On May 5, 1919, an amendment to the insanity law provided that in the City of New York the officer commanded by a warrant to arrest a person alleged to be insane must bring him before the magistrate's court out of which the warrant was issued, instead of before the magistrate issuing the warrant. Though the number of insane or alleged insane persons thus brought to court is small in comparison with the total number committed, still, with the system of rotating magistrates as it exists in New York City, the apparent difficulty and inadvisability of taking an insane person to another section of the city than the one in which he lives, is quite obvious.1

One of the difficulties experienced by friends and relatives as well as by mental hygiene workers of private organizations is in having certain patients brought to the hospital without court proceedings. The police department, acting for the Ambulance Board of the city, must be notified when an ambulance is wanted. As a rule a policeman is either asked to telephone for the ambulance or he is at the house when the ambulance calls. The patient, especially if a paranoiac, will speak lucidly and intelligently and the officer frequently accuses the relatives of the patient of attempting to "railroad" the patient to an insane asylum. The same also happens when a hospital interne responds to an ambulance call, and, not having sufficient experience in the diagnosis of mental diseases, refuses to accept the patient for transfer to the hospital. In a number of cases it is for these reasons a matter of weeks before a person whose relatives realize that a condition of mental abnormality exists, is at last brought to the hospital. Once there, the Commitment Law of the state, probably the most practicable in the country, preserves the constitutional rights of the individual. It involves little publicity, is not cumber

1Laws of 1919, sec. 87, chap. 380.

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some, and is well safeguarded. In other cities in the state the provisions for the care of the insane pending commitment have shown many shortcomings, as such persons have been detained in jails and almshouses. In order to correct this evil a law was passed in 1914 authorizing the State Hospital Commission to enforce its requirements as to suitable care for the dependent insane during the time steps are being completed for their commitment to a state hospital." This has helped reduce the number of instances where improper care is bestowed and within a short time adequate provision for proper care should be found in every county in the state.

3

There are two methods in which studies of the nature of this work may be made: (1) the statistical method; (2) the case method. It is the purpose to follow both these methods in this study, and it may be well to define the various terms to be used, as well as to present the classification and give a brief definition and review of the different psychoses and neuroses to be considered.

IV. DEFINITION OF TERM INSANITY

However, before proceeding to the task of setting forth the definitions spoken of, the question of the meaning or connotation of the concept insanity should be settled if possible. Many attempts have been made to formulate definitions of the term, and several are herein presented for consideration. Thus, White states that insanity is not a

5

1 State Comm. in Lunacy, A. R., 1890, p. 125.

'Laws of 1914, chap. 305. (Incorporated in the Insanity Law as sec. 20.)

'S. H. C., 26th A. R., 1913-1914, p. 277.

For a full discussion of the term see article by William A. White on "Underlying Concepts in Mental Hygiene," in Mental Hygiene, Jan., 1917, pp. 7-8.

5 White, William A., Outlines of Psychiatry, 1918, p. 17.

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disease; it is rather a symbol grouping for a large number of different mental diseases which tend to arrange themselves with greater or less distinctness into circumscribed groups of reaction trends. According to Dercum1 insanity may be defined as a diseased state in which there is more or less persistent departure from the normal manner of thinking, acting, and feeling. Still another, though kindred interpretation of the term is offered by Craig2 in stating that a person may be considered of unusual mind if from some mental cause: (1) he is unable to look after himself and his affairs; (2) he is dangerous to himself or to others; (3) he interferes with society, i. e., is unable to adjust himself to his surroundings. Maudsley wrote that the most prominent pathological characteristic of the insane is a complete or almost complete absence of moral feeling and moral ideas. A more concise definition is that offered by Peterson when he states that "insanity is a manifestation in language or conduct of disease or defect of the brain." 5 As a scientific term, insanity is falling into disuse and now retains a significance mainly in a legal sense; like lunacy it seems destined to become obsolete. It would be best to restrict the application of the term to cases in which the mental disorder is of such a nature as to render advisable commitment for treatment or custody to a special institution, or care under trained and expert supervision.'

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1 Dercum, Francis X., A Clinical Manual of Mental Disease, 1914, p. 21. 2 Craig, Maurice, Psychological Medicine, 1905, p. 20.

Mercier, Charles A., Textbook of Insanity and other Mental Diseases, 1914, P. 42.

'Maudsley, Henry, Responsibility in Mental Disease, 1874, pp. 171-172. 'Church, A. and Peterson F., Nervous and Mental Diseases, 1901, P. 630.

'De Fursac and Rosanoff, op. cit., Introduction, p. xi.

'Peterson, Frederick, Mental Diseases, 1899, p. 603, quotes the noted

V. CAUSES OF INSANITY

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There has been much speculation as to the causes of insanity, though some factors have been definitely determined upon as being responsible for a large proportion of the cases of mental alienation that fill our state hospitals and cost the various communities and states in the country large sums for their care and treatment.1 Broadly speaking and with special reference to causation the mental disorders may be divided into two groups: (1) Exogenous, or where the causes are chiefly external; (2) Endogenous, where the existence of external causes or of primary tissue changes in the brain has not been demonstrated. The causes found in this group are internal, the insanity growing, as it were out of the personality. Among causes affecting the first class, are syphilitic infection, poisons introduced into the body, (as alcohol, cocaine, opium and its derivatives, etc.) or created within the body, and exhaustion. Heredity plays a most important part in the causation of mental disease in the endogenous group. Kraepelin classifies the causes in this class under the divisions of general predisposition and personal predisposition.3 Modern physiological psychology English jurist, Lord Justice Blackburn, who once said while giving evidence before a committee of the House of Commons, "I have read every definition which I could meet with, and never was satisfied with one of them, and have endeavored in vain to make one satisfactory to myself. I verily believe it is not in human power to do so." Clouston, T. S., Unsoundness of Mind, 1911, p. 1, also emphasizes the difficulty encountered when attempting to give a satisfactory definition of the term.

'Number of patients on books in New York State Hospitals at close of fiscal year June 30, 1918: in civil hospitals 37,352; in hospitals for the criminal insane 1,420. (S. H. C., 30th A. R., 1917-1918, p. 9.) Total expenditures for the year approximately $11,000,000. Ibid., p. 25.

"Hoch, August, "The Manageable Causes of Insanity," New York State Hospitals Bulletin, Sept., 1909, pp. 1-3. See also Thomson, J. Arthur, Heredity, 1908, pp. 263-264, for a discussion of this classification from a somewhat different viewpoint.

'Kraepelin, Emil, Psychiatrie, Achte Auflage, I Band, pp. 140-208.

emphasizes the fact that there are innumerable phenomena which indicate that the mind operates as a true cause within the structure of the body, and that the reverse relation is also true.1 Considering another method of classification, it may be stated that the essential causes of insanity are heredity, alcoholism, syphilis, and head injuries; and that there are numerous and complex incidental or contributing causes, which in themselves do not suffice to produce insanity, but do so only in the presence of an essential cause. Alcohol and head injuries belong to this class also, as do various psychic conditions, common among which are business and domestic troubles, love affairs, death or illness of relatives. Other etiological factors that may be mentioned are race, age, sex, environment, occupation, marital condition, education, and immigration.2

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(a) Heredity. In any discussion of insanity the question of heredity looms up as probably the most important factor. An inherited predisposition to mental disorder is found in from 30 to 90 per cent of cases according to different authorities.* This wide variation in percentages is due to the inability to gather such statistics accurately, the lack of cooperation of relatives in obtaining the necessary information, and the failure to consider large enough groups in such studies to render them of any statistical

'Ladd, G. W. and Woodworth, R. S., Elements of Physiological Psychology, 1915, pp. 644-646.

2De Fursac and Rosanoff, op. cit., pp. 2-20.

'Mercier, Charles A., Crime and Criminals, 1918, sets forth his doctrine of the causation of insanity, stating that it is due in varying proportions to the two factors of heredity and stress-to the stress of circumstances acting upon an innate constitution; to varying proportions of heredity and environment, p. 225. Mercier, Charles A., Textbook of Insanity and other Mental Diseases, 1914, pp. 3-4. For opinions similar to the above see 13th A. R., S. Comm. in Lun., 1900-1901, p. 37. • White, William A., Outlines of Psychiatry, 1918, p. 20.