BOOK REVIEWS

(Continued from Page 452)

There are so many permanent disabilities that have followed "sprains" of the ankle which were in fact unrecognized fractures and so much litigation has arisen, that we feel the need of emphasizing this point. After going over this book we feel that no surgeon who accepts industrial surgery should fail to supply himself with a copy and make at least the study of one chapter a daily task. If the surgeon overlooks his own personal interest and takes "chances" he has no right to involve the patient whose livelihood depends on his physical ability.

THE WATERING PLACES OF SWITZERLAND We have received a beautifully illustrated booklet with the above title, issued by the Swiss Watering Places Company. It contains a short account of Switzerland and her people, and of the mineral springs. There are nine important health resorts described; their location, and advantages; analysis of their waters, indications and contraindications. The purpose of this book is to give information in advance as to the character and location of the important Swiss watering places. For further information write to the Official Information Bureau of Switzerland, 241 Fifth avenue, New York.

IT MUST BE MADE RIGHT FROM THE START!

Norway is best known for her midnight sun and her immense harvests of the deep. Nature has nowhere been so prodigal in providing ideal conditions for the spawning, feeding and development of the true Gadus Morrhuae, than in the waters surrounding the far-famed Lofoten Islands, Norway. For a century or more, cod liver oil has been recognized as a dependable and easily absorbed nutrient and more recent investigations reveal that it is an exceedingly fruitful source of the anti-rachitic vitamines. Cod liver oil to be utilized to fullest extent by the system should be pure and sweet and free from admixture with inferior non-cod oils and also free from admixture with blood and gall-due to careless and unscientific handling of the livers. Cod-liver oil is as delicate as butter and in the selection and processing of the livers, should receive as much care as science has thrown around the production of pure milk. For nearly half a century the producers of the "S. & B. Process" Clear Norwegian Cod-liver Oil have concentrated their endeavors and specialized upon the product of the livers of the true Gadus Morrhuae. Several years ago Scott & Browne established their own cod-liver oil plants in Balstad, (Lofoten), Norway, where under most exacting, modern scientific and hygienic conditions, the "S. & B. Process" is produced. This high-grade oil is then brought overseas in special containers to be refined in the unique S. & B. laboratories in America. The “S. & B. Process" is the only cod-liver oil made in Norway and refined in America. This oil is guaranteed a 100 per cent product of the livers of the true Gadus Morrhuae and absolutely free from admixture with other oils or impurities. Samples of this high-grade medicinal cod-liver oil will be sent to physicians on request. Address Scott & Browne, Bloomfield, N. J.

Wassermann and other serological tests.

Autogenous vaccines prepared
Urine, sputum and gastric analyses.
Tissue examination.

"Basal Metabolism” determination in Goitre Cases, etc. Blood chemistry.

Bleeding tubes, culture media and all other necessary containers furnished free.

Dr. Michael G. Wohl, M. D. Clinical Pathologist

COUNCIL REMEDIES

One of the most important developments in the medical history of the past five years has been the work of the Council on Pharmacy and Chemistry, of the American Medical Association. Their examination and analysis of newer remedies has done much to advance the standard of manufacturing pharmacy; it is safeguarding the doctor against inferior products, and indicating those for which misleading claims are made.

The cooperation of the doctor in using and prescribing Council passed products is making this work more effective each year. The cooperation of the manufacturers is, also, an encouraging recognition of the value of this service. A partial list of the Council passed remedies, manufactured by The Abbott Laboratories, Chicago, appears in this issue. These are obtainable on prescription at the leading pharmacies, or may be obtained direct, as desired.

VOL. XI

AN ANALYSIS OF THE FIRST ONE HUNDRED ADMISSIONS TO THE IOWA STATE PSYCHOPATHIC HOSPITAL*

LAWSON G. LOWREY, A.M., M.D., Iowa City Assistant Director: Associate Professor of Psychiatry, State University of Iowa

The law establishing the State Psychopathic Hospital was enacted in 1919 (Chapter 235, acts of the Thirty-eighth General Assembly: this has been issued in pamphlet form and may be obtained from the State Board of Education). It provides for the establishment of such a hospital, "especially designed, kept and administered for the care, observation and treatment of those persons who are afflicted with abnormal mental con

ditions." The hospital is put under the management of the State Board of Education; to be located at Iowa City "and connected with the College of Medicine" of the State University. The board appoints the medical director, "who shall serve as professor of psychiatry in the College of Medicine." The director, in addition to having charge of the hospital, "shall seek to bring about systematic cooperation between the several state hospitals for insane and the said State Psychopathic Hospital." Provision is made for him to visit and advise the hospitals on request.

The law carries the first provision made in the state for admission of voluntary patients to a

state hospital for mental diseases. It provides that they may come voluntarily either as public or private cases. Patients may also be committed by judges of the district or superior courts as "suffering from an abnormal mental condition which can probably be remedied by observation, treatment and hospital care," the expense to be bourne by the family or the county as the court may decide. It will be noted that this form of commit

ment does not carry with it the idea of adjudging the person "insane," which many people do not like, preferring to think that the patient is sick, as indeed he is.

*Read by invitation before the Iowa and Illinois Central District Medical Association, Davenport, Iowa, August 25, 1921.

No. 12

We have then four legal classes of patients: viz., voluntary private, voluntary public, committed private and committed public. Of these, the first type needs no legal papers of any sort; the second an order of the judge that support be paid from public funds; the third an order of commitment by the judge; the fourth an order of commitment and an order for public support.

Ample power is given the director to insure that the hospital may select its cases and transfer to the district state hospitals cases not regarded as suitable for the psychopathic, or cases which prove to be chronic or incurable. The original provisions were somewhat modified at the last General Assembly, but the same ends are sub

served.

A total appropriation of $272,000 was granted by the Thirty-eighth and Thirty-ninth General Assemblies for the building and equipment. The plans for the building, which is expected to be ready for occupancy in January, were drawn by the director, Dr. S. T. Orton. It will contain sixty beds with ample day space, and so arranged that a classification of patients may easily be made with respect to their therapeutic needs. There is an ample and well arranged out-patient department; offices and needed rooms for the medical and social services; laboratories for chemistry, serology, pathology, psychology and experimental work; library, class room and teaching laboratory. It is in my opinion the best plant in this country for its particular work.

The first psychopathic hospital in this country 1906. The Boston Psychopathic was opened as a was established at the University of Michigan in department of the Boston State Hospital in 1912. The Henry Phipps Psychiatric Clinic was opened in Baltimore in 1913. The New York Psychiatric Institute was reorganized in connection with the Manhattan State Hospital in 1902, but certain differences of organization and function render

it not quite comparable to the others. Then there

are several detention hospitals, some of which are called psychopathic hospitals, but the character of their work is considerably different from that of the others named.

The Psychopathic Hospital in Boston, with which I am most familiar, had four principal objects:

1. The first care and observation of cases suspected of having mental trouble: i. e., diagnosis. 2. The treatment of acute and curable conditions, and recommendations for further care and treatment of other cases.

the figures here given refer to the first hundred patients actually admitted to the hospital, and has no reference to cases seen in the out-patient or in consultation.

Fifty-one men and forty-nine women. of ages varying from eight to seventy-one years comprise the group. Of these, sixty-six came voluntarily and thirty-four were committed. This to me 's

4. Teaching of physicians, medical students, social workers, psychologists, nurses, and others having to do with the problems of mental diseases. Serving a large metropolitan district, with an annual admission rate of 2000, and about 1500 new cases per year in its out-patient department, it rapidly developed into chiefly a diagnostic station, with less emphasis on treatment. The teaching and research functions were well carried out in view of this limitation. This "sorting" function has been less in evidence at Michigan, as it is apt to be here. This is explainable, at least to a considerable degree, by the difference in the distribution of population.

These are, however, the four important functions of the psychopathic hospital. It is not, and can not be, if it is to succeed, a custodial institution. Every case must be regarded as a possible research case; every record must be compiled with the idea that it is to be a part of some research; every test or procedure, whether diagnostic or therapeutic, must be viewed in the double light of possible research value and its value to the individual patient. All of the resources of medicine, of psychology, of science in general must be brought to bear on the problems of the individual patient and on the problems of the mental diseases at large.

It is to be remembered that in dealing with mental disease or defect we are dealing with the entire individual. We can not consider one organ or function to the exclusion of another. must always analyze the whole man and his setting, which means an attack upon his problems from all possible points of view. We are building up an organization for just this sort of work, a research and teaching station, but in addition a place for the scientific and humane attempt to rehabilitate the sufferer from mental disease.

GENERAL STATISTICS OF 100 CASES On July 12, 1920, the first patient was admitted to our "temporary quarters," designed to be a diagnostic and advice service, with space to accommodate eight patients. We soon had fourteen patients and a long waiting list, and have ever since been put to it to meet the demand. All of

admission of voluntary patients to hospitals for mental diseases. The necessity for such provision has been recognized in twenty-nine states. In six of these states, the request for voluntary admission must be accompanied by the certificate of a physician. Massachusetts has had such a law since about 1880 although at first only peopie who were able to pay could be accepted, as the counties and towns refused to pay unless patients were committed. Following complete state control of the institutions, adopted in 1904, the law was amended, and now any one may be accepted as a voluntary patient, either as a public or reimbursing patient. In 1919 nearly 20 per cent of the admissions to the Boston Psychopathic Hospital were voluntary cases.

The hospital charges tentatively fixed by the board are $4 per day for both public and private cases, with no extra charges of any sort. While the charge is materially higher than the cost of maintenance in district state hospitals, it is probably nearer to the cost of their reception and acute services than is generally realized. Of this group of cases, forty-seven were publicly and fifty-three privately supported. Of our female patients, 59 per cent (twenty-nine) were privately supported, while among the males 47 per cent (twenty-four) were so supported. Correlated with this is the fact that 77 per cent of the females and 55 per cent of the males were voluntary cases. That is. the men are the earners and it is more frequently necessary to ask for public support.

MEDICAL STATISTICS

It is difficult to arrive at any accurate estimate of the duration of illness before admission. Some eight or ten cases were admitted within a short

time of the onset. The balance had been ill months or years before admission. Fully half the cases had been the round of physician, Christian scientist, osteopath and chiropractor. Some claimed benefit from one, some from another. Some twenty had been in other hospitals or sanitaria. Sixty-six per cent were referred to us by physicians; 11 per cent were sent us by courts wishing to obtain our advice in dealing with some particular situation that had arisen; 5 per cent were referred to us by social agencies interested

in the case from some angle; the remaining 18 per cent came on the initiative of the family or the patient.

It is perhaps unnecessary here to advert to the necessity for early treatment. From the standpoint of results, the earlier the better. Indeed if we must err at all, it seems to me far better to err by calling the case mental when it is physical than to err by calling it physical when it is really mental. I understand the general objection to calling mental cases mental, and the general usage of such terms as nervousness, nervous breakdown, neuritis and other vague terms which mean nothing or a great deal, but it does seem that we need to face more squarely the problems of mental disease, and particularly the need for early treatment. Now that mental cases may be hospitalized on practically the same terms as cases of physical disease, there would seem to be little excuse for any great delay in starting treatment.

In Table I will be found a summary of the diagnoses in the hundred cases, giving the condition of the patient at time of discharge. In general it may be said that the patients did not remain long enough for adequate treatment, as the facilities at our command would not permit. The results at Michigan have indicated the desirability of a period of treatment which averages three months, and this we have not been able to give. Five of the cases were under treatment three months or longer, while fifty-three were in the hospital less than a month.

CLINICAL GROUPS

The ordering of the material in Table I is based upon Southard's diagnostic key, as modified by Menninger and by myself. It will be noticed that in some groups, notably 1, 4, 5, 6, and 7, the delimitation is based upon etiology. The other groups, which are accepted groups in the psychiatric nosology of the day, have been erected on a basis of clinical description and outcome. For them, in general, our ideas of causes are very vague. Hence, whenever a case in this series presents definite etiological factors, it is placed with its etiological rather than descriptive group (vide neurosyphilitic epilepsy and feeblemindedness).

There is presumably only one logical way to group the mental diseases, and that is on a basis of etiology, but as yet our knowledge of etiology in mental cases is not equal to the task (Orton). Descriptive interpretative terms such as "mental disease," "excitement," "depression," "dementia," "feeblemindedness," "epilepsy," etc., are only the starting points for a true diagnosis, and are on about the same level as "edema of the feet," or "fever" or "arrythmia," etc., in general medicine.

In mental cases we do not have a presenting symptom, as is so frequently true in general medicine. Instead, we are presented with complexes of symptoms, or "clinical states." Having determined what this clinical state may be, we proceed to a differential diagnosis. Practically any outstanding mental symptom may occur in any of our various groups, which does not increase the ease of diagnosis.

But it still remains true that our separation of cases into groups is well founded, and that these diagnoses, even in the absence of adequate etiological ideas, have a definite meaning and usually carry a definite prognosis.

The best method of discussion of the medical aspects of the cases is according to the grouping adopted.

Group I. Neurosyphilis-We have included here all cases shown to have syphilis of the nervous system. It happens that these are all the cases known to have had syphilis, and all that gave a positive Wassermann test. Experience in Eastern hospitals shows that about 16 per cent of admissions have a positive Wassermann test, and about 10 per cent have neurosyphilis. Perhaps the low percentage here found is only a matter of chance, the number of cases being small, or perhaps it means only a small amount of syphilis in the state.

Three of the cases were treated intensively with intravenous arsphenamine according to the method developed in the syphilis clinic of the Boston Psychopathic Hospital. One of the cases developed a severe dermatitis and jaundice, so that treatment had to be discontinued. The patient never showed any improvement, and eventually died. The autopsy revealed no gross lesions indicating arsenical poisoning, but there is much intracellular fat in evidence microscopically. Another case of paresis remained in a stationary condition of deterioration with marked. organic signs during the six months he was under

treatment.

The third case is one of the rare types of paranoid neurosyphilis, recovering from the immediate psychosis under treatment, and still weil after the lapse of a year.

A woman of forty-four was admitted on August 25, 1920, because of auditory and visual hallucinations, delusions of persecution, suicidal threats, threats against her sister, and the secretion of a butcher knife in her room. She had been regarded as entirely normal until two years before, when the hallucinations and delusions began following some trouble with her husband. Symptoms of syphilis and treatment for that disease about fifteen years ago, and intermittent treatment since. During this sum