PART I — часть 1

GENERAL CONSIDERATIONS

MENTAL DISEASES

CHAPTER I

THE SOCIAL AND ECONOMIC IMPORTANCE OF MENTAL DISEASES

The importance of mental diseases as a factor in the social and economic welfare of the community has not been given adequate consideration, notwithstanding the remarkable progress of modern psychiatry. Nor is this influence, unfortunately, one which can be easily estimated or accurately determined. We have, as a matter of fact, no data at hand to show the prevalence of disease, either physical or mental, with any degree of exactness even under our most elaborately organized forms of government. There is no complete information available which will enable us to determine the frequency of such important conditions as appendicitis, cardiac or renal diseases, peritonitis, septic infections, diseases of the eye, ear, skin or nervous system. It is true that there are, in the majority of states, records of contagious or readily communicable diseases which are probably fairly reliable. Aside from this, the only information at our disposal is confined to mortality statistics.

This suggests a further consideration of the advisability, if not absolute necessity, of more extensive statistical studies of diseases, both mental and physical, if the welfare of the community is to be safeguarded and the future of medical science assured. Every physician should be required by law to make careful reports to the Board of Health of his state showing all medical conditions requiring treatment by him or coming to his professional notice. The value of such information to medical science would much more than compensate for the comparatively small cost of such an undertaking. Nor is this procedure more radical either in theory or practice than was the proposal to report all communicable diseases only a few years since. The data thus made available in the various states should be correlated and published by the Public Health Service.

The mortality statistics of the United States Census Bureau furnish us with a valuable index of the relative frequency of the various disease processes which determine the death rate of the community. They are based on the transcripts of death certificates received from the so-called registration area, which in 1920 had an estimated population of 87,486,713. The total number of deaths reported in 1920 was 1,142,558, a rate of 13.1 per 1,000 of the population. It is true that the epidemic of influenza was still a factor of some importance at that time. The rate for 1916, however, was fourteen, for 1917 fourteen and two-tenths, for 1918 eighteen and one-tenth and for 1919 twelve and nine-tenths per 1,000 of the population. The registration area now includes thirty-four states:—California, Colorado, Connecticut, Delaware, Florida, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Utah, Vermont, Virginia, Washington and Wisconsin. It is interesting, at least, to note the states not included in the registration area:—Alabama, Arkansas, Arizona, Georgia, Idaho, Iowa, Nevada, New Mexico, North Dakota, Oklahoma, South Dakota, Texas, West Virginia and Wyoming. The results obtained from a study of the reports from such an extensive district must be looked upon as thoroughly representative of the country at large. The last complete statistics available are those for 1920. Influenza was still an important factor at that time, it being responsible for a death rate of 71 per 100,000. The influenza rate was 98.8 in 1919, 302.1 in 1918, 17.3 in 1917, 26.5 in 1916, 16 in 1915, 9.1 in 1914 and 10.3 in 1912.

The important causes of death in 1920 were as follows:

The pneumonia rate (all forms) for 1920 was quite unusual, 137.3 per 100,000, as compared with 123.5 in 1919, 286.6 in 1918, 150.5 in 1917, 137.8 in 1916, 133.1 in 1915, 127.3 in 1914, 132.6 in 1913, 132.4 in 1912, etc.

The following table shows the average rate per 100,000 of some of the more important general diseases during a period of eight years (1912, 1913, 1914, 1915, 1916, 1917, 1918 and 1919):

The death rate from diseases of the nervous system is of particular interest. The average annual rate per 100,000 of the population for the years 1916, 1917, 1918 and 1919 was as follows:

This shows a total death rate for nervous and mental diseases of 126.44 per 100,000. It is a fairly reasonable assumption that of the above, the following, at least, may be classified as having been definitely associated with psychoses:

We may, therefore, reasonably conclude that there was an average number of at least 19.36 per 100,000 (from 1906 to 1910 this amounted to 32.1) in which the primary cause of death was associated with mental diseases, an exceedingly conservative estimate. This does not take into consideration the deaths due to senility (15.5) or suicide (12.8), conditions which might very logically be included for obvious reasons. It is, of course, well known that the psychoses rarely, if ever, appear in the death certificates as a primary cause of death. As a matter of fact, they are not always shown in the secondary causes. Information on this subject is still less satisfactory from a statistical point of view. During the year 1917 (contributory causes have not been reported since that year) there was a total of 1,066,711 primary causes of death shown in the registration area and only 372,291 contributory causes. Of this number the following may be classified as having been associated with psychoses:

The contributory causes definitely showing mental diseases constitute only 3.4 per cent of the whole number, and the death rate for 1917, including both primary and contributory causes suggestive of probable psychoses, was 37.2 per 100,000. This would indicate that the number of deaths from mental diseases shown in the primary causes represents only about fifty-three per cent of all mental cases which are actual factors in determining the death rate of the community. A comparison of these figures with the number of cases dying in hospitals shows that they cannot be looked upon as determining the percentage of the general population showing psychoses. Of the 1,952 persons dying in the institutions for mental diseases in Massachusetts in 1919, approximately nineteen per cent showed the psychoses in the primary causes of death. This percentage would probably be fairly constant throughout the country. It is, of course, a well recognized fact that the death certificate at best is not beyond suspicion and does not furnish information regarding the cause of death which can be accepted without question.

Dr. Richard C. Cabot[1] has made an elaborate study of errors in diagnosis as shown by autopsies. His work shows the following percentage of diagnostic accuracy:

It must be admitted that Cabot's findings are discouraging. They are not so bad as they would seem, however, at first thought. Death certificates, unfortunately, do not have the significance which they should have. Physicians are well known to be entirely too careless in their preparation and inclined to look upon them merely as legal formalities which cannot readily be avoided. It is furthermore difficult, as every doctor knows, to point to one immediate primary cause of death in every instance. Very often there is a combination of factors concerned and it is possible at practically every autopsy to find lesions not represented in any way whatever in the death certificate. It is unquestionably true that statistics of any kind must be based on information some of which we know to be inaccurate. This should not be used as an argument for discontinuing, absolutely, our search for knowledge. It is merely a reason why our clinical standards should be improved.

An exceedingly important contribution to our rather limited fund of accurate information regarding the general health of the country was the publication recently issued by the Metropolitan Life Insurance Company[2] on the mortality statistics of wage earners and their families. This covers a period of six years (1911 to 1916) and represents a study of 635,449 deaths. The cases reported came from every state in the union with the following exceptions: Mississippi, North Dakota, South Dakota, Wyoming, Colorado, Texas, Nevada, Arizona and New Mexico. Canada and many other localities outside of the "Registration Area" of the United States Census Bureau were included. The facts presented in this report are unique in that they render available for the first time a careful and detailed consideration of the diseases which may be looked upon as representative of the industrial population of the country. The various occupations shown in the order of their numerical importance were as follows:—Laborers, teamsters, drivers and chauffeurs, machinists, textile mill operatives, clerks, office assistants, etc. It covers a study of ten million policy holders and nearly fifty-four million years of life in the aggregate. The age groups studied range from one year to seventy-five in ratios not very different from those exhibited in the general population. The death rate for all persons exposed was 11.81 per 1,000 as compared with a rate of over thirteen per 1,000 (white) of the general population of the registration area during the same period of time. The death rate per 100,000 from 1911 to 1916 of some of the more important general diseases was as follows:

The death rate for syphilis, locomotor ataxia and general paralysis of the insane, combined, was 14.3 per 100,000. The percentage of deaths due to diseases of the nervous system, many of which must be looked upon as probably having been associated with mental disturbances, is somewhat surprising, as shown by the following table:

This shows a total rate of 104.5 per 100,000 due to diseases of the nervous system. If to this we add those dying of senility and the suicides as probably representing psychoses it would bring the total up to 123.2 per 100,000. It must be confessed, however, that such speculations mean comparatively little.

Practically the only other source of information at our disposal relative to the incidence of general diseases in the community is the tabulation of communicable diseases by Boards of Heath. The annual report of the United States Public Health Service for 1919 shows a case rate for diphtheria of 137 per 100,000 of the population based on the reports of thirty-seven states. The case rate for measles in thirty-seven states was 170. Poliomyelitis in thirty states showed a rate of 2.5 and scarlet fever a rate of 110 in thirty-seven states. The smallpox rate was sixty-eight and represented thirty-six states. The typhoid fever rate for thirty-seven states was only forty. The case rate for tuberculosis, all forms, was 346.7 in 1918. It was 274.2 in New York, 271.6 in the District of Columbia and 271.3 in New Jersey. These were the highest reported in the United States during that year. Unfortunately these statistics relate to communicable diseases only. This difficulty is due largely to the fact that comparatively few states have made attempts to keep elaborate records. The reports of Massachusetts are probably as comprehensive as any. The case rate per 100,000 of the population of all reportable diseases during the year 1920 was as follows:

The case rates for influenza and pneumonia cannot be looked upon as representative, owing to the epidemic of 1919 and 1920. During 1917 the death rate from influenza was 12.9 per 100,000 and from pneumonia 163.8. The death rate from heart diseases (organic diseases of the heart and endocarditis) in Massachusetts in 1920 was 178 per 100,000 of the population, from apoplexy 108.4, cancer and other malignant diseases 116.7, Bright's disease and nephritis 92.4, diarrhea and enteritis 52.9, violence 76.3, automobile accidents and injuries 11.9 and suicides 10.1.

It must be admitted that it is exceedingly difficult to establish a definite basis for a comparison of our statistics relating to mental disorders and those dealing with the frequency of other diseases in the community. As has been shown, our information on the latter subject, such as it is, has to do only with communicable diseases and the reported death rates. In making an analysis of the reports of mental diseases we are limited almost entirely to the institution population. It is true that these statistics are much more reliable than the others, as we are dealing with a stable population entirely under control. The cases, furthermore, are almost invariably subject to a prolonged observation and careful study. The diagnosis in almost every instance is based on elaborate mental examinations and exhaustive personal and family histories. It is, of course, true that there are innumerable cases of mental diseases outside of institutions. There were 18,268 patients at home on visit from the state hospitals alone on January 1, 1920. Those not requiring hospital treatment or custody in an institution can, however, be eliminated for the purpose of comparative studies. The fact that an analysis of death rates alone does not throw any light whatever on the frequence of psychoses for reasons already given will, I think, be conceded. For statistical purposes, at least, it may be assumed that the frequence of mental diseases as shown by a study of the hospital population is fairly representative of conditions existing in the community.

For purposes of comparison we may contrast the admission rate of mental diseases per 100,000 of the population in Massachusetts in 1920 with the case rate of communicable diseases as follows:

The total institution population (mental cases) at the end of the year 1920 represented a rate of 395.49 per 100,000 of the population. It should be borne in mind that, with the exception of tuberculosis and syphilis, the communicable diseases reported above represent, as a rule, the total number of cases in the state during the year. Comparative studies should, therefore, be based not on the number of mental cases in the hospitals at any one given time, but on the total number under treatment during the year. This would indicate an incidence of mental diseases of 566.98 per 100,000 of the population.

On January 1, 1916, there were 147 state and federal institutions for the care and treatment of mental diseases in the United States, as shown by the Census Bureau reports. There were at this same time twenty-seven institutions for the feebleminded, nine for epileptics, three for inebriates, forty-five for tuberculosis, twenty-eight for the blind, thirty-three for the deaf, twelve for the blind and deaf and eighty-four for the dependent classes. [3]

The appropriations for the maintenance of these institutions for 1915 amounted to $33,557,058.29. This constituted 7.6 per cent of the appropriations made by those states for all purposes. In Massachusetts it represented 14.8 per cent, in New Hampshire 10.1, in New York 12.7, in Ohio 12, in Indiana 10.7, in Illinois 13.4, and in a number of other states over ten per cent of the appropriations for all purposes. It was equivalent to an average of $431.16 per million of the total assessed valuation of these states. In Massachusetts it was as high as $653.62 and in New York $567.37. This means thirty-three cents per capita for all states, eighty-four cents for Massachusetts and sixty-eight cents for New York.

The actual expenditure for the maintenance of these institutions was $36,312,662.20. For purposes of comparison, attention should be called to the fact that the maintenance of the tuberculosis hospitals of the United States for the same year cost $3,539,454.95, institutions for criminals $21,244,892.00, for the feebleminded $3,341,442.85, for epileptics $1,345,821.57, for the blind $1,066,973.14, for the deaf $1,893,490.09 and for the dependent classes $9,675,932.37.

The value of the property invested in the state and federal hospitals for mental diseases in 1916 was estimated at $187,028,728.00. The valuation of these institutions per 100,000 of the population was $184,795.81. This does not include establishments for mental defectives. The average value per patient was $938.43. In Massachusetts it was $1,097.85 and in New York $1,039.85. In Arkansas it was as high as $2,264.00. The total acreage of land was 109,503.2, an average of 744.9 acres per hospital. There were 33,124 persons employed, an average of 226.9 for each institution. This represented one employee for every six patients.

The census taken by the National Committee for Mental Hygiene [4] in 1920 shows 156 state hospitals for mental diseases, two federal institutions, 125 county or city hospitals and twenty-one institutions of a temporary care type. In the public and private hospitals for mental diseases on January 1, 1920, there were 232,680 patients under treatment. Of these, 200,109 were in public and 9,238 in private hospitals. This represented an increase of 8,723 in two years. It is interesting to note that city and county institutions cared for 21,584 persons.

The first authoritative information relative to the institution care of mental diseases was obtained from the federal census reports of 1880. In that year there were 40,942 patients in the public hospitals. In 1890 there were 74,028; in 1904, 150,151; in 1910, 187,791; in 1917, 232,873 and in 1918, 239,820. The rate per 100,000 of the population increased from 81.6 in 1880 to 229.6 in 1918. From 1910 to 1918 the general population increased 13.6 per cent and the hospital population 27.7 per cent. The rate per 100,000 of the population in institutions in Massachusetts[5] on January 1, 1920, was 373.8, in New York 374.6, in Connecticut 317.8, in Iowa 248.1, in Wisconsin 300.6, in California 297.2, in Pennsylvania 215.2, in Ohio 212.1, in Illinois 229.5 and in Michigan 210.8. The admission rate per 100,000 of the population in 1917 was 151.6 in Massachusetts, 109.2 in Illinois, 124.8 in Montana, 97.3 in New York, 80.9 in Connecticut and 85.7 in California.

The cost of maintenance in the state hospitals increased to $43,926,888.88 in 1917 with an average per capita cost of $207.28. The number of cases cared for in some of the more populous states is of interest. On January 1, 1920, the institution population of New York was 38,903, Pennsylvania 18,764, Ohio 12,217, Illinois 14,884, Massachusetts 14,399 and California 10,184.

Based on the estimated population of Massachusetts on July 1, 1920 (3,869,098), the 1,475 deaths in institutions for mental diseases would represent a death rate of 38.12 per 100,000 of the population. The death rate for other diseases for that year was: diphtheria 15.4, measles 9.0, pulmonary tuberculosis 96.7, typhoid fever 2.5, whooping cough 14.0, scarlet fever 5.5, syphilis 5.8, lobar pneumonia 71.9 and influenza 43.9. The importance to be attached, however, to such comparisons is very uncertain at best. From the standpoint of social and economic importance to the community there is another factor under consideration which should not be overlooked. The duration of other diseases, as a general rule, is comparatively short. A study of over ten thousand deaths in New York state hospitals for mental diseases shows the average hospital residence of these cases to have been over six years. At the rate of admission to public institutions for 1917 (62,898) and the average per capita cost for that year ($207.28) the care of persons admitted annually, during their years of hospital life, would mean an expenditure of over seventy-eight millions of dollars.

If we figured the earning capacity of the 62,000 persons admitted to institutions for mental diseases in the United States as averaging only one thousand dollars per year, it would represent an economic loss to the country of sixty-two millions of dollars annually. Estimated in the same way, the total population of the hospitals would represent the staggering sum of nearly two hundred and forty million dollars. This, of course, does not take into consideration at all the cost of maintenance or the property investment represented by hospitals.

To avoid any possibility of confusion, no reference has been made heretofore to statistical studies of mental deficiency or epilepsy. From a public health point of view, however, and as social and economic problems, they are questions which cannot be disregarded in a consideration of mental diseases. As a matter of fact, they are very closely correlated in many ways. A survey made by the National Committee for Mental Hygiene shows that on January 1, 1920, there were in this country thirty-two state institutions for mental defectives, eleven admitting both feebleminded and epileptics and twenty exclusively for the latter class. [6] In addition to this, one city institution was reported. Of the private hospitals twenty-seven care for the feebleminded only, and six for epileptics, while nineteen admit either of these classes. The total number of mental defectives in institutions on January 1, 1920, was 40,519. At that time 34,836 were in state, 2,732 in other public institutions and 2,951 in private hospitals. In the following states they are cared for in hospitals for mental diseases, no other provisions having been made for their treatment:—Alabama, Arizona, Arkansas, Florida, Louisiana, Mississippi, Nevada, South Carolina, Tennessee, Utah and West Virgina. The states reporting the largest number are New York 5,762, Pennsylvania 4,281, Massachusetts 3,192, Illinois 3,147, Ohio 2,435, Michigan 1,849, Iowa 1,704, New Jersey 1,762, Wisconsin 1,624, Minnesota 1,502, Indiana 1,264 and Missouri 1,047. At the same time there were 14,937 epileptics under treatment, 13,223 in state, 859 in other public institutions and 855 in private hospitals. Colorado, Delaware, Georgia, Nebraska, New Mexico and Washington take care of the epileptics in their hospitals for mental diseases. The intimate relation between mental diseases and epilepsy is shown by the fact that as nearly as can be determined at this time approximately thirty per cent of all of the epileptics in our state institutions have been committed as insane. This, however, nowhere nearly includes all of the cases which actually show mental disorders of one kind or another. The states showing the largest numbers of epileptics are New York with 1,683, Ohio 1,680 and Massachusetts 1,227. No other states report over one thousand, although Michigan and Pennsylvania have over eight hundred and Illinois and Missouri over seven hundred.

Although the incidence of mental as compared with other diseases prevalent in the community cannot be established with absolute accuracy, sufficient evidence has been presented to warrant the statement that from the standpoint of the public health we are dealing with no other problem of equal importance today. The state care of mental defects, epilepsy, tuberculosis and the deaf, dumb and blind is, for various reasons, of much less consequence to the community than the hospital treatment of mental diseases. The defective, delinquent, criminal and dependent classes combined do not equal in number the population housed in our state hospitals for mental diseases. Nor does the number of cases cared for in the general hospitals of the state, county or municipal type compare in any way with the mental cases coming under state or federal supervision. It can, I think, be said without any fear of contradiction that no other disease or group of diseases is of equal importance from a social or economic point of view. Perhaps nothing emphasizes this fact more strongly than the report recently issued from the Surgeon General's office relative to the second examination of the first million recruits drafted in 1917. Twelve per cent of these were rejected on account of nervous or mental diseases. The number disqualified for service finally reached a total of over sixty-seven thousand.

Mental integrity is now looked upon as a military necessity and is insisted upon as one of the important requirements of the soldier. It has been demonstrated conclusively that only men of the most stable mental equilibrium can withstand the stress and strain of modern methods of warfare. Nor are peacetime requirements any less exacting. In commercial competition the law of the survival of the fittest is practically absolute. The feebleminded often inherit wealth, but they rarely acquire it. Vaccination for the prevention of smallpox is compulsory and the isolation of communicable diseases dangerous to the public welfare is rigidly enforced. At the same time we allow many paranoics the freedom of the country and they occasionally assassinate a President. Psychopaths are not infrequently elected to public office and epileptics are not disqualified from driving high-powered and dangerous motor vehicles. The engineers of our fastest trains must not be color blind, but they occasionally are victims of the most fatal of all mental diseases,—general paresis. The navigating officer of a transatlantic liner, responsible for the lives of hundreds of passengers, must pass an examination for a license, but he may be dominated by delusions which escape observation because they are not looked for. Important trials, where human lives were at stake, have been presided over by insane judges. Army officers in command of troops in time of war have been influenced by imaginary voices. Insurance companies issue large policies to individuals suffering from incipient mental diseases which could be detected by even a superficial psychiatric examination.

Serious consideration should be given to the advisability of subjecting to a careful mental examination such persons, at least, as are to be charged with an entire responsibility for the lives of others. It is a question as to whether this procedure is not indicated in the case of other important public trusts where the interest of the community should be safeguarded.

The correlation of psychiatry and psychology as scientific aids to industrial efficiency promises to open up entirely new and important sociological fields of research which have only recently attracted attention. [7] This is a subject of far reaching importance. The extent to which the industrial classes of the country are affected is shown by the following analysis of the occupations represented by 104,013 admissions to New York state hospitals: 1. Professional—(clergy, military and naval officers, physicians, lawyers, architects, artists, authors, civil engineers, surveyors, etc.) 1,926 or 1.8 per cent; 2. Commercial—(bankers, merchants, accountants, clerks, salesmen, shopkeepers, shopmen, stenographers, typewriters, etc.) 7,572 or 7.2 per cent; 3. Agricultural—(farmers, gardeners, etc.) 5,942 or 5.7 per cent; 4. Mechanics—at Outdoor Vocations—(blacksmiths, carpenters, enginefitters, sawyers, painters, etc.) 8,564 or 8.2 per cent; 5. Mechanics at Sedentary Vocations—(bootmakers, bookbinders, compositors, tailors, weavers, bakers, etc.) 7,501 or 7.2 per cent; 6. Domestic Service—(waiters, cooks, servants, etc.) 21,037 or 20.2 per cent; 7. Educational and Higher Domestic Duties—(governesses, teachers, students, housekeepers, nurses, etc.) 21,861 or 21 per cent; 8. Commercial—(shopkeepers, saleswomen, stenographers, typewriters, etc.) 1,140 or 1.09 per cent; 9. Employed at Sedentary Occupations— (tailoresses, seamstresses, bookbinders, factory workers, etc.) 4,310 or 4.1 per cent; 10. Miners, Seamen, etc., 581 or .56 per cent; 11. Prostitutes, 81 or .08 per cent; 12. Laborers, 12,962 or 12.4 per cent; No occupation, 7,820 or 7.5 per cent; Unascertained, 2,715 or 2.6 per cent. [8] This certainly indicates an enormous economic loss to the community.

The intimate relation between mental diseases, alcoholism, ignorance, poverty, prostitution, criminality, mental defects, etc., suggests social and economic problems of far reaching importance, each one meriting separate and special consideration. These problems, while perhaps essentially sociological in origin, have at the same time an important educational bearing, invade the realm of psychology and depend largely, if not entirely, upon psychiatry for a solution.

CHAPTER II

THE EVOLUTION OF THE MODERN HOSPITAL

The medical treatment of mental diseases had its inception, in this country, in the wards of the Philadelphia Hospital, established in 1732 and referred to officially for over a century as an almshouse. It included an infirmary for the "sick and insane," although it apparently had no distinct and separate hospital department for many years. "In 1742," to use the words of Dr. D. Hayes Agnew, "it was fulfilling a varied routine of beneficent functions in affording shelter, support and employment for the poor and indigent, a hospital for the sick, and an asylum for the idiotic, the insane and the orphan. It was dispensing its acts of mercy and blessing when Pennsylvania was yet a province and her inhabitants the loyal subjects of Great Britain." In 1772 it housed as many as three hundred and fifty persons. In 1769 the General Assembly passed an act authorizing the "Managers of the Contributions for the Relief and Employment of the Poor," who had charge of the almshouse, to issue bills of credit for the purpose of relieving their indebtedness. This paper currency was issued in three denominations—one shilling, two shillings and a half crown. The law provided that counterfeiters or persons altering the denomination of these bills should be "sentenced to the pillory, have both his or her ears cut off and nailed to the pillory and be publicly whipped on his or her back with thirty-nine lashes, well laid on, and, moreover, every such offender shall forfeit the sum of one hundred pounds, to be levied on his or her land, tenements, goods and chattels." [9] This certainly must have discouraged counterfeiting. It was not until after the institution was removed to the Hamilton estate in Blockley (now a part of West Philadelphia) in 1834 that it came to be known as the "Philadelphia Hospital and Almshouse," although there was no change made in its organization or functions. In 1902, after one hundred and seventy years of continuous existence, it was finally divided officially for administrative purposes into The Philadelphia Home or Hospital for the Indigent, The Philadelphia General Hospital and The Philadelphia Hospital for the Insane. At that time the hospital was, as it is today, the largest on the American continent. The institution, which has admitted mental cases uninterruptedly since 1732, had over seventeen hundred patients in the department for the insane. In 1917 this number had increased to nearly three thousand.

One of the reasons set forth by sundry petitioners in 1751 for a "small Provincial Hospital" in Philadelphia, which at that time had made provision for the care of indigent cases only, was "THAT with the Numbers of People, the Number of Lunaticks or Persons distempered in Mind and deprived of their rational Faculties, hath greatly increased in this Province. That some of them going at large are a Terror to their Neighbours, who are daily apprehensive of the Violences they may commit; And others are continually wasting their Substance, to the great Injury of themselves and Families, ill disposed Persons wickedly taking Advantage of their unhappy Condition, and drawing them into unreasonable Bargains, etc. That few or none of them are so sensible of their Condition, as to submit voluntarily to the Treatment their respective Cases require, and therefore continue in the same deplorable State during their Lives; whereas it has been found, by the Experience of many Years, that above two Thirds of the Mad People received into Bethlehem Hospital, and there treated properly, have been perfectly cured." [10] This resulted eventually in the opening of the Pennsylvania Hospital in 1752. This institution is a general hospital supported by private funds and has always received mental cases. A separate department for mental diseases was established in West Philadelphia in 1841. Before this was done considerable difficulty was experienced on account of the annoyance of the patients by curious-minded citizens of the neighborhood. This developed into such a nuisance in 1760 that it was suggested "That a suitable Pallisade Fence, either of Iron or Wood, the Iron being preferred, shall be erected in Order to prevent the Disturbance which is given to the Lunatics confined in the Cells by the great Number of People who frequently resort and converse with them." [11] It was also deemed advisable to employ "Two Constables or other proper Persons, to attend at such times as are necessary to prevent this Inconvenience until ye Fence is erected." The public was notified later "that such persons who come out of curiosity to visit the house should pay a sum of money, a Groat at least, for admittance." [12] The Pennsylvania Hospital has played a very important part in the history of the care and treatment of mental diseases in this country. In 1919 it had over three hundred patients.

The first institution designed and used exclusively for mental diseases in this country was the Eastern State Hospital at Williamsburg, Virginia. It was incorporated by the House of Burgesses in 1768 and opened for patients on October 12, 1773. It is interesting to note that the act of incorporation, except in the title, makes no use of the word lunatic, refers frequently to the care and treatment of the patients, authorizes the appointment of physicians and nurses, and specifically designates the institution as a hospital and not an asylum. The original building was one hundred feet long by thirty-two feet two inches wide. During the first year thirty-six patients were admitted. The first pay patient was received in 1774 at a rate of fifteen pounds per annum. An allowance of twenty-five pounds per year was made by the legislature for the maintenance and support of each person admitted. Visiting physicians prescribed for the patients, and the "keepers" for the first few years were not graduates in medicine. The superintendents were, however, physicians after 1841. Known for many years as the "Publick Hospital," the legislature made the mistake of changing this designation to The Eastern Lunatic Asylum in 1841 and it was not until 1894 that it again officially became a hospital. Virginia opened its second institution, The Western State Hospital for the Insane, at Staunton on July 25, 1828. Its third hospital was opened at Weston on September 9, 1859. Virginia is thus entitled to the credit of being the first commonwealth to furnish state care for mental cases and make adequate provision for them.

The next step in the evolution of hospital treatment of mental diseases was taken by Maryland in incorporating a hospital for "The Relief of Indigent Sick Persons and for the Reception and Care of Lunatics" in 1797. The hospital was formally opened in 1798 under the management of the city of Baltimore, which leased the establishment in 1808 to two physicians, who conducted it as a private institution until 1834. It then reverted to the state and was operated as the Maryland Hospital. The institution was removed to Catonsville in 1872 and is now known as the Spring Grove State Hospital, the Johns Hopkins Hospital occupying the site of the original building in Baltimore. Another interesting event in the history of this institution was the founding of what subsequently became the Mount Hope Retreat by the Sisters of Charity, who withdrew from the Maryland Hospital in 1840.

The earliest hospital care of mental diseases in New York was in the wards of the New York Hospital which was opened in 1791. A separate building for mental cases was ready for the reception of patients in 1808. The total number of cases treated up to July 1820 was 1,553. The Bloomingdale Asylum replaced this in 1821, on a piece of property which now belongs in part to Columbia University. Public patients were cared for at the expense of the state until the opening of the New York City Asylum in 1839. Church services were inaugurated in 1819. The hospital buildings furnished accommodations for about three hundred patients. In 1894 the property on Bloomingdale Road was abandoned and the hospital removed to White Plains in Westchester County. It is still known as the Bloomingdale Hospital and is supported entirely by public contributions and the income derived from the care of patients. It has about three hundred and fifty beds.

The activities of the "Religious Society of Friends," which were indirectly responsible probably for the inception of the Pennsylvania Hospital, ultimately led to the establishment of the Friends' Asylum for the Insane at Frankford, Pennsylvania, in 1817. It was under sectarian control until 1834, when its doors were thrown open to all, without regard to religious belief. It claims to be the first institution "erected on this side of the Atlantic in which a chain was never used for the confinement of a patient." [13] The hospital is still in a flourishing condition and has accommodations for over two hundred patients.

Massachusetts at the beginning of the nineteenth century had no hospitals of any kind. In 1764, on the death of Thomas Handcock, it was found that provision had been made in his will for the establishment of a hospital for mental diseases in Boston. An expenditure of six hundred pounds was authorized for the purpose of "erecting and furnishing a convenient House for the reception and more comfortable keeping of such unhappy persons as it shall please God, in His Providence, to deprive of their reason in any part of this Province." [14] The Selectmen of Boston declined this legacy on the grounds that there were not enough mental cases in the vicinity to warrant the existence of such an establishment. This proved to be an error of judgment on their part. In 1811 the Massachusetts General Hospital was incorporated and a fund of over $93,000 was subscribed for building purposes. As it was deemed more urgent, the department for mental diseases in Charlestown was opened first. It was ready for the reception of patients on October 6, 1818, when it admitted a young man supposed to be possessed of a devil. This department became the McLean Asylum in 1826 as the result of a legacy of $25,000 left to the institution by a Boston merchant of that name. The corporation finally received in all an amount approximating $120,000 from the McLean estate. As early as 1822 the first published report of the hospital[15] called attention to the fact that the various amusements offered the patients included "draughts, chess, backgammon, ninepins, swinging, sawing wood, gardening, reading, writing, music, etc." A carriage and pair of horses for the use of patients was purchased in 1828. In 1835 the first pianos and billiard tables were installed and a library of one hundred and twenty volumes placed in the wards. Hot water heating was introduced in 1848. It is interesting to note that in 1827 the visiting committee reported that the rates for the maintenance of patients should not be less than three dollars or more than twelve dollars per week. In 1882 the McLean Hospital established the first training school for nurses connected with any institution for mental diseases in this country. The first class was graduated in 1886. In 1895 the hospital was removed to Waverley, Massachusetts. A chemical laboratory was opened in 1900 and a psychological laboratory in 1904. Hydrotherapy was first used in 1899, and a gymnasium was built in 1904. In 1913 the hospital owned three hundred and seventeen acres of land and had a capacity of two hundred and twenty beds, with a plant valued at nearly two million dollars.

The first provision for the care of mental diseases in Connecticut was a direct result of the activities of the State Medical Society. It was on their petition that the Hartford Retreat was chartered in 1822. Over two thousand persons subscribed to a fund for the opening of the hospital. These subscriptions included "$30 payable in medicine," "One gross New London bilious pills, price $30" and two lottery tickets. [16] About fourteen thousand dollars was subscribed in all, the citizens of Hartford contributing four thousand. The hospital building, designed to accommodate forty patients, was opened on April 1, 1824, and has always been conducted on an unusually high plane. It now averages about one hundred and seventy-five patients.

Mental cases were first provided with hospital care in Kentucky when the Eastern State Hospital was opened in Lexington on May 1, 1824. Governor Adams, who suggested the establishment of this institution, in a message written in 1821 expressed the opinion that it would be of great benefit to the students of Transylvania University, "which would in time repay the obligation by useful discoveries in the treatment of mental maladies."

The State Hospital at Columbia, South Carolina, was opened in December, 1828. A curious fact in connection with its history is that in 1829 the management, having received no patients as yet, advertised for them in the newspapers of South Carolina and adjoining states.

In 1829 the necessity of making further provision for mental diseases in Massachusetts became the subject of a legislative investigation and a committee was appointed "to examine and ascertain the practicability and expediency of erecting or procuring, at the expense of the Commonwealth, an asylum for the safe keeping of lunatics and persons furiously mad." [17] The report of this committee, of which Horace Mann was Chairman, is exceedingly interesting. The following is an illustration:—"To him whose mind is alienated, a prison is a tomb, and within its walls he must suffer as one who awakes to life in the solitude of the grave. Existence and the capacity for pain alone are left him. From every former source of pleasure or contentment he is violently sequestered. Every former habit is abruptly broken off. No medical skill seconds the efforts of nature for his recovery, or breaks the strength of pain when it seizes him with convulsive grasp. No friends relieve each other in solacing the weariness of protracted disease. No assiduous affection guards the avenues of approaching disquietude. He is alike removed from all the occupations of health, and from all the attentions everywhere but within his homeless abode bestowed upon sickness. The solitary cell, the noisome atmosphere, the unmitigated cold and the untempered heat, are of themselves sufficient soon to derange every vital function of the body, and this only aggravates the derangement of his mind. On every side is raised up an insurmountable barrier against his recovery. Cut off from all the charities of life, endued with quickened sensibilities to pain, and perpetually stung by annoyances which, though individually small, rise by constant accumulation to agonies almost beyond the power of mortal sufferance; if his exiled mind in its devious wanderings ever approach the light by which it was once cheered and directed, it sees everything unwelcoming, everything repulsive and hostile, and is driven away into returnless banishment." [18] The investigation conducted by this committee led to the establishment of the Worcester Lunatic Hospital, later the Worcester State Hospital, opened on January 19, 1833. The original building was designed to care for one hundred and twenty patients. After many years of agitation on the part of the public, the hospital was removed to a site overlooking Lake Quinsigamond in the outskirts of Worcester in 1877. It was soon found that it was impracticable to dispense with the use of the old building on Summer Street and it became the Worcester Insane Asylum, later the Worcester State Asylum, and finally the Grafton State Hospital. In 1919 it again became a part of the Worcester State Hospital. The original building is in excellent condition today and promises an indefinite continuation of an unusual career of usefulness. Many men destined to occupy positions of importance in the psychiatric world were trained within its walls.

The death of a prominent politician in 1806 is said to have led indirectly to the establishment of the first hospital for mental diseases in Vermont. [19] His medical advisers treated him for some form of mental alienation by submerging him in water until he became unconscious. It was thought that this "would divert his mind and, by breaking the chain of unhappy associations, thus remove the cause of his disease." As this plan failed he was given opium as "the proper agent for the stupefaction of the life forces." In spite of this vigorous treatment he died. The immediate event which made possible the incorporation of the Vermont Asylum for the Insane in 1835 was a legacy of ten thousand dollars rendered available for this purpose by the will of Mrs. Anna Marsh of Hinsdale. The hospital was opened in Brattleboro in 1836 and became the Brattleboro Retreat after the establishment of the State Hospital at Waterbury. The state care of mental diseases began in Ohio with the establishment of the Columbus State Hospital, which was opened on November 30, 1838. This was the first of a number of institutions now under the supervision of the Ohio Board of Administration.

The study of the development of the state hospital system of care now takes us back to Massachusetts. Notwithstanding the fact that the state already had two institutions for mental cases, McLean and the Worcester Lunatic Hospital, further accommodations were urgently indicated. This was largely on account of the needs of the metropolitan population centering in the city of Boston. To meet this situation the city established a hospital of its own in South Boston in 1839,—the first municipal institution for this exclusive purpose in America. Originally known as the Boston Lunatic Hospital and afterwards as the Boston Insane Hospital, it finally became the Boston State Hospital in December, 1908. Charles Dickens on the occasion of his visit to America was very profoundly impressed by the hospital and made the following references to it in 1842 [20]:—"At South Boston, as it is called, in a situation excellently adapted for the purpose, several charitable institutions are clustered together. One of these is the hospital for the insane; admirably conducted on those enlightened principles of conciliation and kindness which 20 years ago would have been worse than heretical, and which have been acted upon with so much success in our own pauper asylum at Hanwell...." "At every meal, moral influence alone restrains the more violent among them from cutting the throats of the rest; but the effect of that influence is reduced to an absolute certainty, and is found, even as a measure of restraint, to say nothing of it as a means of cure, a hundred times more efficacious than all the straight waistcoats, fetters and handcuffs that ignorance, prejudice and cruelty have manufactured since the creation of the world." ... "In the labor department every patient is as freely trusted with the tools of his trade as if he were a sane man. In the garden and on the farm they work with spades, rakes and hoes. For amusement they walk, run, fish, paint, read, and ride out to take the air in carriages provided for the purpose. They have among themselves a sewing society to make clothes for the poor, which holds meetings, passes resolutions, never comes to fisticuffs or bowie-knives as sane assemblies have been known to do elsewhere; and conducts all its proceedings with the greatest decorum. The irritability which would otherwise be expended on their own flesh, clothes and furniture is dissipated in these pursuits. They are cheerful, tranquil and healthy." ... "It is obvious that one great feature of this system is the inculcation and encouragement, even among such unhappy persons, of a decent self-respect." The institution was removed to the Dorchester district of Boston in 1895, where it now houses in the neighborhood of two thousand patients. The Boston State Hospital was the first institution of its kind in the United States to establish a separate psychopathic department, which was opened in 1912.

Influenced doubtless by the attention given to this subject in other states, Maine opened its first state hospital at Augusta in 1840. There were between two and three hundred mental cases in the state at that time. A second hospital was opened at Bangor in 1889. This humanitarian movement naturally extended to New Hampshire. Governor Dinsmore in 1832 [21] called attention to the condition of the insane, seventy-six of whom were in confinement. Of this number seven were in cells or cages, six in chains and irons and four in jail. Of those not in confinement at the time, some had been handcuffed previously, while others had been in cells or chained. After much unavoidable delay the New Hampshire State Hospital was opened at Concord on October 29, 1842. The next hospital development appeared in Georgia. After an active campaign inaugurated by the physicians of the state and continued for several years, the Georgia State Sanitarium was opened in Milledgeville in December, 1842. It now houses over four thousand patients.

By this time it became evident that further procedures on behalf of the persons requiring treatment for mental diseases in New York were imperative. The Bloomingdale Hospital, although taxed to its utmost capacity, was not able to meet the needs of the situation. In 1830 the population of the state had increased to nearly two million. The report of a legislative committee showed that there were 2,695 insane persons in the state in 1830, with hospital accommodations at Bloomingdale and one other private hospital at Hudson for only two hundred and fifty of these cases. An extensive system of state care was inaugurated by the opening of the Utica State Hospital on January 16, 1843. In addition to numerous other industries and occupations, a printing office was established in the hospital and the publication of the "American Journal of Insanity" was undertaken in 1844. This was the first journal in the world to be devoted exclusively to the subject of mental diseases. "The Opal," edited, published and printed by the patients of the hospital, was started at the same time. In the early days, strong rooms, padded cells and mechanical restraint of all kinds were used extensively. The "Utica Crib" has received a great deal of attention. This consisted of an ordinary ward bed enclosed in wooden slats, making it impossible for the patient to escape. These were eliminated for all time by Dr. G. Alder Blumer in 1887. Attendants were first required to wear uniforms in 1887. During the following year female nurses were assigned for the first time to male wards. Annual field day exercises for the benefit of the patients have been held since 1887. Baseball games, steamboat excursions, Fourth of July celebrations and Christmas entertainments have been in vogue since 1888. With the development of a large department on the "Marcy" site, nine miles from the city, the Utica State Hospital promises to add new accomplishments to an already dignified history.

The early care of mental cases in Rhode Island, as shown by a report to the legislature by Thomas R. Hazard in 1851, was perhaps no worse than that of other states, although the conditions he described so graphically have not been attributed to other New England communities by historians. The following extract from a codicil to the will of Nicholas Brown, who died in 1843, is proof of the fact that this unfortunate state of affairs had not entirely escaped notice [22]:—"And whereas it has long been deeply impressed on my mind that an insane or lunatic hospital or retreat for the insane should be established upon a firm and permanent basis, under an act of the Legislature, where that unhappy portion of our fellow beings who are, by the visitation of Providence, deprived of their reason, may find a safe retreat and be provided with whatever may be most conducive to their comfort and to their restoration to a sound state of mind: Therefore, for the purpose of aiding an object so desirable and in the hope that such an establishment may soon be commenced, I do hereby set apart and give and bequeath the sum of $30,000 towards the erection or endowment of an insane or lunatic hospital or retreat for the insane, or by whatever other name it may be called, to be located in Providence or its vicinity." Supplemental contributions by Cyrus Butler made it possible for the incorporators to found the Butler Hospital in Providence. The first patients were received on December 1, 1847.

More than any other one person, Miss Dorothea L. Dix of Massachusetts was undoubtedly directly responsible for the inauguration of the state care of mental diseases in this country. She is credited with having memorialized twenty-two different state legislatures on this subject. One of her first accomplishments consisted in inducing the New Jersey legislature to make an appropriation for the establishment of the state hospital at Trenton. This institution was opened in 1848, after some of the hardest campaigning that Miss Dix conducted. The last years of her life were spent as an honored guest of the hospital and she died there in 1887 at the advanced age of eighty-five.

Indiana inaugurated a system of state care by the establishment of the Central Hospital for the Insane in 1848. The East Louisiana Hospital at Jackson was opened in the same year. Missouri made its first provision for mental cases by opening a hospital at Fulton in 1852. Notwithstanding the fact that the first hospitals for mental diseases in this country were located in Philadelphia, the Commonwealth of Pennsylvania did not make any provision for a state institution until the State Hospital at Harrisburg was opened in 1851. This was only undertaken after a vigorous campaign on the part of Dorothea Dix had made some legislative action almost imperative. This is probably the only hospital in the country which has found it necessary to demolish all of the original buildings and replace them by others. In 1847 Miss Dix visited Tennessee and started a movement which resulted in the opening of The Central Hospital for the Insane at Nashville, the first institution of the kind in the state. California entered the state hospital field in 1853 with the establishment of an institution at Stockton. The St. Elizabeths Hospital in Washington, D.C., the first federal institution for mental diseases, was opened for patients in 1855. It receives cases from the United States Government Services and from the District of Columbia. Dorothea Dix was largely instrumental in its origin. The St. Elizabeths Hospital was an early invader of the field of scientific research. A pathologist was appointed in 1883. It was one of the first institutions to use hydrotherapy extensively. It now cares for nearly four thousand patients. Mississippi established its first state hospital for mental diseases in 1856, North Carolina in 1856, West Virginia in 1859, Michigan in 1859, Wisconsin in 1860, Texas in 1861, Kansas in 1866, Minnesota in 1866, Connecticut in 1868, Rhode Island in 1870 and Vermont in 1891. The Sheppard and Enoch Pratt Hospital, a well known private institution in Baltimore, was also opened in 1891.

It is hardly worth while at this time to emphasize the fact that the necessity of providing adequate facilities for the care and treatment of mental diseases, a problem which received little consideration of any kind for many years, gradually led to the elaboration of an extensive system of state hospitals. These are to be found now in every part of the country. They have long since passed through the purely custodial stage and have developed into highly specialized modern hospitals of most advanced type. Their function is to provide proper treatment for persons who cannot for financial or other reasons be cared for in the private hospitals which are to be found in almost all localities. These institutions, originating in Virginia in 1773, now represent one of the most important activities conducted by any state government. The extent of the field which they cover is illustrated by the fact that Kansas, Kentucky, Nebraska, North Carolina, Oklahoma, Tennessee, Texas, Washington, West Virginia and Wisconsin each maintain three state hospitals for mental diseases; Iowa, Maryland, Missouri and Virginia each have four institutions of this type, Minnesota five, California, Indiana and Michigan six, Pennsylvania seven, Ohio and Illinois nine, Massachusetts twelve and New York fifteen. In addition to this eight other states have two hospitals each and seventeen find one such institution sufficient for their needs. It is worthy of note that every state without any exception has now recognized the necessity of making provision for the care and treatment of mental diseases.