THE PROBLEM OF THE STATE IN THE CARE OF THE

INSANE.*

BY ADOLF MEYER, M. D.

There is in the fabric of our large sociological unit, the State, one great field in which the physician is the agency to be relied upon for proper work, although it is not usually included in the domain of the Health Officer. We find here the insane, and the feeble-minded and the epileptic; and reformatory work. Very few people appreciate what the task involves. The whole modern change of front in the struggle against essentially chronic diseases in the direction of prevention and the radical transition of modern practical sociology from charity to efficiency offers a natural opportunity for a discussion of the question: What has the State got to meet in the care of those afflicted with mental disorders? We are to-day confronted with the problem of so-called State care in this State. That is but part of the whole problem. What is the specific problem?

A fairly large number of our people are exposed, or expose themselves, more or less constantly to conditions in which they jeopardize the health of their brain so as to endanger their individual and social plasticity and efficiency. Many of the resulting difficulties and disorders of balance are merely called nervousness; others interfere so deeply with conduct and behavior, and even the possibility of any regulated conduct and behavior, that the patient's judgment becomes so untrustworthy that to let him follow his morbid will or bent would be a crime-as much so as if you should let a patient in typhoid delirium go to ruin in the wandering of his mind and under its effect on conduct. Thus there are conditions in which it has been found best to give the patient even unsought protection against himself and against strangers, and at times even against his relatives; and it has

* Read at a meeting in the interest of State Care of the Insane held in Baltimore, under the auspices of the Maryland State Lunacy Commission, January 20, 1909.

become a law in most countries that a patient reduced in his capacity of self-conduct and self-determination shall be given the benefit of special supervision by the most impartial and also best organized authorities, and the benefit of care in hospitals which stand under a special pledge (or license), a few of them private, but most of them created by the State. It is the nature of the diseases with their peculiar effect on the legal status of the patient that has led to the demand for a monopoly by our most impartial and most circumspect agency, the State, in the form of complete State care and under these circumstances the State must become equal to a tremendous responsibility, and especially so under our modern conceptions of what the fight against relatively chronic diseases means. Not only must the State or the public provide for the best possible medical treatment and for the physical welfare and comfort of its huge number of patients, but it must strive to make its institutions centers of progress, which must be concerned not only with meeting the emergencies of the day, but with the more far-reaching problems of prophylaxis and of stemming the tide of increase. The institutions for the insane must indeed become the nucleus of a far-reaching work for social and individual mental hygiene and mental readjustment.

Who are the objects of this State provision?

When we mention the insane and mentally defective, the large number of even supposedly well informed persons, among them many physicians, think of a mass of unfortunates doomed by heredity and fate, and hopelessly wrecked, to be segregated as much as possible, provided with proper care, but kept from complicating the life of the normal and from adding to the number of the degenerated.

This sweeping generalization of thinking merely in terms of an "insane class," with the motto "Once insane always insane" is a grave misconception.

In such a State as New York with 8,000,000 inhabitants, and an excellently organized system of State provisions and State supervision, there is to-day one out of each 280 persons under the care or supervision of the Lunacy Commission: over 29,000 in State institutions, and about 1000 in private institutions-an obvious increase over the figures of 1905. These 30,300 persons

are not simply a gradually increasing special class of permanent inmates, but include, as in all hospitals, a fair number of patients only temporarily under treatment. The number of patients admitted per year, exclusive of transfers, reaches over 6000, i. e., over one-fifth of the total number figuring as the capacity of our hospitals; 25 per cent leave well and as many improved. This proves that there is quite a little change in the constituency of the ranks, so much so that we can speak of a class only with considerable reserve.

I wish I could give you exact figures as to how many now in active and responsible life in the community have been in some hospital for months, or for one, two, three, ten and more years, and as to how much time of efficient life has been restored to them by the stay at the hospitals. Most of these facts are not obtainable owing to the insufficient way in which the data are collected by our as yet inadequately organized official departments. But we have some reliable figures after all. As we have seen, the number of cases admitted from their homes per year reaches the ratio of over one-fifth of the total number figuring as capacity of our hospitals; of this number an equivalent of a little over 25 per cent leave the hospital restored to their previous standards, that is, recovered and capable of taking care of themselves; and easily 25 per cent more become well enough to get along at home, while the remainder does indeed swell the ranks of the more permanent hospital population, the non-recovering more than balancing the deaths. The actual hospital residence of the cases which entirely recover covers from a few months to several years; 25 per cent of those who recover have had hospital care for over one year and quite a few must perforce for two, three, four, or more years be part of the more permanent hospital population, whose care therefore must be kept up to a mark, with an atmosphere of activity and hopefulness, and not that of indifferent provision for mere incurables.

The grave responsibility of the work, especially with cases during the first year, is shown by the statistics of 1905 in New York, according to which the total death-rate in the institutions per year was 8 per cent, and 40 per cent of all these deaths occurred among patients in the first year after admission. 15.6 per cent of those

admitted die within a year. You thus see how the admission rate raises the responsibility resting on a hospital. Some of the deaths are inevitable; others are not, and may take away recoverable persons. That is a point on which we should have statistics to compare the efficiency of hospitals. How many recoverable cases are lost annually from avoidable causes?

Looking back over these figures derived from the experience in New York, we evidently find that among those afflicted with mental disorders there is, to be sure, a certain number who form an essentially custodial problem, while at least one-fifth of the beds are occupied transitorily. We shall find the number of transitory inmates even greater in Maryland, hence my warning against merely speaking of a "class." Further, the fact that 25 per cent of the quarter of the admissions which recover do so after a hospital residence of more than one year, and that it is by no means possible to make a sharp line between recoverable and non-recoverable cases, shows why it is not likely that a clean-cut division into custodial asylums and treatment hospitals for the recoverable can be thought of. The insane are not a definite class settled for good or for bad. We must speak of so many beds required or occupied, and the next question is for what varieties of the diseases?

The most rational grouping of mental disorders is that according to causes and their more or less specific effects. In a complex organism such as man, we can of course not expect simplicity and uniformity, but we always meet a combination of different degrees and kinds of causal influences working moreover in different types of make-up or constitution, and with decided individual variations of type of manifestation, course and outcome. But after all, the cases form natural groups of considerable individual significance. I shall merely pick out a few units of special importance which point to relatively plain differences in various strata of the community.

I studied the mental disorders due to alcohol in my observations at the Worcester Insane Hospital, Massachusetts, and found striking differences in percentage. Among the patients of Protestant Massachusetts stock committed to the hospital only 9 out of 100 had some form of alcoholic insanity, while among the men pa

tients born in Ireland 50 per cent had characteristically alcoholic disorders and, of course, quite an additional number had a record of alcoholism as merely a complicating factor-a striking evidence of the differences of the problem of prevention in the two units of population. Comparative statistics of country and city districts. worked up by the Willard and St. Lawrence Hospitals bring out the fact that while a city of 120,000 furnishes 15 per cent of its commitments with general paralysis, rural districts furnish only 6 or 5 per cent, showing the difference in the frequency of syphilis in these regions. On the other hand, the country districts as compared with the cities furnish more than twice the number of agitated depressions, strong evidence that the country has its own faulty ways of reacting to difficulties. The recent racial statistics worked up by my associate, Dr. Kirby, on the admissions to the Manhattan State Hospital during the last year give additional highly instructive data. Here again we see striking contrasts: typically alcoholic mental disorders reach 27 per cent among the Irish, while the Jews did not offer more than I case, and that one complicated. On the other hand, general paralysis figures with but 7 per cent among the Irish, and with 29 per cent among the negroes, and 20 per cent among the Germans, a glaring signal as to where the work against the spreading of syphilis must be done. The functional psychoses, the direct disorders of mental hygiene and mental balance, show analogous differences, very high figures among the Hebrews, small figures among the happy-go-lucky negroes. All this suggests that differences in types and in conditions make themselves felt and that the occurrence of insanity is not merely the fatal and unanalyzable result of our active life. The suburban counties of the metropolitan district of New York have only from 2 to 4 admissions per 10,000 inhabitants per year, while the average for Manhattan Island is 8 to 9 per 10,000. Yet the commuter's life is far from being free of care, and the excess of the patients furnished by the more densely populated districts can hardly be laid altogether at the door of inevitable degeneracy.

So much for some types of diseases. From the point of view of course and duration I ought to present to you similarly individualized statements to bring home the fact that it is not a problem