and remained so until Jan. 13, when a slight amount of sugar appeared in his urine following a slight increase in his diet. This patient's weight chart was of much interest as he gained weight steadily on his reduced diet, and only remained sugar-free when his caloric intake was so reduced following starvation days that his weight made only slight gains. Somewhat similar is the following patient (Peter Bent Brigham Hospital, Med. No. 1963) who was admitted to the Hospital Nov. 27, 1914, with a history of polyuria beginning four or five days before admission. On a gradual reduction of carbohydrate intake, this patient was still putting out sugar in his urine 17 days after admission on a diet of 10 gms. of carbohydrate, and 50-60 gms. of protein. He was then given a day on which he had only thrice-boiled vegetables and alcohol. On the second day of this he became sugar-free. However, he was kept on this diet for four days, but when he was returned to a 10. gm. carbohydrate and 90 gm. protein diet sugar reappeared, but promptly disappeared on a repetition of the thrice-boiled vegetable days. Subsequent to this he remained sugar-free on a 10 gm. carbohydrate and 60 gm. protein diet and established some tolerance, so that he eventually was sugar-free on a diet of 30 gms. of carbohydrate and 80 gms. of protein. In all of these cases fluid, carbohydrate and protein intake were charted in relation to output; the patient's weight was noted; the caloric intake; acetone, diacetic acid and ammonia excretion, etc., were quantitated. However, in the present paper only the glucose excretion has been considered in relation to the time element. In Chart I it will be seen that it required of each patient, with the exception of one exceedingly mild case, a stay in the hospital of from 7 to 20 days before the urine became sugar-free when carbohydrates were gradually reduced, while by Allen's starvation method the same thing was accomplished for all except one patient in 4 days or less. The difference in results obtained from the two methods is shown especially well by the cases treated on two admissions approximately one year apart. In these three patients it required 25 days, 18 days and 15 days respectively to render them sugar-free by the method of gradual reduction of carbohydrate intake, while each was sugar-free on the third day by the Allen starvation method. It will be seen that by this new method of managing cases of diabetes introduced by Dr. Allen the time required for rendering a patient sugar-free has been greatly shortened. It is done, too, so far as we have observed, with very slight inconvenience or discomfort to the patient. What of the third aim of a diabetic treatment, the establishment of an increased tolerance? It has seemed to us that tolerance is as rapidly acquired after the starvation method of getting the patient sugar-free as after gradual carbohydrate reduction. This being true, Dr. Allen's methods have shortened very materially the time of hospital stay required of cases of diabetes of moderate severity, and in this respect have improved PSYCHOPATHIC HOSPITALS AND PROPHYLAXIS.* BY FRANKWOOD E. WILLIAMS, M.D., BOSTON, Executive Secretary, Massachusetts Society for Mental Hygiene. FROM the point of view of mental hygiene, individuals may be said to fall into one of four groups: 1. Those now sane, and who will remain sane except through the working of some exogenous factor. 2. Those now sane, but who will become insane under certain conditions. 3. Those now insane. 4. Those who have been insane but who are now recovered and returned to the community. A fifth group might be added-those yet unborn. A program of mental hygiene must provide adequately for each of these groups. Our present system in Massachusetts provides-but not adequately, as for instance in the case of the feeble-minded and defective delinquent-for the care of those at present suffering from mental disease, and with its social service departments and its newly organized out-patient departments, for those who have been insane but who are now recovered. But from the prophylactic point of view these two groups are of the least import ance.. Providing for the care of the mentally diseased after the damage has been done, important and essential as a humanitarian measure, will have as little effect in the prevention of first attacks of insanity as providing elaborate care for patients suffering from typhoid fever would. have in the prevention of an increase of typhoid fever. The field for prophylaxis lies in the first two groups-those now sane, who will remain sane except through the working of some exogenous factor; and those now sane but who will become insane under certain conditions. proximately 14,000 patients. From a prophyThere are, today, in our state hospitals aplactic standpoint little can be done for these. But new cases are admitted to our hospitals at the rate of about 3,000 a year. The problem is, how to prevent these 3,000 each year from becoming insane. It is too much to expect that the time will ever come when this figure will be reduced to a zero. But at the present we are doing little to impede its progress to a maximum, with the maximum not yet in sight, when we might be taking steps to reduce it to a minimum. The seeds of mental disease were sown in the Read before the Worcester District Medical Society, February 10, 1915. bodies of some of this year's 3,000, ten, fifteen, insane is a legal and not a medical termtwenty years ago, in the form of syphilis. These carries with it no connotation as to possible patients are lost to us. But there are young men outcome. Many of the insanities are not reand young women who have contracted syphilis coverable, it is true. Others are recoverable, today; there are others who will contract it to- and it should be borne in mind that when indimorrow, and thus become candidates for admis-viduals recover from such forms of mental dission. For those who will be admitted this year ease and return to the community, they are as suffering from alcoholic psychoses nothing can capable intellectually as before their illness. now be done. But these individuals are now at the Massachusetts is one of the few states that end of a road which once had a beginning, and has upon its statute books laws providing for there are others entering that road today. A the temporary care and voluntary admission of healthy mentality cannot be given to the feeble- patients in the early stages of mental disease. minded girls now cared for by charity organi- These laws are wisely conceived, capable of servzations in maternity hospitals and nothing ex- ing a splendid purpose, and from the prophycept lack of facilities will prevent them from lactic point of view mark an important advance becoming patients at one of the schools for the in legislation for the insane. Statistics show, feeble-minded as soon as their health will per- however, that outside of the metropolitan dismit. But there was a time, some fifteen or twen- trict of Boston, served by the Boston Psychoty years ago, when prophylactic measures-the pathic Hospital, these laws are but little used. proper segregation of their feeble-minded par- In some districts this is because of lack of proents, for example-would have been effective. In per facilities in the immediate neighborhood. the case of the yet unborn children, prophylactic In others it is because of a lack of a proper unmeasures might have been applied but a few derstanding of the purpose, action and types of months ago. They can still be applied to the cases that are advantageously served by these feeble-minded girls who will otherwise come to laws on the part of the general practitioners. the maternity hospitals in the next twelve In still other communities the difficulty lies in months of this year, and thus would be de- the middle 19th century views of mental disease creased the admission rate for the feebleminded four, five, ten, fifteen years from now. There were graduated from the high schools of the state last June many ambitious young men and women who last fall entered the universities and professional schools, and who before the school year is over will have succumbed to the strain and will have been admitted to our hospitals. Many of these came of neurotic stock, a patient who has been examined at a state and early showed peculiarities and idiosyncrasies of temperament, emotion and mental habit that might have forewarned an alert parent or family physician. Little can now be hoped for; the damage is done. But there are others who will be graduated next June, and through lack of proper understanding of themselves, start on the self-same course. held by members of the legal profession occupying positions as judges. We may experience something of a shock when we learn that a neighboring state still classes the insane with the criminal and places the supervision of the state hospitals in the hands of the board of pris on commissioners. But it is well to examine ourselves. In one district of this commonwealth hospital and found to be suffering from a mental disease, must suffer a trip back to the city from which he came, be taken to the police station, have his name entered upon,the police blotter in the manner of a criminal, and must then be paraded before the police court to permit the judge to make a diagnosis before treatment of more than a week can be vouchsafed to him as One of the great factors impeding the pro- a sick man. Such archaic notions impede mightgress of proper measures is the inertia due to ily proper progress. An individual bereft of the feeling of hopelessness and helplessness with his reason has rights as an individual that must which mental disease is regarded, and the pre- be protected, but in protecting his rights as an judice engendered by misconceptions of the na- individual we must not forget that he has rights ture of mental disease. The idea of diabolical as a patient, and that the hope of soon regainpossession in the case of the insanities is no ing his rights as an individual may largely delonger entertained, but the theological concep- pend upon the respect that is given, at a critical tion which supplanted this middle age explana- time, his rights as a patient. tion that insanity is pure mental and moral These misconceptions, these prejudices, these perversion and represents the outbreak of the exogenous and environmental factors, so importanimal and violent elements of the fallen human ant in the prevention of mental disease, should soul which have culpably been permitted to get be materially influenced in any community by the upper hand of the higher attributes-is still the presence of a psychopathic hospital. A psytoo prevalent. Kindred to this is the fallacy chopathic hospital, in conjunction with its other that "once insane always insane." We must come functions, should serve as a prophylactic and to understand that insanity is a disease. Fur- educational station. Standing in a community ther, that the term represents not a disease en- on the plane with the general hospital or other tity, but a group of diseases. And still further, specialized hospital it emphasizes mental disthat the legal diagnosis "Insane"-and the term ease as a disease and should serve as a center 2. Perception, apperception, visual memory, imagination. 3. Discrimination-(a) visual, (b) and (c) kinaesthetic, 4. Auditory memory for words (digits), attention. to which may come for advice and counsel those suffering from psychoneuroses and the early stages of mental disease as easily and freely, and with as little prejudice as those suffering from the early stages of tuberculosis seek out a hospital for tuberculosis; a center to which can be brought for diagnosis the supposedly backward child, before further social damage has been done; a center to which parents aware of the neurotic inheritance of their children can come for advice in their children's upbringing and protection. From its lecture platform adults should receive instruction which would lead them to a better understanding of their own complex emotions, sensations and impul- 10. Ideation (association and analysis). sions, and practicing physicians should be in- 11. Suggestibility, visual perception, comparstructed in the significance of certain early man 5. Memory, imagination, attention. 9. Analysis and comparison of remembered objects, attention. ison. forms. ifestations of mental disease, that they may be 12. Motor coördination, visual perception. as capable in diagnosing and protecting these 13. Association (free), vocabulary, attention. patients as they are those manifesting the early 14. Imagination and command of language signs and symptoms of tuberculosis or cancer. Prophylaxis is but one of the many functions 15. of a psychopathic hospital, but its possibilities as a prophylactic and educational center should not be overlooked. PROGRAM AND DIRECTIONS FOR THE PSYCHOPATHIC AND DOUBTFUL SUB JECTS. BY ROSE S. HARDWICK, BOSTON, Instructor in Education, Boston School of Physical (Concluded from page 910.) CLASSIFICATION OF TESTS. The following classifications of the tests with respect to the mental functions involved are given for convenience of reference, and not as being by any means exhaustive. The first table shows the tests in the order in which they occur in the Point Scale, the Binet Scale, the Healy Tests, the Knox Scale, and the Miscellaneous group. After each test are indicated the principal functions involved. In the second table the same tests are reclassified under the heads of mental functions likely to be of special interest. TABLE 1. (Showing principal mental functions involved in each test.) THE YERKES-BRIDGES POINT SCALE. 1. Aesthetic judgment involving perception, association, analysis. 16. 17. Practical judgment involving memory and imagination. Visual memory, perception, attention, motor coördination. Logical judgment based on imagination, analysis and reasoning. 18. Ideation, involving vocabulary, analysis, imagination, command of language forms. Ideation, involving vocabulary, memory, analysis. 9. 20. Logical judgment based on analysis and rea soning, attention, memory. 5. Information, color discrimination. = VIII 1 Y 9. 2 = Y 5. tional wealth, come children who know nothing of money, and who, therefore, fail on VIII 4, IX 1 and X 1. On the other hand, children of 3. Information, verbal association, idea- small shopkeepers acquire these notions very tion (notion of time). early. Hence it is important to keep in mind (notion of always the dependence of such tests upon environment, and the danger of resting positive conclusions upon failures therein. 4. Information, ideation value). 5 = Y 4 c. 2. Ideation, analysis, constructive imagi- 3. Information, vocabulary, analysis. The word "information," occurring so frequently in this table, is not intended to stress unduly the more mechanical aspects of the tests, to the obscuring of their real psychological value, but to draw attention to the dependence of these particular tests upon environment. The fact is that, while correct responses in these cases do necessitate a certain mental development, the reverse does not hold true. A child may fail completely in one or more such tests without being in the least retarded mentally, and solely on account of peculiarities of environment. Thus, from the two extremes of social privilege, institution life and homes of excep THE HEALY TESTS. 1. Perception (visual-rarely kinaesthetic) of form, color, and relations of part and whole, motor coördination, attention. Same as I. III. Same as I except for absence of color. VI. Memory (visual) for concrete situation VII. = Y 16. VIII. Memory (visual and kinaesthetic) for arbitrary associations. XII. Memory (visual verbal) for connected ideas. XIII. Memory (auditory verbal) for connected ideas. XIV. Memory (auditory verbal) for arbitrarily associated ideas. = XV. B XV 4. XVI. Motor coördination (accuracy and speed), attention, fatigue. XVIII and XIX. Reaction to formal education. XXII. Information, stock of ideas, sentiments, XXIII. Analysis, constructive imagination. |