period of mental or other stress, which has seemed to determine the onset of the disease.1

(d) Injuries and Other Causes. Head injuries are responsible for but a small percentage of the cases admitted to the state hospitals. In 1918 there were only 15 cases thus admitted, 13 being men and 2 women. In 1917 there were but 18 cases.2 These cases are far more often brought to general hospitals than to hospitals for the insane for reasons that are sufficiently obvious.

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(e) Contributing Causes. As mentioned above there are a number of contributing causes of insanity which in themselves are not responsible for any large percentage of cases of insanity, but which have, however, become recognized as important contributing factors in the causation of insanity. A number of these factors have already been mentioned, and to them may be added bodily diseases; 3 overwork, rarely a cause in healthy persons; and the group of physiological factors including puberty, the puerperal state, the climacteric and senility, all of which are indirect strains to which the organism is subject, by reason of the more or less profound physiological commotions they arouse in the nervous system.

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VI. CLASSIFICATION OF MENTAL DISEASES

(a) Introduction. There has been much difficulty experienced in constructing a final standard classification of mental diseases, due largely to the question as to whether

1

1 Mercier, Textbook of Insanity, p. 244.

'S. H. C., 30th A. R., p. 284.

'Mercier, Textbook of Insanity, pp. 21-22.

'Craig, Maurice, Psychological Medicine, p. 29.

5 See Lugaro, Modern Problems in Psychiatry, pp. 275-276; also Mercier, Crime and Criminals, 1918, p. 195 for a discussion of the puerperal state and insanity.

Church and Peterson, Nervous and Mental Diseases, p. 668.

such classification should be established on an etiological basis, on symptomatology, or from the point of view of pathological anatomy. Various classifications have been proposed, but the one followed in this work is the classification used in the New York State Hospitals and gradually being extended to all the hospitals for the insane in the United States.3

2

Table 3 follows the classification above alluded to and sets forth the psychoses, neuroses, and other ailments of Jewish admissions to the psychopathic wards of Bellevue Hospital for a period of a year. In order that this study may be intelligible to the layman as well as to the social worker, a brief discussion of the nature, prognosis and treatment of the various psychoses will accompany the consideration of the statistics presented. In accounting for the large number of males (673) admitted in comparison to the number of females (454) it should be noted that there are relatively more males in the foreign-born white population of the country than in the native-born white population; a ratio of 129.9 males to 100 females for the former compared with 102.7 to 100 for the latter.*

(b) Senile Psychosis. The senile psychoses, of which there were 16 male and 25 female admissions, are characterized by a gradually progressive mental deterioration accom

1Diefendorf, A. Ross, Clinical Psychiatry, pp. 116-117.

'White, Outlines of Psychiatry, 1918, p. 19, suggests that the following be used: paranoia and paranoia states; manic-depressive psychoses; paresis, dementia praecox, senile and arteriosclerotic psychoses, infection exhaustion psychoses, toxic psychoses, those associated with organic diseases and injury of the brain, symptomatic psychoses, borderline states, and idocy and imbecility.

'Vide Statistical Manual for the Use of Institutions for the Insane, prepared by the American Medico-Psychological Association and the National Committee for Mental Hygiene (pamp. 40 pp.) 1918.

*Insane and Feebleminded in Institutions, Bureau of Census, 1914, p. 27.

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panied by a series of lesions in the central nervous system. The most conspicious feature of these cases is a defect of memory, especially for more recent events, and often an

'Diefendorf, p. 369.

'Mercier, Textbook of Insanity, p. 309.

2

outbreak of ill-temper. The course of the affection is progressive until death. The patients finally become completely demented so that they are wholly disorientated, confused, know no one around them; in fact may not even know their own names.1 The disease is encountered most frequently between sixty and seventy-five years of age; individuals with a faulty constitutional endowment, worn with hardships, and especially those addicted to excesses, may succumb before sixty.

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(c) Arteriosclerosis. Arteriosclerosis was the diagnosis. in the cases of 17 males and 2 females. This disease is not, as some have thought, always of syphilitic origin or affection, but may also be brought on by gout, lead poisoning, alcoholism, pulmonary and cardiac conditions. Among the physical symptoms are headaches, insomnia, muscular weakness, attacks of faintness or dizziness, epileptiform or apoplectiform seizures. The mental symptoms indicate diminished capacity for work, undue fatigability, emotional instability and depression; later, forgetfulness and general mental deterioration. The course of the disease in most cases extends over a number of years, even ten or twenty years. The prognosis is unfavorable for recovery, though under favorable conditions, such as rest, freedom from worry or excitement, moderation in eating and drinking, the condition may remain approximately stationary for months or even years. A study of the New York State Hospital statistics has shown that the senile and arteriosclerotic, as well as the paretic groups, have high rates of first admis

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1 White, Outlines of Psychiatry, p. 183. 'De Fursac and Rosanoff, p. 444.

Church and Peterson, p. 195.

‘De Fursac and Rosanoff, pp. 448, 452.

sions and deaths, with low rates of readmissions and discharges.1

(d) Organic Nervous Diseases. Psychic disorders induced by pathologic processes in the brain, such as meningitis, tumor, softening, and hemorrhage, are included under the category of organic nervous diseases. Emotional irritability, hallucinations of the various senses, defects of intelligence, and stuporous conditions are common mental manifestations of these processes. Eighteen such cases were admitted, 12 males and 6 females.

(e) General Paralysis. Some consideration has already been given to syphilis as a cause of mental disease, and from the figures in Table 3, it is seen that there were 99 cases of general paralysis, 88 males, II females and one case of juvenile general paralysis, all of which were a result of syphilis. About 9 per cent of Jewish admissions were directly traceable to syphilis as the cause of the mental disease; this includes the juvenile case, which developed years after the primary infection. Studies of recent immigration, that is, prior to 1914, indicate that three-fourths of

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1 Psychiatric Bulletin, vol. ii, no. iv, Oct., 1917, New York State Hospital Statistics. Death rate per 1,000 patients under treatment in principal groups of psychoses in civil state hospitals for 1918 was as follows: general paralysis 352.8, cerebral arteriosclerosis 340.2, senile 297.2, these being three highest figures. (S. H. C., 30th A. R., p. 312.)

2 For a comprehensive and thorough study of general paralysis, vide Kraepelin, "General Paresis," Nervous and Mental Disease Mongographs, series no. 14.

• General paralysis constituted 13.4 per cent of all first admissions to the New York State Hospitals for the year ending June 30, 1918. (S. H. C., 30th A. R., p. 284.)

4 Stokes, John H., The Third Great Plague, 1917, presents a satisfactory discussion of the whole question of syphilis and its effects upon society. See also Vedder, Edward B., Syphilis and Public Health, 1918, Salmon, Thomas W., "General Paralysis as a Public Health Problem," Amer Jo. of Ins., 1914-1915, pp. 45-50.