical averages must to some extent, at least, be neutralized by the better and higher standard of care accorded to state hospital patients during the past twenty or more years, with the resultant in- crease in the length of life of large numbers of patients. The following table shows that those who died suffering from general paralysis were 43 in number, equivalent to 40. 1 per cent of the total -number of deaths ; ^ the deaths from senile psychosis numbered 20, or 18.6 per cent of the total deaths. 'Dublin. Louis 1.,' Mortality Statistics of Insured Wage-Earners and their Families, 1919, pp. 271-272, presents a discussion of death rates among a large number of insured persons where the cause of death was general paralysis. 285] STATE HOSPITAL CARE AND TREATMENT 143 Table 26. Diagnosis of Patients who Died in State Hospitals Diagnosis. General Paralysis Senile Psychosis Arteriosclerosis Manic Depressive Dementia Praecox Epileptic Psychosis Constitutionally Psy. Inf. . Involutional Melancholia Infection Exhaustion Psy, Intoxication Psychosis . . . Totals Central Islip. 18 13 Manhattan. 30 4 2 6 3 3 49 4 10 2 4 5 27 Total. 37 67 6 12 4 10 5 I I I 40 The total number of cases admitted during the year and diagnosed as afflicted with general paralysis was 99, out of which as already noted, 43 died within the year. This gives a death rate of approximately 400 out of 1,000 such patients admitted within the year, a figure somewhat higher than the death rate for all the patients similarly diagnosed. The death rate for the senile cases was about the same as the rate for all the cases classified under this diagnosis. XIV. LENGTH OF STAY IN THE HOSPITALS Reference has already been made in explanation of Table 25 to the difference between Central Islip and Manhattan State Hospitals in the ratio of patients signed out asi " recovered " ; in analyzing the above figures the statements referred to should be taken into consideration. This table furthermore emphasizes the facts noted in Qiapter II re- garding the recovery rate of the different psychoses, parti- 144 SOCIAL ASPECTS OF TREATMENT OF INSANE [286 Table 27. Duration of Hospital Life of Recovered Cases M. D. I. Cons. Inf. No. 4 4 8 Para, Cond. No. I I D. P. Kat. All Others. Totals, No. 2 21 II No. I I 2 No, No, 2 24 26 II 63 Per cent. Less than i month I to 3 months 4 to 7 months 8 to II months 3 3 31 38.1 413 17.5 Totals 49 100 cularly the comparative!}^ higher rate among cases of manic depressive insanity. It is seen that nearly all patients who recovered had suffered with manic depressive insanity; the eight cases included as cases of constitutional inferiority suffered depressions similar in nature to those usually in- cluded under the category of manic depressive insanity, de- pressed type, the depression coming in addition to the con- stitutional ailment. Recoveries of cases of dementia prae- cox, katatonic type, are very rare, and some authorities are inclined to the opinion that often such cases as are recorded as having recovered have been inaccurately diagnosed in the hospitals from which they have been discharged in a re- covered or even improved condition. Their contention is that the patients thus diagnosed were suffering from some condition of stupor and were not true cases of katatonic dementia praecox. Be that as it may, the niunber of re- corded recoveries is so^ small as tO' be almost negligible/ Table 28 serves the double purpose of indicating the diag- noses of the improved and much improved cases, and of showing the duration of hospital life of the patients classi- * de Fursac and Rosanoflf, Manual of Psychiatry, p. 262. 287] STATE HOSPITAL CARE AND TREATMENT 145 Table 28. Duration of Hospital Life of Improved and much Improved Cases Q No. 14 36 37 7 94 Q No. I 14 27 13 55 Ph' d No. 4 I I 6 Ph C e of interest to note that there is hardly a con- 379] RECOMMENDATIONS AND CONCLUSION 237 valescent home or institution in or near New York City at present that will accept as an inmate one who has been dis- charged from a state hospital and is in need of a temporary change of environment or convalescent care. The only in- stitution approximating such a place which receives mental cases is the camp already mentioned, and to which, because of lack of room, only adolescent girls are admitted. As a result of this state of affairs, early mental cases and those verging upon a breakdown must be committed to state hos- pitals from which they might otherwise be saved, or they must be sent to private sanatoria, where the standard of care and attention is often inferior. In the case of single persons without any immediate relatives or friends in the community, the attempt has to be made at an early stage to board them in selected private homes. None of these ex- pedients has as yet been found satisfactory. The only solution that seems at all feasible is the establishment of one or more convalescent homes specializing in the care of mental cases. These might be similar to the institutions already in existence to which are sent persons in danger of a physical breakdown, or those recuperating from surgical operations and severe physical ailments. (c) Workshop for Mental Hygiene Patients. From a reading of the cases cited in the preceding chapter it must have been realized that one of the main difficulties faced in trying to assist patients to readjust themselves was the inability to provide suitable employment for them under favorable working conditions. It is not very difficult to find some kind of work when there is a labor shortage, but the problem is so to place mental hygiene patients that for one reason or another they will not feel compelled to leave the job found for them within a few hours or days after beginning work. The difficulty is that these persons cannot fit into what we to-day call, whether rightly or wrongly, the 238 SOCIAL ASPECTS OF TREATMENT OF INSANE [380 normal industrial life. They must liave working condi- tions specially planned to meet their particular needs. Thus, tlie recovered and improved cases of manic depressive insanity find it well-nigh impossible to return to former sweatshop and high-speed industrial life without exposing themselves to a relapse and readmission to the state hospital. The numerous early cases of dementia praecox and others lose one position after another because the employer does not understand and refuses to sympathize with their con- dition and discharges them when they repeatedly come late in the morning, when they feel indisposed and remain away from work, and otherwise fail to measure up to the standard and pace set by their healthy fellow-workers. Suitable occupation under favorable conditions is an established and recognized therapeutic agent for mental cases. To prevent the numerous relapses and hospital read- missions, as well as to stave off, in the first place, the need for commitment because of social maladjustment arising from industrial and occupational difficulties, model work- shops for mental hygiene patients should be established. A workshop for Jewish men and women afflicted with tuberculosis has for several years 1>een in operation in New York City under the direction of a social agency. The project long ago outgrew the experimental stage and has from its inception been a successful venture from the social, medical, occupational and economic viewpoints. The same kind of workshop, with certain necessary modifications, should be established for mental hygiene patients. It would then not be necessarj^ for patients discharged from state hospitals to reenter at once the industry which in the first place contributed to their mental or nervous breakdown. Those suffering from the milder forms of mental disease could find gainful occupation where they would work under the supervision of those who understood their condition, 381] RECOMMENDATIONS AND CONCLUSION 239 and where they would not be compelled to work when they were not well. The establishment of such an industrial unit or center would indeed be a landmark in the develop- ment of the health conscience of the community, and in the progress of the mental hygiene movement. (d) Psychopathic Hospital. The fourth element neces- sary to round out the program of work of a mental hygiene organization is a psychopathic hospital, to which might be admitted for observation and treatment cases of mild men- tal disturbance otherwise destined to go about neglected until they finally had to be sent to a state hospital. The need for such an institution is particularly apparent in a large cosmopolitan city like New York, with its thousands of admissions annually to the psychopathic wards of general hospitals, from which but comparatively few are discharged except to a state hospital. Such an institution as proposed would be in a position to treat patients long before they were in need of state hospital care, and only such patients as it was possible to help to mental health within a compara- tively short time would be admitted for treatment. The question of the utility of psychopathic or reception hospitals has been discussed elsewhere and will not be reopened. It is sufficient to state that in large communities such an institution is essential to a complete plan for the early care and treatment of mental and nervous cases, and that the work and results of the Boston Psychopathic Hos- pital as well as of the Phipps Institute in Baltimore have completely justified the hopes of the original sponsors of the idea. It is felt by many students of the problem in New York City, that, due to the large Jewish population in New York, as well as to the peculiar psychology of the Jew and more especially of the recent immigrants among the Jews, it would be advisable to plan and erect a Jewish psychopathic hos- 240 SOCIAL ASPECTS OF TREATMENT OF INSANE [382 pital or institute, either as an independent unit or as a part of an already established general or special hospital. The organization of a committee representative of various elements of the community and interested primarily in pre- ventive and reconstructive work along lines of mental hygiene, and the establishment of clinics, convalescent homes, workshops, and a psychopathic hospital, would be a great step forward in mental hygiene and psychiatric social work. Such a group has already been formed among the Jews of New York, but its efforts are still in their infancy. The plan outHned for a community program is applicable to any city, though it would have to be modified somewhat to meet local conditions. VII. CONCLUSION In attempting to point out and discuss the social aspects of the treatment of the insane, the primary aim of the writer has been to bring before those who are vitally in- terested in the whole and baffling question of insanity, whether from the viewpoint of the physician, minister, social worker or layman, facts which will lead to a better understanding of the various phases of the problem. The presentation of the development of legislation affecting the insane in New York State in the first chapter was intended as a background upon which to picture the other aspects which were later considered, for much of the care and treatment of the insane is integrally related tO' the question of legislation. The three subsequent chapters presented, first, the patient before coming to and while in the psychopathic ward of a general hospital as well as the disposition of such patients ; second, the patient in the state hospital to which he was transferred from' the psychopathic ward, and his disposition by the state hospital ; and third, the patient after leaving the state hospital. These three chap- 383] RECOMMENDATIONS AND CONCLUSION 241 ters indicated what the city and state were doing for the insane who came under their care. The fifth chapter por- trayed the activities of a privately supported social agency specializing in mental hygiene activities. The recommenda- tions of the final chapter point out the lines the newer work for mental cases will have to follow in order to achieve a higher degree of success in preventing and curing insanity. With the public aroused to a deeper interest in all that per- tains to the insane, improved methods of treating mental disorders would develop apace. INDEX Accommodations, 154 Acute cases, 38, 41, 83, 229 Adjustment, 152, 161, 163, 234 Admissions, Table of, 71 Admissions, total, 155 Adolescence, 85, 2^2, 233, 234 Advice, 176, 178 After-care, Z7, 38, 138, I49, i75 After-care worker, 139, 140, 177 Age, 121 Age distribution, 97, 98 Agency, child-caring, 164 Agency, social, 157, 194 Alcohol, 66 Alcoholic insanity, 66, 67, 68 Alcoholic patients, 99 Alcoholism. 80, 90, 105 Aliens, deported, 100 America, 113 Almshouses, insane in, 19, 24. 60 American Red Cross, 159 Amityville Sanatorium, 103 Anglo-Saxons, insanity among, 50 Ann Arbor, 40 Anorexia, 85 Appropriations, 115 Arabia, 98 Arabs, insanity among, 49 Army, 159 Arteriosclerosis, 68, 72, 98, 105, 142, Assistance, financial, 56, 64 Asylum, insane, 119 Asylum, orphan, 59, 64, 66 Asylum, private, 30 Asylums, state, 19 Attendants, 113, 119, 126, 130, 131, 154 Auburn, 2^ Austria-Hungary, 98 Autointoxication, 87 Bailey, Dr. Pearce, 107 Baltimore, 40, 132, 239 Bandages, restraining, 147 385 J Bath, continuous, 147 Beadles, C. F. 49 Bedouins, insanity among, 49 Beers, Clifford W., 189 Belgium, 98 Belle Meade Sanatorium, 103 Bellevue Hospital, Psychopathic Wards, 23, 38, 39, 48, 50, 52, 55, 70, 93. 108, 115, 116, 117, 120, 126, 127, 135, 149, 150, 162, 168, 180, 185, 191 Binghamton Asylum, 28 Blackwell's Island, 23, 105 Bloomingdale Hospital, 18, 20, 122 Board of Charities, State, 26 Borderline cases, 83, 130, 189, 194 Borderline condition, 195 Borderline patients, commitment of, 58 Boston, 40, 132, 191 Boston Psychopathic Hospital, 139, ^29 Brain tumor, 79 Breakdown, mental, 132 Breakdown, physical, 237 British Commission in Lunacy, 33 Bronx Borough, 52 Brooklyn, 40 Brooklyn State Hospital, 126 Buffalo State Hospital, 26 Cabot, Dr. Richard C, 189, 191 California, 118 Camps, vacation, 232, 234 Cancer, 105 Celtic race, insanity among, 50 Central Islip State Hospital, 127, 128, 129, 135, 136, 137, 139, 143, 150, 170, 178 Chain period, 147 Charitable organizations, repre- sentative of, 58 Charities Aid Association, State, 31, 2,7, 45 Child-placing institutions, 194 243 244 INDEX [386 Child Welfare, Board of, 164 Childhood, 230 Children, Dependent, 95, 167, 185 Children, minor, 158, 159, 163, 166 Children, nervous. 232 Children, placing-out of, 166 Children, psychopathic, 232 Chorea, 78, 79, 81 Chorea, Huntington's, 79 Chronic cases, 229 Citizens, future, 157 City Hospital, 105 City Prison, 106 Classes, arts and crafts, 122 Classification of patients, 120, 130, 131, ^33, 136, 156 Classification, uniformity of, 121 iClimateric, 69 Clinics, mental hygiene. 38, 170. 172, 175, 189, 194, 227, 234, 235, 236 Clinic physician, 182 Clinic staff, 194 Clinics, state hospital, 179 Colonial legislation, 16 Colony, industrial, 91 Combes, Dr., Sanatorium, 103 Commission in Lunacy, State, 32, Commissioner in Lunacy, State, 26, 27, 28, 31, 32, 38 Commitment papers, 103 Commitment of patients, 24, 54, SS, 56, 57, IIS, 118. 125. 137, 174 194 Commitment Law, 59 Confusion, transitory, 92 Consolidated Laws, 54 Constitutional psychopathic infer- iority, 92, loi, 105, 107, 145, 223^ 224, 226 Convalescent care, 194, 237 Convalescent homes, 194 234, 236 Convalescents, 194 Cottages. 121 County asylums. 29, 30 County authorities. 21 Court, children's. 107 Court, magistrate's, 106 Craig. Maurice, 61 Creedmoor, 115 Criminals, insane, 22 Crowded conditions, 116 Cumberland St. Hospital. 108 Daydreams, 233 Death, cause of, no Death rate, 140, 143, 151 Death rates, increasing, 141 Deaths, 140, 146, 155 Deaths in institutions, 141 Deaths in psychopathic wards, 109 Delinquent, 105 Dementia praecox, 78, 99, 122, 129, 130, 145, 181, 183, 205, 206, 208, 228, 233, 238 Dementia praecox, age distribu- tion of, 88 Dementia praecox, allied, 213 Dementia praecox, commitment of, 88 Dementia praecox, hebephrenic 94 Dementia praecox, katatonic, 144, 210 Dementia praecox, paranoid, 211 Demoniacal exorcism, 15 Deportation, 99, 100, 102, 164 Deportation, Bureau of, 37, 100 Depression, episodes of, 92 Depression, undifferentiated, 93 Dercurn, Francis X., 61 Desertion, 167 Detention period, 118, 120 Devine, Dr. Edward T., 150 Diagnosis, methods of, 133 Dietary laws, 131, 192 Disease, venereal. 162, 16S Diseases, infectious, 87 Dispensary, 182 District of Columbia, ir8 Divorce. 168 Dix, Dorothea L., 25 Domestics, 125 Drug addicts, 105 Dubois, Dr. Paul, 160 Dungeon period, 147 Educational Campaign, 193 Efficiency and Economy, Dept. of, 122 Employment. 123, 137, 176, 182, 184 Employment agencies, 195 Empyema. 8r England, 98, 172 EngHsh language, 192 Environment, 92, 100, 112. 118, 139, 194 Epilepsy, 90, IDS, 145 3S7] INDEX 245 Erie County, 29 Europe, 157. I59, i^4 Europe, legislation in, 34 Examination, mental, 117, 188 Excitement, episodes of, 92 Factory, Model, 236 Feebleminded, 44 Field agent, 169, 171 Fishkill-on-the-Hudson, 23 Flatbush, 22, 24 Follow-up, 137, 138, 178, 190 Foreign-born, 70, 96, 97, 98, 125. 130, 131 Foster relatives, 153 France, 98 Frankfort Hospital, 49 Frankfort, Jewish insane in, 49 Free Synagogue, social service dept., 179, 192, 193, 194, 195, 234 General paralysis, 68, 7Z, 78, 122, 142, 143, 145, 146, 157, 162, 219, 228 General paralysis, juvenile, 7^, 77 General paralysis, prognosis of, 75 General paralysis, treatment of,76 Germany, 98 Germany, insanity in, 49 Gesell, Prof. Arnold, 231 Gestation, 94 Girls, adolescent, 237 Girls, wayward, 105 Glands, internal, 87 Greece, 98 Grotius, 188 Hallucinations, 73 Hebrew Infant Asylum, 185 Hebrew Orphan Asylum, 1S5 Hebrew Sheltering Guardian So- ciety, 185 Hemorrhage, cer<;bral, 80 Heredity, 63, 64, 65, 82, 84, 86, 89, 90, 150, 173 Heredity, neuropathic, 83 Homeopathic asylum, 26 Homes, convalescent, 236. 237, 240 Homicide, 36, 155 Hospital Development Commis- sion, 44, 45, 115 Hospital, general, 119, 140, 177, 188, 189, 190, 194, 240 Hospital, municipal, 116 Hospital, psychopathic, ro8, 132. 239 Hospital social service, 191 Hospitals, special, 194, 240 House of Refuge, 105 Hudson Lunatic Asylum, 20, 25, Humanitarianism, era of, 15 Hydrotherapeutic apparatus, 147 Hypomanic, 91 Hysteria, 91, 221 Hysterical episode, 91 Imbecile, 104 Immigrants, 97, 156, 164 Immigration, 72,, loi Immigration, Jewish, .74, 98 Immigration Law, lOi Improvement, rate of, 135 Indifference, era of, 15 Indigent insane, 25, 148 Industries, hospital, 122, 125 Infection exhaustion, 81 Influenza, 81 Injuries, head, 69 Insane, acute, 24, 25 Insane, borderline, 188 Insane, chronic, 24, 28, 29, 33, 156, 168 Insane, classification of, 22 Insane, criminal, 18 Insane, curable, 33 Insane, dangerous, 19 Insane, disorderly, 17 Insane, immigrant 99 Insane, social care of, 132 Insanity, causation of, 20, 62, 6f Insanity, definition of, 60, 61, 133 Insanity Law, 173 Insanity, recoverable, 152 Insomnia, 85 Institute, psychiatric, 236 Involutional melancholia, 84 Inwood House, 105 Jails, insane in, 60 Jewish population, so, 53 Jewish psychopathic cases, 48 Jews, 130, 191, 240 Jews, alcoholic, 53, 80 Jews, distribution of, 50 Jews, insanity among, 48, 49, 50, SZ, 98, 127, 131, 132, 136, 137 Jews in New York, 51 Jews, persecution of, 50 246 INDEX [38S Judges, County, 22 Kings County, 23, 24, 30, 32, 33 Kings County Hospital, 53, 108 Kings Park State Hospital, 135 Kitchens, kosher, 131 Kraepelin, Emil, 62, 77, 81. 85, in Lactation, 94 Legislature of New York, 39, 184 Licenses, marriage, 169 Lombroso, 49 London, insane in, 49. 117 Lues, 78 Manhattan Island, 39, 45 Manhattan State Hospital, 34, 39, 53, 121, 122, 126, 127, 128, 129, 135. 139, 143. 150, 170, 178 Manic depressive insanity, 81, 82, 83, 84, 86, 99, 122, 131, 144, 145, 147, 152, 178, 183, 196. 198, 200, 228 Marcy, 115 Marcy, Gov., 21 ■Marriage Law, modification of, 168 Massachusetts General Hospital, 190 Matteawan asylum, 23 Maudsley, Dr. Henry, 61, 117, 133 Mendel's Law, 64 Meningitis, 73 Mental defective, 105, 193, 220 Mental Defectives, Commission; of, 107 Mental Deficiency Law, 107 Mental diseases, classification of, 69, 70 Mental hygiene, 132, 137, 140, 173, 179, 189, 191, 192, 193, 227, 229, 239. 241 Michigan, it8 Middletown State Hospital, 26, 126 Mineola asylum, 33 Mohansic hospital, 115 Monroe County Asylum. 24, ^o, 32 Narcotics, 80 Native born, 70, 113 Needle trades, 125 Nervous disorders, 193 Neuroses, 91, 195, 231 New York City, 43, 48, no, 115, 132, 137, 140, 191, 228, 235, 23^ 239, 240 New York City Hospital, 16 New York County, 23, 24, 30, 32, 34, 51 New York State. 16, no, 118, 09, 121, 168, 190, 233 New York State Inebriate Asy- lum, 28 New York State Hospital Com- mission, 100 Nurses, 113, 120, 126, 130, 131, 154, 179 Nurses Training School, 37 Observation period, 115, 116, 117, xi8 Occupational therapy. 121 Occupations, 112, 121, 123, 124^ 125. 137, 151, 156, 178, 182, 183 Ogdensburg, 28 Ordronaux, John, 27 Organic nervous disease, 73 Organization, relief, 158, 161, 162 Orphan asylums, 159, 185, 194 Orphans, 161, 162, 165 Orr, Florence I. 64 Out-patient, 38, 169, 170, 189. 190, 191 Overcrowding, 84, 91, 113, 114, 115,. 120, 121, 126, 131, 146, 154, 181 Paranoid Condition, 214, 216, 217, 228 Parole, 138, 139, 152, 169, 172, 174, 177. 178, 179, 180, 182, 189 Parole agents, 149 Parole system, 169, 170 Phipps Institute, 239 Prevention, 137, 170, 193, 229. 231, 238 Prisoners, 153 Propaganda, 193 Psychiatric institute, 236 Psychiatric social worker, 193, 228, 229 Psychiatrist, 138, 140. 179, 192, 234 Psychology, 179, 192, 239 Psychoneuroses. 194. 228, 229 Psychopathic hospital, 229 Puberty, 85, 233 Public Welfare, Department of, 166. 185 Puerperal state, 69 389] Readjustment, 152, 176, 177, 186 Readmissions, 126, 127, 128, 129, 130, 131, 140 Reception hospital, 38, 39, 40, 43 Recommitment, 114, 116 Recoveries, 113, 119, 130, 133, ^2>7, 143, 144, 229 Recovery, retardation of, 153 Red Cross, American, 159, 167 Recreation, 174, 176, 186, 196 Relapse, 131, 137, 182 Relatives, foster, 153 Relief agency, 161, 184, 194 'Relief, financial, 150, 184 Research, iii, 112, 113, 115 Restraint, physical, 147 Retreats, 119 Revenge, era of, 15 Revolutionary War, 16 Richmond Borough, 53 iRivercrest, 103 Rochester, 24 Rosanoff, A. J. 64 Roumania, 98 Russia, 98 Salvarsan, yy, 78 Sanatoria, private, loS, 119. 155, 194. -239 Schoharie County, 52 Schools, reconstruction, 232 Semitic races, 49 Senile psychosis, 70, 126, 142, 143, 145 Senility, 69, 98, 105, 122 Sheet, restraining, 147 Sichel, Max, 49 Social Service, 140, 179, 185, 189, 193, 227, 228, 229 Social worker, 57, 138, 140, 169, 170, 171, 227, 235 Soldier insane. 52 Spain, 98 Speech defective, 2:^2 Spitzka, Edward C, 50 Spoils system, T,y Spring Hill Sanatorium, 103 State architect, 47 State care, 30 State Care Act, 25, 32, 35, 34, 35 State hospitals, 108, 116, 126, 128. 129, 134, 135, 138, 194 State Hospital Commission, ^7, 38, III, 139 INDEX 247 'St. Lawrence State Hospital, 28 iState Lunacy Commission, 38 Stress, 84, 97 Stupor, 144 Suicide, 36, 85, 106, 107, 155 Superintendent of poor, 22, 28 Supervisors, Board of, 118 Survey, 174, 180, 182 Switzerland, 98 Syphilis, 68, y2, 78, 90, 105, I57 Teachers, 123, 181 Teacher-nurses, 22,2 Teutonic race, insanity among, 50 Therapy, occupational, 121, 122, 125 Thomson, J. Arthur, 65 Throop, Gov., 19, 21 Tombs, The, 106 Treatment, 126, 135, 142, 160, 173, 193, 194, 232 Truant school, 105 Tuberculosis, 81 Tumor, y:^ Turkey, 98 Typhoid, 81 United Hebrew Charities, 184 United States, 34, iii United States Census, 94, 96 United States Dept. of Commerce, 49 United States Immigration Ser- vice, 102 Utica, 115 Utica (State Hospital, 22, 24, 25 Venereal diseases, 74 Vienna, insane in, 49 Visits to patients, 139, 153 Voluntary patients, 58 Ward's island, 23 Warren County, 52 Wasserman test, yy, 163 Waverly House, 104 White, Dr. Samuel, 20, 21 White, Dr. WiUiam A. 60 White Plains, 122 Willard Asylum, 25, 29 Willard, Dr. Sylvester D. 25 Workshop, model, 236, 237, 238 Yale University, 231 VITA Jacob Alter Goldberg, born in New York City, June 10, 1890. Educated in New York City public schools; graduated Townsend Harris High School ; College of the City of New York, A.B., February, 19 13. Entered Columbia University in September, 1914, as a graduate student under the Faculty of Political Science; received A.M. degree June, 1916; title of essay submitted for master's degree: Drug Addiction m a Social and Legislative Problem. Continued at Columbia University to Jan. 1921. Special student Union Theological Seminary, 1916-1917. For a number of years in charge of a social settlement; taught in the evening schools; district supervisor of lec- tures ; inspector of dance halls, theatres, etc. ; hospital social service worker; associated with Drs. Stephen S. Wise and Sidney E. Goldstein in the religious, social and educational work of the Free Synagogue. Since 19 17, secretary of the mental hygiene division, social service department, Free Synagogue, At Columbia University studied under Profs. Lindsay, Devine, Giddings, Seager, Barnett, and Chaddock. 249 '-13 SOCIAL ASPECTS OF THE TREATMENT OF THE INSANE Based on a Study of New York Experience BY JACOB A. GOLDBERG, A. M. SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN THE Faculty of Political Science Columbia University MW9 1922 NEW YORK 192I