serious situation until too late, it becomes most decidedly a handicap. This is particularly true in our discharged patients. Those who continue well are those who showed mental responsibility while "on the cure," and these were mainly of the educated class.

Experience in our work among the Negroes shows that it is all-important to get the confidence of this ease-loving, care-free patient, and impress him with the fact that he is a sick man and needs treatment and that this treatment will be absolute rest in bed in the open air for a long time. All of his former convictions have to be shattered and replaced with new ones. He believes, first, that to get into bed with "consumption" means certain death; second, that strong medicine is a specific for all ailments and when this has failed all has failed; third, that a closed room with all "cracks chinked" is the treatment for a "cold."

So new is our field and so deep-grounded is the conviction that consumption is incurable that great difficulty was experienced during the first year in getting cases to enter the sanatorium and to remain long enough to effect a cure. Less difficulty is had now on account of the fact that practically all of our employees are discharged patients and they serve as a concrete illustration of the fact that tuberculosis is curable. Conversations between the in-coming patient and the arrested case in the person of the employee are often amusing and instructive to the interested listener, and show with what effort he discards his former ideas and his incredulity in the new. Concrete examples of the curability of the disease are helpful to all afflicted with tuberculosis, but with the Negro it is almost essential.

SUB-ACUTE DISEASE

Forty-five of the 325 cases discharged to date were classed at sub-acute, or 13.84 per cent. Here again the greatest percentage was

among the blacks, 15 of 81 or 15.55 per cent. being classed as sub-acute. Fourteen of 124 brown mulattoes were classed as sub-acute or 11.22 per cent. and 15 of 114 bright mulattoes or 13.15 per cent. These cases were all between the ages of 14 and 26, most of them of athletic build and gave a history of illness not exceeding three months. Six of them were discharged from the Army within that time with a clean bill of health. All showed upon physical examination large moist rales in two or more lobes and little or no fibrosis. All died within three months after being examined. A highly positive sputum and high temperature were universal in these cases.

HOOK-WORM AS A COMPLICATION

Adams* reports a striking parallelism of incidence between tuberculosis and hook-worm in a series of examinations made at Fort Oglethorpe and covering several southern states. One would expect hook-worm to be a frequent complication of tuberculosis in the hook-worm infected districts of the South, both on account of the sapped vitality and the actual trauma to the lung. A survey made by the Virginia State Board of Health showed southeastern Virginia and the south Piedmont districts of Virginia to have a hook-worm percentage of 14 per cent. and 29 per cent. respectively, and although we draw heavily from these sections, a routine stool examination shows only three positives out of 350 specimens, or less than 1 per cent. Statistics compiled by the Virginia State Board of Health and the International Health Board show that the Negro is infected with hook-worm quite as frequently as his white neighbor,

*Southern Medical Journal-Vol. 13, No. 2. Fifth Annual Report.

(Continued on page 265)

T

HE purpose of the symposium, which forms the program of the evening, is to bring to our attention the results of efforts that have been made by various organizations interested in or conducting the work of public health nursing to solve some of the outstanding problems of organization and administration which have developed as a result of the very vigorous growth of public health nursing in the United States.

Public health nursing has been so uniformly successful in practically all fields of public

A paper presented before the Advisory Council, Sixteenth Annual Meeting of the National Tuberculosis Association, St. Louis, April 22nd, 1920.

health work, and the public health nurse has become so indispensible a part of our health machinery, that practically every organization engaged in health work has before it as an ideal the employment of just as many public health nurses as the means available will allow. So that we have developed, within a very few years, school nurses and tuberculosis nurses; contagious disease and industrial nurses; trachoma nurses and social hygiene nurses; child welfare nurses and prenatal nurses; nurses of as many varieties as there are problems in public health. We have nurses employed by boards of health and boards of

nurses

education; by commissions for the blind, by child welfare associations, by tuberculosis associations, by the Red Cross, by social units, social hygiene societies, Methodist Centenaries, church societies, welfare organizations, and so many other kinds of organizations that it is difficult or impossible even to name them over. We have nurses in the cities and in the remote rural districts, we have nurses with hospital and public health training and nurses with a cap and white apron and very little else. We have nurses who are part of smoothly running, efficient organizations, and nurses who are without any supervision whatever. The organizations supporting these nurses are almost without exception earnestly seeking to contribute to the common welfare, the nurses themselves are almost without exception hard working, conscientious, devoted women. Their contribution to human progress is valuable almost beyond calculation. But it is perfectly evident to any thoughtful person that if the public health nurse is a necessary part of our social machinery, and no one will now deny the necessity for her work, that work must be developed in a more orderly, efficient and thoughtful manner than has been the case up to this time.

The development of an orderly and efficient program of public health nursing cannot come until we have determined clearly in our own minds the goal toward which we are to progress; until we have visualized for ourselves an ideal of public health nursing service and make each step we take carry us towards that ideal.

Inasmuch as we cannot, under the Federal Constitution, contemplate the establishment of a federal welfare service of any kind, but must for the present at least think in terms no larger than a state, we shall therefore consider for a moment, if you please, the ideal of a state-wide public health nursing service as we have formulated it for our own guidance in Ohio.

We believe, first of all, that our nursing service should be state-wide, that nursing service should be available to the citizens of the remote townships of our hill counties as well as to those of our crowded centers of population. To this ideal, haphazard development of the present time is not tending very rapidly. The present tendency is towards a multiplication of nursing services in the larger cities to the dangerous neglect of the very parts of the state which need nursing service most. Funds, public and private, are so much easier to obtain in the larger and more prosperous centers, nurses so much easier to find and to supervise, results so much more spectacular, and, say it softly, so much easier to get credit for that there is little incentive to go into the really difficult parts of a state and start a public health nursing service.

We believe, too, that our ideal nursing service will be adequate. There must be enough nurses to do, and to do promptly, all that needs to be done. No one can as yet say what is the final limit of what needs to be done in

public health nursing, and I have a very strong suspicion that we shall never have enough nurses, that we shall always find new things to do and need for more nurses. But we must always strive to give adequate service. Towards this ideal our voluntary agencies do not tend strongly. There is no compulsion on a voluntary agency to give an adequate service of any kind. The very nature of voluntary organizations supporting public health nurses involves the right to pick the job they are to do and to do as much or as little as they choose.

We believe that our ideal nursing service must be efficient. Nurses must be properly trained, must be chosen for reasons of fitness alone, must be under proper supervision and discipline, must keep proper records. Each nurse must have a definite and suitable territory for work, there must be no over-lapping or waste of effort. We cannot have two nurses covering the same field. If specialized public health nurses are necessary, and it is conceivable that they may be, they must be carefully districted so that sufficient work of the special character will be available to keep them fully occupied. The nursing work of a really efficient organization would be so planned that there is no peak load at any particular season with a corresponding season without sufficient work to keep the nurses fully occupied. The work must be economical, with complete records and accurate accounting. It must be a business organization.

Our ideal nursing organization must not be too highly centralized. The right of each local community to regulate its local affairs must be fully recognized. But within the limits set by the local community, the work must be carried on efficiently and well.

Between this ideal situation and the present conditions there is of course a great gulf fixed. The bridging of this gulf is a task which will call for all the wisdom, all the patience, all the diplomacy and all the energy we can muster. That it must be bridged is not open to question. The responsibility is upon those of us who realize the condition and who are in position to influence the course of events.

The first step to be taken by all organizations, public and private, engaged in public health nursing is solemnly to resolve that there shall be no waste of effort, no duplication of work, and above all no competition for popular support.

The second step is the placing of all nurses in any given territory under unified nursing supervision, and the development of a systematic plan for a state-wide service.

The third step is a unification of program and of finance.

The final step, which may be long delayed, is the organization of an efficient agency, supported by public funds, but advised and supported by interested private agencies to carry on all routine work of public health nursing, leaving the volunteer agencies to develop new fields, to define new problems and to stimulate the development of the whole system.

E

FFECTS are more tangible than causes. They are more easily grasped, and hence more easily utilized, and besides being more useful than causes, they are probably more truthful. The study of the symptoms of tuberculosis edifies us more than the study of the bacillus of Koch. This is the essence of pragmatism. And the very existence of this sociological section of the tuberculosis convention demonstrates that you have grasped this pragmatic principle.2

Bacteriology, with all its splendid achievements, introduced something of a fallacy into medical psychology. It put such emphasis on cause that effects were overlooked. Hence my purpose in emphasizing the pragmatic importance of effects. The subject of tuberculosis is an excellent illustration. The bacillus of Koch was established as the cause of tuberculosis. That discovery eclipsed for a time. the factors contributory to the production of tuberculosis. The attack was directed against the cause, that is, against Koch's acid-fast bacillus. When and only when it was discovered that darkness and filth and poverty encourage this bacillus, the stream of attack was broadened to include darkness and filth and poverty. Thus the attack grew, by extension of the theory of cause.

Meantime the study of effects was neglected. Since feebled-mindedness was in no immediate sense a cause of tuberculosis, it was scarcely considered in the attack. The anti-tuberculosis expert would have regarded an attack on

A paper presented before the Sociological_Section, Sixteenth Annual Meeting of the National Tubercu losis Association, St. Louis, April 23rd, 1920.

But

Psychiatrists, I think, have until recently lacked this insight. We have been too much concerned with causes. For thousands of years there were speculations as to the cause of mental disease, ranging from disordered humors to repressed subconsciousness. it was not until the last decade that the effects of mental diseases were considered seriously enough to instigate preventive work, in the form of the mental hygiene movement. Conspicuously is this true with the mental diseases of deficiency, the feeblemindednesses. Tomes have been devoted to theories of cause, none of them to any great purpose. But it was not until 1848 that any state in this country made provision for the effects of feeble-mindedness. Even at the present time the opportunities for prevention, for preventive psychiatry, are sadly neglected. Sixteen states (The Growth of Provision for Feeblemindedness in the U. S.; Fernald, W. E., Mental Hygiene, vol. I, No. 1, pp. 34-59; Jan. 1917; reprinted in 1919.) still make no provision for them, and many of the states with nominal institutions are providing therein nothing but custody, and custody for only a fraction of the patients needing care. Training and educational therapy as so magnificently demonstrated by Fernald. Goddard, Sequin and others, is for the most part sadly underdeveloped.

feeblemindedness as without his province, as scarcely germane to the subject.

Thus I can conceive the mingled curiosity and skepticism of a certain portion of my audience. You have read the assigned title of this paper, and you have wondered what dexterity might be necessary to construe a presentation of a relationship at best remote, indirect, obscure, into tolerable dialectic. I maintain that this is because you have missed a certain advantage accruing from studying effects. This has made it difficult for some of you to appreciate the significance to you, as anti-tuberculosis workers, of the efforts of the mental hygiene movement. In seeking causes of tuberculosis, feeblemindedness was overlooked. But in seeking effects of feeblemindedness, tuberculosis cannot be overlooked.

My general theme, then, is that we should study effects; that one of the effects of feeblemindedness is tuberculosis and that therein lies a relationship which justifies the cooperative interest of every anti-tuberculosis worker in the work of mental hygiene. To achieve this, I shall try to show, first, that all physical diseases have psychic effects, and tuberculosis, as a physical disease, has such psychic effects; secondly, that likewise all mental diseases have physical effects; and feeblemindedness will serve as a type of mental disease, justified as such by nature, frequency, sociological importance, etc.; that as such it has, according to rule, certain physical effects which arise out of social situations and evils produced; and finally, that one of these physical effects is syphilis, another one tuberculosis; that, hence, your problem is ours, and more fundamentally, our problem is yours!

One might put this whole question in terms of the interrelationships of mental and physical disease. In a broad sense, feeblemindedness stands for mental unhealthiness, just as tuberculosis is representative of physical unhealthiness. With the integrating tendency of modern medical specialization, one needs reminders of the unity of the human organism. We are constantly reminded, with good need, that we must take a broader aspect of our patient, and treat him and not his disease. The Y. M. C. A. symbol of soul, mind, and body might be a useful talisman to the physician who sees habitually only his one part.

And as a psychiatrist, speaking to men primarily interested in tuberculosis, I echo this Jeremiad: Look at the whole patient. Ill fares that man, or his patients, who conceives them, as it were, carrying their lungs in one

basket and their brains in another! Yet I question whether any of us can altogether plead innocent to this very fault.

Physical diseases generally have psychic effects. The stupor of typhoid, the anxiety of hyperthyroidism, the depression of myxedema, the coma of diabetes, the delirium of pellagra -all these and many others are familiar to us. Perhaps it is less well recognized that influenza, pernicious anaemia, chronic nephritis and many of the every-day afflictions seen by the internist are accompanied by more or less characteristic mental states. So definite are these states that one great psychiatrist, Kraepelin, thought that we would eventually be able to make a diagnosis of the disease from the mental symptoms alone, i. e., to say from the form of delirium that this is influenza, this pneumonia, this typhoid. Some of us do not agree with Kraepelin. My own work in studying the mental diseases of influenza did not bear out the hypothesis. But this may be because of our ignorance of the fine points of these mental phases of physical illnesses.

For let me confess to you an open secret among psychiatrists. The interrelations of somatic and psychic disease are probably far more numerous, more intricate and more intimate than we know or at present can know. It is the most unexplored and the most debated field in psychiatry. As internists and phthisiologists, you may have assumed, because of our prattle about "subconsciousness" and "dementia praecox" and "persecutory hallucinations," that we were exquisitely erudite on all phases of mental disease manifestations. Consequently, I can conceive something of your astonishment, not to say amusement, to learn that we do not even know the nature or the mechanism of simple febrile delirium. There is, as a matter of fact, no accepted definition of what actually constitutes delirium, although there are multitudes of descriptions.

I mention this not to show our weaknesses, for I shall try rather to show you some of our strengths. But it exemplifies what has been said about the wealth of unmined treasure beneath an apparently barren desert.

Tuberculosis, like other physical diseases, has certain psychic effects. The delirium accompanying virulent acute forms is an interesting study, and assumes a practical importance when it is a question of deciding whether the symptoms arise from a brain bathed in toxins or a brain riddled with tubercles. The neuropsychiatrist can often help here.*

Some evidence has been produced that "there is a definite group of cases of dementia

J. A. M. A. 72: 235, Jan. 25, 1919. Archives Neurol. & Psych. II, 291-337, Sept., 1919. Archives Int. Med. 24: 98, July 1919.

See Chaddock, Chas. G. Early Diagnosis in Tuberculosis of the Nervous System. Recent Studies of Tuberculosis, from the Interstate Medical Journal, St. Louis, 1914.

See Gosline, H. I., The Role of Tuberculosis in Dementia Praecox; Journal Laboratory and Clinical Medicine, vol. IV, Nos. 4 and 7, Jan. and April, 1919.

praecox in which tuberculosis may be considered to be a causative factor and possibly the causative factor." I hasten to add, lest an erroneous impression be given, that this is not to assign a special role to tuberculosis, as the speaker has put forth the same idea in regard to influenza, and the trend of the data is to show that some forms of dementia praecox are dependent upon physical or somatic disease.

Mental symptoms of less severe nature, however, are far more frequent. The peculiar psychology of the typical tuberculosis patient is doubtless familiar to you all.

Fishberg ascribes to the euphoric, optimistic, credulous, hopeful, and extremely suggestible nature of most phthisical subjects not only the extensive victimization of them by newspaper quacks, but also the actual improvement of many under treatment acting largely by suggestion. And surely everyone to-day recognizes the importance of psychotherapy in tuberculosis, even though it be only the psychotherapy of a cheerful, sympathetic, encouraging personality on the part of the physician and nurse. Some psychiatrists, such as my friend, Dr. Jelliffe, apply psychanalysis to tuberculosis patients. I protest that I have never wholly understood psychanalysis, and so I am not sure I understand the results, but we all welcome any means that will further the elucidation of this obscure field of somatic and psychic disease.

Approaching this interesting topic of the psychic side of tuberculosis from another angle, one might pursue the suggestions of John Bessner Huber and Arthur C. Jacobson,❞ who find a relationship between tuberculosis and genius. Whether we regard genius as a mental disease or merely as an abnormal mental type, is a matter of words, but the relationship between it and tuberculosis is a research question wholly apropos of the present discussion. Of the "notable examples of genius as influenced by tuberculosis" usually apparently in the direction of stimulation, there is much too long a list to quote here and now, but representative names are those of John Milton, Alexander Pope, Elizabeth Browning, Moliere, Thoreau, Goethe, Balzac, Voltaire, Scott, Rousseau, Ruskin, Kingsley, Kant, Mozart, Bichat, Trudeau, Calvin and, of course, Robert Louis Stevenson. We might criticize this list as containing many who could scarcely qualify as geniuses, but the point would not be thus disproved. Aside from the tremendous theoretical interest, this point tosses into the ring an apple of discord. "It is an ill wind that blows no one good," and is tuberculosis,

6 Fishberg, Maurice; Some Psychic Traits of the Tuberculous, Interstate Medical Journal, 1913.

Jelliffe, S. E., and Evans, Elida; Psychotherapy and Tuberculosis, American Review of Tuberculosis, vol III, No. 7. Sept. 1919.

"Consumption and Civilization," 1906.

Tuberculosis and Genius; Medical Library and Historical Journal, December, 1907; Aesculapian, December 1908, Interstate Medical Journal, 1913, and Recent Studies on Tuberculosis, St. Louis, 1914.

then, a blessing in disguise, a producer or stimulator of genius? A hasty denial is surely appropriate, the more so for our growing recognition of the possibilities of bonum ex nocentibus, in pathology as well as ethics. No less a scourge than influenza has actually produced some good results in physical and mental pathology. Several cases of mental disease of long standing recovering after influenza have been reported, and I may mention here informally that at the convention of the American Medical Association next week I present a case of feeblemindedness which was likewise improved greatly by an attack of influenza. Tuberculosis, which so stimulates some hyperfunctionating minds, the geniuses, might in occasional instances act as did influenza in this case, yet it were wretched logic, to say nothing of scientific truth or public policy, to interpret these as substantial atonement for the evil effects of these plagues. The importance of these cases lies in their value in the study of the relationship of mental and physical pathology, that great, unexplored field. And here we conclude the topic of this portion of these remarks.

Now, as physical diseases have their mental effects, so mental diseases have their physical effects. I shall not delay now to point out the well-known stigmata of hysteria in the form of anethesias, paralysis, etc., or to more than mention the recent ideas of Babinski and Froment in regard to actual organic changes. I may refer thus briefly to the fact that brain syphilis, epilepsy, deliria, encephalitis, dementia praecox, and, in fact, practically all mental diseases have definite concomitant

physical signs, which we may assume effects.

are

Representative of the mental diseases stands feeblemindedness. It is a qualified example of all mental diseases-just as is tuberculosis of all physical diseases-because it is one of the most frequent, it is one of the most difficult to alleviate, and is the one most conspicuous in its relations to other sociological questions. At the risk of being regarded as pedantic, I shall attempt to lay down some general facts concerning feeblemindedness.

Conceive, for working purposes, that the mind is made up of intellect, emotion, and will. Conceive that from the standpoint of pathology these elements may vary quantitatively and qualitatively. Beyond certain limits, qualitative variation constitutes psychosis, or craziness, or "insanity." Beyond certain limits, reading downward, quantitative variation constitutes feeblemindedness. In other words, feeblemindedness means mental defect, intellectual, emotional, volitional.

This delimitation of the realm of feeblemindedness is perhaps a naïve presentation of facts universally conceded. It would only confuse us to dilate upon the fact that volitional weakness, without intellectual defect, is also called psychopathy; or to point out that perhaps emotional balance rather than emotional content is most often lacking in the feebleminded. Suffice it to say that we know

little enough about emotional and volitional defects. We are learning more and more about intelligence defects, and it is of these that most people speak when they refer broadly to the subject. It is these, primarily, that I shall have in mind to-day. Let us not forget, however, that feeblemindedness, or the much more desirable term hypophrenia, really inIcludes these many others of whom we know so very little.

By means of the Binet-Simon test and its modifications, we can measure intelligence defect, and hence we can grade the feebleminded on a certain basis with a considerable degree of accuracy. Persons of marked intellectual defect, the more familiar type of hypophrenia, fall into four groups.

Lowest of all are the idiots. These are the cases of infant intelligence, baby-minds. They are helpless and hopeless, and they are commonly supposed to be the most numerous of all forms of feeblemindedness. Actually, they comprise the smallest group.

Imbeciles form the next higher grade. They are the child-minds. They are capable of learning simple things if rightly taught; they can be trained to avoid common dangers and to care for their persons.

Now, the popular conception of the range of feeblemindedness ends here. Idiots and imbeciles present so many and such obvious physical effects that they can often be recognized at a glance. And few people appreciate the fact that they constitute the minority of the feebleminded totality! The word "feebleminded" brings up in the minds of most people a hideous, helpless, drooling thing, and the pretty, attractive, healthy human beings of the higher grades of feeblemindedness can by them scarcely be accepted as having even a remote relationship.

Moron is the name given to the next higher grade of feeblemindedness, above imbeciles. They are adults with the minds of ten-yearold children. With all the physical desires and capacities of adults, they have the intelligence and judgment only of children, and it is easy to understand how they become involved in every conceivable form of trouble. Worst of all, as has already been suggested, they are usually assumed even by their friends and by public officials and by physicians and by everyone to be mentally normal! They are often attractive, likable-even in certain ways quite capable. They are permitted to marry and to reproduce which they do with greater fecundity than the normally minded, and as feeblemindedness is directly transmissible, the increase in the feebleminded population of the world goes on apace.

Above the morons and below the normal standards is a vague group of "sub-normals." They are a poorly-defined group and seem unimportant only because the morons are at present so conspicuously more important.

Weigh, now, something of the numerical frequency of this disease. The older estimates place it at from three to twenty per thousand population, usually giving the lower figure.