DISCUSSION OF DR. MACCURDY'S PAPER
"PRACTICAL FUNCTIONS OF THE

PSYCHIATRIC CLINIC"

BY DR. W. W. WRIGHT,

Senior Assistant in Clinical Psychiatry, Psychiatric Institute.

Dr. MacCurdy has described in detail the functions of the psychiatric clinic, and has given the results obtained in a large collection of his cases. In spite of the fact that the results obtained are excellent, even from a statistical point of view, we have become so accustomed to look upon these cases as potential hospital residents that we are likely to hear the old question soon repeated, "Is it worth while?"

To show further that it is worth while, I thought it might be well to supplement Dr. MacCurdy's remarks by referring to certain types of cases that come under my observation during the few years I have been associated with the Cornell Clinic.

The cases that I have chosen were selected not because they belong to any particular diagnostic groups but because they represent fairly the problems with which we have to deal. Furthermore, they are not cases that required, as a rule, treatment over an extended period of time, but instead are cases that have reacted rather quickly to suggestions when their actual difficulties were clearly pointed out to them.

The cases may be rather roughly divided into three groups: those requiring some assistance in readjusting themselves; those needing a different environment; those needing early institutional care. The diagnosis in each case will, I think, be fairly obvious.

CASE 1. E. R. Age 34. Florist. Interviewed at clinic March 18, 1915.

His father suicided.

Two years before the interview took place his brother entered into partnership with him. This was an unsatisfactory arrangement, since the brother was evidently not very efficient. For a year the patient worked very hard night and day to save the business. Finally he sold out. Because of his selling out, the brother quarreled with

him. The patient felt shocked, became worried and despondent, went home, lay down, felt as if he were going crazy. From that time he was unable to do things, lacked ambition. During the summer he tried to cheer up by drinking six or eight glasses of beer a day. This made him feel rather stupid, so he stopped drinking. Feeling then a little brighter, he took over a florist's business. About this time his son became ill. His brother, after promising him not to do so, started in business two blocks away from him. He then became despondent, paid little attention to his business. He says things became mixed up. Though he felt that he was losing everything, he was quite powerless to prevent it. During the winter he had various hypochondriacal complaints, thought he had consumption. became so tense that he would shout. At times he felt like committing suicide, as his father had done; again he feared he would injure himself. A few times he took his wife and children by the throats; afterwards he felt penitent. He said he really meant to do them no

harm.

Often he

At the time he came to the clinic he felt hopeless, could not stand the strain any longer. One naturally asks, What can be done in one interview for such a man? He has been given advice before. You can not analyze him! This much we can say-the patient came for advice and help; he was advised; his difficulties were talked over with him. It was shown to him that he had no physical disorder; that he was in fact a strong healthy man who had become unsuccessful, in large measure, because of useless worry and lack of application. At the close of the interview he promised that he would return to his business and try to apply himself as he should. This was the only time he was seen at the clinic.

A year and a half later his clergymen, who had brought him, returned with another patient. It was then we learned that the patient at once attempted to readjust himself, and that, in spite of his various setbacks and of his badly tangled business, which required the services of an actuary for several months to straighten out, he finally recovered.

CASE 2. L. K. Age 47. Married.

At 39 she suddenly began to realize the absolute emptiness of her life. She worried constantly, and grew more and more downhearted for three years. After this she was well for two years, that is, during the time she was caring for a nephew of her husband who was a consumptive. After his death she gradually drifted back into this worrying, dissatisfied state. She worried about everything. She was

dissatisfied with her married life, but she did not want to leave her husband because she felt it was her duty to remain with him. She could not bear to be out later than 10.30 at night. She felt uneasy when she saw young girls on the street. Heaven and hell worried her. "To have a hard world here and be uncertain about the next" was a cause of much concern. She felt she would like to do things FEB.-1917-D

for people-the poor, the ill. She found little interest in her home. Frequently when she came to the clinic she said she felt irritable, "This morning I took spite out on the cat, put the cat out of the house." "If I can make a little noise I feel happier." "If any one crosses me during these spells I take it out on them." Afterwards she felt sorry for her conduct. On another occasion she said, "I am constantly nervous, I am living in the past."

Though she has a rather long history, this brief description will doubtless give one a fairly good idea of the state of her mind and the nature of her worries. Day in and day out, and week in and week out, she came to the clinic, sometimes twice a week. The week was quite too long for her to wait, so she had to consult two physicians. She was originally Dr. MacCurdy's case, but because of feeling the need of more frequent advice she came to me also.

We tried in various ways to suggest to her healthy pursuits, outside interests, but with varying degrees of success. Sometimes she felt better, again she was not so well. In the history we noted that while she was caring for the nephew of her husband she was quite well for two years. She had frequently spoken of her desire to have a child to care for. With this in mind, we suggested that she adopt a child, but the husband was unwilling. Later another nephew of his, a small boy of nine or ten, was taken into their home by the urgent request of the patient. From that time her improvement began.

When seen on a friendly visit to the clinic a short time ago, she seemed happy, contented, and quite care free. Somewhat later she came to Miss Wells, the social worker, to thank her personally for the attention she had received.

For four months the patient complained much of pains in his back. After he had worked for two or three hours the pains became so excessive that he had to stop. When he was examined nothing abnormal in his physical condition was found, but when closely questioned it was brought out that he was about to be married, was worried about it, dreaded the ordeal, then developed the physical symptoms above mentioned. He also had certain hypochondriacal notions about his sexual organs, feared he was not like other men.

He was seen only a few times. A rather superficial analysis of his symptoms was made. He improved rapidly and within a short time married. A letter received somewhat later stated that the patient was in good condition. He expressed much gratitude for what had been done for him.

CASE 6. M. D. Italian. Age 45. Organization Society.

Referred by the Patterson

Seven years ago some stomach trouble; recovered.

Six months before coming to the clinic his wife died. After that he began to complain of pain in his stomach. A surgeon made a

diagnosis of gastric ulcer. Operation was performed but no ulcer was found. After the operation the patient became depressed, worried, was unable to care for his children.

When seen at the clinic he felt quite hopeless, unable to work; was emotional, with a good deal of crying. He complained much of abdominal pains. It was difficult at first to convince him that he was able to work, but finally a plan was laid out for him. He was given a certain amount of work to do each day. His diet was regulated. A week or so later the amount of work was increased. Eventually he was able to do quite a little each day. He improved gradually, and the last letter from the Society stated he was much improved.

CASE 7. B. B. Age 30. Silversmith.

A number of years ago he visited the clinic a few times. He complained of various peculiar sensations in his head like a chill or cramp, of being nervous. Sometimes he had to stop work, occasionally had to take time off. Doubtless because of language difficulties and his rather peculiar manner of expressing himself, his real difficulties were not at first well understood.

In February, 1916, he returned to the clinic. He stated that for two years he had been drinking a pint of beer daily to make him sleep. About a week before visiting the clinic he stopped both drinking and smoking because he thought they made him nervous. He said he was much inclined to worry over trivial affairs. He took things too seriously. If any one said anything in a joking way, he would ponder over it. Sometimes he had peculiar sensations as if something were rushing up the back of his head. He also complained of his thoughts troubling him. He had certain compulsive ideas, "If I want to sit down, the thought comes to me to run around the chair two or, three times." "If I am going to bed, the thought comes to me not to go to bed." When out fishing he sometimes feared he might jump into the water, or when crossing a bridge that he might jump off.. Insane people sometimes committed suicide in that way. In the presence of people, he was evidently much embarrassed, could not express himself well, felt stupid. He said, "When people talk to me, I talk too much in my mind but I can not express myself." He often felt like dropping, felt he would go insane.

me.

In March he still complained much of his thoughts, "When I put my mind on something, another thought creeps in and overpowers He felt quite inefficient, thought he could not compete with the men in another department doing the same line of work. He was rather discouraged. On this occasion he was accompanied by his relatives, who thought the patient was going insane and that it was advisable to have him committed. The patient himself was quite discouraged and was willing to go to Bellevue Hospital. At this time an attempt was made to understand more thoroughly what the actual difficulties of the patient were, and an effort was made to explain to

him, in a simple way, the meaning of his ideas. Probably the thing of most value to him, and the thing which occasioned the most surprise to him, was to know that other people sometimes have queer thoughts which come to their minds but that they disregard them.

By June the patient showed very marked improvement. He was then working regularly.

He was not seen again until about a month ago, when he brought his brother to the clinic for treatment. In regard to his own condition the patient then said, quite to our surprise, that he was well. Whether one should take so optimistic a view, may be open to question. At any rate, he was apparently in a more nearly normal state than he had been for several years.

CASE 8. E. A. Age 13. Seen at the clinic in March, 1915. Father and mother both defectives and immoral. Father alcoholic and in State prison for forgery. The children taken from the parents in 1913.

In September, 1913, the patient was placed in a free home. They had no difficulty with her excepting that she claimed she was "boy crazy."

In 1914 the people who cared for her feared she was pregnant. It was said she was quite shameless in speaking of her indiscretions. On investigation it was claimed that the patient had made advances to men. In school it was said that she had recently been demoted.

When seen at the clinic the patient made quite a frank admission of her delinquency, and expressed regret for her bad conduct. She told of having been in six or seven different homes during the time that she had been placed out. In some places she claimed she got along well; in other places, that she was unhappy. Her unhappy state of mind probably had much to do with her misbehavior; apparently she craved a good deal of sympathy and attention.

Before she was sent to the clinic it was thought that it would be necessary to place her in a reformatory. This probably would have been about the worst thing that could happen to this type of patient. The advice given at the clinic was that there be found for her a more suitable home-a home with people who would understand her and would give her a certain amount of attention, sympathy and kindness such as she desired. Evidently such a home was found for her.

When she reported six months later she was pleasant and agreeable, was again in school, was working hard and was expecting to be promoted.

According to her own statement and the statements of those who knew about her, she was trying hard to live a good life. She did not go out alone any more, and avoided as much as possible the society of men.

CASE 9. A. K. Age 35. Janitress. Married, six children. Seen at the dispensary January 21, 1915.