New York (State). State Hospital Commission.

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ception of the extreme variations which the human mind is capable
of assuming in psychopathic conditions.

As to the difficulties surrounding diagnoses, it may be said that
the differential conditions are so interlaced and the type of
psychoses so complex that not infrequently as many as four or
five, and in a large majority of cases, two or three forms have
lK?en vigorously exploited by the various members of the medical
staff, each with plausible evidence of exactness. Also, that the



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State Commission in Lunacy 1053

MANHATTAN STATE HOSPITAL — ANNUAL REPORT

fiubtilty of the^ morbid mind, when viewed by the normal, is sub-
ordinated largely to the individuality of the critic. Different
minds are guided by their own individuality, and consequently
opinions are rendered in accordance with the various sources and
extent of knowledge of cases. In this respect, it would seem that
the difficulties arising are increased by the number of individuals
engaged in making the analyses, these being of varied experiences.
Happily this is obviated to some extent by the elements in control,
that, what on first proposition seem to be absolutely irreconcilable
conditions, are through open discussion and comment, ultimately
placed by the organized body as near their proper classification as
the exactness of the science will at present permit In the final
result, the organized body figures as a unit, wherein lies the value
of results in the study of the psychiatrical problems arising in this
hospital. Persistent methodical work will evolve its own future.

Admissions

The number of patients admitted to the women's department
during the year ending October 1, 1906, was 848. Some 275
cases were sent to the hospital at Central Islip from the boroughs
of Manhattan and the Bronx, making the total number of
women committed from these boroughs, about 1,123. The num-
ber is a considerable increase over admissions of 10 years ago, but
is not out of proportion to the population

Alcoholic psychoses. As to the nature of psychoses in admis-
fcions, many varieties show uniformity in number to such degree
rhat certain fixed percentages may be counted upon with accuracy.
In the alcoholic psychoses, for example, there has been a very
slight incroHs(\ they usually constitute al)out eight to 10 per cent
of the admissions. This grouping includes merely the cases in
which alcohol has been absolutely demonstrated as an etiological
factor in the disease. In many forms of the classification alcohol
has appeared as a subordinate or accessor^' element in the etiology.
In the paranoic conditions, the anxiety and involution and un-
differentiated depressions, and in the manic types, the use of
alcohol has sometimes complicated the etiology, yet we may say
of the sympton complex in what are considered as the alcoholic
psychoses, is so definite, we have sometimes attempted to diagnose
the same without corroboration by evidence that the habit has
existed. Alcohol also enters largely into the group complicated
by the neuroses. Fortunately this group yields readily to treat-
ment, over 40 per cent of the same having already recovered.

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ConstitviioncLl Inferiority. — Under this designation we have
considerable increase in number. As this condition is one closely
allied to the amentias, imbecility, etc., it seems to have increased
at the expense of these conditions. In the groupings of manic
depressive insanity and dementia prsecox and the hysterical psy-
choses, we not infrequently have recognized the psychosis as
existing on a constitutional basis. As a term its signification
is usually a bodily as well as mental defect of developmental con-
ditions. The problem of placing the patient under two headings
has frequently presented itself in this and in the imbecile and
epileptic groupings. Manic depressive insanity and other forms
on a constitutional basis, or in an imbecile or epileptic, have
occurred not infrequently.

Drug addiction was the assigned cause in five admissions the
toxicant being opium in three cases, cocaine in one and chloral in
one. Pure drug intoxication has been rather infrequent. The
majority of habitues are, or have at one time, been alcoholic, and
are from the lower planes of life; two were syphilitic. The
psychoses have been of rather mixed type, pure deliria occurring
in only two cases.

Under the designation of depressions not sufficiently differen-
tiated and depressive hallucinoses have occurred C9 cases, em-
bracing a rather large class for which our classification seems
wholly unable to do more than temporarily designate their domi-
nant symptoms. Fifty per cent of these have already been
discharged from the hospital. This class has been largely subject
to emotional episodes and morbid fears, sometimes preceded or
followed by hallucinatory disturbances. Some have been of an
evanescent and transitory type, recovering after a few days of hos-
pital treatment. They are at times recurrent conditions; man;j
of them apparently arise de novo, or from the temporary vicissi-
tudes of life, nostalgia, etc., and, at times, exhaustive conditions
rapidly yielding to treatment. Additional light on some has
j)laced them in the more permanent and better defined, the manic,
paranoic and deteriorating groups. The terms have been ex-
tremely convenient as well as useful, their signification being
fairly well understood from a semeiotic standpoint. They are
devoid of the complex conditions encountered in other groups,
though at times, at least, a temporary subterfuge. Their prog-
nosis is usually favorable or they early develop additional phe- f
nomena during their residence in the hospital. t



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MANHATTAN STAIE HOSPITAL — ANNUAL REPORT ^

Infective Exhaustive Psychoses,—^ An etiological subdivision
which has been the subject of special study. In our nosology
this group has clearly been decimated by a more critical analysis,
and cases formerly considered here have through a clearer and
deeper insight been correctly placed in the manic or other groups.
Formerly cases of delirium with febrile symptoms and their phe-
nomena, have been so placed as infective and exhaustive. The
mental transformations coincident with the puerperium, the i)8y-
eiiic trauma of illegitimacy, states of mental collapse following
protracted bodily illness, as in tuberculosis, the sequete of fright,
nostalgia, etc., have contributed a majority of cases in this group.

One of the most pleasing results of the newer methods of study
in psychiatry is observed here, and which has practically forced
itself upon us, not through preconceived thought, but through
actual experience with the material under investigation, that is,
the occurrence or occasion of delirium during the puerperium,
or the rise of bodily temperature coincident with the psychosis
does not formulate as formerly a puerperal insanity, likewise with
gestation or prolonged lactation. In other words, we have learned -
to not so greedily grasp at what is seemingly the most accessible
and prominent etiological factor and use it as an easy makeshift,
but to study and classify the psychoses occurring in the female
during pregnancy, the puerperium and lactation in the same
manner and method as prevails in the other 90 per cent of ad-
missions, that is on a symptomological basis. By so doing the
above conditions do not seem of such pronounced import as causa-
tive agents and becomes subordinate to unstable states of a con-
stitutional type.

The prognosis of such numbers remaining after the above dis-
crimination is extremely favorable; 70 per cent of these cases
have already been discharged from the hospital. Here, as in
other forms, where delirium predominates, the continuous bath
has been at times almost specific as a curative agent.

Dementia Prcecox. This and its allied forms have compulsed
as usual by far a greater number of admissions than any other,
representins: 28 per cent. Of this numl)er 51 have been dis-
charsred, 13 of whom were deported, leaving alx)ut 15 per
cent for discharijo in various stages of recovery. Unfortunately
nothing has been discovered to check the slow mental disintegra-
tion occurring in this form of disease. Variable and compre-
hensive conditions and wide range of disturbance of the intellect
67

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1056 Eighteenth Annual Keport of the

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and the sensory spheres covering the decades of early and middle
life, characterise this form. Further it does not seem to diminish
in numbers, but bids fair to be enlarged by additions from other
groupings, through a more accurate differentiation. The type
of the disease is largely subject to the influences of ancestral in-
dividuality, etc. Much of the time allotted to the staff meetings
has properly been occupied by the discussion of this disease in
connection with the presentation of cases for diagnosis. It may
not be out of place to enumerate the differences and difficulties
encountered. Probably 'the greatest obstacle is the recognition or
not of deterioration in some of its various types. The vignette
gives us a quiet shading; on the one hand toward constitutional
inferiority, illiteracy and depravity in the lower types; on the
other hand, the more acute and excited or delirious types of
sudden onset are at times extremely difficult to differentiate from
the manic, the alcoholic, and exhaustive groups. No great im-
portance has been attached to the subdivision of this group, admix-
tures being extremely "common. Cases were also met showing
manic traits, such as occur in the field of the emotions and of
attention. On the whole it may be said that these finer discrimin-
ations have been almost innumerable and hard and fast lines were
difficult to establish. Border cases were frequent and cast an
unavoidable reflection upon the exactness of the science of psychia-
try. '

Involutional Psychoses, etc. — This term applies to a rather
definite symptom complex, most frequently occurring around the
menopau.se or as a pre-senile condition. A type of anxiety which
although seen both in early life and advanced years, is met with
most, frequently between the ages of 40 and 60. Several of
these have been so complicated by conditions, possibly arising
through excessive use of alcohol or through senility, that it was
almost impossible to definitely establish their exact nature. Only
three have recovered up to the present time, one of whom, how-
ever, -was 80 years old on admission.

The occurrence of insanity in epileptic and imbecile persons
accounts for 26 of our admissions. Five of the epileptics were
received by transfer from Craig Colony.

Hysteria dominated the psychoses in six cases ; five of these have
already recovered.

Manic Depressive Insanity. — An extremely interesting and
important group embracing with its allied forms 13 per cent of



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MANHATTAN STATE HOSPITAL — ANNUAL REPORT

the admissions of this year, compared with 14 per cent hist year,
and 12 per cent the year before, but little variation in ratio is
ei^own. Of those admitted, 38 per cent have already been dis-
cl^arged recovered. In this group probably more than in some
others, the diagnosis has rested upon a syndrome more easily recog-
nized, emotional states, disturbances of consciousness and difficul-
ties in the field of attention and thought processes; these have a
corresponding affect upon the motility of the patient, causing
hyperactivity or retardation. No single symptom has distracted
the attention of the medical staff more than retardation. While
the hypermotility conditions are almost exclusively confined to
the manic groups, it has been extremely difficult to establish in
the depressed forms retardation as it is at present understood.
The trend of opinion is that probable undue importance is attached
to the same as a diagnostic feature.

Manic depressive insanity has frequently established itself upon
a constitutional basis; recurrent attacks have been excited by the
nso of alcohol. One case has been admitted 12 and another
18 times. In one patient the attacks appeared to have oc-
curred with some periodicy, beginning at the age of nine years
and extending throughout the patient's entire life. Hereditary
tendencies are very pronounced in the etiology of this psychosis.
In one family in which eight members suffered from insanity,
two were manic; from another family two sister.s were admitted
with similar attacks. Difficulties have arisen in differentiating
the delirium types from delirium of, for example, the infective
exhaustive psychoses, and the excitements occurring in dementia
prsecox. Again, manic traits have occurred in almost all the otlic r
psychoses in isolated cases. Distractibility, retardation and soimd
association, etc., has been not infrequently observed in cases of
dementia praecox, yet the syndrome of manic depressive insanity
is from a point of accuracy probably the best defined and one of
the most easily recognized forms in the classification. It has been
demonstrated during the year that manic attacks may be pre-
cipitated in the same individual through various exciting causes,^
In one case that has been in the hospital 10 -times it is observed
with each attack the etiology varied, as when the patient was
single, fright, after marriage childbirth was assigned, after the
menopause upon alcohol fell responsibility. In a number of cases
the manic depressive equivalent seemed to be an affect upon a



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1058 Eighteenth Annual Repobt of the

MANHATl'AN STATE HOSPITAL — ANNUAL REPORT

mild paranoic basis. Thia condition existed especially in the
attacks of manic depressive insanity occurring late in life, and
in those types who do not acquire a thorough insight but seem
always to have a grievance, as a residual condition. Speci^il
efforts were made to exactly reproduce the patient's spontaneity
in this group, as it seems to be of great value for diagnostic pur-
poses. Hallucinations of the most vivid and harrassing type have
been met with in several cases. Delirious types have also occurred
in which the diagnosis was necessarily in abeyance, manic traits
appearing after the delirium had subsided. Different sensory
channels, for the disturbances of attention seem to exist, distracti-
bility for colors and of an aesthetic type have existed, and a most
interesting study was made of the various types of distraction.
Suicidal tendencies were encountered in the depreasions of this
group of a very determined nature. Several patients were ad-
mitted beyond the age of sixty, and it, at times, has appeared on
a senile basis. Throughout the work it may be said that the
manic equivalent has held out as ar ather clear conception. As
before stated, the difficulties have been greatest in the depressed
form, some of which were deferred for additional light and
outcome.

Paresis. — Amongst the remaining groups we have 50 cases of
paresis, or nearly six per cent on the women admissions. This
ratio has not varied for some years past. Compared with this the
admissions oil the male division have for many years past averaged
from 16 to 17 per cent. This would indicate on the mixed popula-
tion 10 per cent of admission. Various types have been desig-
nated which it would seem aie nothing more than mere stages of
development of the same definite process. One case formerly
diagnosed as paresis was readmitted with a primary specific lesion ;
should the diagnosis prove correct the anomaly would be a most
interesting one. In at least three instances the wives of paretic
husbands have been admitted with the same disease. There does
not appear to have been any increase in the frequency of paresis
ih this hospital during the past decade.

Paranoic Conditions. — This grouping appears to have shown
considerable decrease in number, representing this year only seven
per cent of admissipns as against nine per cent last year and 12
per cent the year before. ' This may be accounted for by the fact
that a finer discrimination and an effort to exclude from this



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MANHATTAN STATE HOSPITAL ~ ANNUAL REPORT

group cases which show any marked degree of deterioration has
been made. It has also somewhat complicated the alcoholi*.'.
psychoses and has also appeared during the senile epoch. An
effort has been made to keep this form as much as possible within
the range of the purely intellectual psychoses. There seems U*
be a progressive gradation or an interlacing between the paranoid
types of dementia prsecox and the paranoic conditions which is
difficult to eliminate; the border lines seem not clearly defined
from a practical standpoint. The differential conditions seem-
ingly dependent upon developmental degree rather than specific
semeiosis.

The psychoses with neuroses embrace the alcoholic cases, ac-
companied by a polyneuritic process, the characteristic mental
phenomena being memory defect, a tendency toward fabrica-
tion, etc.

Amongst the remaining gi'oups are placed organic conditions
in most instances of indefinite pathology, diagnosed as vascular
lesions or the mental reductions following hemiplegic attacks.

One case of brain tumor occurred of extreitie interest, a sar-
coma originating in the dura and penetrating the brain in the
left sylvian area, and which will be reported in detail in a
medical periodical.

A recapitulation of the work of the year indicates that con-
siderable objection has seemed paramount to the etiological terms
used in cur classification, the trend of which is that the ?ame ar»3
unscientific unless absolutely established and specific. A mul-
tiplicity of forms have been diagnosed from the same etiology;
there is likewise a multiplicity of causes assigned to the different
individuals suffering from the same psychosis. Many interesting?
problems have presented themselves during the year, that of
heredity seems to stand in bolder relief the deeper it is investi-
gated; yet it has been shown that inheritance has an utter dis-
regard for forms.

It seems definitely established also that the different epochs in
life are prone to certain forms of psychoses, out of which may
be constructed a basis for further study, and these forms ma.y
bear a distinct relation to developmental and regressive conditions.

To Dr. D. S. Spellman I would express my indebtedness for
his efforts in reviewing the work in psychiatry among the admis-
sions on the men's service. It has been the effort of the staff on



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1060 Eighteenth Annual Report of the

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the merits division t6 classify the cases on the facts, without at-
tempting to force the issue. As a result a large number of cases
have been assigned to the unclassified groilp.

Many difficulties confront us .in gaining adequate facts. The
diversity of population, coming as it does from all parts of the
earth, many without available friends, who are practically in-
accessible on account of lack of knowledge of our language, the
absence of a competent interpreter and the unreliability of the
information obtained, through ignorance or inhibition on the
part of relatives, leave us on grounds of partial assumption at
times. Again, some cases, though freely accessible, present such
atypical complexes that we are without a name for them.

We have endeavored to digest as far as possible the valuable
facts in each case, so as to round them out and enable us to
conform consistently to the classification adopted by the State
Commission in Lunacy in 1905.

Our work has gained headway during the year. Owing to the
comparatively recent adoption of the classification now in use,
we have a very inadequate basis for comparison. Comparison's
with other hospitals where the Krsepelin methods have been pur-
sued would not be satisfactory, owing to the difference in the gen-
eral make-up of the community from which their population i-
drawn. Comparing our percentage of dementia prsecox with the
same class in one of the large New England hospitals, we find
that the average there for a period of years is about 27 per cent,
and in their last report at hand, about 32 per cent, while in
another hospital for one year it was six per cent.

Paresis in the former institution was about nine per cent and in
the latter about 20 per cent. The alcoholic psychoses in one
about 16 per cent and in another about five per cent.

As an example of the relative completeness of our work during
the year, we find in consulting table No. 3, that in only about 12
per cent was heredity ascertained in 1905. Referring to the
annual reports for the years ending September 30, 1901, and
Soptcmber 30, 1904, we find that ascertained heredity as a pro-
disposing factor was established in 14 per cent and 17 per cent
of the cases adm'tted to two other hospitals, while our present
year shows an increape to 37 per cent.

Table A, which gives the classification of men admitted
during the year ending September 30, 1906, and Table B,



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State Commission in Lunacy 1061

MANHATTAN STATE HOSPITAL — ANNUAL REPORT

giving the ages on admission, with classifications, will conclude
the report of Dr. Spellman.

Intoxication Psychosis.-^ln this grouping, alcohol has as before
been the principal etiological factor. It is from this group that
a very satisfactory number of our recoveries are obtained. Of
the 64 cases placed in this class, only two could be placed out-
side of its domain. One of the latter being directly traceable
to plumbic absorption, the other to the action of the urea re-
tained within the system due to the pathological condition of
the excretory functions. The remaining 62 cases, which were
distinctly alcoholic, were classified as follows: Twenty-eight
were of the acute variety, characterized by rapid onset with
marked hallucinations, as a rule lowered and consistent emotional
tone with either partial or complete disorientation, increased
abnormal psycho-motor activity and pronounced insoir.nia.
Eighteen of these recovered. Two were discharged after 10 and
16 days' residence as " improved,'' but both would no doubt
have recovered had they been permitted to remain. Eight arc
still under care, showing varying degrees of improvement.

The average duration of residence of those recovered was
92 days. The shortest period was 20, and the longest 186 days.
The average age on admission was 38^ years. Sixteen of these
were placed in the chronic alcoholic group and presented, as a
rule, ideas of infidelity and a loosely connected paranoic trend, the
emotional tone varying from moderate indifference to a substantial
consistent reaction. In this class much difficulty has been ex-
perienced from a prognostic standpoint. While several of these
liave recovered, others again have continued and now possess fairly
well defined evidence of chronic mental aberration. Considerable
stress has been laid in these cases on the indifferent emotional re-
action as indicating a bad prognosis, which, in our experience, is
not as trustworthy a guide as we would wish. It would seem that
greater efforts should be made in the future in the study of this
division which will help as to the outcome. Eight were in various
stages of deterioration; two presenting the classical Korsakoff's
symptom complex.

Dementia Prcecox and Constitutional Psychopathic Inferiority.
— As indicated by reports which are available and our own
observations we have in the dementia precox group the largest
percentage of admissions. They include the most hopeless class,



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1062 Eighteenth Annual Report of the

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as a rule, outside of paralytic dementia and a few of the otIu*i
minor groupings. Under this head we had the large numLcr
of 105 admissions, which includes seven allied cases, or about 2t>
per cent of the whole number received. Twenly-two cases, som<-
of whom, we believe, would have a few years ago been placed
in this division were after critical consideration placed under t! e
head of constitutional inferiority with episodes. Possibly with
more definite information, a few more cases woidd have teen
relegated to the group of inferiors, who after some abnormal
psychic manifestation, readjust themselves to their normal stand-



Online LibraryNew York (State). State Hospital CommissionAnnual report → online text (page 80 of 97)