incurable mental disease. Although in its inception, enough has been accomplished to demonstrate the value of an intelligently applied system of after-care. The very causes that led to the original attack in a mind not overstrong and possibly predisposed to mental disease are all the more operative after collapse has already occurred. By careful supervision after discharge such a recovered patient may be prevented from overdoing, may be removed from a depressing or unhealthful environment, and may be so favorably situated that a second attack will never recur, and the individual himself remain a productive member of society.

In this country at least the solution of the immigration problem must play a prominent part in the prophylaxis of insanity. Change of food, climate and native home environment, together with the strenuous life in a new country, all prove a serious stress for those immigrants who are not physically and mentally equipped to meet the new conditions. The immigration laws now in force must prove of the greatest ultimate service in enabling our state officials to detect and remove defective aliens that come to our shores. Those that escape the immigration officers are pretty sure to appear in some institution before three years have elapsed from the time of their landing. Our specialty should be ever on the alert to detect these defective recent arrivals and refer them to the proper authorities for deportation. Unless we, as a nation, exercise the greatest precaution it is easy to foresee how soon a large burden of insanity will be engendered through the scattering far and wide of those whose congenital or other mental handicap should never have permitted emigration from their native land.

Closely related to the immigration problem is the steady increase in the number of criminal aliens that fill our jails and prisons. Crime, degeneracy and insanity are frequently allied. When one considers that out of the thirty thousand foreign-born persons serving sentences for crime about eighteen thousand have never taken out naturalization papers and six thousand speak no English, the necessity for preventing the entry of such persons into this country and for securing their deportation if possible after the expiration of their sentences, becomes self-evident. That such degenerates should furnish the nucleus for future crime and insanity if allowed to roam over the country after release from confinement, is likewise self-evident. It is to be hoped that the pro

posed national legislation for the deportation of these criminal aliens at the time of their discharge may be realized. I believe that our Association would do well at this present session to memorialize the national Congress as to the importance and necessity of such legislation.

It is evident from this very cursory view that public medicine has a large obligation to fulfill in the prevention of insanity. A low recovery rate in the past emphasizes the necessity for prophylaxis in the future. One of the most encouraging features in the psychiatric outlook is the growing conviction that psychiatry must be included as one important department of public medicine. The service problem presents another most discouraging feature in the psychiatric outlook. The difficulty of securing good male attendants is increasing every year. Good women nurses are more readily engaged than men because the training-school presents an opportunity for acquiring an honorable and lucrative profession. So many excellent avenues for earning a livelihood are open to men, the care of the insane is to many so distasteful, the wages so low and the hours so long that the securing desirable male attendants is extremely difficult. When to these disadvantages is added the impossibility of a satisfactory home and family life, there is little wonder that good men seek other employment. Relief will not come until an enlightened public intelligence recognizes the responsible and onerous character of the service, and the necessity of such a per capita maintenance rate as will admit of adequate remuneration and privileges attractive to desirable men.

It is to be hoped that the taking of medical expert testimony int cases of insanity will soon be placed upon a higher plane, and put beyond the pale of narrow partisanship. It is most discouraging that the psychiatrist should be forced by circumstances into a position at once unjust to himself and discreditable to the specialty he represents. The dawn of a better day is near. The two great professions most interested already demand a change of method. The adoption of an observation law in some states, by which the doubtful criminal is committed to the state hospital for the purpose of more satisfactory study than is possible in a jail, is a step in the right direction. Instead of a prolonged fight in court with experts arrayed against one another, the suspected criminal is

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placed in a hospital where his case can be studied under the best possible conditions, and where, if malingering is attempted, it can be positively detected. The success of the observation law wherever it has been adopted is the best argument for its extension. The very fact that such a law has been successfully established in many states is an evidence of a changed attitude on the part of the legal profession. Justice rather than a spectacular fight is the aim of the observation law, and the expert testimony of the hospital physician assumes the importance and dignity to which it is entitled.

If all causes could be so tried that experts could be impartially consulted and their opinion, untrammeled by any partisan interests, become an unbiased aid to the judge, the jury and counsel, the dignity and self-respect of our specialty before the court and the public would be maintained. Whether this consummation will be attained by the summoning of experts by the court, by their election through mutual consent of counsel on either side, or by the refusal of physicians to appear as partisans in any case, the result will be most welcome. Let us all contribute toward the hastening of the day when the name expert will not arouse the contempt of the bench nor the cynical smile of the jury and the public.

In conclusion I merely wish to affirm my own personal belief in a hopeful outlook for the psychiatry of the future. If the results of treatment have been discouraging, our knowledge of the genesis and evolution of insanity is clearer than ever before. If we have learned the impossibility of curing the disease in a large majority of cases, we have also learned the importance and the possibility of preventing the disease itself. We understand the nature of mental disease as never before. We recognize the almost innumerable factors that enter into its causation, and we welcome the affiliation of psychiatry with the allied sciences of psychology, neurology, bacteriology and penology which will enable us to accomplish so much in the way of an intelligent prophylaxis. No longer will the alienist work alone; he will join hands with workers in these allied sciences, and I have faith to believe that ultimately, not in our day perhaps, but in the not distant future, mental diseases will decrease just as the infectious fevers have decreased by removal of their causes.

PSYCHIATRY AS A PART OF PREVENTIVE

MEDICINE.*

BY HENRY M. HURD, M. D., BALTIMORE, Md.

The object of preventive medicine being to lessen the burdens of mankind by obviating preventable diseases, it is deemed appropriate at this time to inquire in what manner the experience of those who are familiar with the problems of psychiatry may be utilized to assist in this good work. It needs no elaborate demonstration to show the evils of insanity and the heavy public and private burdens which it entails upon every community. Next to alcoholism it is probably the most potent cause of pauperism and dependence. Where the State does not promptly interfere to lift the burden of the support of a patient suffering from chronic insanity in a family of moderate means, whether inside or outside an institution, the tendency of that family is to poverty. Every person who has had even moderate experience in the care of the insane can recall instances where the expense attendant upon the care of such a person has eventually proved the ruin of the whole family and has brought its members to poverty, if not to the almshouse. In addition to this somewhat material view of the effects of insanity, it is proper to mention a still more important factor, the distress and sorrow which fall upon the other members of the family and too often the influence of the insanity of one person upon susceptible sons and daughters, brothers or sisters. It is therefore important to make use of the experience of alienists to prevent the spread of insanity and to check its development among persons who have inherited or acquired a predisposition to mental disease. Alienists being as a rule isolated workers, unless there is some concerted action on their part elicited by a loud call for help from the whole community, it is doubtful whether they will accomplish much. How then can this call be voiced, and in what manner can the experience of alienists be made available for the public welfare when such experience has been gathered?

* Read at the sixty-fourth annual meeting of the American MedicoPsychological Association, Cincinnati, Ohio, May 12-15, 1908.

Much can be accomplished by informing the public fully of the true nature of heredity. The knowledge should become universal that every individual represents the sum total of the vices and virtues, faults and perfections, strength and weaknesses of his remote ancestors, plus special morbid conditions or otherwise which existed among his immediate progenitors. In the question of marriage, education and occupation, the consideration of heredity seems forgotten or wholly ignored by the majority of people. People with neurotic heredities marry; they bring neurotic children into the world; they educate them faultily and in such a manner as to add to their neurotic inheritance; they allow them to choose unsuitable employments; and finally their children develop in their turn insanity. Much of the faulty educational methods at the present day springs from false ideas on the part of parents, and even teachers, of the value of knowledge as knowledge and not as a training of the powers. It is not sufficient for neurotic persons to acquire knowledge alone; they should acquire with it a discipline which will help them to overcome the morbid and vagrant tendencies which spring from a neurotic organization. They should be trained to use their mental powers judiciously, to strengthen their wills and to build up their physical energies. They should learn that the process of education is not a cultivation of the memory merely, but a training of all the powers of mind and body. The neurotic individual cannot with. safety be subjected to the educational methods which may apply to the healthy-minded. His training should not be so much stimulating as inhibitory. It should teach him to resist morbid impulses and to forego artistic pursuits and cultivate prosaic virtues and commonplace aims. Where a pronounced tendency to mental disease has been inherited, it should be borne in mind that this tendency cannot be eradicated, because the roots of the disease are deeply laid, and further because the individual may represent the defects of several antecedent generations. The neurotic individual can be more easily helped by proper education than he who has inherited a tendency to insanity. A notoriously bad stock will eventually exhaust itself and run out. Psychiatry therefore should concern itself largely with questions of education. The prevention of insanity may be beyond us, but the proper educa