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Assistant Physician, McLean Hospital, Waverley, Mass.


In order that preventive and curative measures may be most effectively applied in relation to insanity, it is important to know what kinds of insanity occur in any community, the relative numbers or proportions of the different kinds, and their outcome. Knowing these, we have a standard or norm for that community, from which to determine what kinds and proportions of cases will best repay prophylactic and curative efforts, and with which to compare the results of such efforts.

Several years' records of one large hospital will furnish approximate figures for such a standard, but it draws its patients from too small and too ill defined an area to be free from the possible influence of local conditions. If, then, we can get data from a sharply defined region large enough to support several large hospitals, and having varied conditions of living, we should be able to establish a present norm of incidence and outcome of insanity. The figures here given represent an attempt to find such norms. They are, however, only suggestive, for the period covered is too short and there is too little uniformity and accuracy of diagnosis to make them more than this.

The Commonwealth of Massachusetts represents such a sharply defined area. It has several State hospitals for the insane, varying in capacity from about 500 to 1600 beds each, and several private hospitals and licensed physicians who take care of insane patients. From all these hospitals and physicians the State Board of Insanity has required uniform statistics concerning the insane patients under their care, and has published certain of these data in its

* Read at the sixty-fifth annual meeting of the American Medico-Psycho logical Association, Atlantic City, N. J., June 1-4, 1909.

annual reports. Previous to five years ago it tabulated the data from the state hospitals and the McLean Hospital only. Since then it has included those from all the smaller private hospitals and licensed physicians as well. It is from these data concerning all insane persons in the State of Massachusetts who have required hospital care during the last five years that the figures in this paper are drawn. Through the courtesy of the Executive Officer of the Board the figures for the current year have been included in the table which I shall present, and I take this opportunity to express my appreciation of his kindness in giving me access to them in advance of their publication.

Massachusetts, though small in area compared with many of the States in the Union, has a large population-somewhat less than 3,000,000 on October 1, 1903, and somewhat more than 3,000,000 on October 1, 1908. Besides the people native to the State for three or more generations, there are large numbers of Irish, French-Canadian, Italian, Russian, and Portuguese birth or descent, with a fair sprinkling of other European and Asiatic nationalities. There are comparatively large agricultural regions, thinly populated with farmers. There are small towns, and small and large cities. There are large manufacturing communities. There is a long coast line, with excellent harbors, and there is much fishing, and coastwise and foreign commerce. There are numerous railways, both steam and electric. There are abundant schools and colleges. The only great industry that is not represented is mining. There is local option as to the sale of alcoholic drinks, and high license where they are granted. It would seem that such a community, with such varied conditions of living, should furnish the data for determining approximate standards of incidence and of outcome of insanity, and that wide departure in any given community from such standard would be due to local or racial conditions peculiar to that community.

During the five-year period between October 1, 1903, and October 1, 1908, 14,770 patients were admitted, and 11,903 were discharged. The State Board classes them under 47 diagnoses, and these are condensed from the more numerous diagnoses submitted to it by the different hospitals. It is improbable that there are so many different kinds of insanity, though there are many varieties. The number merely illustrates the difficulties of diagnosis, and different points of view in diagnosis. It seems to me that there are not many, perhaps eight or nine, fundamentally different kinds of insanity. Briefly, the grounds for this belief are the following inferences and facts:

All mental activity is in its fundamental nature a reaction of the individual to his environment, himself, and all his own mental and physical reactions being included in the environment. Each individual reacts normally provided the organs for such reactions, the nervous system in all its ramifications, is normal. If this nervous system is altered in any part, whether temporarily or permanently, that part cannot subserve its reactions normally. The reactions that do result, if they are not entirely abolished, are abnormal, i. e., are symptoms of disease or pathological condition of the nervous system. The symptoms shown by any given case of insanity will be determined by the distribution, extent, intensity, and nature of the pathological changes (whether temporary or permanent) in the nervous system; the parts that are unaffected will continue to react normally. Since we know the nervous system only imperfectly, and its pathology still less perfectly, and since we cannot examine it directly during the life of the patient, we infer pathological changes when we see abnormal reactions. Often we are at a loss to even guess with probability at the nature of the underlying change. But when we find certain types or groups of abnormal reactions, i. e., symptoms, we infer certain types of underlying pathological change or condition. There are many symptoms and combinations of symptoms the relative value of which we do not know; hence individual judgments will vary concerning the inferences that may properly be drawn from them. Thus we get a wide range of nomenclature or diagnosis. And since we find in a disease like general paralysis, whose pathology is fairly well known, a very great variety of symptoms, and in individual cases peculiar combinations of symptoms, yet, in all, a common pathology, it is fair to infer that there may be an equally diversified symptomatology as a result of some other pathological condition which is less well or not at all known. And, in fact, I believe this to be the case. And since there are comparatively few kinds of pathological changes which occur in other organs, so, I believe, it is with the nervous system.



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