EXCLUSION OF THE MENTALLY UNFIT FROM THE MILITARY SERVICES

By

R. SHEEHAN'::: Paaaed Aniatant Surgeon, United States Navy Naval Medical Officer, Government Hospital for the Insane; lnttructor in Psychiatry, United States Naval Medical School: Member of Staft, U nited States Naval Hospital: Conauhant in Nervou1 D iaeases, United States N aval D ispensary

R eprinted from United States Naval Medical Bulletin, Volume 10, No. 2

WASHINGTON GOVERNMENT PRINTING OFFICE 1916 E XCLUSION OF THE MEN TALLY UNFIT FROM TH E MILITAR Y SERVICES.

Jl y H. Sm ·: EHA x, P assed Assistant Surgeon, United States Navy. P eru sa 1 of the statistical tables presented in the annual reports of the Surgeon Generals of the Army and Navy makes it immediately npparent, that as a cause of nonefficiency and disability in the serv­ ices, mental and the so-called nervous diseases are far from a negligi­ ble factor. In most cases they represent the total loss of the indi­ vidual, and often a prolonged and therefore large expense to the Government for maintenance and transportation. In addition there is the loss of the money expended in his training, and even the possi­ bility of claim for a pension. Therefore it seems that more decisive measnres should be taken to safeguard our military forces from the entrance into them of those mentally unfit, and this term is quite comprehensive. In the Army during the year 1913 the discharge rate for mental diseases, as is shown below, ·was higher than that for nny other cause.

N umber D isease. of cases. Rate. Per cent. ------1------Mental alienation ...... 210 2. 5i 18. 80 'l' ubercttlosis ...... _...... _ 185 2. 26 18. II Venereal diseases ...... 92 1.13 8. 50 67 . 82 7. 52 ~ : ~;~g \;e;..·, i: c:i i s~a,~:: :::::::::::::::::::::::::::::::::::::::::::::::::: :I 34 . 42 4. 04

T he admi ssion rate for mental alienation-that is, the amount of nonefii ciency- was among white enlisted men 3.49 and among col­ ored 2.59. The discharges for both nervous and mental diseases totaled 285. In the ;\rmy, during 1914, 30 officers were retired on account of disability, making a rate for retirement of 6.22 per 1,000. These in­ cluded 3 for psychasthenia, 3 for neurasthenia, 2 for epilepsy, 1 for locomotor ataxia, 1 for paresis, making a total of 10, with a rate of 2.07, for th

:C isease. Number. Rate.

Mental alienation ...... 259 2. 94 Flat foot ...... •...... •...... 182 2. 07 Venereal disease ...... 67 • 76 Epilepsy ...... 56 . 64 Organic heart disease ...... 47 . 53

Mental alienation and epilepsy totaling 315, with a combined rate of 3.58. 28559c- 16 3 4 SHEEHAN-THE MENTALLY UNFIT. In the Navy the disability discharges for nenous and mental dis- eases were as follows: 1909 ------130 1910 ------195 1911 ------408 1912 ------431 1913 ------249 1914 ------285 The nwnber of patients from the Navy and Marine Corps admitted to hospitals for the insane in years past wa s as follows : Etemaining June 30, 1907------183 During fiscal year ending June 30, 1908 : ~drnitted ------86 Discharged ______57 Etemaining June 30, 1908------21 2: During fi scal year ending June 30, 1909: ~dmitt e d ----'------_------______130 Discharged ------______76 Remaining June 30, 1909------242 During fi scal year ending June 30, 1910: Admitted ______------______101 Discharged ~------______------______65 Rema ining June 30, 1910------260- Beginning in 1911 cognizance "-as taken only of those men re­ maining in hospitals who were actually in the service. During fi scal year encling June 30, l Ull : "~d 1n it te d ------1 1 ~ Dischar ged ------94 Remaining June 30, 191L------,------21 During fi scal year ending June 30, 1912 : Admitted ______-' ______-~ ______96 Discha rged ------______------______84 Hemaining .June 30, 1912------33- During fi scal year ending June 30, 1913 : Adn1itted ------~------78 Discharged ------59 Etemaining June 30, Hi13______19 · During fis cal year ending June 30, 1914: Ad1nitted ------~------102 Discharged ------72 Remaining June 30, 1914~ ------,------30 Statistics for the entire senice for 1913 and 1914 show nervous and mental diseases as follows:

IA dmitted . D ied. I n va lided . Sick days.

-M-en-{-~}-3~-~s-_e_a--~-~s-_: _-__- _-__ -__- _------_-__ -__- _-__ -__- _-- _-__-_ -- ---_I 285 5 123 18,458 Ner!~~~- iliseases:- --·-·- ·------·· -- ·--- -- ·- -- ·------~ 276 3 142 18, 205 1913.------.- -.-- -.- .. ----.------.- -.------.---- 45-1 7 126 20, 11 7 1914 . -·------·------·------476 7 143 18,355 SHEEliAK- THE MENTALLY UNFIT. 5 The total number of sick days for these disorders is only exceeued by syphilis and tuberculosis. The total damage,1 235.26, almost equals that due to wounds and injuries, and exceeds that due to diseases of the digestive system, and is almost twice that due to respiratory dis­ eases. It is exceeded only by infectious and venereal diseases. During the year 1913 there was a slight increase in the rate for mental diseases over the previous year. The rate per 1,000 of those invalided from the ser vice for mental disorders during the year 1913 was larger for the Marine Corps than for the Navy, the rate for the X avy being 1.81 per 1,000 and that for the marines 2.33 per 1,000. About 10 per cent of those admitted for mental diseases during the year were sun·eyed from the service within four months of the time of enlistment. In 1914 the naYal admission rate for mental diseases was the same as the preceding year. There are at present in the GoYemment Hospital for the Insane, ns patients from the Navy and Marine Corps, 27 men and officers on the nctive list, 10 retired, and 241 who ha,·e been discharged from the se n ·ice; this making a total of 278. Besides, there are 39 supernumeraries. Of the 27 on the acti ,-e list, it is considered that in 24 the disability is " not in the line of duty." T " ·o are ginn i.n " line of duty," :mel in 1 thi s C]H estion has not been decided. It is estimated that of the cases admitted about 54 per cent show predisposition to mental disease prior to enlistment. As to the form of insanity which service men are most likely to de l"<:- lop the records show that m·er 56 per cent were diagnosed as dementia precox. That of general paresis was made in about 20 pe r cent. cerebrnl syphilis 3 per cent, manic-depressi-re psychosis about 2 per cent, and miscellaneous in about 20 per cent of the admis­ sions. It is seen immediately that mo1:e than half of the cases ad­ mitted "·ere of the dementia precox type. This is not surprising \rhen it is considered that the Navy is composed largely of men under 30 years. of age, and that dementia p recox is a mental disease essen­ t iall y of the adolescent period. Becau se of the marked preponderance of this form of insanity it seems important to consider it more in detail and to endeavor to determine and aggregate the signs that portend the later development of the symptom-complex or group which has been designated de­ mentia precox. This, to remind you, is a progressi ,-e, dementi.ng process of n fairly definite and specific character. It shows itself in the end pha ses in a typical di sturbance of conduct ba sed upon the deterioration or destruction of certain basal mental mechanism;;: .

1 T otnl cln mnge is in term s of iodi\·idu:-tls w hO ~C' loss of se r vice by SiCl\ness, d isclHll'ge ft·om sen ·ic<', o t· d enfh would be r ctH'ese nt·ecJ ns continuous t hrou ghou t t he y enr. 6 SHEEHAN-THE MENTALLY UNFIT.

It may be assumed that what "·e re~ ogni:..:e as the disease prop e r ~ which from its inception travels a well-beaten track, is made possible by the occurrence of a fairly fixed constitutional make-up ot· character in those who finally develop the disease. Ble"tJ.ler (1) considers dementia precox as a disease without transi­ tions to others, a group of m(lntal diseases which either run a chronic course or occur in attacks. He inclines to the idea that the disease is essentially functional in1iature. The process may stop or improYe at any stage, but there is perhaps never again restoration to absolute mental health. The symptoms consist in an alteration of thinking and feeling, and a change of relations to the outer world, a disorder of the asso­ ciations and emotional life. There is a tendency to replace or shut out reality with the patient's own imaginative experiences. Now to consider from our viewpoint the mental and physical features of this type of individual or preceding character. For it is to these that we in our capacity of recruiting officers must look, in order to preYent the admission into the service of those IY h o~ unless most carefully treated, are doomed to become mentally in­ volYed. \Ve well know that the conditions pertaining in the senice are not conducive to mental prophylaxis. If once enlisted these in­ dividuals are sure to go along uninterruptedly toward the catastrophe. Dementia precox has been regarded by ·many writers as nothing more than a generalization, or group of disorders, into which has been placed for convenience of classification a number of similar con­ ditions. However, if not :111 entity, these cases are all some sort of a mental disease having its onset in adolescence or early adult life. There is getting to be less doubt that there is a fairly definite pathology underlying these cases. Still there is not a uniformity of opinion regarding this question. Adolf Meyer (2) contends that the disease is possibly but "incidentally organic." In 1910 Southard (3) showed that a vast majority of cases of dementia precox were characterized by coarse anomalies or scleroses in par­ ticular regions of the cerebral cortex. These areas seemed to deter­ mine the character of the signs and symptoms displayed. P aranoid and catatonic colorings are associated with lesions predominantly in the frontal and parietal regions. Lately ( 4) he reported anothee series of cases, which he believes goes very far toward placing dementia precox in the structural group of mental diseases. There is a marked tendency for the process to become diffused and invade the entire cerebrum, so that to the more striking mental symptoms are added physical signs which are fairly definite. Necessarily the clinical picture will vary according to the anatomi­ cal localization of the process. The course will also vary, and the end level will be reached, largely according to the more or less gen­ eral diffusion of the process and the areas of special predilection. Sheehan-The M entally U nfit.

Fig. 1.- D ementia precox, hebephrenic for m. Palatal a rch high and narrow. Case N o. 2 1587. ( See page 218. )

Fig. 2. - Dernentia precox, llebephrenic fo rm, on a feeble-minded basis. Phy sical and neu- rological examinations negative. Case N o. 216 19. ISee page 224. )

2l lil Sheehan-The Mentally Unfit.

Fig. 3.-Defective individual, who had a precox ep isode. Noted: Facial and c ranial asymmetry; pa latal arch h igh and narrow; teet h abnormal in f or m, location, and development; hai r brown and abundant, pec uliarl y distr ibuted in whorl s. Case N o. 22027. (See page 227.)

F ig. 4.- Not i nsane. Constitutional psychopath and mal inge rer. Noted: Physical examination negative except fo r old ununited f rac ture of t hi rd metaca rpa l. Case N os. 20780,21229, and 21709. (See page 230. )

2 Jtj :! Sheehan- The M entally Unfit.

Fig. 5.- Epilepsy. Noted: Pigeon ct1est; palatal arch high and narrow. Case N o. 21605. (Se e page 239.)

Fig. 6. - Dementia precox on a defective basis. Clinical diagnosis syphil is. Noted: Lateral ri gh t scoliosis; cicatrix on dorsum of penis; ce rvi ca l and inguinal adenopathy. Case N o. 22401. (See page 242. )

2 Jfi 3 Sheehan- T he M entally U nfit.

F ig. 7. - Chronic alcoholic hallucinosis. Precox reaction in a psychopathic individual. P hysical examination negative except for fin e tremors and dilatation of th e superficia l facial capilla ries . Case N o. 2 1574 . (See page 245. )

F1 g 8 - D ementia precox, hebephrenic form N oted: F ine tremors: quite profuse chloasma. Fa ther and one SISter 1nmates of tnsane hosptt al . Insane upon enlistment . D ese rte d while awaiting discharge as undesirable because of inaptitude. Case N o. 2136 1.

216·1 Sheehan-Tile M ental ly U nfit.

F ig. 9.- Constitutional psychopath. N oted. Palatal arch high and narrow; upper and lower teeth notched; physical examination otherwise negative. M orphin habitue, has numerou s needle scars; also alcohol ic; has had convulsions. Syphilitic, probably hereditary. Is quarter­ blooded I ndian. Passed all intelligence tests. Father alcoholic and gambler. Case N o. 21 142.

Fig. 10.- Defective character, showing episode of excitement. Noted: Father inmate of insane hospital; also alcoholic. Parents separated . Patient alcoholic, inveterate cigarette user. W as previously rejected for en!istment because of being underweight and underheight. Coca in suspect; habitua! devotee of prostitution. E nlisted under alias. Palatal arch high and narrow. Case N o. 21304. Sheehan- The Mentally Unfit.

Fig. 11.-Constitutional psychopath. Prison psychosis; not insane. Noted: Deserter. Se n ­ tenced to five years imprisonment. Readm itted f rom prison . Maternal aunt insane. Inmate of insane hospital two years prior t o enlistment; also has been in the psychopathic ward of Bellevue H ospital, and in the M anhattan State H ospital, New York. I s macrocephalic. Face asymmetr ical. Case N os. 18902 and 19782.

Fi g. 12.- Dementia precox, mixed form. N oted: Marked mastu rbation without any enw t ional reaction. Illiterate. Case N o. 21 439.

21()6 SHEEHAN- THE M E NTALLY UNF I1'. 7 It is not determinable 'Yhether the lesions presented are of a con­ genital or acquired nature. Ho"·ever, it is more than likely that the potential victim of dementia precox is born ,,-ith the normal stock of brain cells, but their arrange1nent and denlopment are at times early interfered with. It is not entirely valueless to consider these cases as the result of faulty adaptation to em-ironment, and while not causatiYe this may be the determining or precipitating factor. This idea of an exact pathology has not been accepted by a number of authorities, who, like Blenler, adhere to the functional theory to a greater or less degree. Still the pathologic findings are there, and they no doubt represent atrophies of unused association tracts, which ba ,.e resulted from the fixation of pernicious habits of mental devel­ opment. Of late considerable attention has been gin n to the intoxication theory of the production of the disease. Holmes ( 5) believes that it is clu e to the presence oi certain toxic amiues of a biochemical nature "·hich have a pressor action. The blood pressure in these cases is always belo\v normal and can not be raised by aclrenalin injections. These toxic bodies are no doubt clu e to a malmetabolism of the inter­ nal secreting glands. This may be clu e to an abnormal, nonfunction­ ating, or degeneratiYe condition of the genital glands, or an involve­ ment of the thymus OL" pituitary body. That there is a destruction of gland tissue seems unquestionably substantiated by the use of the Abderhalden reaction ( 6). It is probable that the lesions found are clue to some toxic agency, the so urce of which inYestigators seem in a fair way to determine. While these theories regarding the genesis of the disease are inter­ esting to us, they are not as im]jortant from our viewpoint ns are the etiologica l considerations, for these may enable us to exclude the po­ tential dement. " Te must consider the make-up of the individual, tbe heredity, the ancestral features, and the environment. At to make-up, their early history \Yill show symptoms that de­ Yelop in childhood as a result of overwork plus other factors. In the predementia period there is a pathologic tire, an unnatural fatiga­ bility, anxiety, changes in mood, sudden rudeness, excessive selfish­ ness, irritability, peevishness, and quarrelsomeness. These are the precursors of the frank mental tire indicating the disease. The amount of mental work is of less importance than the method of acquirement. It has been shown that when an ill-directed ambition has stimulated children of physically poor rural parents to take up intellectual pursuits in cities, dementia is not an infrequent result. They do not seem able to resist the effects of the strenuous competition, reversals, and eli sa ppointments of city life. This is well shown in the following case from our series : l\1. W.-Hospital No. 21587. (See fig. 1.) White male. Age 23 on ndmission September 9, 1914. Summary of family history : Father 8 SHEEHAN"-THE MENTALLY UNFIT. alcoholic; mother asthmatic; one brother died of injuries received in a saloon brawl, nlso nlcoholic; one younger brother alcoholic. Personal history: Born in Gerinnny, brought to this country as an infnnt. Birth and development normnl. Attended common school until H years of age. He then went to work in a cigar factory at $1.50 per 1-reek. Remained there six weeks and then worked in the 'Vabash car shops for 2-t years at $45 a month, at different times receiving $60 a month. HaYing saved up some money he decided to go to school, ueing encouraged to do this by the congregation of the chnrch he attended. They wished him to study for the ministry, as he was regarded as being exceptional. He went to college, where he endea rorecl to do t1vo yenrs' work in one. It was considered by the teaching staff that he 1vas undertaking entirely too much. He re­ mained one term, when he began to renlize that he could not do the 1rork, so he ran nway. He gaYe as an excuse thnt he wanted to go home to protect his mother, who, he understood, was being abused by his father. He encleaYorecl to secure employment but was lmsuc­ cessful. Therefore, he decided to enlist in the Navy, which he did March 4, 1914. H e 1ras sent to the Nanl Training Station, Norfolk, where he seemed to get along all right for three months. HoweYer, he 1ns regarded as seclusive and peculiar. His present illness be­ gan in May, 1014. He believes it was due to the fact that he could not get hi s mind on anything but conditions at his home. Thus obsessed , he deserted, and hoboed his way as far as Fort Wayne, Incl., but could get no farther, so gaYe himself up to the naval authorities, 1rho returned him to Norfolk. He was recommended for a court­ martial. ·while a\\·aiting trial he ran awn,y and managed to reach his home. H e was there only one clay when he wa s arrested by the ci Yil a nthorities and remanded to Norfolk. As his actions were noted ns so mewhat peculinr he wn s placed under observntion by the medical oH1cer. He was transferred to the naval hospital, and nfter a few 1reeks to this hospitnl. Upon admission he was well oriented, contented, hnd good insight, slept well, no hallucinations or delusions could be elicited. Speech normal. Nie.mory good. Associations and specinl tests well done. H e wa s attenti 1·e, but during the examination displayed considerable emotion and continually wrung his hands. Physical condition was good. His conduct was not unusual. He was rather seclusiYe, indifferent, and someiYhat retarded. He denied that he had evei· had hallucinations. He continued to improYe gradually. Took more interest in his environment and expressed a desire to get well. He wa s dischnrged in December and allowed to go to his home. H e was ad1·ised to content himself with some rnral occupation. Other cases will show day dreaming without efficient activity, an exaggerated ego-complex with maladjusted attempts nt compensa- SHEEHAN- THE MENTALLY U KFIT. 9 tion, and par ticularly prominent, the emotionall y accentuated love­ complex. Meyer (7) has described what he ca lls the deterioration type, stat­ ing that in dementia precox he repeatedly finds a history of ex­ emplary childhood with a gradual change at .the period of emancipa­ tion. Close investigation may show, howeYer , that the exemplary child wa s an exemplarily inadequate ideal, an example of goodness and meekness, rather than that of strength and determination, ,-vith a tendency to keep good in order to aYoid fights and struggles. Later, religious interests may become YiYid , uncontrollable whims may make their appearance. At home irritability sho,-r s itself. He may often be wrapped up in moralizing over the easy life of brothers and sisters. Abnormal sensitiveness drives the patient into seclusion. Thel'e occur headaches, freaky appetite, general malaise, hypo­ chondriacal complaints about the heart, then there will be unsteadi­ ness of occupation and inefficiency, day dreaming, and utterly un­ natural philosophizing, and aboYe all, loss of direction, energy, and activity without obvious cause. All these traits may be transient, but they are more than a mere " neurasthenia," usually being the beginning of a serious deterioration. This is more and more ma rked by indifference to the emotional life and ambitions, and a peculiar fragmentary type of attention, with all the transitions to the apathetic state of terminal deinentia. Those who later deYelop tlw abnormal reaction of dementia precox are the peculiar rather than the defectir e. In the sense '-re har e in mind they are those ad

can not possibly be put to the test of action. All this is at the expense of really fruitful activity, which tends to appear to the patient as insignificant compared with what he considers loftier achievements. There is an eYer widening cleavage between the mere thought of life and the life of actual application, such as would bring with it the con ections found in concrete experience. Then, under some strain: which a normal-minded individual would be prepared for, a suffi­ ciently weakened and sensitive one will react with manifestations which constitute the mental disorder or deterioration process which we denote dementia precox. · Unfinished or chronically subefficient action, a, life apa.rt from wholesome companionship and concrete test, finall y a progressi ,-e in­ congruity in meeting the inevitably complex demands of the higher instincts- this is essentially the formula of the process. The natural and almost normal tendencies gradually become ab­ normal. This emphasizes the necessity of getting full and circum­ stantial histories of all cases. Note whether the subject >vas able to fill adequately small demands and did he fail under the heavier strains. If so, under what stress did he have difficulty in transmuting thoughts into action? I mportant are the specific defec ts or di sorders of balance mani­ fested by spec ial tendencies and habitual ways of bungling and sub­ stitution, the gradual malndjustments, that come abont through the e1·er-increasing influence of these at f-ir st harmless substitutions and subterfuges, which are later harmfnl and uncontrollable. Hoch's (8) term: the "shut-in " personality, is especially descr.iptive of these individuals. ·where a breakdown or marked reaction ha s once set in, it is Yery difficult to bring relief directly. The fundamental shut­ ting in of the whole mechanism enables the preoccupations to li Ye themoel ''es out and exclude intenentions. Au tom a tic resistnnce against the most natural impulses frustrates eren the occasional pathetic spontaneou s appeals of the subject for relief. The pamnoid clement particularly has been rather brilliant, but with the lights tumed in instead of outward. They are extremely impracticable in the use of their hands or in any adaptation to material ends. Thus it is usual to find that they are never successful at mechanical trades. They are utterly unable to observe with accuracy anything physical or material, because their minds are constantly occupied with their own meditations. They are unready to adapt themselves to uncon­ geni al employment or environment, not necessarily including personal comfort, as this they often ignore. They revolt against the control of other minds, of imposed regulations, or standard requirement!:. Discipline is odious. They are subject to fits of abstraction, when they will not see or hea r what would attract a normal youth. They are usually irritable to their families, but most desirous of being SHEEHAN- THE MENTALLY UNFIT. 11

thought amiable and brilliant by strangers. They are abnormally secretive and suspicious and prone to discuss deep or unsolvable problems. You will readily see that this type of individual is the one who because of his pec uliar make-up is likely through trouble at home, with dissatisfaction, or imaginary grievances or unrequited love affairs, to drift to a recruiting station as a possible means of escape f rom these conditions. F r om the mental side the history is most important. A con­ .· ider ation of the early life of the candidate, his progress at school, his adaptability to occupation, whether he was quarrelsome, un­ socia ble, in trouble continuously, dissatisfi ed with his surroundings, ~rh eth e r he has wandered about as a hobo, frequently idle, arrested, and confined in jails, " ·orkhouses, or reform schools. Here may be cited in brief t 1r o cases lately under observation, one an electrician, third class, who ~ v a s in the service less than a year and who, because of his inadaptability, did not receiY e promotion as rapidly as he deemed desened. H e became sullen, morose, irritable, seclusive, imagined that he was bei11g persecuted by his superiors. He was unable to sleep, and "·as fo und ~Y and ering about the ship at night. H e threatened to throw himself o1·erboard. Finally he gave vent to his feeli ngs by pounding the dynamos with a hammer. His pre­ Yious history was one of an unhappy home life, trouble at school, wandering about from place to place, and from one occupation to another, ending with a decision to enter the Navy, because he im­ agined that would take him away from all his troubles. In this you will recognize a typical paranoid dement. Another case gave a prev ious history of an unsettled and vagrant existence, also with en~rance into the Navy to escape, as he believed, from his unhappy condition, who, in less than a year, driven to distraction by the gibes and tormenting of his shipmates because of his sloYenly habits and eccentric manners, in a moment of frenzy stabbed one of them almost fatally. Much valuable information can be elicited in a consideration of the heredity. This factor has received considerable study. In a series of 647 cases, at the Bergholzi Asylum, in Zurich (9), 90 per cent showed hereditary taints, and the most important of these were mental diseases, which were shown in 64 per cent. In a series of 550 cases in the New York State hospitals, 90 per cent showed heredity of some sort. The 5'28 navy admissions in the period from January 1, 1899: to January 1, 1910, gave a definite history of mental or nervous diseases in 101 ca ses and a vague history in 34. (10) Of the forms of mental disease in the ancestry, dementia precox itself is the most important. 12 SHEEHAN-THE MENTALLY UNFIT. Hickson ( 11) in observation of a thousand cases found that there was not one case in which there was not a well-defined heredity of this psychosis, and he claims that dementia precox is always hereditary. However, the bearing of other diseases must not be lost sight of. Next to mental disease, the most emphatic element in the heredity is alcohol, and in the above- quoted series of 528 cases this was defi- nitely shown in 74. . Abnormal characters appear in the antecedents in a very large percentage, 33 per cent, and neuropaths in 59 per cent. These appear both in the direct and indirect lines. Some of these were no doubt derelicts, themselves suffering in all probability with some slight form of dementia precox, coming on later in life or as the residual dilapidation resultant from an early attack of the same disorder. Many of these are also in the alcoholic class, since with the adYent of manhood they sink in the struggle for subsistence and are the semi­ fa ilures in life, those pushed aside and forced to be contented in eking out an existence. It is this class that contributes the majority of the precocious dements to the population. Especial stress may be laid on the unnatural fatigability of these individuals "·hich is in­ duced by intellectual strain, abetted by abnormal sexual life or alcoholism, which in itself is a symptom of profound " neurasthenia:" Syphilis per se, or as tabes or paresis, is not infrequent in the parents. We have been particularly impressed with the importance of mental incompatability in the parents as a factor in determining the onset of precox. There has been an inability of one or both to adapt themselves to common-sense relations. This results in discord in the home life, oftentimes to the :family being disrupted and the children placed in institutions. The only child seems to be a special sufferer from the engendered tension. In the Domestic Relations Court of Chicago, of a group of 342 cases examined, 71 or :w per cent, were :found to h aYe dementia precox, which shows what an important role this psychosis plays in domestic disturbances.

'l'HE FEEBLE-~U::\'DED. Under this caption should be included only those indi riduals "h<> are deficient in the sphere of intelligence. It is this type that often serves as the basis upon which dementia precox is grafted. In a group of 789 cases of high, middle, and low grade defectives, 94, or 12 per cent, were found to have this psychosis. Of course only the milder grades of feeble-mindedness should cause any diagnostic difficulty. It is a common experience in the service to fi nd men who are physically desirable, but mentally nnfit; men, \Yho through their inefficiency and misdoings are sources of annoyance, expense, and even danger. Their work is poody done. q'hey are tmtrustworthy and unreliable. They take up the places of valuable SHEEH AK- THE MENTALLY UNFIT. 13 individuals. Besides it is a waste of time and effort fo r an officer to endeaYor to teach an imbecile, who is perhaps predestined to a hospital :fo r mental diseases. It is only the fundamentally abnormal individual whose mentality becomes impaired under the stress of service conditions in the fi rst t hree or four months of his enlistment. A normal individual has a wonderful power of adjustment and adaptability to almost any en Yironment withou t sho,1ing any mental impairment. So in the last analysis it is the individual with whom we haYe to deal rather than t he em-ironment : change of "·hi ch only serves to bring about the mental reaction. In the elimination of the feeble-minded great assistance was e2>. ­ pected from the use of the Binet-Simon scale. HmYeYer, it has not been found that this, in its present form, is adaptable to service nse. Its limitations and imperfections haYe been considered pre­ Yiou sly (12) . The high-grade defecti\·es, which really are the only one that come seriously to our attention, e\·idently need other methods. This has been so well realized that there -is no doubt that :,;ome such assistance y,·ilJ soon be a ntilable, as the matter is receiving a ttention f rom "\YOrkers throughout the country. This perhaps will be in the nature of Yisual memory and performance tests with modi­ fi cation s to sho''" emotional reacti ons. To date none of the mental t ests acl e

He was sent to the training station, San Francisco, where he re­ mained six months, and was then transferred to Bremerton, vVash. ~ where he remained a year. He then "\lent to duty aboard the U. S. S. Galveston, on which ship he remained about eight weeks, when he was transferred to the U. S. S. Pampanga, where he re­ mained about three weeks, when he began to manifest mental symp­ toms and was recommended for transfer to the Mare I sland Hos­ pital,·where he remained four days before being sent to the Mendo­ cino State Hospital, from which place he wa s sent here. Patient does not think he is ill either mentally or physically. He denies the excessive use of alcohol; says he never had any trouble in the Navy, but he does not like the service. · Present illness: Patient states he was not ill mentally or physically, but one day did not feel very well, and when the officer told him to work he refused, and says on that account he was sent to Mare I sl:mcL He says the only trouble he ever had was for refusing to sign the pay roll because a safety-razor had been stolen from him. He did not think this wa·s a peculiar attitude to take. He denied all hallnci: nations. The medical certificate states he used alcohol modern tely, mental capacity only fair. First symptoms began on the U. S. S. Pampanga about December 1, 1913, when the patient wa s noticed ncting pecu­ liarly. He would not do his work and was markedly inattentin_ The onset was gradual. He showed impairment of mental faculties; his attention was hard to retain; ideas were confused; retardation prominent. It was stated that he refused to eat or nttend to him­ self. Mental examination showed the patient to be fully oriented in all spheres. Emotionally he was contented, slept well, dreamed occa­ sionally, but the dreams were of no import. He hnd very little in- . sight into his condition, did not think there wns anything ''rong with him. He could not give the cowboy story. His special memory was meager. He was unable to perform the Masselon or Ziehen tests. Calculations were all incorrectly given. He was unable. to name the months correctly backward, but managed to give them forward after considerable hesitancy. He had almost no general information, and a very limited knowledge of current events. H e was entirely unable to respond to the Finchk test. His ethica l reactions were normal. Physical and neurological examinations were negative. He appeared to be somewhat retarded and did not make a normal impression. His conduct following admission was good, and he was placed at work in the dining room. He became fairly ''ell interested in his surroundings, and was neat and tidy in personal appearance and habits. He now stated that he was not certain whether he had heard strange voices previous to his admission here or not. He continued to ·work in the dining room and was hirlv SHEEHAN-THE MENTALLY UN:FIT. 15 efficient, although he was rather childish and could not answer any of the intelligence tests. He was unable to write his name and could not read. The tests that he was able to comply with showed that he had a basic psychological age of 8. He was continued in the hospital until. February 9, 1915, and as he did not display any evi­ dences of a psychosis he was discharged into the care of his father.

PSYCHOPATHIC CH ARACTERS. Under this heading may be considered the indi vicluals who are "failures of mental adaptation." They haYe, as an essential, a men­ tality which deviates from the normal. If looked at from the purely social point of view they would all seem to be defectives. However, examination shmYs that at the most but 30 per cent can be included in this category. This leaves a group that is important, including those who are not feeLle-minded o~· insa ne but who are· clearly a b­ normal mentally. Here may be include<;!. the so-called defective de­ linquents, the moral imbeciles, the constitu_tional psychopaths and in­ feriors, and the pathological liars and swindlers. The defectiYe de­ linquents do not give eYidences of mental defect, but their conduct is abnormal. They are antisocial, and display certain character de­ fects. They are impulsiYe, Yehement, emotional, and inhibitionless. They are easily unbalanced, and thus liable to social difficulties in a complex environment. The moral imbeciles comprise a group of those psychologically of unsound mental temperament. They are without any moral sense. Destitute of even the possibility of moral feeling, they are truly insensible to the moral relations of life, as deficient in this regard as a person who is color blind is to certain colors. Although it is usual that they ha>e more or less acuteness of mind, in some instances there is a remarkably acute intellect of the cunning type. They are nsually burdened by heredity. Many are ignonmt, lmt others may be highly educated. Constitutional inferiors ( 13). These individuals are not strictly feeble-minded, but present physical abnormalities combined "·ith a mental equipment which is not equal to the strain imposed by ordinary social conditions. They are unable to occupy their places in society. Physically they may show markedly delayed signs of puberty, infantile form of torso, weak and flabby muscles, stigmata of degen­ eration, such as facial and cranial asymmetries, palatal and dental abnormalities, peculiarities of the external ear, polydactylism, etc. They may exhibit -tremors, facial and other ti cs, nystagmus, mi­ graine and vertigo, a history of enuresis in childhood, which may persist. Defective vision, pigmentation of the irides, malformations of the genitals, weakness of the ocular muscles, and a peculiar gait are frequent. Stammering occurs often. 16 SHEEHAN-THE MENTALLY UNFIT. Mentally there is indecision, moodiness, irritability, violent temper , instability, and vacillation. Dependence is prominent. They read­ ily adopt every vice, prostitution, alcohol, and other drugs; Their mental operations are slow. Reason, judgment, and attention are defectiYe. They are impulsive. They crave continual and unusual excitement; this often leads them to criminality. T hey are impelled to travel, and thus become hoboes. The following case is quite descriptive: A. A. K.-Apprentice seaman. No. 22027. (See fig. 3.) Age 18 3/12 years. Nativity, ' Visconsin. Education, practically 11one. Admitted May 10, 1915. Medical certificate states : Father wa s a chronic alcoholic. Patient "·as wild and headstrong. vVas under no restraint. 'Vas religious, talkati,·e, egotisticnl. No history of previous nttacks. First sympto1ps of the disease became manifest while on sick list with bronchitis. Began annoying the other pa­ tients and nurses by interfering with the treatments. DeYeloped delusions that the nurses '~ere old friends of his prior to enlistment. Had a number of altercations. PrH ious to becoming sick had been regarded as queer and inquisitiYe. He is assertiYe, noisy, :mel an­ noying; kicked one of the nurses on the shins, as he says, to sho"· his friendship. Also belieYes that the hospital corpsmen were civil engineers on a railroad with him prior to his enlistment. I s rnm­ bling in his conversation. Probnble ca use, defective basis. Status on admission: Patient is hypern ctiYe, .-ohmtee rs consider­ able assistHnce in the ward, but is inclined to interfere nnd assert his own peculiar ideas regarding the work. He has an exaggerated idea of his own ability. H e is tnlknti,·e. tPlling Hbout himself and his great accomplishments. C01wersation is irrele,·a nt. He is grandiose, restless, and appenrs to be of a low grade of mentality. Family history: Father nnd mother were divorced 17 years ago, due to excessive nlcoholism on the part of the father. !::lince that time he has not heard nnything from his father. Pntient is the only child. Personal history: States he wa s born in vVisconsin .Tannnry 30, 1897; is now 18 years of age. Had Yery little schooling; then went to work on a farm, where he remained with practicnlly no associa te but his mother until he enlisted in the Navy October 29, 1914, at Minneapolis, Minn. He was sent to the Grent Lnkes Training Sta­ tion, where he remained until sent to this hospita 1. He acknowl edges frequent masturbation. Present illness : Patient states he was alwa~ ' S much interested in mo.-ing pictures, and that he liked to write plays when he "·as at school, so he wrote a play which he gave to the lieutenant. Shortly after that he got sick and they sent him to the hospital, which he believes "·ns clue to studying too hHrd oYer this moving-pictme play. SHEEHAN-THE MENTALLY UNFIT. 17

Mental status : Stream of talk free, relevant, coherent, and rather circumstantial. His only complaint is overstudy. Emotional status : Patient is quite euphoric, well sa tisfied, says he has neYer been treated better in his life. Is under the impression he was serit here as part of his duty as ~ sa ilor. Says he never had any trouble. No hallucinations or delusions ca n be elicited. Orientation is good, as is his memory for remote and recent events. Insight and judgment are entirely lacking. He does not seem to appreciate that he is re­ garded as mentally defective. He appears unable to give the emo­ tional va lue to events, or the real politic value to circumstances of his life. Habits and character : A greater part of his life he lived on a farm with his mother, who had considerable influence over him, and his horizon seems to have been bounded by her training, and his opportunity to compare his ideas of his surroundings with the reality of his existence has been limited. His first real contact with the outside world was when he was sent to the training station at Great Lakes. He was entirely unable to appreciate his status, or the value of his surroundings, and as a result overreacted. H e seemed to appreciate somewhat that his difficulties were not due to outside influences entirely but were partly due to himself, and his difficulties have arisen from the fact that his experience has been entirely too limited to enabl e him to properly interpret his social rela tionships. His special memory is good. The intelligence tests >Yere quite >Yell done. The Ziehen test was clone fairly well. H e comprehended the Finchk test. The cowboy story was well repeated. F orward and backward associations were correctly performed. His ethica l reactions are apparently normal. He has a good lmow ledge of cu rrcn t enn ts. Calculations were quite well clone, in multi plica ­ tion and addition, and fairly well in diYision, but very poor in sub­ traction. lie was unable to perform the 50- cent problem. Physica l examination: Head asymmetrical. Peculiar distribution of the hair. Difference in the formation of the ears. P alate is high arched, teeth misshapen and poorly kept. Diagnosis : A precox episode in a defectiYe indi\·irlual.

Trm COKS'l.'I'l'U 'l'JONAL P SY CHOPATHS. T his gronp is neither sane nor insane. They are borderland cases that sho·w an inefficient type of adjustment. They have a fair amount of intelligence, comparable with their station in life. They are cool and calculating, deliberate, indolent, superficial, very selfish, egoistic, and cruel. They are strongly individualistic, being nonsocial, which is clue to lack of proper influences at their developmental period. They show varying degrees of adaptability for certain periods. Usually they are emotional, and show eccentricities of character and behavior. 28559c- 16--3 18 SHEEHAN-THE MENTALLY U NFIT. Their make-up favors the development of psychoses. Even in childhood they are considered queer, dull, and different. Later they are one-sided, impulsive, unstable. They are hyperquanti valent, in­ clined to magnify trifles, visionary, exalted, conceited, pessimistic, and prejudiced. They have little creative imagination, and rarely see the application of what they learn. T hey are dull of comprehen­ sion, sensitive, distractible, shy, secretive, timid, introspective, over­ conscientious, su spicious, seclusive, indecisi Ye, erotic, inclined to lying and theft. They may be geniuses in music or display mathematical talent. PSYCHOPATHIC LIARS AND SWI:SDLERS (14). It is often that this class of in.eli vi duals causes tronble in the serv­ ice by false accusations and irregular practices. This pathological lying is falsification entirely disproportionate to any discernible enc1 in view, engaged in by a person who at the time of observation can not be declared psychotic, feeble-minded, or epileptic. Such lying rarely, if ever, centers around a single event. Although exhibited in Yery occasional cases for a short time, it manifests itself most fre­ quently by extending O\'er a period of years or even a lifetime. It represents a trait of character rather than an .episode. Extensive, Yery complicated fabrications may be evolved, hence the synonyms­ mythomania, pseudologia phantastica. Pathological accusation is false accusation indulged in a part from ob.-ious purpose that is of advantage to the individuaL It is eas.v to see how such a person in his effort to make himself conspicuous, thus satisfying his grandiosity, may cause serious trouble for those with whom he is associated. In particular we recollect one such case where an officer IYas st jected to considerable humiliation in being involved by such an individual. These subjects are invariably egotistical, grandiose in manner, self­ satisfied, and these characteristics are reflected even in their co1wersa­ tion, which tends to be circumstantial and self-laudatory.

PRISON P SYCHOSES.1 This term (Hi) has been applied to the group of psychotic com­ plexes which can not be satisfactorily classified under any of the regular terms used to denote mental disease entities. They show by their symptoms that the disorder is the result of a psychogeneti­ cally ev oked complex of a purely reacti.-e nature. They are to be looked upon as merely the reacti.-e manifestations of a particularly predisposed mental make-up to certain specifically unfaYorable en­ Yironmental conditions. The term is of value as it emphasizes the etiologic potential of imprisonment, as a proYocati,·e agent in the causation of psychotic states requiring hospital care. These con-

' .\ tt enl ion is called t o an abstn1. ct of a n a rticle upon malingerin g by Glueck on p. :;.!9 nf this number. SHEEHAN-THE MENTALLY UNFIT. 19 ditions occur in individuals who have apparently been normal in their free life, but who, as soon as they are placed under the restraint of prison regimen, show their incapability of adjusting themselves to its restrictions. Their response is an overreaction. \V e have seen prisoners brought here as insane who, almost as soon as they were placed in the ward, ceased to show any psychotic symptoms, but would do so as soon as they were returned to prison. This sort of a condition always suggests malingering, but this element is not as frequent as one would think. These individuals present a prob­ lem, as it is difficult to decide under our present system the best way to handle them. In prison their reactions are of an insane nature and decidedly abnormal, and when they are sent here they fail to show any psychotic symptoms. The best solution seems to be the providing of a psychotic ward in the hospital attached to prisons, where these prisoners can be placed until they reach an ad­ justment, thllS avoiding the large expense invohed in transferring them back and forth between prison and insane hospital. , The following cases are familiar to many naval medical officers and are good examples of the perverse characters described above. H. J.-Apprentice seaman, No. 20780, No. 21229, No. 21709. (See fig. 4.) White male. Aged 27 years on admission November 13. 191-t. Education, fifth-grade grammar school. While serving a year's sentence at the Portsmouth Naval Prison for· fmnclulent enlistment the patient told the authorities there that on August 7. 1909, he had murdered a girl in Rochester, N. Y. He described the murder in great detail; stated that he met the girl in one of the Rochester cemeteries and attempted l1 sexual assault upon her, gnd when she resisted he choked her to death. He stated that he did not mean to kill his victim, but that he had inflicted the fatal injnry before he was aware of it. He said that it was remorse and the desire to expiate his crime which prompted his confession. He persisted in this confession until the naval authorities were per­ suaded to di scharge him and turn him over to the civil authorities of Rochester, N. Y. Upon arrin1l there an alibi was easily estab­ li shed, freeing the patient of all suspicion of the murder. It took n good deal of investigation on the part of the authorities to establish the patient's real legal status. It was finally decided that he belonged to the naval authorities, and he was accordingly returned to prison and was given· an additional sentence of a year for this fraud. He began to sen·e this time on December 13, 1909. \Vhile awaiting sentence he assaulted a master-at-arms, 'vhom he claimed ~tbu s ed him. For this offense he received an additional five yenrs' sentence. He served this sentence until his first admission to this hospital on July 16, 1913, on the following medical certificate:" First symptoms became manifest in 1910. Patient showed fixed delusions 20 SHEEHAN- THE MENTALLY UNF IT. of haYing murdered a girl on August 7, 1909. Present symptoms: Fixed delusions of a self-accusatory nature, delusions of persecution, accused a medi cal officer whom he had never seen before as being among those who were hounding him. Becomes excited, violent. profane, incoherent, and obscene in speech, and attempted to assault this officer. H e attempted suicide on F ebruary 15, 1910, while at Concord (N. I-I.) State prison." During the patient's first sojourn at this hospital he conducted him­ self in an orded y manner, and aside from the expression of mild persec utory ideas with reference to the prison personnel he wa s free f rom psychotic manifestations. On only one occasion was he involved in any trouble here which was entirely his own fault. H e was dis­ charged on September 28, 1913, with a diagnosis of " not insane. constitutional psychopath," and "·as returned to the Nava l P r i s ~n , P ortsmouth, N. H . He was rendmitted here on March 15, 1914, on a medica l cert ifica te which stated that. " the patient sa id he snuffed cocain prior to ad­ mission to the ~avy , and that the murder he beli eves he com mitted . \Yas done, according to his statement. beca use of the refusal of the Yictim to permit sexual intercourse. The patient has at present tlw same fi xed delusion of haYing committed this murder in 1909. ·w ants to expiate hi s c r in~e to escape those who are continually hou nding him. ' Vhen irritated he flies into a rage, cries, tries to do himself injury, and talks incoherently. While working in the yard, for no ca use at all he struck a fellow prisoner and pursued him ·Yvith a shovel. During maniacal attacks he can be restrained wi th rl iifi cnlty, smashes furniture in his cell, and is slovenly in habits. He com pbins con£.tantly of numbness and needlelike pains in the Yertex of the skull. Probable canse-prison routine." It "-ill thns be seen that the same fraud about the murder, ''" hi ch served at one time to bring him an additional sentence of rt yPnJ ·. \Y as considered at another t ime one of the sympto ms which :jnstifi ed his retmn to this hospital. The patient's Yersion of the reason for hi s return is as follows : Soon after his transfer to Portsmo11 th the gnards began to annoy him. calling him crazy guy, hard gn _, .. etc. ] le also got into trouble with the sergeant because the la tter cnrsed him. H e began to express the same ideas about the murder and thought this was the reason they sent him back. Mental examination and physicians' notes made during his second admission showed no gross psychotic symptoms. He still maintained that he had actually committed the crime in Rochester and related it in great detail. H e stated that while he was confined in Ports­ mouth prison he became remorseful over this crime and decided to confess. His conduct here was exemplary. He appeared at the staff conference on April 20, 1914, and a diagnosis of "psychopathic Sheehan-The M entally U nfit.

F ig. 13. - Dementia precox, hebepl1renic form, on a feeble-minded basis. Noted: Well nourished. Posture awkward, somewhat stooped. P igeo n chest. Cranium small and rather recessive. Facial asymmetry. Palatal arch 11 igh and narrow. M astu r bates pub I icly without any emotional reaction. Attempted suicide at training station. Case N o. 21675.

Fig. 14.-Psychosis associated with organic disease of the brain and syphilis, and occurring in an individual of the precox type. Is alcoholic, sexual ly perverse, and with old cicatrix on penis. Case N o. 2232 1.

2321 Sheehan- The Mentally Unfit.

Fig. 15.- Dementia precox, hebephrenic form, in a psychopathic individual . Noted: Under­ weight; cranium small and asymmetrical; forehead recessive; nasal septu mdeflected; palatal arch high and narrow. Acknowledges habitual mastu r bation, also incest, bestiality, and both active and rassive pederasty. Case N o. 21614.

F ig. 16.-Not insane since admission. Probably psychotic episode in an interior individual. Noted: Undernourished and underdeveloped. Palatal arch high and narrow. Orphan at 5 years of age. Deserter. H ysterical episode. Showed psychotic reactions as a result of his inabil it y to adjust himself to service condit ions. Case N o. 21586.

232' Sheehan-The M entally Unfit.

Fig. 17.- D ementia precox. Noted: Patient i n psy chopathic hospital pr io r t o enl istment. Al co­ holic. G onorr hea pr ior t o en I ist ment , discharge present on admission. Stole $60 and en I ist ed to " ge t away." D ete rminants of attack. venereal disease and inadeq uacy to se rvice conditions . Case N o. 21950.

Fig. lB.-Dementia precox, in a defective ind iv id ual. Noted : Alcoholic, marked hepatic hype r ­ trophy. Sec lusive. Speech def ect. Alway s inadequate. " N eurasth en ia " in 19 11 . H eat exha ust ion in 19 12. Ca se N o. 21758. Sheehan- The Mentally Unfit.

Fig. 19.- Dementia precox, catatonic form. N oted . Height, 63i inches; weight, 1:!8 pounds. Palatal arch higr. and narrow, external ears low placed. H abitual masturbation. Act ive and passive pederasty. Self-:nutilation of penis. Case N o. 21342.

Fig. 20.-Undifferentiated psychosis in a defective individual . N oted: Father alcoholic and diabetic. Patient could not speak until 5 years of age. Attended school until 15 years of age and only rP.ached the fifth grade. N o regular employment, always incompetent. Illiterate, can not write own name unassisted. Physical examination negative. Determinant, nostalgia. Case N o. 21628. Sheehan-The M entall y Unfit.

Fig. 21.- Syphilis (ce reb ral). N oted: Fat her alcoholic. Parents sepa rated . H ead injury in child hood; scal p show s cicatrix ove r ve rtex. Palatat arch high and narrow. Sent to reform­ atory at 15 years of age, later became a" hobo." E nlisted in D ecember, 1913 ; deserted after seven weeks. M ent al symptom s appeared in August , 19 14. Attempted su icide. Denies syphilt s; W assermann reaction + + + . Case N o. 21622.

Fig. 22.- Paranoid state, in a defect ive. N oted: W orked on a rail road for one year and a half. quit beca use brother would not work; became a "hobo.'' Al coholic. D eafness ; can not hear a watch tick on t he right side and only w ithin 4 inches on the left side. H omosexual rever­ sion. D eterminant, sod om istic episode. Case No. 21847.

232'• Sheehan- T he Mentally Unfit.

Fig. 23.- Dementia precox, hebephrenic form. P ri son psychosis. N otej: Maternal grandfather suicide. M aternal uncle insane. tather alcoholic and tuberculous, mother tuberculous. Pa· tient did not learn to walk or talk until 6 years of age. Always had •· fits." N ever could retain employment because he was" slow and crazy." " H obo. " Alcoholic, paranoid, illiterate. I nsane prior to enlistment. AtterPpted suicide. D eserter. Case Nos. 20428 and 21 137.

Fig. 24.- Dementia precox in a constitutional inferior of a psychopathic make-up. Noted: Enlisted May 22, 1915, psychotic symptoms on N ovember I , 1915. Wass en'lann reaction + + . Cranium small , prognathous, forehead recessive. Case N o. 2254 7. SHEEHAN- THE MENTALLY UNFIT. 21 'C haracter " was made. At this time it was extremely diffi cult to pick out the true from the abnormal elements in the patient's story, and there were a great many things in the general emotional reaction of the patient that fitted into this story. The patient seemed to have a &ort of determination to get into difficulties for the sake of posing as a mar tyr, and all this fitted in with the grandiose element of his char­ ncter. Being oppressed, he had taken a way that was very satisfying to his feeling of importance. L ater during his sojourn here the pati :mt became rather anxious to be returned to prison, stating that he had given up all the ideas which he had expressed on admission, assuring the examiner that he had malingered on both occasions of his transfer to this hospital. He stated that his chief anxiety, which caused him to ma1inger, was the fear that he might be given addi­ tional sentences because of his inability to get along in the prison, and he thought the only way to avoid this would be to be pronounced insane. Patient was discharged from here and sent to the naval prison, Norfolk, on July 9, 1914. H e was again readmitted to this hospital on November 13, 1914, on a medical certificate, which stated: " Diagnosis, constitutional psychopathic state, not in line of duty. Existed prior to enlistment. He was in the Government H ospital for the Insane in vVashington for about fom months during this year. H is condition is not im­ proving. A few clays ago a sudden outburst occurred and he has been in close confinement since. H e struck a recruit, and after being placed in a cell destroyed a chair, and had to be restrained. It is con­ sidered that his retention in the prison at this barracks is not de­ sirable." Nothing essentially new developed in the case during this admis­ sion. The patient was from the fi rst quiet, well-behaved, a willing ''orker in the industrial department, and f ree from any signs of mental disorder. Of course, he again blamed the guards at the prison for the trouble in which he became involved and which necessitated his third n dmission to this hospit

officer by a guard for some alleged minor infraction of discipline, of which he claims not to have been guilty. After the guard \Ya s through making his report the patient asked the commanding officer whether this alleged offense would prevent his release in July of this year, as he had been promised if he conducted himself well. The officer replied that it certainly would. Upon hearing this he could 1~ot restrain himself, became quite overwhelmed with anger, and struck the guard- for reporting him. His behavior which necessitated his readmission to this hospital took place following this episode. The patient dwells upon the fact that prior to this episode he be­ ha Yed in an excellent manner under prison regime for abont four months, and that during his sojourn here he "·as practically a model patient. This latter statement is true. During his last admission he certainly did not manifest any signs of mental disorder, and still insisted that he malingered all of the symptoms which led to his formrr two admissions because he feared more punishment at the hands of the naval authorities unless he 'vcre considered insane. Anamnesis: The patient comes from a family of farmers in med i­ ocre circumstances. Grandparents are in Bohemia and he knmvs nothing concerning them. Father died of Bright's disease; was a lco­ holic; otherwise family history is negative. Pnticnt "·as uncertain about the time :mel place of birth: belieYed he "·as nbo11t 30 ye;u·s o:f r~ge. He entered school at 7 or 8 years, but proYed to be a confirmed truant. and hi s father fina11~' had to take him ont of school entirel.v. He was in the habit of nmning a'vay fr·om home n.nd school to 'rander about the country, where he would stop at different farmhouses, claiming that he was an orphnn and without a home, until hi s father ''"ould discoYer his whereabouts and bring him back home. After giving up school he \Yorked as a farm hand earning the ordinary 'nges paid for this labor. H e changed places frequently, 'ns a spendthrift, and assisted his parents only yery slightly financially. He led this mode of existence until 1904 when he forged his father's name to a $25 check for "·hich he received a fi ve-year term of imprisonment, part of which he spent in the Minnesota State rcformator.1· and part at the State penitentiary. In the fall of 190'7 he was paroled, but broke hi s parole by enlisting in the Army under the name of Kimlicka, at Fort Snelling, Minn. About a month later this fraud "·as discovered throngh hi s father. He was given a dishonornble dischnrge, ancl sent back to the peni­ tentiary, where he remained about six months. At the end of thi s time (December, 1907) he 'IYas granted another parole and \rent to work for a man named George Hall on a farm in Minnesota. He was there nearly two months 'lvhen he cnt his foot while chopping wood. He said that after this accident he '-ras not able to do mn ch SHEEHAN-THE MENTALLY UNFIT. 23 work and his employer did not seem to like to have him hanging around, so he went back to prison, which he said paroled patients were supposed to do when they lost their jobs. As his time was up in two months the prison authorities made no effort to get him a new job, but kept him there until his sentence expired. He left the penitentiary in March, 1908, and went home for a couple of weeks. He then went to Minneapolis and enlisted in the Navy under the name James Hall, but did not tell the recruiting officer about his prison and Army experiences. About four months after enlistment, while at Newport, he was found in civilian clothes, and for this offense received a dishonorable discharge ( ? ) . He then went to Providence, R I., and enlisted in the Army under the name of Her­ man Ha'nson. At Fort Andrews, Boston Harbor, patient was caught out again in civilian clothes and got into a bra1d with a sergeant. Patient stated that the sergeant was drunk and provoked the quarrel. As a result the patient was put in the guardhouse and received a sentence of six months and a dishonorable discharge. He served most of this sentence at GoYernors Island. After being discharged he hung around New York City for a week and then went to Roches­ ter, N. Y. This was in May, 1909. Here he worked for a Mrs. Nfc­ Cale on a farm, and the following month, June, 1909, he en listed in the Marine Corps under the name of Yilt. He was sent to the Brook­ lyn NaYy Yurd, but got into trouble on account of not haYing his rifle cleaned. He feared that he 1roul d be reported for this, and his previous frauds might be discoYered, so he deserted. He returned to Rochester, and went to work on a fn rm. Soon after, he enlisted in the Army, this time under the name of James Hall, but was rejected on account of some nasal defect This IYas at Columbus Barracks. After being rejected by the Army he attempted to enlist in the N a YY, and was sent to N odolk, Va. I-Ie was here likewise rejected on ac­ count of the same defect, and \Yhile awaiting his discharge papers it was discoYered that he had fraudulently enlisted. He wa s comt­ martialed and given a year's sentence. This was on N onmber 20, 1909. The patient continued to behaYe nry ''" ell :mel did not display any eY idences of a psychosis. On a number of occasions he requested that he be allowed to return to prison in order to sene out h.is sentence, stating that "he had had enough" and that he felt that he could get along all right. Accordingly, it was recommended to the Navy De­ partment that he be retumed to prison, and he was discharged on August 12, 1915, and retumed to the naval prison at Norfolk, Va. A letter 'Yas recei.-ed on December 23, 1915, from the commanding officer of the marine barracks there IYhich stated that the patient's conduct while confined at the prison \Yas "in enry respect satis­ factory and all that could be desired, being in all respects normal, and 24 SHEEHAN-THE MENTALLY UNFIT.

that he had been discharged by authority of the Secretary of the Navy on December 1 8 ~ 1915, which was prior to the expiration of his sentence, the unexpired portion haYing been r emitted on recom­ mendation of this offi ce for extraordinary clemency." On J nnuary 9, 1916, a letter \vas received from Capt. B. S. Hutcheson, medical offi ­ cer Ninety-seYenth Battalion, C. E. F., Toronto, Canada, requesting information about a man, James Hill, who six weeks preYiously had enlisted at "VVindsor, Ontario. H e had appeared on sick parade every morning complaining of vague symptoms, but p resented no objectiYe signs. When accused of malingering he had related his history. \vhich led to the above-mentioned letter. The inquirer "·as furnisherl an abstract of the history of this patient, who, to enlist, had only changed an " a " to " i " in his surname. In r eply, we were informed that there was no doubt he was the same man, that he hacl deserted 10 dnys before, and there had been no t race of h im. It is readily seen how this individual, ns a result of his inherent inadequacy, seems bound to gravitate t o the military sen-ice, because he believes it offers him hann. He is readily enlisted becanse he appears physically fit. He no doubt selected the Canadian sen ice b<:>cau se he hall been carefully impressed with the possibilities should he endenror to enlist again in one of our own services. Howe--e1·, with him n(l rift again \Y e must not feel immune. S. J.- Ordinary seaman. No. 2Jf\Gi'i . " 7 hite m:1l e. .\ ge 2G years on admission August 2G, 1914-. Family history, as obtained from the patient. is ncgati1·e. Per· sonal history : Patient was born in Galicia, Austria, F ebnhtry LS. 1888, and is now 25 years of age. His education \Ya s meager. .\bont t.he age of 12 he \las arrested for peddling without a license ant1 sen-eel a month in jail. A year after this he \Yas bronght to the United States by his family. He worked in a tailor shop for n yen r. From that time he engaged in various occupations until he enlisted in the. Army February 15, 1904, saying he did this because he IY ns out of \York. He deserted from the Army because he did not get along \Yell and "-ent to L ondon, England, working his pass;tgc. While there he was arrested for burglary, for which he sen·ed a sen­ tence. Upon discharge he enlisted in the British .Army, remRining three years, spending most of the time in South Africa. H e thell deserted and returned to England, where he worked for a "·l!ile. H e then returned to the United States, where he joined his family in New York. \Vhile there he was taken by them to Bellevue Hospital for examination and \vas sent to the Central I slip Hospital for the I nsane, where he remained four months. He was discharged and allowed to return to his home. He then engaged in various odd jobs. not being able to hold any position very long because of incompb· SHEEHAN- THE MENTALLY UNFIT. 25

tence. In the meantime his family moved to Springfield, Mass., from which place he was sent to the Tewksbury State Hospital, where he remained six months, when he eloped and hoboed his way to CleYe­ land, Ohio,. and tried to enlist in the Marine Corps, but was unsuc­ cessful. He then enlisted'in the Navy November 15, 1913. He was sent to the west coast, where he remained six weeks, when he deserted and went into Canada. There he tried to gi,,e himself up us a deserter·, but the military authorities would have nothing to do '"ith him, so he returned to St. P aul, where he gave himself up as a deserter from the Navy. He was sent to the Brooklyn Navy Yarct , where he 'vas court-martialed and sent to Portsmouth Naval Prison for two years. Medical certificate states: "The father is suspected of being feeble­ minded. Patient has manifested evidence of being feeble-minded. Has delusions of grandeur following a period of depression. He is npathetic, slovenly, and careless. On August 9 began to laugh, sing, nnd dance and believed himself to be a prince. Developed halluci­ nations of sight and hearing. No snicidal or homicidal tendencies." Mental xamination showed the patient to be accurately oriented. Emotional statns somewhat apathetic. Insight poor. Sleeps well ; does not dream. No hallncinations or delnsions could be elicited. Speech was rather jerky in charcter. He pronounces the test words and phrases fairly well. His effort to repeat the cowboy story was pooL'. Special memory fair. Masselon and Ziehen tests were poorly done. Calcu la tions were correctly performed. He could not do the 50-cent problem. Forward nncl baclnY arcl associations were fairly '"ell clone. His fund of general information was Ye1·y limited and he took little interest in cunent eYents. The performance of the Finchk test wa s only fair. His ethical reactions were abnormal. Physical examination showed a spinal scoliosis. Face was some­ what drawn toward the left in a frequent grimace. Superficial re­ flexes were exaggerated. Otherwise the examination was negatiYe. The medical record stated that he was admitted to the naval hos­ pital at Portsmouth, N.H., on Jnne 26, 1914, because of mental symp­ toms, and he was subsequently transferred to this hospital on Angust 25, 1914. · After admission the patient showed no evidences of a psychosis. He was clearly oriented, fairly coherent, but his statements were con­ tradictory and unreliable. He nns\vered questions in· a dull and apa­ thetic manner, was highly suggestible, and readily attributed dates to certain events suggested by the examiner. He said that for some ti me past he had heard voices which accused him of deserting from the Army~ and a lot of other things. However, definite hallucina­ tions could not be established. He did not sleep well. Frequently during his examination he bn rst out in to sill:v , childi sh~ la nghter, 26 SHEEHAN- THE MENTALLY UNFIT. \Yithout any apparent provocation. The patient was placed to work in the laundry, where he did quite well. He then asked for limited­ parole privileges, assuring the conference upon his honor that he would not elope. Although it was belieYed that he \vould elope, it was decided to try him, as he had not shown any harmful tendencies. T''"o days after this he failed to report at his ward, and nothing has been heard from him since. He was drol)ped from the rolls with a diagnosis of constitutional psychopath, unimproved.

P S Y C JIO~E U TI OSES . These ha ,·e been ,·ariously termed the minor psychoses or psy­ chonem·oses. This, after all, is an arbitra1·y exclusion, for the im­ portance of these conditions is relati,·e. They often bear a close rela­ tion to each other and are.often coexistent, forming a syndrome of much interest, and a group of disorders responsible for most of the cases in oflicers that come to our attention in a mental \Yay. They are chargeable with considerable inefficiency, and al so cause discom­ fort .to those who haYc to liYe with them. No greater mistake cm1 be made than to regard these enmescent diso rders as of little mo­ ment, for there is ahYays an underlying psychopathic organi;.;ation , and no prolonged manifestation of an y of the psychonem oses occurs unless there is some constitutional susceptibility. "Neurasthenia," which has been termed a disease of " fatigability and irritability " (Meyer ), is not regarded as it on ce "·as, and can not be separated from obsessional states: hysteria, and the anxiety neuroses. Hysteria usually consists of a combination of somatic and mental symptoms. It is a subtle arrangement, consisting of two strik­ ing essentials-a penersion of the ''"ill and emotional instability- with a dissociation between the emotional tone and the ideational content. There is ahrays impairment of memory and more or less confusion. The normal mental operations appear to be thrust temporarily into the background, with a predominance of the automatic o1·er the Yol ­ untary and conscious psychic operations. The resultant emotion often creates fear and anxiety. Physically these subjects show constriction of the Yislla l fi elds, irregularly distributed areas of anesthesia and analgesia , globns and motor disorders of various kinds, at times even convulsions. The obsessional psychosis is really an exaggeration of the doubts expressed by mai1y normal people. Here besetting and coercive ideas arise which pass the borderline of introspection and obtrude them­ sehes upon the environment. These patients may express fear of dirt or contamination, fear of open or closed spaces, and numerous other phobias. All these forms of mental disorder do not come strictly under the head of insanity, because the subject knows the SHEEHAN-THE MENTALLY UNFIT. 27

nature of his obsessions and their absurdity, yet is unable to escape their influence. These besetting ideas enter the foreground of con­ sciousness against and despite the subject's will, with consequent derangement of the train of ideas, and lastly the subjective conscious­ ness of the abnormality. The anxiety that results from the obses­ sion may be accompanied by hallucinations and delusions when the condition approaches a true psychosis. They are practically the expression of degeneracy, and they have a common origin in heredity

EPILEPTICS. Epilepsy is chru:geable with a considerable number of admissions, and also damage, as is shown by the following figures:

1910 I 1911 1912 1913 I 1914 1 &--1:-a ~-r~-i~-:-;'~-;~--~ -:~-; i--~:-_:_-: _: -:: -: :-:.-: : -: :-::-: .-: : -: : -: :-: :-: -::-: :-::_: _: --1 . -s~-l ,, ;~ - ,,ro~ '·:!! I '·'~

In all armies it is a prolific source of admissions and disabilities, numbering as high as 28 per cent of mental cases during war, so it is seen that these individuals are especially undesirable dming times of stress. In the United States Army during the period from 1903 to 1910 they ranged from 1.23 per thousand (83 cases) to 2.43 (159 cases), averaging 1.97 per thousand, or 120 cases yearly. This disease may be very Yague in its manifestations. One obser ver ( 17) found no less than 7:! per cent in a series of repeated offenders, and considers that the number is probably greater. The epileptic is dangerous. His motins are unsuspected, and he may suddenly become irrational. A sudden ·whim or impulse may lead him to commit any deed. The states of consciousness of an epileptic vary from complete conscious­ ness to coma, and the question of responsibility is always dubious. Epileptics are, as a rule, conceited and arrogant. They prefer indolence to occupation. They possess a tendency to lie. True gratitude is absent, and general instability and weakness are pre­ dominant characteristics. They are erratic in judgment, lack self­ control, are excessively emotional, and at times given to religiosity. They are fond of notoriety, and use various methods to secure it. The violent acts of an epileptic are frequently performed during the automatic states preceding or following a convulsive attack. These seem to be committed in a perfectly conscious and coherent manner, but in reality this is not so, as when the subject regains his normality there is no recollection of any event that occun:ed during the period of the convulsion, after which he is confused, dazed, and weak. All cases do not show convulsions, and many obscure cases have the epi­ leptic character and mental symptoms. These are quarrelsome, irri­ table, insubordinate, and tend to violence and impulsive actions. The epileptic may be eliminated by a careful history, with attention to evidences of head injury, a scarred tongue, and the evidences of the epileptic make-up. To show how an epileptic may get into the ser vice the following case is cited briefly : M. ''' · W.- Apprentice seaman. Caiie No. 21605. (See fi g. 5.) '\Vhite male. Age 18 years on admission September 18, 191-±. SHEEHAN-- THE MENTALLY UN VI I . 29 Family history : One uncle had tuberculosis. History otherwise negative. Personal history : P atient states he was born in Knoxville, Tenn., November 15, 1896. Birth and deYelopment w€re normal. He began to go to school at 6, continued irregularly for three years nnd reached the fourth grade. Claims he got along all right and that he was sociable. Says he stopped school at 10 years of age, r unning away f rom home because he had gotten tired of going to ~c hoo l. H e hoboed his \YaY to B irmingham, A la. Says he did this l>ecause he had heard the town talked about, and IYanted to see it. H e remained there tiYO or three days, during '"hich t ime lte liYed by beg­ gin g, then went to Decatur, Ala., "·here he got work driving a team. l-Ie led an itiner ant sort of existence in various parts of Alabama and T ennessee, liY ing by begging and \YO rking at odd jobs. H e finally returned to his home town, but said that he did not go to his family, as he desired to avoid them because he didn't want to go h ome. Finally he did go to see his mother , and worked for awhile on his father 's farm, when he decided to join the Na ,·y, because he ''wanted to see the world." H is father approved of this, saying that if he di d this he would know where he was. H e enlisted March 22, 1914, and was sent to Atlanta to be sworn in. \ iV hile awaiting this, he hired a horse from a liYcry stable and \Y ent riding. The horse n m away, throwing him o1f. He claims to have bee< unconscious for nbout 20 minutes, but can give no exact idea as to the length of time. He says his head was not cut or bruised. H e ca me to anJ had a headache for about 10 hours aftenY ard, which gra l nall y got bet­ ter. H O\reYer: he says that he was able to get up and find the horse which had IY anclered about a mile and a haH up the road. A week f.l.fter this injury he had a convulsion , felt sick and cli;~,zy, and then became nnconscious: but did not bite his tongue. A fter the con­ Yulsion he fell asleep for two hours. Following this he co uld not sleep and walked. the Hoor in the dormitories. H e was ordered to go to bed but refused to do so. \i'\Tas fin ally placed in bed by force. He did not inform the medical offi cer or the naval authoriti~s of this action nor of the convul sion, as he stated he knew this would prevent him from being admitted to the service, as a man had been rejected for this reason a few days before. H e was sent to Norfolk, Va., to the training station, and while there he had another convulsion. H e IYas sent to the hospital where he had about one convulsion a week for four weeks, '" hen he was sent here. Medical certificate states: "The first symptoms became manifest August 20, 1914. A cted queerly , had delusions and was depressed. Present symptoms : Delusions of persecution. Maniacal at times: very irritable, and refuses to eat or talk for cl ays at a time. Probable cause-heredity and ch ange of environment." 30 SHEEHAN-THE MENTALLY UNFIT.

Mental examination : Patient is \vell oriented. Emotionally is rather apathetic, has good insigh_t, sleeps well, claims he does not dream often, but when he does his dreams are unpleasant. Last dream was that he ran away from camp and they were catching him. No hallucinations or delusions could be elicited. Speech is normal. Repeated the cowboy story fairly well. Special memory tests "·ere well done. Masselon test was well given. Ziehen test quite \Yell understood. Calculations were poorly done, his answers being only approximate. Forward and backward associations were almost all correctly given. General information was poor, knowl­ edge of current events was limited. Finchk test was poorly done. Ethical reactions were normal. During the examination patient was attentive, but sluggish. He ans"·ered questions ''illlngly lmt slo"-Iy. His hesitancy seemed to be due to ignorance. Physical examination: Patient was somewhat pigeon-breasted. Palatal arch high and narro"·· Examination othenYise negatiYe. MeJical record states: Admitted to the sick li st .August 20, 191-t. He had been acting queerly for seYe ral clays; refused to eat; sa,,· imaginary things. He \Yas depressed at times, excited at others. He " ·as extremely dull and stupid, would not talk, and it was im­ p ossible to get any histOl'y from him as he \Yould not answer ques­ tions. He continually repeated the word "sick." Examination failed to rerenl any physical condition. August 2G patient still refused to talk; but ate and slept \YelL At night he would Le found sitting on the edge of his bed, and he asked for a rocking chair, snying he could sleep lJe tter in it than in the Led. T his \Y as the only thing he said since admission. On A11gust 30 he shO\recl some delu­ sions. September 2, became maniacal, threatened eYeryone \rho came near him, broke up his mess gear. Used profane language. Sep­ tember 17 was transferred to this hospital. Evidently here we have a psychosis associated ''"ith epileps.)', nnd the question of line of duty is not at all clear. He probably \nts an epileptic and had been for some time prior to enlistment, and he sustained the tmumatism as a result of a conntlsion rather than the epilepsy as a result of the traumatism. He is rather stupid nnd is evidently a rather inferior type of individuaL The patient continued to have connllsive attacks at about weekly intervals, but these were not severe and he rapidly reco.-ered from the following confusion. He was discharged from the hospital into the care of his father on April 3, 1915.

SYPHILITICS.

Vedder (18) has stated that a large part of the syphilis of the Army is contracted prior to enlistment. It was found that 16.77 per SHEEHAN-THE MENTALLY UNFIT. 31 cent of recruits gave positive ·wassermann reactions. These did not display any clinical evidences of syphilis, and were unrecognizable at the usual physical examination. It is considered that about 20 per cent of the applicants for enlistment are syphilitic. It has been estimated that 5.46 per cent of the cadets at \Vest Point are probably syphilitic, and that 30 per cent of the white males in the Government hospital (19) ha,-e syphilis, and that at least 10 per cent of the in­ sanity here is directly due to syphilis. Of the NaYy insane 7.69 per cent are knO\m as syphilitic and 10.44 probably syphilitic, making a total of 18.13 per cent. In the Navy 13.63 pet· cent of the cases of " insanity" are directly Jue to syphilis. Lea,·ing out of account the multiplicity of other disorders that it may lead to, it is important to detect syphilitics who apply for en­ ~ istment in order to exclude a likely source of mental disease. It is e\·en more important to reject syphilitics who are candidates :for a commission , as the manifestations of syphilis that indicate aneurism, locomotor a taxi a, and paresis are late in deYelopment, so that there is a tendency to reti1·e these cases as in line of duty. One can ne,·er predict when mental symptoms wi ll occ ur in a syphilitic, and under the stress of war conditions he is likely to break do,Yn; so ''"e ha,·e the possiLilit_v, in time of \\ar, of a battleship being com­ manded by a paretic. Steir (20) says those who haYe hnd lues, especially of long stnnciillg, are particularly prone to mental dis­ ease in time of ,,-ar, and "White (21) has said no man "-ho has a positi ,- e \Vassennann shonld command a ship. Recently three offi­ <'ers continued in positions of importance after they \Yere manifest­ ing undoubted mental symptoms. At present there are still remaining in the senice at this hospital 3 officers and 15 enlisted men, and of these the 3 officers and 8 of the men are here because of syphilis, with one more of the latter having syphili s, but this is nrt the direct cause of his mental dison1er. So it is readily seen hmv i,mportant a factor we have to contend \Tith in this disease. It would be desirable to h:ne a \Vassermann made on all recruits after they reach the training station, during the recommended proba­ tionary period, on all midshipmen at the Nanl Academy as a part of their examination for a commission, and as a safety measure upon all offi cers as a part of their examinations, both upon entrance from ci vii life and for promotion. To show how soon a syphilitic may come to our attention in a mental way the following case is abstracted: B. F.-Coal passer. Case No. 22401. (See fig. 6.) White male. Age 25 years on admission October 30, 1915. Family history obtained from patient : Mother is easily affected by heat. One uncle committed sni cide. Otherwise negatiYe. . 32 SHEEHAN-THE MENTALLY UNFIT.

Personal history: Patient was born January 17, 1890, in N ewal'k, N. J . \Vent to school at 8 years of age, and attended for seven years; states he always just passed. He did not care much for school. He was in the fifth grade when he finished; failed of promotion in his last class. At the age of 15 he went to wo rk as carpenter's appren­ tice, receiving $7 a week. After eight months he received a raise of $1 a week. He did not tell his father of this, but kept it for spend­ ing money. "When his father found it out he threatened the patient, who then ran away from home. Says he went to vVest Point, where he tried to be a cadet, but ended bytaking a job as waiter in the mess hall, receiving at first $18 and later $23 a month. He remained there only a few months. He then hoboed his way to Indianapolis, where he got a job at $3 a week. He did not keep this long, but went to work on a lake steamer plying between Buffalo and Detroi t. He then drifted to vVyoming, working for several years on ranches at 'nges varying from $30 to $45 and his keep. Says he never worked oYer three or four months on any one job. Last fall he went to the· han-est fields of North Dakota, and after being there 10 or 12 clays ''"ent to Minneapolis, '''here he worked in a restaurant for a month,. following ''hich he enlisted in the Navy. H e was sent to the Great L akes Training Station, where he remained for six months; then was sent to the U. S. S. Michigan, where he remained for three months, '"hen he had an argument in the fireroom, and because of this ''"as sent to the Philadelphia Naval Hospital, subseq11ently com­ ing here. Present illness: Says he got into an argument aboard ship. H e did not 'nmt to leaYe the firerciom, saying he got "crummy, foolish , dopey, and funny," and lots of the fello,Ys were jeering at him. Says he sat clown and would not do anything. They called him "soup." " \Yhen a man's the cheese he don't like to be called the cheese. They called me Bessie. A man named S-- aboard ship acted foolish. He asked me to come over and lay down by him. This man S-­ called me Bessie." By calling him these names he thinks the men were intimating that he was guilty of various perverted sexual acts. Patient was ndmittecl to the hospital on October 30, 1915, and complied readily with the routine procedure. Sn,ys he hnd been confined in the Lrig becnuse he had trouble with n man named S--, who called him bad names. He did not pay any attention to this man, "·ho got mad at him and took his reYenge by calling him Bessie, "to make a woman out of him." He says that on shipboard if a person does not like another he tries to make a woman out of him; thnt is, a sexual pervert. The patient never liked this mnn S--. No hallucinations or delusions have been formed by the pa­ tient in his present e1wironment. He states that about a year ago ''"hile in North D akota he had a venereal sore. Three or four months SHEEHAN-THE MENTALLY UNFIT, 33 later a fine rash appeared on his abdomen. He states that he took treatment for this condition. He does not believe he is crazy, but states that he has not a very keen mind. He says he is no different than he has always been. Says he would like to be discharged from the Navy, ap.d in almost the sa me voice states that he wants to finish out his enlistment so that he can go home, because he does not want his people to think that he can not work out his full time. Says he is sad and depressed because of the fear that he will lose the regard of his relatiYes on account of his illness and his being discharged from the service. He does not believe there is anything wrong with his mind, and says he does not see how the Navy cnn figure out in 19 months what he has been unable to determine in 26 years. He is correctly oriented in all spheres. He believes that there are sev­ ·eral crazy people in the ward where he is, and he does not think it was right for him to be sent here. He states that he merely sat down on the deck, and was quiet and would not think. He says, " I would not think until.they stopped believing that I was a pervert." He says that everyone in the fireroom was crazy, because all the firemen on the ship tried to pnt out the fires with coal, while he just sat around, and they tho11ght he 1ras crazy, and he might have acted quiet in order to be like the rest. H e says if he is allowed to lea...-e the hospital he n·ill leaYe the United States forever. Says he is depressed and believes he will be so all hi s life. H e says that one o£ t he nurses in the Philadelphia hospital wa s put up to make love to him. He is yery accessible and is inclined to be emotionnl '' hen questioned regarding hi s present difficulties. Says "I haven't got any troubles, only I am crazy, and I want to get out of here." H allu­ cinations and delusions are denied, but he says he has been asked so many times if he hears Yoices that he thought he may have, but now he kno\vs he has not. Insight and judgment: Says there is nothing wrong with his mind; in fact, he has not a donbt of it. Thinks he might be crazy before he leaves. He says the Navy got him here for three years ; that he will leave, money or no money, and will get a way to escape. Habits and character: This patient for the past 10 years has been a wanderer , never remaining in one position very long. Admits using alcohol, but says that it makes him sick. .. While nt the training station he was not apt, was insubordinate and cre­ ated disturbances, and wa s confined in the brig . . There is no doubt that he has been frequently guilty of perverted sexual practices. He is well oriented, his memory for remote events is good, and is -especially good for recent events. Special memory tests were well done. His fund of general information is quite complete. vVas able to perform the intelligence tests, and understood the Ziehen test, and also the Finchk test. He gave the forward and backward asso- 34 SHEEHAN- THE M E NTALLY UNFI T . ciations correctly, and performed the required calculations. H is ethical reactions ·were indecisive. P hysical examination was negati ,-e except the evidences of a sca t· upon the penis, the presence of a facial asymmetry, and a slight speech defect. Wassermann reaction with the blood serum was double plus. Here we have an individual who is unqu estionably of a psycho­ pathic make-up, and in whom syphili s was the determinant of the psychosis. A LCOJJ OLlCS . Alcohol has ceased to be as important as formerly in the direct causation of mental diseases: and it is not often no"· thnt it is the sole factor in the production of a psychosis. In going oYer the hi s­ tory of ca ses (22) it is ascertained that the drink habit leading to alcoholic " insanity " is always formed early in life. The a veragc duration of the habit prior to admission to a hospital for t h ~ insane is 22 years. The liquor principally causing ·"insanity" is \Yhisky. Either regular or periodic drinking may lead to a psychosis. A fix ed habit of excessiYe drinking, with frequent intoxication, precedes the mental breakdom1. The deteriorating effect of the alcoholic habit is reflected in the occnpational ineffi ciency. The physical health is impaired in about 40 per cent of patients. The nse of drugs is a negligible factor in the production of alcoholic p s ~ ·ch ose s . Abnormal mental conditions cause excessiY e nse of alcohol in some ca ses, especially in epileptics, psychopaths, and dementia precox in­ lood serum was now negative. Ten years ago he sustained an injury to his head by falling off a lumber pile and wn s unconscious for 20 hours. Medical certificate states that he had been nn inmate of Providence Retrent, Buffalo, N. Y., where he had taken a cure for nlcoholism. He is verbose, somewhat delusionary, and has had hallLlcinations. ·Made two attempts at suicide. Probable cause, heredity nnd nlcohol. Mental examination was negative. The special tests were all well performed. His niedical record stated that be was ndmitted to the sick list on July 26, 1914. Had been drinking considerably, and conld not sleep. About 8.30 p. m. he was found running about the deck, and insisted that enemies 'vere after him to cut his throat, and that he heard voices, and had committed a wrong for which he would have to for­ feit his life. He was transferred to the Naval H ospital, New York, where he continued to have about the sn me symptoms, which re­ sulted in his transfer to this hospital. After admission the patient behaved quietly q.ncl orderly, and did not occasion any trouble. He assisted with the ward work willingly and quite effi ciently, and did not Yi olate any of his privil eges, with 36 ~HEEHAN-THE MENTALLY UNFIT. the exception that on January 30 he was found under the influence of alcohol, which he acknowledged having obtained from the medi­ cine closet in one of the wards. As result of this he became excited, cursed, and attempted to assault the attendants and physicians. After this time he apparently returned to his normal condition, and he was discharged from the hospital on April 23, 1915. A short time after this he was returned to the hospital by his mother, who stated that he had been drinking, and desired to return to the hospital. He was retained here for about a month and a.gain discharged. H ere is a patient who ·admits having used alcohol to excess for several years, often as much as 30 or 35 glasses of whisky a day. H e gives a history of having been in two hospitals for mental disease, and of having taken special treatment for alcoholism ; also gives a probable history of syphilis. He makes the general impression of a chronic al coholic.

DRUG ADDICTS.

Drugs in themselves are not frequent causes of insanity in the service, but, aside from that, are productive of considerable trouble. It is believed that many men form the habit after enlistment, through association with those already addicted, either among their ship­ mates, or with women of the underworld, who are notoriously prone to these habits. In one or two centers this might almost be termed endemic. In Philadelphia cocain addiction is especially prevalent, while in Boston, and Portsmouth, N. H., the heroin habit is noted as frequent. Morphinism is not as common. With this latter we have defects of attention, particularly in the realm of sense observations. The ethical sense is dulled. The habitue is unable to discriminate morally. H e is impulsive, while his will power is lost, and his con­ trol over his impulses therefore lessened. H e is subtle and conceal­ ing, and is likely to be dominated by unforeseen impulses. His re­ sponsibility is impaired, and he is constantly doing and saying things the import of which he does not comprehend. The tendency to lying is almost pathognomonic. Cocainism has apparently been widespread in the service. It is invariably taken by snuffing. It causes fairly definite symptoms, restlessness, insomnia, and anorexia. There is a tendency to elation, at times sullenness; there may be hallucinations and mild delusions. Physically there is tremor, exaggerated refl exes, incoordination , spasmodic twitchings, and even convulsions. Owens ('23) has called attention to the characteristic ulceration of the mucous membrane of the na sa l fossro as au aid to detecting suspected cases. H eroin 1 when snuffed also causes inflammation of the nose.

1 Atten tion is called to nn abstract of un a r t icle on heroin habitues in t he U. S. Nava l Medical Bullet in, Janua ry, 1916, p. 129. SHEEHAN-THE MENTALLY UNFIT. 37

In conclusion it may be stated that- 1. Dementia precox is by far the most important mental disease with which we have to contend. 2. Feeble-mindedness in itself is not a serious factor. i3. Drug addictions 1:arely cause mental disease in the service. 4. Alcohol has ceased to be important as a direct cause of mental diseases in the service, but it is frequently a contributing factor in their production, especially when associated with syphilis. fi . Syphilis causes considerable damage. It is the ca nse of most of the mental disease in officers and men of long service. Means should be taken to preYent the risk of having a syphilitic in a posi­ tion of responsibility, especially during the stress of war. It is urged that more effort be made to acquaint the officers of the Navy, also the midshipmen, with the widespread damage of this disease, extending as it does for years after the initial lesion, and often enlminating in hopeless dementia. 6. As the examination at enlistment does not permit the excluding of all unfit, it is considered that a probationary period, say, of three months at a training station should be required before the comple­ tion of the recruit's enlistment. This would give opportunity for examinations to be made, and aboYe all, to obsene the individual's reactions to his environment. 7. The history of the candidate's life- that is, a cross section of his <·r.reer- gives the best information on which to exclude the unde­ sirable. It "·ould be well, while the need of men is not pressing, to require candidates to provide credentials giving information of this kind. Many patients here are found to have been inmates of insane hospitals prior to enlistment, and this fact is frequently easily ascertainable. HEFEHK'(CicS.

I. Bleuler. Schizophrenia. Ashaff:enburg's Handbuch der P sychiatrie, 1913. 2. 1\leyer, Adol f. Dementia Precox : A Monograph. Meyer, Hoch and J elliff:e, If) j] . 3. Southard, l D. K A Study of t he Dementia Precox Group in the Li ght of < ~e rtain Cases show ing Anomnlies or Scleroses in particular Bmin Regions. Am erican .Journal of Insanity, May, 1910. 4. Southartl, E. E. Cortex Lesions in Dementia Precox. Contributions Mas­ sn chusett · State Board of Insanity, 1914. 5. Holmes. The Relation between Dementia Precox and certain Toxic Amines. J ou1'11al Cli nical Medicine, June, 1915. 6. Ludlum and White. The Thymus and Pituitary in Dementia Precox. American Journal of Insanity, April, 1915. 7. Meyer, Adolf. Fundamental Conceptions of Dementia Precox. British Medical Journal, September 29, 1906. 8. Hoch, August. Constitutional Factors in the Dementia P1·ecox Group. Heview of Neurology and Psychiatry, Au gust, 1910. 38 SHEEHAN-THE MENTALLY UNFIT.

9. \Volfsohn. Die Hereditat der Dementia Precox. .\llg. Zeitschr. f. Psych., 1907. 10. Butts. Insanity iu the N:lYy. U. S. Naval Medical Bulletin, 1910, p. 459. 11. Hickson. The Relation of Pfropfhebephrenia and Dementia P recox to Cl'ime. Illinois Medical Journal, 1915 . .-12. Sheehan. Service Use of Intelligence Tests. U. S. Naval l\Ie1lical Bulle- ..-­ tin, April, 1915. 13. Bowers. Constitutional Immorality. Intemational Clinics. Yol. 4, series \ 23, 1913. 14. Healy and Tenney. Pathological Lying, A.ccusation, and Swindling. _ >:'ct·iminal Science Monograph No. 1, 1915. 15. Nitsche and Wilmanns. Prison Psychoses. Kervous a nd Mental Disease 1\lonogrnph No. 13. 16. King. l\Iental Disease and Defect in Unitetl States T roops. Bull etin Xo. ~ 5. War Department, March, 1914. 17. Healy, William. Modern Treatment of NerYous and l\lental Disease:;. White and Jelliffe. Vol. 1. 18. Veddet·. Prevalence of Syphil is in the Army. Bulletin No. 8. \Var De­ Jl:lrtment. 19. Hough. Prevalence of Syphilis among the Inmates of Government Hos­ pital for the Insane. Jout·. Am. l\:Iecl. Assn., p. 972, 1914. 20. Steil'. l\[ilitm·;irztliche Zeitschrift. 1908 u 1907. 21. White. The Application of Psychiatry to cer tain l\Iilitary P roblems. Lecture U. S. Naml Wa r Co ll e~e . 1913. 22. Pollock. 'l'he Use and Effect of Ail'ohol in Hel ation to the Alcoholic Psychoses. State Hospital Bulletin, August, 1915. 23. Owens. Signs a nd Symptom;:; Jlresented h.,. those nt1di C" tl•t1 to Coca in . .Tour. Am. l\fetl. Assn., F e ht · unr~ · 3, 1012. 0

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