The Phipps Psychiatric Clinic at the Johns Hopkins Hospital in Baltimore was established in 1913. An integral part of a large general hospital and intimately associated with a medical school, it conforms rather closely to the plan of the German psychiatric clinics. A study of its activities shows that during a period of five years (ending January 31, 1918) the admission rate averaged 403.8 per year. Fourteen and three-tenths per cent of the cases were diagnosed as dementia praecox or schizophrenic reaction and 13.7 per cent conform apparently to the classification of manic-depressive psychoses. Ten and five-tenths per cent were diagnosed as neuroses or psychoneuroses; 6.1 per cent as general paresis; fifteen per cent as agitated depressions; 2.3 per cent as alcoholic psychoses; and 6.1 per cent as constitutional inferiority or constitutional psychopathic states. Seven and nine-tenths per cent were cases of anxiety neuroses, agitated depressions or anxiety psychoses; 2.3 per cent were paranoic states or reactions; 3.5 per cent were cases of alcoholism, and 3.7 per cent of drug habits. The dispensary service of the Phipps Clinic has reported an average of 565 cases per year, representing a total of 2,260.5 visits annually.
The work of Drs. Meyer, Hoch and Kirby at the Psychiatric Institute, of Dr. Barrett at the Psychopathic Hospital at the University of Michigan, of Dr. Southard at the Psychopathic Department of the Boston State Hospital, and that of Drs. Meyer and Campbell at the Phipps Psychiatric Clinic in Baltimore has brought the subject of psychopathic hospitals very prominently before the public. Various other establishments of a similar nature have been planned and some are in process of construction, or already in operation. The State Psychopathic Institute at Chicago and the Psychopathic Hospital of the University of Iowa should be mentioned in this connection. Psychopathic hospitals have been planned for New York City and one is to be built by the State of California. The legislature of Colorado has already made an appropriation of $350,000 for the establishment of an institution of this type in the city of Denver.
The work already done in this field shows quite conclusively that general hospital methods are not inconsistent with the developments of modern psychiatric progress. The large percentage of voluntary cases received and the number of persons consulting the physicians in the out-patient departments shows an unexpected demand on the part of the public for institutions of a new type. As Dr. Adolf Meyer[36] has pointed out, "Our organized system for the care of mental disorder is in many respects forbidding. It throws together all kinds of diseases, and shocks in that way the already sensitive patient who fears the worst for himself or herself. It comes at once with an outspoken declaration of insanity in the very commitment to a hospital, an expression which carries a humiliation to the patient and adds insult to injury. It often means carrying the patient off to a remote asylum which is too widely supposed to have the inscription, 'Leave hope behind all ye that enter here.' Helpfulness rather than coercion must take the place of all this." What the psychiatric clinic may be expected to accomplish in remedying this difficulty was summarized by Dr. Meyer[37] in the following words:—"It is eminently necessary to get model institutions in which medical students and physicians can learn how to deal with the many problems of the disorders of the organ of behaviour from their inceptions into all their ramifications. The clinic must do the work for at least one limited district, with its out-patient and social service and consultation department, and with its hospital wards. Everything must be done to make help in mental disorders more acceptable and convincingly helpful. More patients must learn to look to it for help and the organization must be so as to give the patient and the physician and the public at large a conception very different from that to-day associated with insanity. It is not so much the issue of more help to the curable, but the issue of more work near where the troubles begin, and work against that which breeds trouble. For this we must learn to put the chief weight on hospitals and organizations for natural districts for intensive work rather than upon the mere economy of large hospitals far away from where the troubles develop."
Southard has raised the question as to the correct designation of institutions of the psychopathic hospital type:—"A word is again necessary as to the meaning of the term 'psychopathic hospital.' For various reasons the term has become so attractive in propaganda that a comparatively large number of institutions of whatever scope have been founded or recommended to receive the term 'psychopathic hospital,' 'institute,' 'department' or 'ward.' Thus there is developing a tendency in state hospitals to denominate the receiving ward 'psychopathic.' There can be no advantage in this designation other than that of calling old ideas by new names. The idea of the receiving ward for committed cases destined to receive the ordinary probate court group of cases is not altered or improved in any manner by the designation 'psychopathic.' The best opinion seems to be that a psychopathic hospital or institute shall be an institution in which all types of mental cases, from the probate court group on the one hand up to the most dubious and difficult cases of mental disorder on the other, may be examined; but if an institution is primarily or chiefly concerned with patients of the medicolegal, committable or custodial group, to serve merely as a vestibule through which committed cases pass, such an institution has by no means the broad scope which the very general term 'psychopathic' implies. The institution is not a modified or sublimated form of receiving ward for a great district hospital."
There is, of course, no reason why the reception service of an ordinary state hospital should be spoken of as constituting a psychopathic ward. This accomplishes nothing more, perhaps, than to raise some question as to what the functions of the rest of the institution may be. The designation psychopathic hospital has been rather loosely used and is, as Southard has definitely shown, of American origin. It has been applied somewhat indiscriminately from time to time to practically every form of activity related to the care and treatment of mental diseases outside of the generally recognized state hospital field. These may be summarized as follows:—
1. Detention wards, pavilions, etc. Intended for no purpose other than the custody of the "insane" pending commitment.
2. Psychiatric wards of general hospitals—such as Pavilion F in Albany. There would appear to be no reason for the use of the word psychopathic in such cases, the term psychiatric being much more clearly applicable.
3. Institutes designed primarily for research only or for research and instruction, with or without clinical facilities.
4. Psychopathic hospitals. Independent units or integral parts of a general hospital—with or without facilities for research and instruction. Designed exclusively for mental cases, without regard to legal status, whether committed or voluntary, their detailed examination and careful observation with intensive treatment in the wards for limited periods when indicated, or their supervision and direction in out-patient departments, serving also in some instances as receiving and distributing centers supplying other institutions.
Owing to their limited size, the necessity of treating large numbers in a short space of time, and the fact that institutional care is already amply provided for in the existing state hospitals, the obvious field of the psychopathic hospital is primarily the acute and recoverable psychoses and the milder forms of mental disorder which may or may not require a residence in the wards. Only a thorough examination and a brief period of observation can determine whether or not that is needed. The question at issue is largely that of determining the necessity of a more or less indefinite committed status. These problems arise particularly in dealing with the so-called psychogenic disorders and the psychopathic states—hysteria, neurasthenia, psychasthenia, the psychoneuroses in general and the episodes which characterize the psychopathic personalities. Traumatic psychoses often come into consideration, as well as cases of cerebrospinal syphilis, toxic conditions, drug addictions, the psychoses of infection and exhaustion, and above all, of course, manic-depressive insanity and incipient forms of dementia praecox. Many of these cases require only a brief hospital treatment and are able in a short time to return to home surroundings and resume their former occupations. Often a contact with the chronic and custodial classes is not only without advantage but actually detrimental. The psychopathic hospitals thus exercise a sort of clearing house function and return to the community many patients who otherwise would be subjected to the stigma, if there is one, of a legal commitment. While questions relating to the public health cannot be analyzed in terms of dollars and cents, the saving to the state which is made by substituting a short period of supervision and treatment, for a protracted residence in an institution of the custodial class amounts to millions. In view of the difficulties encountered in obtaining adequate appropriations for the proper maintenance of the enormous population now housed in our state hospitals, this is a factor which cannot be disregarded.
CHAPTER VII
THE MENTAL HYGIENE MOVEMENT
As the result of an intimate personal knowledge of the subject, acquired during an extended hospital residence as a patient in both public and private institutions, Clifford W. Beers, having recovered his health, resumed his place in the world profoundly impressed with the feeling that the question of mental diseases as a public health problem was one which demanded immediate consideration. In no position financially to institute a campaign for the purpose of interesting the public in the importance of topics which had not been made the subject of general discussion in the past, he was confronted with the necessity of securing the cooperation and support of persons who had the means to launch such an undertaking. With this object in view he wrote his book—"A Mind That Found Itself,"[38] now in its fourth edition and destined, to use the words of the "American Journal of Insanity,"[39] "to become one of the classics of psychological literature." There is some question as to the accuracy with which Mr. Beers analyzed the experiences through which he had passed. Although there is no reason for questioning his mental condition when the book was written, his conclusions were apparently formulated when he had not as yet had sufficient time in which to readjust himself and recover his perspective. Some of his viewpoints certainly reflect a morbid coloring of which he was probably unconscious, although at the time he recognized in himself "symptoms hardly distinguishable from those which had obtained eight months earlier when it had been deemed expedient temporarily to restrict my freedom." His work was referred to as an "autopathography" by Farrar,[40] who made a detailed study of the various psychological trends manifested. These are more or less immaterial. The interesting feature of his book is the elaborate description of a common but exceedingly important psychosis written by a well educated observer with a collegiate training. Its greatest value, however, lies in the fact that he brings home to us so graphically the overwhelming importance of the personal element so often overlooked by those who are accustomed to dealing with mental cases in large numbers. "It carries the reader away from the technical dissertations, and brings him face to face with the feelings and reactions of a distorted mind, showing him the patient as a human being with a sentient soul and not as a case."[41]
That the plan which Mr. Beers had formulated for an organized mental hygiene movement had a practical application was recognized at once by Dr. Adolf Meyer,[42] who expressed the following views on the subject as early as 1907:—"It will be a difficult task to find the not very common level-headed and well-informed persons in various parts of the country capable of organizing the public conscience of the people. Neglected by physicians and dreaded by the fiscal authorities, the facts are not available today, except in fragments, mixed up with innumerable extraneous considerations; the hospitals are closed corporations, the press injudicious in inquiry and reform, and those capable of judgment unable to get the facts. The crying needs persist in the meantime. Instead of a land fund (the 12,225,000 acres bill and ideal of Dorothea Dix) we must have a permanent survey of the facts and efficient handling of what is not prevented. The experience with what remains as inevitable experiments of nature, as well as with people who should know better, must be put into practical form for communication and teaching, and brought home where it will tell; in opportunities of work and education for physicians, and cooperation between our educational forces and those who labor for physical hygiene and prophylaxis. Most of us are already under too definite obligations to meet the call for devoted work for the maintenance of an organization as well as can Mr. Beers. In my judgment, he deserves the assistance which will make it possible for others to join in the work which will be one of the greatest achievements of this country and of this century,—less sensational than the breaking of chains but more far-reaching and also more exacting in labor. A Society for Mental Hygiene with a capable and devoted and judicious agent of organization will put an end to the work of makeshift and short-sighted opportunism, and initiate work of prevention and of helping the existing hospitals to attain what they should attain, and further of adding those links which are needed to put an end to conditions almost unfit for publication. What officialism will never do alone must be helped along by an organized body of persons who have set their hearts on serious devotion to the cause. If Mr. Beers gets the means to pursue his aim he will secure the body which will guarantee proper judgment in a cause which has been a mere foster-child in the field of charitable donations merely because it seemed too difficult. Here is a man who is not afraid of the task. May he get the help to enable him to surround himself with the best wisdom of our nation!"
Encouraged by this and many other such expressions of opinion, Mr. Beers proceeded to the organization of the first state mental hygiene society, that of Connecticut, which began its activities in 1908. The National Committee for Mental Hygiene was formally organized on February 19, 1909. The first few years were devoted to raising funds and making comprehensive preparations for further activities which did not start until 1912. In the meanwhile the cooperation of many prominent philanthropists, educators, physicians, etc., was assured. The importance of this movement is illustrated by the prominence of the persons who were willing to associate themselves with an undertaking of this nature. The membership of the committee has included, in addition to many others, Professor William James, Dr. Lewellys F. Barker, Dr. Rupert Blue, Dr. George Blumer, Dr. G. Alder Blumer, Professor Russell H. Chittenden, Ex-President Charles W. Eliot, President W. H. P. Faunce, President John H. Finley, Professor Irving Fisher, Dr. Charles H. Frazier, Cardinal Gibbons, President Arthur T. Hadley, Chancellor David Starr Jordan, President Cyrus Northrop, Dr. Stewart Paton, Dr. Frederick Peterson, Professor Gifford Pinchot, President Jacob G. Sherman, Rev. Anson Phelps Stokes, Mrs. William K. Vanderbilt, Professor Henry VanDyke, Dr. William H. Welch and Ex-President Benjamin Ide Wheeler. Important financial contributions were made by Professor William James, Mr. Jacob A. Riis, Mr. Henry Phipps, Mrs. Elizabeth M. Anderson, Mrs. William K. Vanderbilt, Mrs. E. H. Harriman, Mrs. Willard Straight, the Rockefeller Foundation, etc. With the appointment of Dr. Thomas W. Salmon as Medical Director in 1912 the committee commenced active operations with its future success assured in every way.
The objects and purposes of the National Committee have been very adequately summarized in the following language used in one of its publications:—"The National Committee for Mental Hygiene and its affiliated state societies and committees are organized to work for the conservation of mental health; to help prevent nervous and mental disorders and mental defect; to help raise the standards of care and treatment for those suffering from any of these disorders or mental defect; to secure and disseminate reliable information on these subjects and also on mental factors involved in problems related to industry, education, delinquency, dependency, and the like; to aid ex-service men disabled in the war; to cooperate with the federal, state, and local agencies and with officials and with public and private agencies whose work is in any way related to that of a society or committee for mental hygiene. Though methods vary, these organizations seek to accomplish their purposes by means of education, encouraging psychiatric social service, conducting surveys, promoting legislation, and through cooperation with the many agencies whose work touches at one point or another the field of mental hygiene. When one considers the large groups of people who may be benefited by organized work in mental hygiene, the importance of the movement at once becomes apparent. Such work is not only for the mentally disordered and those suffering from mental defect, but for all those who, through mental causes, are unable so to adjust themselves to their environment as to live happy and efficient lives." The first few years of the committee's existence have demonstrated conclusively that it is the most powerful factor in promoting the welfare and interests of the insane in this country since the time of Dorothea Dix. The elaborate surveys which it has made of conditions existing in various states have resulted in beneficial legislation which had been needed for years. Surveys have been completed in California, Tennessee, Louisiana, Pennsylvania, Texas, Connecticut, Georgia, Wisconsin and South Carolina, and others are under way. It has brought about an interest in mental diseases and mental defects such as has never been manifested before in this country. Its activities during the early part of the war were responsible largely, if not entirely, for the attention given by the Army and Navy to matters relating to psychiatry. The National Committee has taken a very active part in encouraging the establishment of psychiatric clinics in connection with the state hospitals. It has been largely responsible for the psychological and psychiatric examination of defectives in penal institutions and reformatories now generally recognized as being of vital importance. Its activities have emphasized the importance of a preliminary mental examination of obviously defective individuals brought before the courts. One of its accomplishments has been the publication of a very successful quarterly magazine, "Mental Hygiene," which was undertaken in 1917 and has long since passed the experimental stage. A summary of its activities would not be complete without a reference to the valuable work which the committee has done in standardizing the reports made of institutions and compiling accurate statistics relating to mental diseases and defects which will be of inestimable value to all who are interested in the progress of psychiatry in this country.
State mental hygiene societies now exist in Alabama, California, Connecticut, the District of Columbia, Georgia, Illinois, Indiana, Iowa, Kansas, Louisiana, Maryland, Massachusetts, Maine, Mississippi, Missouri, North Carolina, Oregon, Pennsylvania, Rhode Island, Tennessee and Virginia. The committee on mental hygiene in New York is a department of the State Charities Aid Association, which has been actively interested in matters relating to the care and treatment of the insane for many years. The chief purposes of the state organizations have been officially described as follows:—[43] "To work for the conservation of mental health; for the prevention of mental diseases and mental deficiency and for improvement in the care and treatment of those suffering from nervous or mental diseases or mental deficiency." The interest of the public is stimulated by pamphlets, reports and publications of various kinds, mental hygiene exhibits of an educational nature, public lectures, mental hygiene conferences, etc. The local societies have as a definite object, moreover, the encouragement of[44] "(a) Out-patient departments for mental cases in connection with hospitals for mental diseases and general hospitals, and independent of either of these agencies, such, for instance, as dispensaries and mental hygiene clinics, (b) Systematic psychiatric as well as psychological examination of school children, (e) Provision for incipient and emergency cases in psychopathic wards of general hospitals, (d) Psychopathic hospitals in which cases of mental disorder may be treated in their earliest and most curable stages and where practical work in prevention and social service may be done, (e) Increased institutional provision for the feebleminded and epileptic." One of their most important objects is the enactment of laws in the various states which will take care of the insane pending commitment out of the hands of the poor authorities and delegate it to health officers or physicians. As Dr. William L. Russell[45] has pointed out, the mere provision of institutional care for the mental diseases of a community is not the only thing to be considered, "Unless the vital issues occasioned by mental disorders in the homes, the schools, the industries, and in social relations are intelligently grasped and dealt with by means of the state system, state institutions are liable to be looked upon as a resource which is only to be appealed to when complete separation of the patient from his usual environment has become imperative. They will still be regarded as asylums. In such case, their development is likely to be in the direction of great custodial centers, and economic and so-called business consideration in their management are likely to prevail over those dictated by science and humanity. This has happened in more than one state in which state care has been adopted under conditions of great promise. A system of state care must, to be effective, not only be adopted, but it must be planned and developed with reference to the known needs of the sufferers from mental disorder."
The Canadian National Committee for Mental Hygiene, the second national organization of this type, was established at Ottawa on April 26, 1918, largely as a result of the activities of Dr. Clarence M. Hincks of Toronto University. Arrangements were at once effected for an active participation in war work, a comprehensive study of immigration, elaborate statistical institutional studies, the establishment of a library, special investigation of delinquency and a series of lectures to be given in various parts of the Dominion. This organization has been an exceedingly active one from the beginning. The first number of the "Canadian Journal of Mental Hygiene" appeared early in 1919. A survey was made of Manitoba and its needs during the first year. The University of Toronto announced an extension course beginning April, 1919, for the special training of social workers desiring to enter the mental hygiene field. Instruction was given in psychiatry, social and economic problems, neurology, mental tests, case work, social institutions, occupational therapy, child welfare, home economics and recreation. In 1919 a mental hygiene survey was made of British Columbia. Alberta, New Brunswick and Nova Scotia have already requested similar surveys with the intention of improving the methods of caring for mental diseases and defects in those provinces. Psychiatric clinics have been established in connection with the Toronto University and the Royal Victoria Hospital in Quebec. New institutions have been planned in British Columbia and a psychopathic hospital is to be built in Toronto. In 1920 a mental hygiene committee was instituted in France[46] by the Minister of Hygiene, Assistance and Social Providence. The committee is made up of about forty members, psychiatrists, pathologists, physiologists, managers and magistrates. Dr. Dron, Senator and Mayor of Tourcoing, was elected chairman. The committee is to make a study of all questions relating to mental hygiene and psychiatry. It will consider particularly methods of coordinating the activities of various organizations already at work, the creation of new interests and spreading broadcast information on mental hygiene topics. A representative of this society has already made a visit to this country to study methods employed here. The mental hygiene movement has even reached South Africa. "Mental Hygiene"[47] has called attention to the fact that the Cape Province Society for Mental Hygiene has actively interested itself in the provisions discussed by the government for the care, education and training of the feebleminded. Two institutions are to be opened for this purpose. The Cape Province Society has already instituted a campaign for the purpose of organizing other local societies as well as a national council.
When Mr. Beers wrote his well-known book he evidently had in mind more particularly the amelioration of material conditions existing in institutions. He was looking forward to provision for the more humane and scientific care of mental diseases. This is unquestionably a consideration of vital importance and these objects have not been neglected in the practical operation of the mental hygiene organizations. Mental hygiene in its broadest sense, however, has come to mean much more than that. The foundation of the present-day conception of mental hygiene may be said to have been laid by Adolf Meyer in 1906, when he described the fundamental principles which he believed to be concerned in the development of dementia praecox. He saw in this disease a disorder of the personality due to a deterioration of mental habits, in other words, to faulty mental hygiene. While his views as to the etiology of dementia praecox have not been generally accepted, they suggested an entirely new avenue of approach to the problem of mental diseases in general. Hoch's "shut in" personality and Bleuler's "autismus" were more or less comparable hypotheses which do warrant to a certain extent the tenability of such theories as were advanced by Meyer. The same may be said of some of the mental mechanisms advocated by Freud and others of the more purely psychological school of psychiatrists. This viewpoint is reflected somewhat by White[48] in his conception of childhood as the golden period for mental hygiene. "The outstanding fact that present-day psychiatry emphasizes is that mental illness is a type of reaction of the individual to his problems of adjustment which is conditioned by two factors—the nature of those problems and the character equipment with which they are met.... Mental illnesses, defects of adjustment at the psychological level, are therefore dependent upon defects in the personality make-up, and as this personality make-up is what it is as a result of its development from infancy onward, it follows that the foundation of those defects which later issue in mental illness are to be found in the past history of that development." He protests very properly against accepting the theory that the characteristics of the personality are entirely the products of germ-plasm determiners moulded in strict accordance with the laws of heredity and therefore immutable.
Copp[49] has called attention to the fact that the dominant figure in mental hygiene activities must eventually be the family physician, who has an opportunity to see the beginnings of mental disorders when they first manifest themselves. He must, therefore, be qualified to intelligently understand such conditions and be prepared to suggest a remedy. His is inevitably the first point of contact. Mental hygienists have found a fertile and almost untouched field in our public school system. As Professor Burnham[50] suggests, "It is a grave reflection upon the schools that so many of their graduates have to be reeducated in the sanitarium or the hospital." The hygiene movement in the school population, as suggested by Professor Gesell,[51] means something more than psychological examinations and mental tests, important as they are. It means a study of the individual. He would have a new type of school nurse or social worker, one interested particularly in "the child with the night terrors, the nail biter, the over-tearful child, the over-silent child, the stammering child, the extremely indifferent child, the pervert, the infantile child, the unstable choreic, and a whole host of suffering, frustrated and unhealthily constituted growing minds, that we are barely aware of in a quantitative sense, because we do not have the agencies to bring them to our attention as problems of public hygiene and prophylaxis." They require highly specialized supervision and training if they are not to become future residents of our hospitals for mental diseases or possibly of institutions of a reformatory type. If such reforms as these are to be brought about in our public school system it is hardly necessary to suggest that the teacher herself must have very clear conceptions as to the significance and importance of mental training in youth.
If these matters are important in the public schools they must be even more serious factors in higher education. Campbell[52] has raised the question as to how far the universities "fulfill their responsibilities with regard to the mental hygiene of the community? It is doubtful whether they have attained a clear recognition of the fact that a man's mind may be richly supplied with a great variety of special information, that he may have attained a high intellectual level, and yet the man's life may be rendered inefficient because it rests upon insecure foundations. An education may enable a man to solve abstruse intellectual problems, and yet leave him so hopelessly unable to cope with a bereavement, an unsuccessful love affair, difficult marriage relations, or even simple instructive impulses that he may lose control of the direction of his life and for a period be dominated by factors which have been almost entirely repressed in his conscious life; the disorder may be so marked as to be included under the wide term "insanity." To rear a superb intellectual structure on such a foundation is surely not an ideal education; it is like building a house on the sand, or, to speak more hygienically, it is like building a superb mansion without paying any attention to the plumbing." Deplorable as it may seem that such important elements in the education of the individual have been overlooked, it is not nearly so surprising as the fact that no instruction of any consequence is given in psychiatry in the great majority of our medical schools. This is a matter which is well worthy of attention and is fortunately beginning to receive some consideration. A rather systematic campaign has been instituted by the mental hygiene organizations to bring about some instruction in these topics in our schools and universities,—a campaign which promises to be productive of results sooner or later.
An interesting phase of the mental hygiene movement is the relation which it has been shown to hold to the field of industry. It must be admitted that this is an intensely practical question. We even have a Journal of Industrial Hygiene, which has been published successfully now for some time. The mere taking of intelligence tests for industrial purposes is only an incident. The important thing, as shown by Cobb,[53] is the prevention of mental disorder by bringing about a proper relation of the worker to his environment and the elimination of causes of discontent. Beyond this there is, of course, the early treatment of individuals before the opportunity of bringing about a proper adjustment has been lost for all time. Cobb[54] suggests that, above all, the physician must "forget orthodox psychiatry (as the economist seems to be forgetting cut-and-dried political economy) and interest himself in a dynamic, individual psychology which recognizes the essentials of human nature and at last begins to analyze for us the elements of which human nature really consists, looking on each case as a human experiment in reaction to environment."
There would appear to be no limit to the possibilities of the mental hygiene movement. Perhaps no more comprehensive summary of its objects and purposes can be given at this time than that contained in a definition recently formulated by Southard:[55] "To stem the tide of syphilis, to wage war on alcohol, to counsel against marriage of defectives, to generalize the insane hospitals, to specialize the general hospitals, to weed defects out of general school classes, to open out the shut-in personality, to ventilate sex questions, to perturb and at the same time reassure the interested public—these are infinitives that belong perhaps in a rational movement for mental hygiene. They are things the past has taught us more or less clearly to do and in that sense the movement for mental hygiene is surely not much more than the elaboration of the obvious."
It may be suggested that these are functions which properly belong to the medical profession exclusively. A little reflection will, however, be sufficient to show that this is not the case. Efforts have been made for years to prevent the spread of venereal disease. Attempts were made to accomplish this by legislative enactment. That these methods of control have been ineffectual is now well known to everyone. Continental governments have for a long while been trying to regulate prostitution by police supervision and frequent medical inspections. The percentage of venereal disease has, however, not been appreciably reduced by this plan and it has been repeatedly condemned by vice commissions as a result of official investigations. It may be stated now, I think, without fear of contradiction that this is a matter which must be regulated by educating the public and which can be handled in no other way. It is a well known fact that no law can be enforced unless it meets with public approval. The will of the majority rules. When the effects of venereal disease are generally recognized there will no longer be a necessity for much legislation on the subject. This is a question of far-reaching importance. When it is recalled that twelve per cent of the cases admitted to our hospitals for mental diseases are suffering from general paresis or cerebral syphilis, the necessity of a more general understanding of these conditions is readily apparent. The percentage is much higher in the densely populated metropolitan districts.
Legislative restrictions in the past were never very successful in limiting the use of alcoholic beverages. It is true that the Eighteenth Amendment to the Constitution of the United States and the Volstead Act have had a very material effect on the number of cases of alcoholism admitted to our institutions. The influences which resulted in alcoholism, however, will find an outlet in some other direction unless they are modified in some way. This again is largely a matter of education. There never was a time in the history of the country when a knowledge of the effect of drugs of various kinds on the nervous system was as important as it is today.
The history of the movement to prevent the marriage of mental defectives is more or less familiar to all. The sentiment of the community is apparently not such at this time as to encourage the regulation of the marriage of the mentally or physically unfit by legislative restrictions. Attempts to do so have been almost a flat failure. Various states have passed laws providing for the sterilization of defective delinquents. These laws, generally speaking, have accomplished nothing because public sentiment was not behind them. All of these matters have been brought to the attention of the public by prominent speakers on numerous occasions. Frequent articles have been printed in medical journals, well-known periodicals, and even in the daily papers. Attention has been called to the mental clinics established here and there and repeated reference has been made to the fact that physicians at our state hospitals may be consulted at any time on questions pertaining to mental diseases or mental defects.
Something has been accomplished along these lines. It is unfortunate that, as a rule, people look with more or less suspicion upon institutions which are even now generally referred to as asylums. There are many who still believe that every hospital for mental diseases has its padded cells and underground dungeons. There is a rather widespread idea that the most common causes of insanity are cigarette smoking, religion and self abuse. Even in our most progressive communities it has been difficult, if not impossible, to entirely prevent the temporary detention, at least, of mental cases in jails and police stations. Very few general hospitals have psychopathic wards or any realization as to the necessity of establishing them. It is not to be denied that in many states the care of the mentally ill in our public institutions is far from being what it should be in this enlightened day. These are conditions that cannot be remedied by the medical profession without the active assistance of leaders of public sentiment. The fact that the importance of these questions is recognized by prominent educators, business men, lawyers, and other persons active in the affairs of the community, and well known to the public, will accomplish more than articles in the medical journals by physicians. This constitutes the great field of the mental hygiene organizations. They will mould public sentiment as nothing else ever has, in matters which relate to the mental health of the country. They will influence legislation where it is needed in a way that no medical society can hope to do. Above all, they can in time bring the public face to face with the fact that mental diseases should be discussed, generally understood and prevented, instead of being merely concealed and misrepresented. Possibly it would not be looking too far into the future to express the hope that an organization composed largely of laymen may be able eventually to accomplish something that the medical profession has never been able to do,—induce those who frame our laws to provide medical treatment for defective delinquents instead of merely locking them up for the protection of society. It would seem, moreover, that the time has come when the public should insist that the mental condition of persons accused of crime be made a medical rather than a legal question exclusively.
CHAPTER VIII
THE ETIOLOGY OF MENTAL DISEASES
In reviewing the history of medicine there is nothing more discouraging than the references found in literature to the views entertained from time to time relative to the cause of mental diseases. To a certain extent this may be looked upon as an index of the progress of civilization. It must be admitted that it is at the same time, nevertheless, a reflection upon the medical profession which has never shown the interest in psychiatry that the importance of the subject warrants. It has been suggested that mental diseases did not play a prominent part in ancient history, owing to the fact that the law of the survival of the fittest automatically eliminated the insane and defective. As Tuke[56] says, "They perished in the course of nature, or were stamped out of existence; many of the perverse and morally insane were stoned to death; war destroyed a large number of feeble persons; while the Romans deliberately, and in the interests of the race, threw down from the Tarpeian Rock the children who were unfit to live." The papyri of the fifteenth century before Christ show clearly that the doctrine of demoniacal possession was generally entertained at that time.
One of the earliest attempts to explain the origin of mental diseases perhaps was that of Plato. "There are two kinds of madness, one arising from human diseases, the other from an inspired deviation from established custom." Hippocrates[56] had some very clearly defined views on this subject: "As long as the brain is at rest a man enjoys his reason; but the depravement of the brain arises from phlegm and bile, either of which you may recognise in this manner: Those who are mad from phlegm are quiet, and do not cry out or make a noise, but those from bile are vociferous, malignant, and will not be quiet, but are always doing something improper. If the madness be constant, these are the causes thereof; but if terrors and fears assail, they are connected with derangement of the brain, and derangement is owing to its being heated. And it is heated by bile when it is determined to the brain along the blood-vessels running from the trunk, and fear is present until it return again to the veins and trunk, when it ceases. He is grieved and troubled when the brain is unreasonably cooled and contracted beyond its wont. It suffers this from phlegm, and from the same affection the patient becomes oblivious." An interesting theory which he evolved was that the appearance of varicose veins or hemorrhoids tended to relieve the patient's mental suffering. Celsus subscribed to the black bile doctrine. Galen's teaching was that fatuity was due to moisture, while dryness produced sagacity. In cases where the whole body contained melancholy blood he recommended venesection. Thick and black wine was to be avoided, "as from it the melancholy humour is made."[57] This he described as a condition of the blood "thickened, and more like black bile, which exhaling to the brain, causes melancholy symptoms to affect the mind." The Roman custom of appealing to the household gods, sons of the Goddess of Madness, was quite significant. Horace, in speaking of Orestes, says: "Was he not driven into frenzy by those wicked Furies, before he pierced his mother's throat with the reeking point of his sword? Nay, from the time that Orestes passed for being unsound of mind he did nothing in any way to be condemned; he never dared wound with his sword either his friend Pylades or his sister Electra; he merely abused both, calling one a Fury, the other some other name suggested by his active or bright bile." In the story of Argive, Horace says that "his relations cured him with much labour and care, by expelling the disease and the bile by doses of pure hellebore."
Little progress was made, if any, by the time of the Christian era. In fact, as Clouston[58] says, "The mental pathology of the New Testament and of the early ages of Christianity was founded on the idea that the disease was a possession of the devil, and the feeling towards this afflicted class of human beings was naturally that of repulsion and hatred, their treatment following on those lines. Neglect, the whip, chains, confinement in stone cells, starvation, unsuitable medical treatment, speedy death were the natural results."
Passing to the seventeenth century we find that Sennert, a professor in Wittenberg, believed that maniacs evacuated stones, iron, living animals, etc., things not produced in the natural body and therefore caused by demons. He also believed firmly in witchcraft. Thomas Willis (1682) is said by some to have been one of the first to suggest a relation between insanity and pathological changes in the brain. Prochaska in 1784 went so far as to say, "We think, with Haller, that no light can be thrown upon it in any other way than by a careful dissection of the brains of fatuous persons, apoplectics, and such as have other disorders of the understanding." It would appear to have been the belief of Pinel that the primary seat of disease in mental conditions was in the stomach and intestinal tract. Spreading from these centers it caused a derangement of the mind when the brain became involved. The influence of the moon, as well as the stars, was spoken of by Hippocrates and admitted by Galen. To these ideas we owe the word lunacy which appeared in the laws of England in 1320 and may be found there today.
The influence of the moon on the mind was taken quite seriously. Rush seems to have been somewhat in doubt on this subject and suggested the probability of there being a kind of sixth sense involved—a perception of the state of the air, and of light and darkness, as Pritchard expressed it, to which we are insensible in health. It was thought that the full moon, by rarefying the air, increased the amount of light, thus affecting the mind. Dr. Rush noted that during an eclipse of the sun in 1806 "there was a sudden and total silence in all the cells of the hospital." He expressed the opinion in his "Medical Inquiries and Observations" in 1812 that there are few cases in which the insane feel the influence of the moon and that the excitement resulting in such cases is to be attributed to the resulting increase of light. It is interesting to note that von Feuchtersleben, an eminent German writer, in 1845 was unwilling to go on record as stating positively that the moon was not a factor in the causation of insanity. Esquirol, in his "Maladies Mentales," in 1838, branded this belief as a superstition, but admitted that there were certain facts which could not be overlooked. "It is true that the insane are more agitated at the full moon as they are also at the dawn of day; but is it not the bright light of the moon that excites them, as that of the day every morning? Nevertheless, an opinion which has existed for ages—which has spread over all lands, and which is consecrated by popular language—demands the most careful attention of observers." Dr. Allen of the York Lunatic Asylum was very firmly of the opinion that the moon had a decided influence on the time of death in mental diseases. This question was given very serious consideration by various writers as late as 1856.
In the meanwhile efforts were being made to ascertain the cause of mental disease by means of pathological researches. Morgagni,[59] one of the earlier investigators, came to the conclusion that the more common lesions were in the pineal gland, although he found some induration of the brain and various other well-defined changes. Arnold (1782) thought that insanity was due to an increased density of the cerebral substance, particularly, according to Tuke, "of those parts of the brain by means of which the soul is connected with the body." Pinel finally concluded that pathology had practically nothing to do with the problem and Esquirol in 1838 wrote very discouragingly on the subject. Early contributions of considerable importance were made, however, by Foville, Bayle, Greding, Calmeil, Guislain, Parchappe and others. These were confined almost entirely to a study of gross or macroscopic lesions of the brain. Griesinger in 1845 reviewed the pathological changes in the nervous system quite thoroughly as far as they were known at that time. It must be admitted that the greater part of our knowledge of the pathology of mental diseases was acquired at a much later date.
A very definite indication of the progress, or lack of progress, made in determining the etiology of the psychoses is the list of causes agreed upon at the International Congress of Alienists[60] in 1867:—1. Physical causes: Artificial deformities of cranium; convulsions of infancy and dentition; cerebral congestion (primary, not that which arises in the course of certain forms of insanity); organic affections of the brain; senility; pellagra; anemia; constitutional syphilis; intermittent fever; typhoid fever; acute rheumatism; gout and chronic rheumatism; organic affections of the heart; pulmonary phthisis; intestinal worms; other acute diseases; other chronic diseases; suppression of the hemorrhoidal flux; menstrual disorders; metastasis; alcoholic drinks; abuse of tobacco; other vegetable poisons; mineral poisons (lead, mercury, coffee, etc.); insolation; intense heat; intense cold; blows and falls upon the head; other traumatic causes. 2. Moral causes: Appertain to religion; education; love (love thwarted, jealousy); family affections; fluctuations of fortune; domestic troubles; pride; disappointed ambition; fright; irritation; anger; wounded modesty; political events; nostalgia; ennui; misanthropy; sudden joy; simple imprisonment; solitary confinement.
In 1897 the New York State Commission in Lunacy in its eighth annual report published an analysis of the assigned causes of insanity given in 39,369 cases admitted from 1888 to 1896. Of these 11,999 were reported as unascertained. In the remaining 27,370 cases the important "assigned causes" in the order of their frequency were as follows: Moral causes (including domestic trouble, loss of friends, business anxieties, pecuniary difficulties, grief, fright, disappointed affections, disappointed ambition, political excitement, religious excitement, etc.) 6,608, intemperance in drink 4,763, hereditary predisposition 2,095, old age 1,723, general ill health 1,681, epilepsy 1,605, ill health following overwork 1,092, masturbation 1,063, puerperal (including childbirth and abortion) 773, traumatic 608, climacteric 502, la grippe 442, sunstroke 402, physical diseases 375, syphilis 368, cerebral diseases 312, intemperance in drink and narcotics 277, congenital defects 223, shock from injury 167, fever 147, uterine and ovarian disease 132, pregnancy 109, privation and overwork 110, etc. These are given in detail not that they throw any light on the question of etiology but that they are quite significant as to the ideas prevalent on this subject only a few years ago. In justice to the Commission in Lunacy attention should be called to the fact that this tabulation does not purport to give actual causes but those officially "assigned" by the examining authorities or others interested. Clouston[61] in 1911, in making a statistical study of 11,346 cases admitted to the Royal Edinburgh Mental Hospital in the course of thirty-five years, enumerated a long list of causes shown in the hospital reports. It is interesting to note that they include nursing, disordered menstruation, self abuse, sexual excess, surgical operations, bronchitis, prostatic disease, lupus, commencing menstruation, transference of morbid action from other organs to the brain, excessive tobacco smoking, chloroform inhalation, excessive number of children, religious excitement, marriage, changes of residence, sedentary habits, political excitement, bad temper, the Queen's Jubilee, etc. As he says, "No other disease has anything like this list of 107 causes. A black and terrible roll it is. Poor humanity has much to contend with to keep sound in mind." Analyzing these statistical findings, Clouston concludes that "bad heredity, congenital defects, and previous attacks are the great predisposing causes, and that alcohol, the crises of life, epilepsy, the various forms of brain poisons and the gross brain and nervous diseases constitute the mass of exciting causes. Together they account for over seventy per cent of the defects and diseases of the mind that come under my observation."
A reference to the statistical reports of the past as published by the hospitals of this and other countries will show nothing radically different until within the last few years. It will readily be observed that fundamentals were almost entirely lost sight of and nonessentials overemphasized. Masturbation, for instance, is often a symptom of dementia praecox and other forms of mental disease, but is not now looked upon as an important etiological factor. The immediate cause, so-called, is usually a mere incident, often not without some significance, but bearing little if any definite relation to the fundamental underlying condition responsible for a mental breakdown. The studies of Meyer, Hoch, Kraepelin, Freud, Jung, Bleuler and many others have shown that in manic-depressive insanity, dementia praecox and various other psychoses we are dealing with very definite constitutional conditions, morbid temperaments, personality defects, etc., which are responsible for the maladjustments leading to the development of psychoses. Financial reverses, domestic difficulties, the death of near relatives, the ordinary hardships and disappointments of life, even ill health, do not as a rule mean the development of a psychosis in the normal, properly balanced individual. In the constitutionally predisposed, the love affair, the loss of a position, the upsetting factor, whatever it may be, is merely the "straw that breaks the camel's back" and is nothing more than an accident of fate, a pure coincidence. Any other comparatively trifling occurrence out of the ordinary, any difficult situation which the makeup of the individual could not adequately meet and react to, would have accomplished the same result. There are, however, of course, certain psychic traumas to which these inadequate personalities are particularly susceptible.
Experience has shown that without any doubt there are conditions for which defective heredity is largely responsible. It is often difficult to determine the actual rôle which this plays in a given case. Efforts have been made to reduce the study of these factors to a definite scientific basis. In 1865 Gregor Mendel,[62] Abbot of Brünn, published an account of a series of experiments made by him with the common pea (pisum sativum) which was destined to revolutionize our views on the subject of heredity. On crossing a tall with a dwarf plant, tall hybrids resulted with no intermediate forms. This inheritance is said to be due to the presence of a definite "determiner" in the germ plasm. All of his hybrids being of the tall variety, he designated that character as the "dominant," the dwarf being spoken of as the "recessive." On the fertilization of these hybrids he obtained another generation, which averages three tall plants to one dwarf. Further investigation showed that the dwarfs always bred true, as did about one out of three of the tall varieties, the remaining two behaving as did the original hybrids and giving three talls to one dwarf. He therefore observed that he was dealing with three varieties of inheritance, the dwarfs which bred true, the talls which bred true and the talls with a fixed proportion of talls and dwarfs. The phenomenon as noted by Mendel is not, however, universal in its application. Curiously enough no attention was given to Mendel's experiments until eighteen years after his death, when his work was rediscovered by de Vries, Correns and Tschermak in 1900.
Davenport[63] has shown that there are six possible matings of germ cells as illustrated by the pigment of the eye:—1. Both parents, pigmented iris (brown eyes) and duplex—all offspring with pigmented iris and duplex; 2. Both parents brown-eyed, one duplex, one simplex—all children brown-eyed, but half simplex; 3. One parent brown-eyed and duplex, the other blue-eyed—all children brown-eyed and simplex; 4. Both parents brown-eyed and simplex—one-fourth of the children brown-eyed and duplex, one-half brown-eyed and simplex, and one-fourth blue-eyed; 5. One parent brown-eyed and simplex, and the other blue-eyed—one-half the children brown-eyed and simplex, the other half blue-eyed; 6. Both parents blue-eyed—all children blue-eyed. It should be explained that a duplex origin means the inheritance of a character from both parents and simplex from only one. The principles of the Mendelian laws of heredity have been applied to a study of the color of the eyes and skin, the color and form of the hair, the stature, body weight and many other family traits such as musical knowledge, ability along artistic and literary lines, mechanical skill, etc. They have also been applied to the study of various diseases, such as Huntington's chorea, hereditary ataxia, deaf-mutism, feeblemindedness, epilepsy and insanity, etc.
Rosanoff[64] and Orr have suggested the following hypothesis relative to the transmission of the neuropathic constitution as based on the Mendelian theory:—1. Both parents being neuropathic, all children will be neuropathic; 2. One parent being normal but with the neuropathic taint from one grandparent, and the other parent being neuropathic, half the children will be normal but capable of transmitting the neuropathic constitution to their progeny, and half will themselves be neuropathic; 3. One parent being normal and of pure normal ancestry, and the other parent being neuropathic, all the children will be normal but capable of transmitting the neuropathic makeup to their progeny; 4. Both parents being normal, but each with the neuropathic taint from one grandparent, one-fourth of the children will be normal and not capable of transmitting the neuropathic makeup to their progeny, one-half will be normal but capable of transmitting the neuropathic makeup, and the remaining one-fourth will be neuropathic; 5. Both parents being normal, one of pure normal ancestry and the other with the neuropathic taint from one grandparent, all the children will be normal; half of them will be capable and half not capable of transmitting the neuropathic makeup to their progeny; 6. Both parents being normal and of pure normal ancestry, all the children will be normal and not capable of transmitting the neuropathic makeup to their progeny.
Just how much importance is to be attached to these theories is a difficult matter to determine. A study of a considerable number of families by Rosanoff[65] would appear to be very suggestive, although his conclusions must be looked upon as fairly conservative:—"On the whole, taking into consideration the limited amount of material as well as the various sources of possible error, the correspondence between the actual findings and theoretical expectation, as shown in the table, must be regarded as strikingly close." On the other hand, as White[66] says, "In dealing with the subject of heredity, however, it must not be forgotten that our ideas are of necessity largely founded upon hypotheses, as biological science has not yet unfolded a sufficient number of facts to make it possible to tell just how much, in any individual case, must be attributed to the inherent qualities of the "germ plasm" and just how much to the influences of environment. The view which is pretty generally admitted among biologists at present is that there is little warrant for the belief in the Lamarckian hypothesis of the inheritance of acquired characters."
The New York statistical tables on heredity were discontinued in 1907, at which time a total of 104,013 cases had been reported. In 31,290 of these no information was available, leaving a total of 72,622, excluding the not insane. A history of insanity was shown in the paternal branch of the family in 8.6 per cent of the ascertained cases, in the maternal branch in 10.1 per cent, in both paternal and maternal in 1.7 per cent, and in collateral branches in eleven per cent,—a total of 31.4 per cent in which some form of heredity was reported. These statistics relate only to insanity in the family history. There were so many sources of inaccuracy that it was not thought worth while to continue these studies after 1907. Comparisons between the heredity of mental cases and that of normal individuals have been rather surprising. Koller, for instance, as quoted by Kraepelin,[67] in a comparison of 370 healthy with a similar number of insane individuals found a history of psychopathic defects in the immediate families of fifty-nine per cent of the former and 76.8 per cent of the latter. Diem[68] in 1905 made an analysis of the family history of 1193 healthy individuals. This was compared with 1850 mental cases. Neuropathic heredity of some kind was found in 78.2 per cent of the mental cases and 66.9 per cent of the healthy individuals. There was, however, a history of mental diseases in the families of 38.3 per cent of the insane patients as compared with 7.1 per cent of the normal individuals. Somewhat different results were noted in a study of the parents. There was a paternal or maternal history of insanity in 18.1 per cent of the families of the mental cases as compared with 2.2 per cent in the cases of the normal individuals. In the direct parentage, Koller found mental diseases in 57.3 per cent of the families of the insane as compared with 28 per cent in the case of normal individuals. Kraepelin states that the influence of the father is greater in heredity than is that of the mother. The father, furthermore, usually transmits to the son while the mother influences the daughter more.