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THE KINGDOM OF EVILS

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THE MACMILLAN COMPANY

NEW YORK • BOSTON' • CHICAGO • DALLAS
ATLANTA • SAN FRANCISCO

MACMILLAN & CO., Limited

LONDON • BOMBAY • CALCUTTA
MELBOURNE

THE MACMILLAN CO. OF CANADA, Ltd.

TORONTO

THE KINGDOM OF EVILS

Psychiatric Social JVork Presented in One Hundred Case Histories To-
gether with a Classification of Social Divisions of Evil

E. E. SOUTHARD, M.D.

Late Bullard Professor of Neuropathology, Harvard Medical School; Pathologist

Massachusetts Commission on Mental Diseases; Director, Boston Psychopathic

Hospital; President, American Medico-Psychological Association

MARY C. JARRETT

Associate Director, Smith College Training School for Social Work; formerly Chiei
of Social Service, Boston Psychopathic Hospital

WITH AN INTRODUCTION BY

RICHARD C. CABOT, M.D.

Professor of Social Ethics, Harvard University
AND

A NOTE UPON LEGAL ENTANGLEMENT
AS A DIVISION OF EVIL BY

ROSCOE POUND

Dean of the Harvard Law School

BOSTON COLLEGE LI BRAKY
CHESTNUT HILL, MASS.

THE MACMILLAN COMPANY
1922

PRINTED IN THE UNITED STATES OF AMERICA

Set up and printed. Published October, 1932.

Press of
J. J. Little & Ives Company
New York. U. S. A.

The Memory of

JOSIAH ROYCE

WHOSE WORK ON

THE SOCIAL CONSCIOUSNESS

THE PROBLEM OF EVIL AND

THE PRINCIPLES OF ORDER

HELD OUR OWN WORK

IN SOLUTION.

PREFACE

The writing of this book had been completed, with the excep-
tion of a few passages, and the form of it had been planned
before Dr. Southard's sudden death from pneumonia in Feb-
ruary, 1920. He had said that he would do no more work
upon it after February first, for one might continue indefi-
nitely to elaborate a book such as this. We felt that its chief
value would lie in the suggestiveness of the ideas presented and
not in their completeness. It was not intended that the book
should be either a treatise or a text-book, but a record of ex-
perience with comment. Such a work might serve several
purposes, — to suggest ideas to social workers, to reveal to other
professional persons the nature of social work, and to throw
light upon the problems of mental hygiene for all persons inter-
ested in human life. Mr. Pound has said that "it is a book
to quarry in."

Among the passages that Dr. Southard had not written were
some on medical subjects, which his friend. Dr. Harry C.
Solomon, was kind enough to write in accordance with views
held by Dr. Southard.

The cases were not chosen as examples of successful social
work, but were selected because they were believed to be in-
structive, whether by reason of success or failure.

The work of the social service of the Psychopathic Hospital
during the period that this book records was the sum of much
earnest and thoughtful effort on the part of many workers,
assistants, students, and volunteers, to whom I wish that I
might make personal acknowledgment at this time. Among
the assistant social workers who had most to do with the de-
velopment of the work were Mrs. Helen Anderson Young,
Mrs. Maida H. Solomon, Miss Helen Wright, and Miss

viii PREFACE

Dorothy Q. Hale. Among the physicians who helped most to
develop the social work of the hospital were Dr. Herman M.
Adler, Dr. A. Warren Stearns, Dr. Abraham Myerson, Dr.
Frankwood E. Williams, and Dr. Harry C. Solomon.

Mary C. Jarrett.
Boston,

July 22,, 1922.

INTRODUCTION

This book should appeal to a very wide pubhc because it is
a vivid transcript of poignant human experience — a record of
human misfortunes and their healing. But this record should
be especially illuminating because it is written by a man who
was many men at once. He gathered these human documents
as a student of mental disease and mental suffering; but he
saw them also with the sympathies of a social worker and the
insight of a philosopher. Philosophers do not often go to
psychiatric hospitals. Psychiatrists are rarely of a philosophic
turn of mind. Neither philosophers nor psychiatrists have
until lately been concerned with concrete, moral, educational, or
juristic problems, with which the authors here deal.

But Dr. Southard has in this book given us the mirror image
of his many-sided mind, incurably interested in all human suf-
fering, no matter where it led or whence it came, unwilling to
confine his interest within any boundaries, — scientific, profes-
sional, or temperamental, — until he had understood a sufferer's
troubles to the bottom. He has given us, therefore, a book
full of cross-lights. He lights education from the side of medi-
cine, law, and economics. He shows the doctor how he looks
to the educator, to the lawyer, and to the social worker. He
brings medical habits of thought into jurisprudence, economics,
and education.

The book is full of technical terms not all of which are
translated. But their meaning is soon clear from the context
and their inclusion, — unexplained, — gives one a stimulating
sense of looking straight into a busy workshop and gathering
there the unexpurgated details of the situation. A heightened
sense of reality and frankness results. Meantime, we get a sat-
isfactory familiarity with the psychiatric jargon with which
ere long pretty much all professions must be familiar. Army
men will have to know it — since so many malingerers are psy-
chopaths and so many mental tests (psychologic) are sure to
be incorporated in the army routine of the future.

Judges and lawyers have for some years past been getting

X INTRODUCTION

inoculated with the terms, the mental habits, and concepts of
the psychiatrist, since defective delinquents, epileptics, and the
feeble-minded, as well as the insane, so often are before the
courts.

Politicians and lawmakers must be familiar with the
methods and concepts employed in this book. For our laws
on sedition, our problems of free speech, the purposes and per-
formances of our prison officials, almshouse superintendents,
and asylum attendants can be judged only in the light of psy-
chiatric tests and psychiatric results.

* * * *

The book is written in part to illustrate how doctor and
social worker can co-operate in the care of the mentally
deranged. It also illustrates, I think, how fruitful such co-
operation can be, because the doctor, whose long suit is diag-
nosis, gets the aid of one much stronger than he on treatment,
— namely, the social worker. After the diagnosis there is
often little that the doctor, unaided, can do. The social worker
comes to the front just there. Provided she can get a diagnosis
and prognosis to start from, she mobilizes for the patient's
good resources altogether out of the doctor's reach.

This has been part of Miss Jarrett's contribution to the book.
She has been co-author of the text throughout. But her in-
fluence and her point of view as well as her diagnostic and
therapeutic efforts have been active in the daily dealings witli
the patients here pictured, as well as in the printed pictures
themselves.

I think, myself, that if the psychiatrist were yet a little more
broad-minded, he would call the clergyman as well as the
social worker to his aid and would find his patients thanking
him for a new sort of help now given by neither doctor nor
social worker. But that is for the Utopian future when the
clergy get their rights and come to earn almost the wages of

hodcarriers.

* * * *

One fact certified to in this book is alone and of itself worth'
reading the whole for, — the fact that more than one man who
was too crazy to get along at all in the community outside an
asylum did perfectly well in the army! The army, apparently,
is sometimes wiser than the doctors and social workers in its
environmental guidance of certain poor chaps, who, as soon

INTRODUCTION XI

as demobilized, must again be clapped into an insane asylum.
Surely this sheds light both on the army and on the asylum.
Even though such cases are admittedly rare, even though many
more are driven into asylums by army life, it is surely an
arresting bit of information, that army life is good for the
wits of some. Does this mean that the army provides more
discipline or less than the non-military life, more work or less,
more interest or less, more variety or less? All these possi-
bilities are open. Indeed, I have seen them all fulfilled. But
in any case a new remedy is added to the therapeutic accoutre-
ment of the average psychiatrist when he learns (and if he
believes) that army life did really suit some of the mentally
diseased patients studied by the authors.

^ ^jc ^ ^

Dr. Southard saw his profession as others see it. That is
a rare and valuable power. He did not "claim everything" for
psychiatry. Yet he claimed more, perhaps, than anyone else
ever did, up to his time. For since he included "mental hy-
giene" in the domain of his art and believed that labor dis-
putes, family rows, and international ambitions, as well as
crime, alcoholism, and school-backwardness, belong in the field
of mental hygiene, — it might at first sight appear that he set
no limits to his profession or its scope. But in point of fact,
limits, definitions, clear dividing-lines between adjacent fields
of professional work, were almost a hobby of his, — as this
book abundantly proves. He divides the science of psychology
from the art of psychiatry, and the alienist from the psychia-
trist. He refuses to confound (as psychiatrists and psycholo-
gists often do) the sphere of immorality with the sphere of
disease. Not all sinners are sick — in his view, nor all criminals
psychopaths.

This admirable clearness of definition is one of the out-
standing merits of the book. He ranges everywhere through
the emotions, struggles, diseases, weaknesses, delusions of
humanity. We are beside him in the courtroom, in the labora-
tory, and in the homes of some very queer people. But he
always keeps a clear head. He is never swept into a panic nor
into a wide glittering generalization, never tempted into mer-
gers that obliterate valuable differences. He has nothing of
the fanatic or the doctrinaire except their energy, nothing of
the imperialist except his sweep of vision.

Xll INTRODUCTION

I Wish he could have lived to compress this book some-
what. It is perhaps too literal a transcript from his daily life
and work. Yet there is an advantage in his very copiousness
and reiteration. It is like life and teaches like experience. Its
faithfulness to fact is in some ways more impressive than it
would have been had he cut and selected his material more
rigidly. Who reads this book will learn, — as the writer him-
self learned, — a body of balanced and cautious doctrine, docile
under the "bludgeonings of chance." We can hardly forget
teachings reiterated from so many points of view — just as real
life reiterates them. In the end we are landed square in the
middle of a moving train of thought, orderly and progressive,
but by no means at the end of its run. We are abreast of the
same difficulties, equipped with the same solutions that Dr.
Southard and Miss Jarrett were daily presenting to the current
army of workers, — doctors, judges, social workers, parents, —
who weave themselves in and out of these pages.

That is what he would have wished.

Richard C. Cabot.

CONTENTS

BOOK I— THE THREE MAJOR SPHERES OF SOCIAL
WORK (Cases i to 7)

Public, Social^ Individual

NojE — The literal formulas (P, S, I; P, S; etc.) stand for Public, Social,

Individual.

PAGE

Agnes Jackson, pathetic nuisance (P, S, I)

Richard Sully, morbid altruist (P, S) 8

Jennie Walton, peculiar thievery (P, I) 17

Henry Loyal, "black sheep" ; devoted, irresponsible

father (S, I) 22

Nora Campbell, ladylike adventuress (P) 29"

Alfred Mack, industrial disabilitj^ due to alcoholism

(S) 35

James Bailey, "shell-shock" analogue (I) 42

BOOK n— THE FIVE MAJOR FORMS OF EVIL IN

THE REGNUM MALORUM (Cases 8 to 38)

Six Complex Cases {One Pentadic, Five Tetradic) Analyzed
by Forms of Evil

Note — The literal formulas (M, E, V, L, P; M, E, V, L; etc) stand for
Morbi, Errores, Vitia, Litigia, Penuriae.

8. Rose Talbot, highly intelligent sex delinquent

(M, E, V, L, P) 51

9. Thomas Fuller, moron who set a fire (M, E, V, L) 65

10. Bertha Greenwood, hysterical sex delinquent (M,

E, V, P) 69

11. Lewis Goldstein, illiterate, industrially disabled

(M, E, L, P) 83

XIV CONTENTS

PAGE

12. Elsa Albrecht, mother of illegitimate children

(M, V, L, P) ■ 87

13. Agnes O'Brien, moron, divorcee, devoted mother

(E, V, L, P) 95

Ten Less Complex Cases ( Triadic Combinations of Evil)

14. Margaret Hersey, deaf, suspicious (M, E, V) 98

15. Bessie Polski, "mystery girl," hysterical (M, E, L) 103

16. Mark White, grown-up "spoiled child," psycho-

pathic (M, E, P) 107

17. Eva Collins, weak-willed, alcoholic, syphilitic

(M, V, L) 109

■ 18. Hamilton Green, "ej-e case," alcoholic, spoiled child

(M, V, P) 113

19. John Flynn, industrial traumatic neurosis (M, L,

P) . . . "5

20. Dora Hadley, intelligent sex delinquent (E, V, L) 121

21. Bessie Silverman, ambitious for an education (E,

V, P) 126

22. Elliot Calderwood, so-called "little fiend," quite

amenable (E, L, P) 128

23. Julia Brown, who lived as a man (V, L, P) 133

Ten Binary Combinations of Evil

24. David Stone, who feared open spaces (M, E) 137

25. Alfred Stevens, pilferer (M, V) 142

26. Kevork Ardinian, "work or fight" problem (M, L) 146

27. Herman Simonson, psychoneurotic clothes-presser

(M, P) 151

28. Aimee Prevost, suicidal psychopath (E, V) 154

29. John Manaos, technical deserter (E, L) 158

30. Emma Marburg, poor housekeeper with scolding

husband (E, P) 161

31. Alice Nardini, married to a "black sheep" (V, L) 167

CONTENTS XV

PAGE

32. Catherine O'Connor, quarrelsome wife (V, P) 172

33. Ignatz Simanski, forger (L, P) 177

Five Simple Cases of Evil

34. Daniel Griffin, afraid to go out alone (M) 178

35. John Henry, lad kept a prisoner by his mother (E) 182

36. Clara Perkins, fabricator, mother of illegitimate

children (V) 189

37. Nathan Blumberg, frugality or non-support (L) 192

38. Margaret Dolan, poor, old, overworked (P) 195

BOOK III— ELEVEN MAJOR GROUPS OF MEN-
TAL DISEASES (Cases 39 to 100)

/. Syphilopsychoses

39. Greeley Harrison, costly delay of diagnosis in gen-

eral paresis 203

40. Greta Meyer, widow with syphilis, depressed 205

41. Walter Heinmas, familial syphilis, revealed by

routine examination 207

42. David Collins, foreman in machine shop with gen-

eral paresis 211

"43. Carl Spindler, paretic soldier 215

44. Thomas Scannell, steady young soldier began to

sing, dance, and fight 215

45. Archibald Sherry, twelve-year-old victim of con-

genital locomotor ataxia 2 16

46. Harold Gordon, industrial disability caused by

syphilis 218

//. Hypophrenoses

47. Florence Warner, high-grade moron "football of

environment" 219

48. Bessie Newman, psychopathic family of ten mem-

bers, each an individual problem 223

XVI CONTENTS

PAdE

49. Nathan Rosenthal, imbecile kept at work 229

50. Bernard Bomstein, moron street-car conductor in

the navy 232

51. Howard Driscoll, recidivist with honorable dis-

charge from the army 233

52. Beatrice Cellini, subnormal girl called "vain, idle,

lazy, selfish, untruthful, immoral" 234

///. Epileptoses

53. Luigi Silva, alcoholic epileptic once a reliable

workman 236

54. Patrick Donovan, epileptic who killed his mother 238

55. Charles Lovell, drafted but discharged 240

56. Frank Wayne, enlisted man with seizures after In-

oculation 241

57. John Bristol, policeman, enlisted, had night attacks

following inoculation 242

IV. Pharmacopsychoses

58. John Logan, alcoholic, expert physicist; valuable

employee 244

59. Patrick Nolan, delirium tremens during wife's ab-

sence ■ 250

60. John Sullivan, discouraged real-estate agent with

alcoholic hallucinosis 252

61. Margaret Murray, the root of family dissension,

alcoholic hallucinosis 257

62. Michael Piso, jealous, feeble-minded teamster with

family in need 262

63. Marian Spring, psychopathic woman with drug

habit 267

F. Encephalopsychoses

64. Thomas Warren, salesman with moments when he

"lost himself" 270

CONTENTS XVll

PAGE

65. Helen Fitzpatrick, choreic girl with illegitimate

child 273

VI. Somatopsychoses

66. Ethel Murphy, unmarried mother with mild men-

tal disease 276

67. Joseph O'Brien, mind affected after influenza 277

VII. Geriopsychoses

68. Jeanette Burroughs, widow who saw her dead son 279

69. Catherine Cudahy, enraged by the vindictive tick-

ing of the clock 283

VIII. Schizophrenoses

70. Dana Scott, a chore-man in the country suffering

from dementia simplex 284

71. Ralph Johnson, compensated schizophrenic, once a

vagrant 29 1

72. Manual Rizzo, litigious vagrant and counterfeiter 294

73. Paul Ernst, salesman who lost his position through

an acute attack 295

74. Nora McCarthy, spoiled child who made attempts

at suicide 299

75. Clara Goldberg, girl committed after three years'

observation. 301

76. George Stone, soldier with croix de guerre who

developed paranoid conditions after discharge 306

77. George Mullen, left a state hospital and enlisted 308

78. Paul Dawson, soldier who claimed to be faking

mental disease 308

79. Howard Lancaster, corporal with dementia praecox 310

80. James Hill, army captain with dual personality 310

XVlli CONTENTS

IX. Cyclothymoses

PAGE

8i. Winifred Reed, young woman with wandering

spells 312

82. William Donahue, came as an out-patient because

he "lacked initiative" 317

83. Marie Dubois, governess who needs hospital care

occasionally 319

84. Joe Marino, mischievous boy on probation 321

85. Robert MacPherson, sailor given to "excited

actions" 323

86. Clarence Adams, discharged soldier restless and

over-talkative 326

X. Psychoneuroses

87. Maurice Eastman, psychoneurotic cigar-maker with

financial worries 328

88. Sadie Strauss, hysterical convulsions in a young girl 335

89. Joseph Fangillo, periodic voluntary^ patient 337

90. Dennis O'Donnell, industrial accident case 339

91. Walter Nelson, naval machinist with traumatic

hysteria 341

92. Martin O'Hara, feeble-minded soldier discharged

for hysteria 342

93. Joseph Levenson, drafted soldier discharged for

physical incapacity, is case of psychasthenia 344

XI. Psychopathoses

94. Harriet Farmer, psychopathic typesetter, at-

tempted suicide, trained to competence 347

95. Louis Sand, educated Belgian, wandering and ir-

regular worker 352

96. Theresa Beauvais, girl of bad heredity, victim of

hypersexualis 353

97. Leon Blumer, borderline psychopath, quarrels with

his wife 356

CONTENTS XIX

FAGS

98. Francis Corcoran, boy discharged from the navy

sick and "nervous" 359

99. Manuel Giordani, band sergeant who broke dovrn 360
100. Henry Allen, draughtsman v^^ho had to work alone 361

BOOK IV— EPICRISIS

I. Relations of Social Work to Sociology and Psychiatry 367

II. Method of Approach 375

III. The Method of Book I: Spheres of Influence 385

IV. The Method of Book II : Kingdom of Evils 390

1. Comparison of the Kingdom of Evils with Other

Schemes of Sociological Analysis 402

2. Definitions of the Five Groups of Evils 408

(i) Morbi (Diseases and Defects of Body and

Mind) 409

(2) Errores (Educational Deficiencies and Mis-

information) 411

(3) Vitia (Vices and Bad Habits) 412

(4) Litigia (Legal Entanglements) 413

(5) Penuriae (Poverty and Other Forms of Re-

sourcelessness) 415

3. Causes of Error 41^

4. The Problem of Evil 423

5. Applications of the Five-Fold Classification of Evils

Outside the Field of Social Work 430

V. The Method of Book III: Main Groups of Mental

Diseases 436

1. Neurosyphilis 455

2. Feeble-mindedness 463

3. Epilepsies 469

4. Mental Diseases Caused by Alcohol and Drugs 470

5. Brain Disease 472

6. Bodily Disease 472

7. Old Age 472

8. Dementia Praecox 473

9. Manic-Depressive Psychoses 477

XX CONTENTS

»AGE

10. Psychoneuroses 483

11. Dubious and Special Psychopathias 486

VI. Recent Applications of Mental Hygiene 492

1. Mental Disease in the Great War 492

2. Mental Hygiene of Industry 498

3. Out-Patient Service 512

VII. Psychiatric Social Work 517

1. History 517

2. Organization and Functions of the Social Service

at the Boston Psychopathic Hospital 523

3. Social Case Records 534

4. Technique of Social Diagnosis and Treatment 538

5. Medical Treatment in Social Case Work 549

6. Education for Psychiatric Social Work 552

A Note upon Legal Entanglement as a Division of Evil, by

Roscoc Pound 565

Appendices

A. Social records (full text) of cases 46, 89, and 94 571

B. Social service forms 671

C. Legislation in relation to mental disease, by Frankwood

E. Williams, M.D. 677

Bibliography 683

Index 699

THE KINGDOM OF EVILS

BOOK I

THE THREE MAJOR SPHERES
OF SOCIAL WORK

Public (Governmental)
Social (Voluntary)
Individual (Personal)

ANALYZED IN SEVEN SPECIMEN PSYCHIATRIC CASES

Then Job ansivered and said,

Be it indeed that I have erred,
Mine error remaincth with myself.

Behold, I cry out of zvrong,

but I am not heard;
I cry for help, but there is no justice.

All my familiar friends abhor me.

And they whom I loved are turned against me.

Have pity upon me, 0 ye my friends;
For the luind of God hath touched me.

Job, Chapter 19, Verses i, 4, 7, 19, 21.

WOMAN ART STUDENT
IMMIGRATION SERVICE

In England

Bad Heredity
Quarreling

Estrangement from Family
Threats Against Family
"Nervous Breakdown"
Irregular Occupation
Sex Delinquency

In U. S. '

Convalescent Care
Unemployment (Voluntary)
Insufficient Income
Charitable Aid
Suicidal Threats
Public Nuisance
Deportation

Undesirable immigrant and pathetic nuisance: vicissitudes;
deportation. Effects of a faulty diagnosis and therefore
prognosis (neurasthenia in a woman not at all neurasthenic).
To illustrate public, social, individual problems.

Case I. Miss Agnes Jackson was sent to the Psychopathic
Hospital for observation from the Immigration Station at
Boston. She was a "mental" suspect and rather an appealing
figure. She herself said that in England she had had a "nerv-
ous breakdown." It seemed doubtful whether she could main-
tain herself on the small income she possessed, an allowance
from her family and a scholarship to cover art school tuition.
But finally she was admitted to the country in the joint care
of the director of the school she was to attend and the social
service of the hospital.

Correspondence with England shortly proved her the daugh-
ter of a professional man who had committed suicide a year
before. It appeared that her mother, brother, and sister were
living in England; but that she could not get on with them
and believed that they were persecuting her. Several years
earlier she had had a spell of bad temper and quarrelsomeness
after a love affair that did not come off. She won a scholarship
to study art in London, but had not fulfilled her contract.
About this time she had been observed in a London hospital,
where the (erroneous) diagnosis "neurasthenia" was made.
The parish rector wrote that she was "thought to be not right
in her head and her work as an artist was considered very
moderate." At the art school here, however, she was said to
have some unusual native ability.

After a week in the hospital she was sent to the country to
recuperate (through funds raised for the purpose) because
she complained of feeling weak and distraught as a result of
her detention at the Immigration Station under uncongenial
conditions. At the boarding house where she stayed she made
unreasonable demands and complaints, was untidy, and alto-
gether made herself a great nuisance. She returned to begin

6 THE KINGDOM OF EVILS

her studies at the art school, boarding at a working-woman's
hotel. But in a few weeks she took to her bed and insisted
on having her meals brought to her, saying that she would not
return to her work, as she couM not stand the atmosphere of
the school. It was found that she had been very rude to her
associates there.

Yet she went back after a time and gave no trouble for nearly
six months. A piece of her work was exhibited at a well-
known shop. As the pound-a-week allowance from England
had stopped a friendly artist helped her out with small sums.
Miss Jackson herself made no effort to sell her work and
showed no industry. She talked a great deal about what would
be done for her by this friend and another young woman, a
fellow student, who had become interested in her. She con-
tinually talked about wanting to meet men, insisting that her
friends should help her find a husband. She wrote volumi-
nous rambling letters to them, and also to a physician at the
Immigration Station, telling of her misfortunes and her
unhappiness.

Meanwhile, she had turned against the social worker; but
finally she came to the hospital, weeping and distraught, and
was taken in as a voluntary patient. After a brief stay she
was discharged, but pursued the same tactics. After two
months the more serious step was taken of committing her to
a state hospital for longer observation. In the course of time
she was sent to England in care of a special attendant, to be
returned to her family. This ends the American story of
Agnes Jackson and the whole story so far as it has yet
unfolded.

The American history of Miss Agnes Jackson thus lasted
hardly over a year. The nucleus of these troubles was beyond
a doubt psychopathic. Although a psychopath ought to engage
one's sympathy and although Miss Jackson at the outset pulled
every one's heartstrings, she remains in the minds of all more
a pest than a patient.

Erom the immigration office standpoint she was an undesir-
able citizen, because a small art scholarship and the pound-a-
week allowance plainly could not support her in America.

Erom the point of view of the social worker, the initial ap-
peal of a young English art student of refinement, dropped
from a Cunarder into the detention quarters of the United

THE KINGDOM OF EVILS 7

States Immigration Office, was extreme. Yet whatever was
done for her by officials or by new-found private friends, all
ended in a pathetic tangle of minor troubles, amounting to a
bit of a tragedy. Whether in England there had been anything
really tragic may never be knbwn, though our full accounts
from London leave Love largely out of account and minimize
the part that Money might have played in the unfolding of
events. What tragedy may in future come to her in England
we cannot say; but no doubt the same initial appeals and the
same lapses into misunderstanding will continue to be her lot.

What after all is she from the medical point of view? Is
the fact significant that an elder brother is badly affected with
a disseminated sclerosis? On the whole, the hereditary taint
in Miss Jackson strikes one as rather slight. Ample studies
of her personality both here and abroad fail to place her case
beyond cavil in any major group of mental diseases, though
no doubt can attach to considering her in some wise psycho-
pathic, and even possibly amongst that group of degenerative
diseases so unfortunately termed dementia praecox.

As we study the case in detail we are not only able to bring
out the governmental, social, and medical troubles, of which
this "pathetic nuisance" was a paradigm, but we also find her
more or less the vehicle of many, if not all, of the major sorts
of evil that the world (according to our classification) has to
face. As we hope to show in the sequel of this book, there are
evils and evils. But amongst these, we may distinguish at least
five great classes. There is, for example, the class of Diseases
into which Miss Jackson readily falls by virtue of her psychop-
athy. Again, there are the evils of Ignorance ; that is, of poor
education, of misinformation, of the improper digestion of
facts through lack of judgment, not necessarily in itself psycho-
pathic, and of these, our paradigm case is not without good
examples, of which her coming to America at all may serve
as the greatest. There are also evils of which the sequel will
supply far more striking examples in which various Bad Habits
and Vices, non-psychopathic, form the chief constituents. Con-
cerning these in the case of Miss Jackson, it may be difficult
to disengage her laziness and tactlessness from the effects of
psychopathy; but at first sight at least these ways of hers struck
her friends and acquaintances as the effects not of disease, but
of poor training. Sometimes again, the individual victims of

8 THE KINGDOM OF EVILS

trouble fall into the clutches of the Law or of public service in
sundry ways. Miss Jackson was a good enough example of an
"undesirable immigrant." Again there are evils of a purely
economic nature, Poverty and other forms of resourcelessness
— and it may be well supposed that under certain circumstances,
if the Jackson family in England had been on a higher eco-
nomic level, the life of Miss Agnes would not have been cast
in its peculiar way, and in particular she might never have
undertaken her American journey.

Hours spent by Medical record, 65 pages

Social record, 26 pages
Physician, 145^^ Social work :

Visits. 13
Psychologist, i Interviews at hospital, 14

Telephone calls, 20
Social worker, 36 Letters, 20

Morbid altruist and boys' club organiser. Delinquency ex-
plained as due to mental disease (psychopathic personality). Re-
covery, in all public and social senses.

Case 2. Richard Sully was a kind of morbid altruist. Like
Agnes Jackson, Richard was beyond a doubt psychopathic,
yet the psychopathic difficulty — a mild defect of the group of
so-called constitutional inferiority — was not of such a sort as
to perturb Richard's peace of mind or any other of his internal
relations and self -adjustments. The trouble seemed almost
wholly one of a social nature with occasional public contacts,

Richard first came under expert observation at fourteen.
He became beset with the idea of starting boys' clubs. It dis-
tressed him, he said, to see boys idle on the street — they ought
to get into clubs where they could read. He would hire a
room, or perhaps a building, and give orders for suitable furni-
ture. Sometimes he bought refreshments, hid them in his own
house, and ended by eating them himself, as the proposed boys'
clubs had as yet no members ! Between these organizing efiforts
he worked hard, helping about the house and helping in neigh-
bors' houses. He so helped his church janitor that he was even

THE KINGDOM OF EVILS 9

finally made janitor of the church at $3 a week. His earnings
he gave to his mother.

His school work had been lapsing for about two years. A
psychological examination at the age of fourteen showed him
to be by the Binet Scale actually of a higher mental age level
than his actual age ; namely, fifteen. A test a year later showed
a Binet rating of 12 2/5, but by the Point Scale he still rated
at fifteen; in fact at the highest level which the Point Scale
of Yerkes was at that time able to register. The psychological
examiner reported that Richard was not feeble-minded and
yielded no evidence of deterioration, that he was quick and
accurate in learning. His analytic ability was especially good.
So far as tests went, he was perhaps slightly limited in his
power to interpret complexities (so-called "apperception"
tests). As for the other mental faculties tested, they were of
satisfactory quality, nor would one perhaps often find in a
youthful psychopathic suspect like Richard so regular a test.
In particular, he had grasped and retained his school knowledge
well. On the basis that his imaginative and planning powers
were not quite as strong and rapid as normal, the examiner
risked the suggestion that Richard might possibly be a patient
defective on the side of the will (and hence not defective within
the range of many of the tests) and normal as to emotions and
intelligence.

We here specify, concerning these psychometric tests, a little
more detail than is strictly necessary; for we want to stress
the great negative value of the mental tests. The patient's com-
paratively high intelligence is a factor to reckon with in ex-
plaining the peculiarity of his delinquencies, and a factor to
be considered in building up a treatment procedure and a
prognosis.

Now the outcome, at least in the six years during which
Richard has been under observation, seems a comparatively
good one. During the past four years there have been slight
ruffiings of the surface (occasional inquiries as to whether it
was not now time to organize another boys' club), but these
suggestions have been readily nipped in the bud by his
advisers. Once even he went so far as to utter a small
check, so that there is no doubt that the defect of will is
still latent.

Along with Richard's rather minor individual difficulties,

10 THE KINGDOM OF EVILS

chiefly a defect of will, it is plain that the bulk of his diffi-
culties are in his relations with his family, with the church
people, with the boys whom he tried to steer into his vaguely
altruistic clubs, and with the tradesmen and others from whom
he tried to obtain money. The public — that is, governmental —
aspect of Richard's case was, with respect to the courts, rather
more a matter of the "eternal not quite" (when brought to
court the judge would tend to file the case, or not consider it,
on the score of Richard's youth and the peculiarity of his of-
fense) ; yet Richard was a pretty well-known figure to the local
police, who would from time to time step in as good neighbors
and help his mother straighten out his tangles. Another public,
or governmental, feature of Richard's case was his commit-
ment to a state hospital, which seemed advisable upon his at-
tempt to float his fifth club enterprise. That he had a definite
psychosis was perhaps never actually proved.

Richard entered the Psychopathic Hospital under the volun-
tary relation in a rather peculiar way in his fourteenth year.
He arose from bed at home one night very late, took sixty
cents from his mother's purse, climbed out of the window,
hatless and coatless in a pouring rain, and reached the hospital
drenched.

There was a kind of suggestion of the epileptic fugue in this
and similar escapades, yet no convincing epileptic features were
otherwise discernible. According to Richard, he read too
much and got to day-dreaming. The physicians who com-
mitted Richard to the state hospital (under Massachusetts law
physicians not connected with the state hospital staff must in
the interest of the patient be called in) perhaps suspected that
he was an early case of schizophrenia, (dementia praecox), as
they called attention to a change in Richard's nature at the age
of twelve, wherein he became less thoughtful and began to have
things bother him. He told the committing officers that he did
not sleep for six months at a time. He told them that he had
formed about fifty boys' clubs of the same general nature. He
was accordingly sent to a state hospital, and thence went home
on a visit after a period of six months, for the greater part of
which he was granted parole and helped about the laundry, a
good and willing worker. He was there regarded as a "con-
stitutional inferior." He was carried on the books of the hos-
pital for six months and then discharged, with a request to

THE KINGDOM OF EVILS II

report from time to time at the Psychopathic Hospital. There
he took baths, as prescribed, somewhat regularly.

With the exception of the two small upsets mentioned above,
he now became and still remains an industrious and faithful
shoe worker in a factory. The clubable side of Richard's
nature has now got its satisfaction in sundry church societies.
Richard has always been on good terms with the Psychopathic
Hospital and continually brings magazines for the patients,
and at one time brought over his church club to entertain them.

We are not here attempting to expound the entire medical
story of Richard Sully; yet it is clear that the diagnosis "con-
stitutional inferior," accurate though it may be, might well
give the wrong impression to laity and to physicians of the
prognosis. At the age of tw^elve a boy undergoes a change
of character and develops a sort of morbid altruism, endeavor-
ing to organize boys' clubs and breaking rather obvious busi-
ness rules in the process. He gets into medical and social
hands, both under the voluntary relation and under the legal
cjmmitment relation in the state hospital system, and somehow
works out of his psychopathic phase into a comparatively nor-
mal status. To be sure, in this normal status traces of his altru-
istic trend persist; he joins church clubs, sings in the church
choir, is a member of the Massachusetts State Guard, of the
Young Men's Christian Association and the like. Yet at pres-
ent he cannot be regarded as much, if at all, outside the range
of the normal.

Were there any features in Richard's earlier life which
might have given a warning? It is said that he had been some-
what seclusive from early childhood, not caring to play with
other children and preferring to read and study alone. He
cared for no games or sports except skating. He rather early
attempted to assume responsibility in his family and always
wanted to escort his mother to the street cars and the like. He
was for a long time troubled with tonsillitis, for which he was
operated upon. Antitoxin administered for diphtheria at eight
years of age partially paralyzed him for a time. The sex side
was regarded as normal.

The boy's father deserted his mother, and during the father's
numerous unexplained absences (before the final desertion and
imprisonment) Richard grieved greatly and sat by the window
to watch for his father. After the final desertion, the boy con-

12 THE KINGDOM OF EVILS

ceived and stated that he now had a family to support, though
he was then but eight years of age. It is possible, or at least
conceivable, that a precocious ripening process in the boy's
mind was somehow started after his father's desertion of the
family. Both the father and the paternal grandfather were sex
delinquents, and the paternal grandfather was a suicide. The
paternal grandmother and two siblings were respectively un-
social, suicidal, and sex delinquent. A younger sister of the
patient is choreic. Upon the maternal side there seems to be
no taint, unless a certain tendency to vascular disease. So far
in Richard's history the other sex has not appeared, save in
his normal relations with his sisters. His interests have con-
stantly attached themselves to persons of his own sex. A psy-
choanalyst who examined him was inclined to regard him as
showing a "conflict, somewhat homosexual." This diagnostic
suggestion was thought to be supported by the so-called "intel-
ligence complex" shown in association tests, wherein twenty-
eight per cent proved to be "logical definitions." The thought
that after his father's desertion he must now be the head of
the family was also regarded by the psychoanalyst as supporting
the above mentioned "conflict." It seems that at the age of six
Richard had been excluded from some club of boys of his own
age, whereupon he had begun to dream of a club of his own,
which dreams may possibly have started the club forming habit
of his early teens.

The social worker at the state hospital where Richard spent
six months several years ago still supervises him. She wrote
us the following report recently : —

"Since I reported to you in March 1919, Richard has been
getting on exceedingly well. He has been working regularly
at Gordon's Shoe factory in East Boston and is now on piece
work and earns an average of four or five dollars a day, and
sometimes makes as much as seven dollars a day. He has not
attempted to take any responsibility in the Church, although he
has attended their young people's meetings faithfully and still
enjoys his associations there.

"During the summer he had a vegetable garden in one of the
lots given out by the City, in which he worked after returning
from the factory at night and during other spare hours. This
proved to be very beneficial, as it kept him outdoors and gave
him healthful exercise, as well as helping the family with the
food problem. His mother helped him in this.

THE KINGDOM OF EVILS 13

"Although he had secured his discharge from the Local State
Guard Company, in which he had been a Corporal, — upon our
suggestion, — when the Police Strike occurred in September the
men asked him to re-enlist and he felt it his duty to do so. He
served with them during this trouble, but when the worst was
over, he resigned again upon our urging him to do so, as it
was keeping him from getting as much sleep as he needs.
Because of his mental condition we did not approve of his doing
a thing of that sort, although we did not know he was out on
duty until he had been there a few weeks. As it was, nothing
happened and he quite enjoyed the experience, and the factory
made up his weekly pay to the average of what he was making
at the plant.

"The local Red Cross Home Service has been visiting the
family during the past year as Mrs. Sully discovered that her
husband was in the Canadian Army and they helped her
to get money from Canada. They have kept strictly off the
problem of Richard individually, but I am glad to have them in
closer touch with the family than I could be."

We have to deal, then, with a boy who apparently passes
through a minor psychopathic phase for a period of three or
four years about the time of adolescence, but before and after
this phase shows but few signs of such a trend. Various
diagnoses from the medical side, such as constitutional inferior,
predementia praecox, early dementia praecox, even epilepsy and
manic-depressive psychosis, were from time to time offered.
The committing officers, bound to act on concrete data, were
nevertheless in not the slightest doubt as to their duty to com-
mit him to a state hospital. Before this latter decision w^as
arrived at, all sorts of doubts had reigned concerning the diag-
nosis, some physicians proposing that he was not demonstrably
psychopathic, but was, on the contrary, a rather pure example
of a delinquent, deserving prison bars rather than the comforts
of an asylum.

We analyzed the case of Agnes Jackson not only from the
standpoint of the description of her troubles as public, social,
and individual, but also (anticipating the considerations of
Book H) from the standpoint of the kinds of social evil, of
maladjustment, which she displayed. Following a similar plan
with Richard Sully, we find him falling, of course, in the class
of Morhi (Diseases) by virtue of his mild psychopathy.
Whatever be the trend, or eventual outcome, of this psychop-

14 THE KINGDOM OF EVILS

athy, (schizophrenic, epileptic, or otherwise), Richard Sully
has at all events what physicians call a forme fruste of some
sort of mental disease or defect.

How shall we classify Richard with respect to Err ores, the
evils of Ignorance? Unlike Agnes Jackson, who did show the
effects to some extent of poor education, misinformation, and
lack of judgment, Richard not only tested well by the set psy-
chological tests, but seems, on the whole, to have been rather
well educated and well informed. An adult insight and judg-
ment should not be expected.

On the side of the Vitia, that is, the Bad Habits and Vices,
Richard must be regarded as equally without pronounced de-
fect, unless we regard with some authors any sort of exagger-
ated altruism as a form of vice ! Shall we regard the forgeries
and other delinquencies as at all the effects of moral perversion?
Certainly, the tendency of the Psychopathic Hospital staff in its
analysis of Richard was to regard these defects as rather more
psychopathic (that is. 'falling within the group of mental dis-
eases), than morally vicious. (We do not care to take up here
the question of an eventual proof that some one may bring
that moral perversion is in and of itself psychopathic. Such
a proof may possibly arrive. For the present, however, we are
employing the group of the Vitia to contain such bad habits
and vices as might conceivably be drilled out of the bearer by
proper moral training, or even prevented by proper early man-
agement. It is in this latter sense of the group of the Vitia
that we do not regard Richard Sully as a morally dishonest or
immoral person.)

Clearly Richard's case falls in the group of the Litigia, that
is, of legal and similar entanglements ; for as we have seen, he
was frequently at least within the shadow of the courts.

It is true that the economic status of the family was at best
"marginal," but no special effect upon the psychopathic status
of the boy can be ascribed to the plight of domestic economy.

Hours spent by Medical record, 47 pages

Social record, 10 pages
Physician, 7 Social work:

Visits, 4
Psychologist, i Interviews at hospital, 4

Telephone calls, 8
Social worker, 12 Letters, 13

PSYCHOPATHIC THIEF
WOMAN (ILLEG.) 27

1Q16 19 1 y

Arrest Discharged from Probation

Poor Health Care of Body (incl. Teeth)

Cut Off from Family Living with Friends

COMPLICATION : CHILDHOOD SEX TRAUMA

Thief. Infantile sex experience. Physical and psychical
waves of disease. "Empathic index" question. "The patient's
confidence." Public and individual problems.

Case 3. Jennie Walton's mother is said to have had some
Indian blood. Jennie was an illegitimate child, and her pater-
nity was never established. We present her as a paradigm of
mental disorder leading to public (governmental) rather than
family or other social complications. Medically, she should
probably be placed amongst the psychopathies. She was
arrested for stealing, and, although one might be tempted to
make a diagnosis of kleptomania, on the whole the delinquency
is probably a minor incident rather than the effect of a strongly
marked special instinct, and the fact that simple and obvious
social service measures served to straighten out the Walton
case (without resort to elaborate and specially designed reedu-
cation or moral reformation) permits us to think that her psy-
chopathy was of a minor degree. Such merely social (non-gov-
ernmental) complications as did exist were so slight as to be
negligible.

Jennie Walton came under hospital observation at the age of
twenty-seven, having been arrested for stealing patients'
clothes, linen, a fur coat, and utensils from two hospitals,
where she had been employed as a domestic for half a year
previous. The girl had been of such exemplary character and
had so many intelligent, good friends amongst previous em-
ployers that the arrest came as a shock to these friends, one of
whom wrote that the arrest must be a "fearful mistake" due to
a "conjunction of circumstances seeming to implicate her."

However, it appeared that her work at the hospitals from
which she stole had not really been satisfactory and that for
a period of some five years those who knew her well thought
her disposition peculiar in that she was "almost morbidly sensi-
tive, heedless, impulsive, and reckless with money." As for a
previous history of stealing, there was none; but she was noted
for collecting and hoarding buttons, ribbons, clippings, and

l8 THE KINGDOM OF EVILS

poems. She seemed to be rather ambitious and of the type
known as a "born leader." She had a certain skill in making
clothes out of cast-off things, but no motive of self -adornment
could be traced in several of her pilferings. In thirteen years
of work in various families she had saved no money what-
ever. One might naturally inquire whether such a patient as
Jennie was more or less hypophrenic (feeble-minded). Mental
tests led the psychologist to say that the patient was certainly
not feeble-minded. She yielded a fairly even rating at the four-
teen year level, losing some points on her association tests and
on the tests for logical and practical judgment ; that is, the see-
ing of analogies and absurdities and the like. Should she be
regarded as, if not a moron, then perhaps a border-line or sub-
normal person, in the sense of being above the moron level but
below the normal? The psychologist remained in doubt, but
went so far as to say that the patient graded somewhat below
expectation for her age and class. Now her "class" looked
better to the psychologist and to any casual observer than it
proved to be. She had a shell of special information, having
taken special courses in domestic science and in first aid for the
injured, but in the meantime had never completed her grammar
grades.

When the girl was a baby, her mother was married to a man,
not the girl's father, an alcoholic and abusive person who
allowed the mother to support the family. Sex relations (age
seven to fourteen) with this alcoholic stepfather formed a
rather extraordinary episode in the girl's history, according to
her own story. In the girl's conscious life this history played
a considerable part. She complained bitterly of the robbery
"of all that is dear to a woman." She would readily tell neither
about the larceny nor about the sex history, nor was any one
of several medical approaches successful in starting a stream
of confidences. Finally a friend and confidante was found to
whom enough of both stories was confessed that the main out-
lines of the situation were clear.

The medical side of the story was not without bearing on
the patient's estimate of herself and upon the psychiatric diag-
nosis. She had had many and various children's diseases. At
eighteen she described herself as having had a kind of general
debility from overwork. Whether this was connected with her
engagement to a man at nineteen, broken off when the man

THE KINGDOM OF EVILS 1 9

shortly afterwards entered a forced marriage with another
woman, remains doubtful ; but the old incest story and the
breaking of this engagement "soured her," she said, "on all
mankind," so that she was in a way "to become a man-hater."
In this nineteenth year it appears that she had a sort of exhaus-
tion attack for a fortnight. She was operated on at the age of
twenty-four for appendicitis, and in her twenty-fifth year re-
sorted to an osteopath for exhausted muscles. In her twenty-
fifth year she was operated on for peritoneal adhesions; her
ovaries were removed at this time. Concerning the oophorec-
tomy, she claimed that it was. in the opinion of her physicians,
made necessary by the trauma of her childhood. She had then
woven her incapacity to bear children into the general situation
of disgust with the world.

Yet, despite all this checkered history and interweaving of
embittered comment by the victim and although for the first
part of after-care by the social service her behavior was in
some respects queer and even psychopathic, at the end of a
year she had so far restored herself to a normal attitude that
her case was closed by the hospital social service and was placed
on file by the court.

One's prediction about the future of such a case as that of
Jennie Walton might well be influenced by preconceived no-
tions. If we took her for an inborn psychopath of mild degree
— the psychopathia being, as it were, stamped in by childhood
sex experiences and at last emerging in the overt act of lar-
ceny— we might give her a rather unfavorable prognosis. At
the time of hospital observation she was in rather poor health.
Her teeth, especially, were bad. It transpired also that she
had been for eighteen months at a state hospital for tubercu-
losis (pulmonary, no longer in evidence), ^\'e must remember
the occasional spells of exhaustion, dating from the late teens,
which though ill described, may possibly represent some sort of
periodic or wave eft'ect in her physique, reflected also in her
mental life.

We have recorded that the psychometric rating left case
Walton as certainly not a moron and as not clearly subnormal
in a milder degree. Psychiatrically examined she proved not
abnormal. She was, to be sure, somewhat sad at times, but a
psychopathic depression could not be proved. The only ques-
tion raised was that of delusions, as lennie told a storv of the

20 THE KINGDOM OF EVILS

conspiracy of fellow employees, suggestions to inaugurate a
strike, refusal to admit sex advances by hospital employees,
placement of articles in her room by fellow employees wishing
to do her injury, and the like. These stories were interpreted
by us as part of the defense-reaction of one charged with
delinquency.

A systematic review of her case by physicians and social
workers in staff meeting led to the diagnosis of "psychopathic
personality," but without especial grounds therefor, except the
patient's history and the general impression that somehow she
was psychopathic rather than delinquent. Several physicians
thought the outlook was medically bad. Some physicians
thought she might be merely psychopathic in the mild sense of
the so-called psychopathic personality, but that she might even-
tually turn out to be psychotic (in the sense of having a definite
mental disease).

After the first six months of her period of social supervision,
she seemed to bear out this idea of poor prognosis. In a vari-
ety of domestic places the girl did on the whole rather poorly,
and from time to time rather suspicious things happened. A
pin or two disappeared, which she might have stolen ; a fire
was set, possibly by her. One night she moaned in bed for
hours and stayed in bed the next day. She sometimes resorted
to osteopathy, and got a diagnosis at a general hospital out-
patient department of "chronic arthritis (teeth)" whereupon
she went regularly to a dental clinic. She came down with
German measles and had a bad cold and the grippe. Mean-
time she kept endeavoring to get work and to do it as well as
possible, and by the end of a year she seemed to have worked
out of her susceptibility to illnesses and got upon a better level
of physique (all this helped out by a pleasant summer with
friendly people). There were no further suspected stealings or
other bits of odd behavior. Accordingly, as above noted, her
case was put upon file.

We note that the exceedingly few social complications in
Jennie Walton's case rendered social service relatively easy, as
throughout her adult life it still proved possible, after her mis-
adventures, for her to find good and highly appreciative friends.
It took some six months for her psychopathic phase (if it was
such) to pass and for the social workers to establish them-
selves on a confidential basis. This was not so much a ques-

THE KINGDOM OF EVILS 21

tion of continued or increasingly clever efforts at gaining Jen-
nie's confidence as it was a matter of the passing of what we
finally concluded to be a pretty definite psychopathic phase.
Whereas it would not be safe to think of Jennie Walton as
clearly a periodical psychopath (in the sense, e.g., of the so-
called cyclothymic constitution), nevertheless a review of her
entire history yields traces of such a phasic course.

Should she again appear in the courts or in the hospital and
fall again within the medical and social service range, no doubt
the procedure would be much clearer. In the meantime it would
be medically impossible to say either that she is definitely peri-
odic or that she is at all certain to have a further episode.
Amongst the ill-defined psychopathias which fall short of the
full-blown psychoses (which latter we find typically in insti-
tutions), there may be a kind of psychopath with a periodical
trend, a sort of forme fruste of the out-and-out "manic-depres-
sive" psychosis. Yet various other psychoses have periodical
or phasic tendencies. After all, the psychologist did find a
certain subnormality about- the case, a certain lack of logical
and practical judgment. Sundry misspellings and a certain
simplicity characterize her letters. Thus (after receiving a
Christmas present) :

"I simply cannot find a thank you big enough to tell you
how delighted I was with the dear little book you sent me.
When I read it my delight was doubled threefold, for I think
the good fairy whispered to you that it was a set of my favorite
quotations which I have scattered around on scraps of paper
and which never can be found when needed most to drive a
cloud of the blues away."

Again we may try to resolve this case from the standpoint
of the distribution of social evils. We have sufficiently dis-
cussed her disease and its rather doubtful end, yet there are
plain somatic as well as psychic factors therein. As for poor
education, there is a certain evidence of this, and a certain
superficiality in the education which she had actually received ;
.but it does not appear that her comparatively poor education
really contributed much to her difficulty, nor is it easy to ascribe
to her any altogether unfortunate moral attitude, despite the
fact that her interpretation of her childhood misfortunes and
of her later psychopathic complications were not always sound.
Yet it is probable that the unsoundness of these interpretations

22 THE KINGDOM OF EVILS

is to be attributed rather to her psychopathy than to any actually
poor moral training. Her legal difficulties are obvious and
no doubt tended to obscure the physician's interpretation of
her case on account of the defense-reactions so natural to men
and women when entangled in court. Nor was the Walton case
particularly a case of economic disability, though her state was
"marginal" rather than on the so-called "comfortable" level.
Nor was the will to earn her living ever lost. The difficulties
facing the social workers in their general attitude to such a
case are not easy to state. In the face of a rather poor medi-
cal prognosis (to say nothing of the prevailing general, though
baseless, feeling of doubt as to the outcome in all psychopathic
cases), the social workers had the duty of keeping up their
supervision steadfastly until somehow the patient's mental
state cleared up. This process of clarification of Jennie Wal-
ton's mind, running pari passu with a great improvement in her
physique, took about a year to bring itself about.

Hours spent by Medical record, 33 pages

Social record, 26 pages
Physician, 6 Social work:

Visits, 66
Psychologist, i Interviews at hospital, 4

Telephone calls, 17
Social worker, 112 Letters, 40

Black sheep. Generalized psychopathia sexualis. Neuras-
thenia elements removed. Moral improvement ("more of a
man" suggestions) . Social and individual problems.

Case 4. Henry Loyal was a steamfitter. He had been for
many years, at least since puberty, in constant social difficulties.
Looking back over his life up to the age of forty-eight, one
was tempted to relate these difficulties to drunkenness, gambling
habits, sex escapades, and a sort of general irresponsibility in
life. He was the acknowledged black sheep of a middle-class
American family. An analysis of this so-called black sheep
will prove conclusively that he was a psychopath, and that all
his troubles, medical and social, could be, and have in fact been,
greatly improved by the hard work of his official friends.

His friends, whether medical, social, or casual, could not

THE KINGDOM OF EVILS 23

fail to be impressed with the profound irresponsibility of the
steamfitter. What with the fit fulness of his trade and the
numerous occasions in which his psychopathy would break out,
the task of adjusting him to an environment was not easy.
Nevertheless, in the end, what with advice to the man, advice to
his wife, and an unusually close supervision, he has now become
what, without straining the point, may be called an encourag-
ing example of psychiatric social work.

The case was most unpromising, and, throughout our four
years' supervision, it was never possible to avoid an occasional
lapse into destitution on the part of the family, and recurrent
dissipation on the part of its central figure. There was a slack,
profane wife, who was alternately devoted and jealous, and
there were four children, all variously affected by disease or
defect (one choreic, another tuberculous).

The husband had long been so hopeless a figure that one's
first impulse would naturally be to sever him from the family,
try him a while, and perhaps finally set him adrift (as one says,
"close the case"), and do one's best with the wife and children.
The family, however, despite the centrifugal tendencies of the
father and the profanity and extraordinary jealousy of the
mother, was close knit with profound affection. The paternal
affection was, in fact, the main social lever. The existence of
this lever was all the more astonishing as the man had for
years come home drunk and surly, or stayed away from
home in irregular sex life, or loafed about for days,
weeks, and months, gambling: every now and then subject to
violent spells of rage and cruelty. When one learned from
the history in his teens of all manner of unspeakable sex prac-
tices, and an early development of thoughtless and irregular
tendencies, one was the more convinced that really nothing
could be done. When one looked into the family history and
discovered psychopathic taint in several near relatives, one could
only feel the more certain that, after all, one's efforts might well
be wasted.

What shall we term Henry Loyal medically? The strong
heredity, though it strengthens our idea that there exists some
unusual blot in this social defective, does not point to a particu-
lar group of mental diseases having a particular prognosis.
When the man came before the Psychopathic Hospital staff, it
showed diagnostic leanings in many directions. For example.

24 THE KINGDOM OF EVILS

he was suspicious of his hospital friends and rather apprehen-
sive. If one stretched a point, one might think of him as sub-
ject to the so-called paranoid trend, and therefore almost think
of dementia praecox. Yet on the whole, the suspiciousness and
apprehensiveness of the man were hardly more than might be
expected. Again, Loyal had been markedly depressed and his
depression was in sundry details not inconsistent with the diag-
nosis of manic-depressive psychosis (in fact, he had feared
that he was going to commit suicide about three weeks before
he was observed in hospital). On the whole, however, there
was no good reason for regarding the depression as psychic,
and suicide might, with a certain type of mind, be regarded
almost as a natural thought in the family abyss. Again, Loyal
might be regarded as inclined toward the group of the psycho-
neuroses on account of his hypochondria and headaches. Head-
aches had been, in fact, for him the main medical feature in
his life. Once, too, he had fallen and had an attack which,
owing to his being drunk at the time, was called delirium tre-
mens. Whether this attack was actually alcoholic, whether it
was not in part hysterical, or whether it may have been at bot-
tom epileptoid, was another group of questions. Amongst the
ten or eleven great groups of mental disease recognized by
most modern psychiatrists, one might therefore think of ade-
quate reasons for putting him in more than half.^

When a case with numerous psychopathic features does not
strike one as definitely epileptic, psychoneurotic, schizophrenic
(dementia praecox), or cyclothymic (manic-depressive), one
is likely to let it fall into a group for which the favorite psychic
designation of the present day is "psychopathic personality."
Though the psychiatrist might be put to it to define this term,
it is enough to say here that the so-called psychopathic person-
alities are rather apt to bear traits that look in one or other
of the directions just mentioned, and on the whole to strike
even the lay observer as in some degree childish. This latter
idea of the childishness of these patients is expressed by some
authors by the phrase "infantilism," as if the "below par" level
(Minderzvcrtigkeit of the Germans) was somehow an expres-
sion of a slight lack of development. Some classifiers use the
phrase "constitutional psychopathic inferiority" for these cases,

' See pages 436-491 for general discussion and charts dealing with the main
groups of mental diseases.

THE KINGDOM OF EVILS 25

and this phrase is even to be found in our American immigra-
tion laws.

But when we choose to term a man a psychopathic personahty
or a psychopathic inferior, we must constantly bear in mind
the dififerent directions which the mild infantilism may take.
There was always a doubt in the Loyal case just what particular
direction we could describe the psychopathy as taking, espe-
cially since there was, in addition to the suspiciousness, the
depression, the hypochondria and headaches, and the possibly
epileptoid attacks, also a tremendous hypersexuality, so that
one might almost think of terming the man a sort of diffuse
psychopathia sexiialis. In most of these directions he was
somewhat influenceable, and on the whole the psychoneurotic
trend is perhaps to be preferred, if we must press Loyal into a
single compartment. How profoundly important the choice of
a diagnosis may be is to be seen from the fact that by pursuing
the way of therapy (even in this very unpromising case), the
year-long tendency to worry and the habit of headaches (fifteen
years) were actually terminated by treatment.

At this point let us try to throw Henry Loyal into contrast
with Agnes Jackson. Miss Jackson was for us a paradigm of
medical, social, and governmental troubles, a victim perhaps of
mild schizophrenia (dementia praecox), the primary solution
of whose troubles lay in the proper adjustment of medical and
social work to the Immigration Office rules and regulations. If
we try to analyze the case of Henry Loyal from this standpoint,
we find his troubles chiefly medical and social. To be sure,
from time to time the Loyal family would fall into destitution
and require public or semi-public aid mechanized by more elastic
means than are ordinarily possible for strictly public agencies.
In short, Henry Loyal was a public or governmental case only
in an incidental or occasional way. He is a fairly pure com-
pound of medical and social troubles, with the emphasis per-
haps more upon the social than the personal side.

The case of Miss Jackson we found more or less the vehicle
of all the major sorts of evil that we tried to classify under
the five headings of disease {Morhi), ignorance {Err ores),
vices and bad habits (Vitia), legal entanglements (Litigia),
and poverty or other forms of resourcelessness (Penuriae).
Studying the case of Henry Loyal, we find that, as in the
majority of instances in this book, he is the victim of disease;

26 THE KINGDOM OF EVILS

at all events, of a degree of psychopathy that is sufficient to
bring him into all sorts of personal and social difficulty. Shall
we charge him also with being the victim of the evil we call
ignorance? We found him on the verge of feeble-mindedness
by tests, but the psychologists felt that on the whole he must
be regarded as of normal mental level. He was neither a good
nor a poor scholar. He was an adequate steamfitter. He
proved amenable to persuasion if not to conviction, and no
elaborate reeducation or implantation of totally new ideas had
to be carried out in the process. His sex irregularities cannot
on the whole be said to be due to ignorance or poor intellectual
training. On the whole, there was a good deal to go upon
in the practical handling of Henry Loyal, and we must count
him as not falling to any extent into the evil-group termed
ignorance.

Re the third group of evils, as in our paradigm case of
Agnes Jackson, so in the present case, it is difficult to disengage
the bad habits and vices shown from effects of disease. H our
separation of the bad habits and vices, on the one hand, from
the diseases and character defects on the other, is a logically
sound separation, then there ought to be some cases in the
world of persons who unfortunately have not been properly
trained and given the proper moral set-up in life; and these
persons ought, by hypothesis, not to be instances of mental
disease or defect. Such persons ought to be trainable by suit-
able methods, either by way of telling them or showing them
what to do, by precept, example, reward, or punishment. So
far as mere precept and mere example and the common methods
of reward and punishment were concerned, hardly anything
could have been done with Loyal. Punishment would no doubt
have failed. The kind of reward offered was the pleasing sense
conveyed to him of increased responsibility for a family to
which he was tremendously though interruptedly devoted. He
was made to feel more of a man. That Loyal had sundry bad
habits and vices aside from his psychopathia, we do not know
for certain. But whether we are dealing merely with psycho-
pathic instability or with the eft'ects of poor moral training, no
doubt the plan of reeducation is at first identical for a victim of
either form of evil.

Of legal entanglements, our first paradigm, Jackson, was a
prime example in that she was an "undesirable immigrant."

THE KINGDOM OF EVILS 27

Loyal's succession of predicaments for the most part failed to
lapse into the legal group, though he was in court four times
for non-support and wife-beating. The wife never had to
appear in court to make her point, and his official friends and
supervisors made use of the point once only, when he was
threatened with the prospect of a separation.

How far can the Loyal family difficulties be regarded as
purely economic? That is, how far does the evil in question
fall into the group of poverty and other forms of resourceless-
ness? We said that if the Jackson family had been on a higher
economic level, the life of Miss Jackson would not have been
cast in its peculiar way and that she might never have become
an immigrant, desirable or otherwise. What can be said of
this point in the Loyal case? The family as a whole is on a
fairly high middle-class level, with a number of relatives re-
garded.as well-to-do. Some non-psychopathic relatives are suc-
cessful in their professions. The courses in life of some of
the psychopathic relatives indicate that their economic level,
high or low, has little to do with the behavior adopted. Hence
the social treatment of this case or of the Loyal family group
^s a purely economic problem would quite miss the point. In
point of fact, Henry Loyal while at work could earn, both
before and during war time, exceedingly good pay.

We shall now turn to a few further details of the case
Loyal. Note should be taken of the slow and slight, but steady,
and on the whole uniform, stabilizing which Loyal's character
is undergoing. Doubtless he would have to live several lives
tandem to get sufficiently stabilized so that he would no longer
require supervision ; but our general principle of hope for stabil-
ization even in the most difficult cases remains a principle. Our
records run to over a hundred pages, but for the purpose of
this exposition we will limit ourselves to a few of the more
striking episodes in the Loyal history.

Loyal first came to the Psychopathic Hospital on the advice
of a social worker in a general hospital where his little daughter
was under treatment for chorea. He was out of work ai the
time and for years had failed to support his family. The oldest
girl was fifteen, the second one, who was choreic, was twelve,
and the youngest child, also a girl, was five years old. A
fourth girl was born four months later. At this time the
family was living in a shack on the outskirts of a suburban

28 THE KINGDOM OF EVILS

town, and their economic condition was acute. On the ground
that there might be a nervous cause for his headaches, which
he claimed prevented him from 'working steadily. Loyal was
persuaded to come to the out-patient department for an exam-
ination and even consented to enter the hospital for a week's
observation.

He got a job and moved to a good neighborhood. Some of
the debts were paid off, and a much coveted piano was obtained
on the installment plan. All went well for about eight months,
when Loyal again became irregular in all his habits. He con-
tracted gonorrhea and his wife became infected. Meanwhile,
one of the children had developed a tuberculous hip, required
long, patient treatment in a hospital, and was later boarded out
in the care of a children's agency. Throughout her illness Mr.
Loyal was in a state of anxiety and excitement which threatened
to interfere with the child's proper care, but in the end the
social worker prevailed and the little girl made a good recovery.
The second child recovered from her attack of chorea under
the exceptionally good nursing given her by her mother. The
baby too was sick, but not seriously.

Work became slack and the landlady threatened prosecution
for arrears of rent. From time to time it was necessary to
give financial assistance, for which funds were given anony-
mously by a relative. Finally public aid had to be sought. In
time, Mr. Loyal found new work on government buildings and
had no more difficulty in getting employment, although he was
likely to be idle for short periods between jobs. It was never
possible to find out what he did with the high wages he re-
ceived. Certainly the results were not evident. In one of these
intervals of unemployment, nearly four years after the family
became known to us, a crisis arose. Mrs. Loyal was sick and
in need of hospital care (she had been having serious trouble
with varicose veins), funds were exhausted, and the landlord
had set a date for eviction. Loyal had a job in view, but could
not get it until he was restored to good standing in the union.
The way out was found by sending one of the girls to a rela-
tive, Mrs. Loyal to a hospital, and the two younger children to
the public authorities for temporary boarding-out. The oldest
girl by this time was married to a man considerably older than
she, a distant relative with some means. She had developed
a character much like her father's. Nevertheless with the fam-

THE KINGDOM OF EVILS 29

ily provided for and his financial condition revamped, Mr.
Loyal started for his new job. In a few months he was able
to take the children from public care to their mother, who went
to live with her sister in a city near the scene of work. At
last report, he and his wife were making efforts to get together
■a home again.

Hours spent by Medical record, 42 pages

Social record, 106 pages
Physician, 15 Social work :

Visits, 120
Psychologist, i Interviews at hospital, 57

Telephone calls, 105
Social worker, 245 Letters, 75

Adventuress, thief, liar — psychopathic persofiality. Mental
level testing very high. A "public" problem in hands of the
law, sent for observation by alienist.

Case 5. We possess numerous newspaper clippings about
the possible deportation of the supposed wife of a famous
British army officer. "Lady" Nora Campbell was brought
to the Psychopathic Hospital by a social worker. Mrs. Camp-
bell had been doing voluntary war work. Her husband, she
said, had been a major in the army, killed on service in the
war, leaving her a child, which about six months since had
died at the age of eighteen months. Now, it chanced, she
said, that she was the goddaughter of the King, a niece of a
well-known general, had given from her ample estate a hos-
pital for the use of English soldiers and had had some seventy
per cent of her money taken over by the British Government.
She said at one time that she was the illegitimate child of a
person high in English society, who was paying her seven
thousand pounds a year as sort of hush money. ,

From various physicians and Boston people with whom the
patient had had dealings, a number of stories were collected
concerning Mrs. Campbell. The biggest story hung upon the
loss of a brooch by a fellow war worker, who had known her
for two or three months and regarded her as a quiet, ladylike
victim of the war who was only to be pitied for her wanderings,
the loss of her husband and baby, and her present loneliness.
To be sure, Mrs. Campbell it seems had flirted with a son of

30 THE KINGDOM OF EVILS

one of the war workers, and had on sonae pretext obtained
twenty dollars from him. There also was a somewhat unlikely
story about a man's coming to get two hundred dollars hush
money and making away with eight hundred dollars more which
was in her purse. Finally, a valuable brooch disappeared under
very suspicious circumstances, and shortly thereafter Mrs.
Campbell tried to sell a brooch on account of its "evil associa-
tions." Detectives were finally called in. Several inconsistent
stories were told them. In the end the brooch was found, and
after sundry vicissitudes, also the central stone, which at one
time Mrs. Campbell tried to isolate by burying it.

The eventual diagnosis from the psychopathic point of view
in the case of Mrs. Nora Campbell was that of psychopathic
personality, a phrase intended to convey the idea that she was
not a mere delinquent but that her tendencies were in large
part psychopathic. Of course, there were numerous and sun-
dry defense reactions of the true delinquent in Mrs. Campbell,
who told many forms of tales and lied more or less expertly on
all occasions (never, even in the end, confessing her theft of
the brooch) about her life and status. Physically, there was
no certain evidence of there having been a child born, and
conditions were, on the whole, rather consistent with the idea
that no such obstetric history could ever have occurred. The
physical examination proved, in fact, to be practically normal
in all respects.

Psychologically, she rated extremely high, achieving 95
points in a possible 100. She did many of the tests exception-
ally well, was perhaps somewhat over-suggestible and fell off
particularly in certain performance tests. Whether or not on
account of her intentional and unintentional lying, she gave the
impression of a slight memory defect.

The case of Nora Campbell is schematically simple. To be
sure, from one point of view, if Mrs. Campbell was a psycho-
path, then it is clear that we must logically conceive that she
possessed "individual difficulty." There is presumably no
psychopath who is not a "damaged individual." In the first
place, there remains judicial doubt and also doubt in the lay
mind whether this adventuress, liar, and thief was really a
psychopath at all. For example (the judge or the layman
might say) an adventuress, thief, and liar might be such from
faulty education, as the criminals taught by Fagin in Oliver

THE KINGDOM OF EVILS 3 1

Twist were victims of faulty education rather than of disease
or moral deficiency. So it might be that Mrs. Nora Campbell
had been educated under conditions which made a life of ad-
venture with the fleecing of society, subject to the accompani-
ment of picturesque lying, a natural career for a woman. Ad-
mittedly, this would be doubtful, but the hypothesis must neces-
sarily be entertained, if only to be dismissed. A far more
likely hypothesis concerning the intra-individual blemishes of
Mrs. Campbell would be that she was a vicious person, a per-
son of faulty mental and moral habits who had slipped into a
life of crime of this "grafting" sort more than half intention-
ally. Such a hypothesis would, no doubt, fit a good deal of
what we term crime (in the minds of the laity).

However all this may be, the point in not classifying Nora
Campbell as a case in the "individual" group is that she did not
fall under the sphere of authority which deals with the indi-
vidual as such. She was and remained an almost purely legal
case, despite the fact of her observation at the Psychopathic
Hospital under much more lax conditions than most com-
munities permit.

Should we not classify Mrs. Campbell as falling under the
sphere of social influence or authority? To be sure, many
interested society people and many social workers became inter-
ested in her and spent some time upon her devious ways.
Nevertheless, throughout the whole situation, the hand of the
law and the penetrative technique of the detective drew the red
herring of public influence over all the social and individual
interests which might otherwise have prevailed. The point for
the general or psychiatric social worker to bear in mind is that,
whatever may be the medical information concerning the pro-
found and delicately balanced psychopathic interior of the case,
nevertheless a case like Campbell is without the range of the
physician to influence thoroughgoingly, simply because the iron
of the situation remains in the hand of the law. Again, what-
ever the social worker may think as to the excellence of her
own technique in managing a case like Campbell, she must
always remember that the case remains one under public author-
ity. She may supply a good deal of velvet for the outside of
the glove, but the iron remains therein. Upon whatever logical
or profoundly sentimental grounds the physician or the social
worker may want to proceed, he or she is forthwith stopped,

32 THE KINGDOM OF EVILS

in all authoritative procedure, by the hand of the law. There
are public interests here which are organized and crystallized
from the habits of centuries on the part of the legal world.
These old, crystallized judicial and institutional habits must
prevail until they are bowled over or turned into dead letters
by the new knowledge which may accrue in future systematic
studies of delinquency and near-delinquency.

We concede that we have presumably no right to draw such
heavy conclusions as the above from the case of the adventuress
Campbell. Throughout the rest of the book, however, we shall
find these public interests interwoven through the social and
individual interests that we are tempted to think ought often
to have the right of way. The interests of the state as a juris-
tic person and the interest of the state as guardian of social
interests (phrases of Dean Roscoe Pound) are interests often
paramount to the individual interests in personality, domestic
relations, and economic circumstances, and paramount over
such general social interests as the security of social institu-
tions, the maintenance of general morality, the conservation
of social resources and general progress — all of these phrases
borrowed from a legal statement of certain fundamental con-
ceptions of the "legal order." "The legal order," writes Dean
Pound, is "an adjustment of human actions and relations in
order to conserve the goods of existence, prevent friction in
human use and enjoyment of these goods, and eliminate waste
of them." In the case of Campbell, it is a question of a brooch,
borrowings of money, etc., an enormous waste of good people's
time, and a question of prevention. Aside from imprison-
ment, it must be granted that the legal order does not seek the
methods of prevention that social workers and physicians
would be eager to establish. Punishment and redress are far
more prominent in the legal order than prevention. But that
is another story and one calculated to be extraordinarily devel-
oped by a systematic attack on the problems of general and
psychiatric social work.

Hours spent by Medical record, 6i pages

Social record, 9 pages
Physician, 9 Social work :

Visits, 4
Psychologist, I Interviews at hospital, I

Telephone calls, 3
Social worker, 9 Letters, 15

ALCOHOLIC PSYCHOSIS

IN A PACKER

November, 1915 November, ipi6

Inebriety Sobriety

Unemployment Steady Work

Physically Disabled Good Health

No Income Good Wages

After-care of an alcoholic. Rationalisation. Point of view
of a hospital organization knozvn as tlw Men's Club. Non-
psychiatric social ivorker likely to miss the point of such a
case. Patient now better than lie ever was. Problem social,
rather than public or individual in the special senses of those
terms.

Case 6. Alfred Mack, an Irish elevator man, is now al-
most forty years old. We describe him, with some misgivings,
as a paradigm of social troubles, occurring practically pure,
that is, without any public (governmental) complications and
without special medical difficulties. Mack was under our social
supervision for some three years. A recent inquiry has shown
him socially adequate, after a period of about five years since
the medical incidents that brought him to the hospital.

Possibly the layman would not regard the episodes which
brought him to the Psychopathic Hospital as mere "incidents,"
since he there got a definite diagnosis of mental disease, due to
alcoholism, and since doubts were there raised as to whether
he might not be a victim of very severe mental disease leading
possibly to deterioration. No such deterioration has set in.
The mental tests, in point of fact, yielded, five years ago,
according to the Yerkes Point Scale, an age level of fifteen
years plus. It is true that the Binet tests left him at an eleven
year level at the time he was first examined; but the psycho-
logical examiners even then attributed his deficiency to the
alcoholic traces which he still showed.

The alcoholic mental disease, severe as it was (he had definite
delusions of persecution and even hallucinations of hearing,
possibly of vision) ended in a relatively perfect recovery, so
that he could be discharged recovered in nineteen days. Ac-
cording to the usual psychopathic hospital technique, Mack
was discharged to the out-patient department of the hospital,
where he has since been carried on the books.

Upon a further study of his situation, another bothersome,
but rather banal medical condition was drawn into the fore-
ground. He had, for a number of years, had ulcers of his feet
which had been variously treated in general hospitals and which

36 THE KINGDOM OF EVILS

have left him, up to date, quite unable to do certain kinds of
work. At various times a packer and a shipper's assistant, he
has finally settled into being an elevator man. (As to actual
nature of the disorder of his feet there is doubt. The ulcers
were apparently treated at one time as syphilitic, but our blood
tests proved negative in this regard. On the whole, the dis-
order seems to be almost purely orthopedic.)

Far more serious than the severe, acute episode of mental
disease through which he was carried, and of less consequence
than the orthopedic disorder just noted seemed, at first blush,
his twenty years' history of alcoholism.

Mack was a somewhat appealing little man, looking rather
old for his years, with a pigeon breast, trouble with both arches
of his feet, and poor teeth. A study of his heredity left one
much concerned for his outcome. Both parents (the mother,
a Roman Catholic, had married a Church of England father)
were alcoholic, and the father died of cirrhosis of the liver, the
mother of paralysis following five years "of being peculiar
after her first stroke."

The father had been a sex delinquent and nothing was known
of his brothers and sisters if, indeed, there were any. The
mother's brothers and sisters were all alcoholic, two dying of
paralysis (one of the aunts had a kind of mental disorder at
menopause and died at a hospital for the insane after a para-
lytic stroke in the sixties). It is difficult to choose a general
epithet for the family, whether "alcoholic," "paralytic," or
"cardiac," though possibly these conditions are in this particu-
lar family closely interrelated. Nevertheless, Alfred Mack, him-
self alcoholic and given inordinately to tobacco, despite his
somewhat melancholic self-depreciative and rather unsocial
frame of mind, was always considered a man of normal in-
telligence and a fair worker. He held his first position for
eighteen years and was not known by his employer to be the
steady alcoholic that he really was. He may have been held
in this position somewhat out of pity for himself and his
mother, whom he helped to support for ten years. The rheu-
matism and ulcers of the toe were said to have followed a
severe attack of scarlet fever in childhood. There is history
of a supposed concussion of the brain from a fall at the age
of seventeen. (The psychiatrist is apt to think of such con-
cussion cases as subject to unusual intolerance for alcohol.)

THE KINGDOM OF EVILS 37

There is a still more obscure history of a supposed love affair
in the teens, but for the rest of the patient's life, at least, he
showed no interest in girls, had a few male chums, but was
never "hail fellow, well met."

In his thirty-fifth year. Mack had an attack which it would
seem safe to describe as one of delirium tremens. The second
attack, which came on at a general hospital to which he had
reported for an operation on his foot, brought him to the
Psychopathic Hospital.

Up to the time of development of the first attack called
delirium tremens, there appears to have been no sign of mental
or nervous disorder save that, apparently at about the age of
thirty-two, he once had a sudden attack of blindness lasting a
quarter of an hour. For the rest, in early life he may or may
not have had certain fainting fits in the course of the "rheu-
matism" which followed his scarlet fever.

In this analysis we are intentionally overemphasizing and
throwing into relief sundry minor points in Mack's medical
history with the idea of showing that the main complications
which social treatment had to face were either not medical or
else were perfectly obvious matters to deal with. In short, if
we are searching for a case of practically pure social difficulty
and confine ourselves to drawing upon hospital cases, we shall
rarely find a purer instance of social difficulty without public
complications and with rather obvious medical indications.

Let us contrast the problems as they faced the medical man
and the social worker respectively. The physician confronted
a rather prematurely aged alcoholic of twenty years' standing
who had had two rather serious attacks of an acute mental
disease due to alcohol. The heredity was in several respects
poor and the stock in general given to disease of the blood
vessels. The situation was complicated by rheumatism, ulcers,
and some obscure though slight nervous phenomena, appar-
ently attributable to a severe scarlet fever in childhood. The
general medical indications were merely those of proper hygiene
(possibly with special reference to work that might spare the
heart).

Confronting Mack's case in the same general way, the social
worker found him on a basis of (a) inebriety, (&) a case of un-
employment of about a year's duration, and hence (c) without
income and even possibly (d) disabled industrially.

38 THE KINGDOM OF EVILS

As for the industrial disability of orthopedic origin, the cure
was relatively easy, and general hospital care soon helped his
feet so that he could undertake a new job as elevator man.
Meantime, until the disability for work could be removed, small
sums of money were got for him (this the very well-inten-
tioned man later repaid) and the next step was to get him an-
other permanent job. As the man's general nature was such
that he liked to work in one place (his "occupational orbit"
was very small) and as, moreover, the foot trouble helped de-
fine the issue, it was fitting that he should go back to an ele-
vator job. But the desirable permanent job did not come until
he had tried several temporary ones. Yet to remove the foot
trouble, tide him over his convalescence and to get him a job,
was not to abolish his inebriety. For this purpose he was com-
pliant with a plan of coming to the so-called "Men's Club"
which ran at the Psychopathic Hospital for several years (up
to war emergencies) and was a most effective agency for hold-
ing certain recovered alcoholics to a program of abstinence or
temperance. Mack took no especially prominent part in club
meetings, but drank his coffee and ate his cake with the other
social convalescents every evening after the club business was
discussed, namely — how to beat inebriety. The Psychopathic
Hospital Men's Club would be worth a detailed elaboration as
an interesting application of the class method in psychotherapy.
Mack was simply "one of the boys" at these meetings, which
were presided over by convalescents elected to their jobs and
run in the presence of a social worker or two. From month
to month the program of the meetings varied, but as a rule
some physician would help lead the attack on alcohol. A deep
analysis of the operations of such a club would have to take
into account the frequent successes of a psychotherapy for
alcoholism which did not utilize music, religion, or even ethics
in the common manner of so-called "uplift." In fact, a plain
rationalization of the alcoholic's plight was the mainstay of
these meetings where each man's endeavor was to some extent
bolstered by a certain sense of competition with his brother
convalescents. As for spiritual appeal, the case of Alfred Mack
might have been difficult. With a Roman Catholic mother and
a Church of England but sexually delinquent father, a boy who
had been embraced rather than guided into the Baptist church

THE KINGDOM OF EVILS 39

was no specially suitable vessel for spiritualization, unless in-
deed some complete conversion could have been undertaken.

The elements in getting hold of a case like Mack's were not
complex. To adjust the simple medical care, to get him a
little money in the meantime, and to get him temporary, and
at last permanent jobs, to rationalize and support a proper at-
titude (through the Men's Club) to alcoholism, were measures
to which but one other had to be added. It was necessary to
secure and maintain a proper attitude on the part of Mack's
family to his history and his outlook. This family consisted
of a sister and her husband. The brother-in-law was not a
drinking man and was friendly to Mack. It did not take long
to patch everything properly up. It is worth noting that the
patient's sister had herself, at one time, been a charity case on
account of the drinking habits of her mother. But married, as
she finally was to a non-alcoholic painter, she herself had made
what might be called a social recovery. All of which leads
one to ponder upon the entire family background of the Mack
case which, absolutely black as it was from alcoholism and
tendencies to blood-vessel disease, nevertheless gave room for
successful social measures.

We must not say that the insight of the psychiatric social
worker is extraordinarily more penetrative in a case like Mack's
than that of the medical social worker approaching the problem
from more general ground. Nevertheless we think it safe to
say that many a case with as black a heredity and family back-
ground, a history of years of social failure, might well drop
into the discard in the presence of ever so many more "prom-
ising" cases. Of course one does not know what, for example,
the orthopedic division of a social service department would
have accomplished for Mack. It is a little bizarre, yet profit-
able, to think that without an attack of outspoken alcoholic
mental disease. Mack might thus have been handled by an
orthopedic social worker after a successful course of foot treat-
ment at a general hospital. It is a question whether his alco-
holism would have been handled as intensively as the Men's
Club allowed it to be handled at the Psychopathic Hospital.
Perhaps we unduly malign the non-psychiatric social worker in
the above reflection, but it seems safe to say that without a
good bit of experience with the temperaments of alcoholics

40 THE KINGDOM OF EVILS

and of more pronounced psychopaths, the routine social worker
of economic bent or with the everyday philanthropic point of
view would scarcely be tempted out of the ordinary run of
measures. The concrete thing which the psychiatric social
worker here did was to utilize the Men's Club for rationalizing
the patient's outlook on life, but more than that, to employ the
entire fundamental plan of attack which underlies the Men's
Club and all other social psychiatric measures — namely, the
temperamental or characterological point of attack. To be
sure, any human being with insight into human nature and
considerable experience therein might have seen through the
slight unsociableness of the patient, marked out his native
timidity as an avenue of approach, and fed his waning self-
respect in a variety of ways.

We cannot claim that the church has not accomplished as
much or more with equally alcoholic patients. But the church
would probably have been of lesser service in this man of mixed
religious antecedents. Nor do we deny that the technique of
conversion or regeneration by the process of the "twice born
men" would have been applicable. The social psychiatric ques-
tion is, as the child W. K. Clifford used to say, "What is the
particular go of itf" At all events, whatever the technique,
we can safely say that Mack is at this time medically a much
sounder unit in the world than he was at the time of his alco-
holic psychosis and for many years preceding. Whether on
the account of the social treatment or by reason of unknown
factors, there has been a decided up-gradient in Mack's life.
For years, during his early employment, he was something of
an object of pity and might have been thrown completely out
of employment had his steady alcoholism been known. Now
Mack is one of the most reliable and efficient minor employees
in a big shop.

We need no extended analysis in the case of Mack to show
how the major sorts of evil that we have classified in the pre-
vious cases fall out. Into the class of diseases readily fall the
tendency to blood-vessel disorder, rheumatism, and other effects
of scarlet fever, and more probably (although not demon-
strable) a certain tendency of mind which naturally led him
into alcoholism. With such a heredity as Mack's it would be
impossible to deny that there was not at least more latent
tendency to disease in him than in the majority of men.

THE KINGDOM OF EVILS 4I

Turning to the matter of ignorance or errors of education,
we find Mack singularly free from these. To be sure, two
parents not agreeing upon religion probably gave him little
enough of true home education or moral training. Despite
these lacks, the man is relatively free of their concrete effects.
A long controversy might be waged as to whether Mack's
alcoholism was a vice or a bad habit into which he was led
by nature on one hand or by imitation on the other. The pres-
ent tendency is to underscore the hereditary standpoint and to
scout somewhat the factor of mere imitation of parental ideas
and habits. As to the tentacles of the law, Mack failed to be
caught thereby, save in the benign circumstances that the tem-
porary care law (that mildest of all legal adventures for the
psychopath) became available when he was out of his head at
the general hospital. The existence of such a law as the tem-
porary care law (see Appendix C) is, no doubt, of extraordi-
nary importance in the potentialities of social service for
psychopaths and psychopathic suspects in any community. But
that is another story.

As for the fifth group of evils which we have discussed, the
economic factor was drawn only temporarily into view. We
are dealing then with an almost purely social case whose minor
complications are, to be sure, medical, but whose central fea-
ture, the alcoholic tendency, must be regarded as a kind of
psychopathic tendency, whose effects are distinctly curable.
This, indeed, is a frequent lay point of view toward the alco-
holic unfortunate. It does not do to throw the alcoholic out
at the door, even if his history be a long and sad one and his
hereditary taint even more terrible.

We must here leave the large question of temperament un-
analyzed. Below we shall meet many instances of a more
striking temperamental make-up which the disease itself will
have brought out in exceeding sharp relief.

Hours spent by Medical record, 36 pages

Social record, 15 pages
Physician, 4 Social work :

Visits, 12
Psychologist, I Interviews at hospital, 5

Telephone calls, 6
Social worker, 23 Letters, 15

42 THE KINGDOM OF EVILS

Industrial injury (shell-shock analogue from civilian life).
Looked highly ''organic." Problem chiefly individual: the
mans relation to himself. Resentful of sympathy.

Case 7. James Bailey, a Jewish laundryman, twenty-four
years old when he was first seen, is presented as a case of almost
purely medical interest, whose social aspects (both from the
standpoint of diagnosis and from the standpoint of treatment)
were of an obvious nature and who presented no public serv-
ice aspects whatever, (his coming voluntarily to an out-patient
clinic in the Massachusetts State Hospital system may be re-
garded as putting him in contact with governmental agencies :
and his damage case against the Elevated Railway was in the
hands of a lawyer).

Medically speaking, James Bailey was a rather intriguing
case, since his disorder not only followed a definite street rail-
way accident, but also looked to the neurologist like an "or-
ganic" case. Yet, Bailey's nervous system was really reacting
(as was eventually determined) to a tuberculous pleurisy. This
pleurisy, we came to think, formed a perfectly genuine nucleus
of pain in the back, around which the peculiar, at first sight
"organic," disorder crystallized.

It was somewhat with Bailey's case as with sundry shell-
shock hysteria cases of the war group, in that there was a
genuine focus of pain of organic origin around which the
functional, and perfectly curable, disease grew. Many func-
tional disorders of the back and legs in the war neurosis group
have apparently developed in precisely this way around strained
ligaments, small hemorrhages, or other lesions incidental in
the strains, falls, or "windage" of war service.

Here, then, we were dealing medically with a "shell-shock
analogue" ; but the military factor in the situation is replaced
by a pleurisy which was perhaps, although not certainly,
lighted up by the railway accident. Curiously enough, Bailey
developed his peculiar gait and reactions (somewhat at first
sight resembling an ataxic paraplegia) in camp. For Bailey,
about a month after his railway accident, in which two ribs
were fractured in alighting from a car, was drafted into the
United States Army and sent to camp. Six weeks later he had
to be discharged on the ground of physical disability, as he

THE KINGDOM OF EVILS 43

could not keep up with the drilHng and dragged his foot. It is,
of course, post facto obvious that Bailey should not have been
accepted for military service. Yet even in the light of these
subsequent developments, the draft board physician now as-
sures us that there was certainly nothing demonstrable about
the man which could possibly have led to his rejection as a
draftee.

We present this case as an almost purely medical case. The
social work of the case might be characterized as supportive,
as a sort of splint to Bailey's will, to keep him in contact with
medical officers who only could cure him.

Bailey is of rather a refined and meticulous nature. Al-
though a laundry worker in this country, he had been a teacher
in Russia (whence he had emigrated at the age of nineteen)
and had nourished ambitions to become a physician. With
characteristically racial intensity, he had tried to improve his
status in the world, had studied hard and gone to evening
school. It appears that his mother was a worrier, or as one
might technically say, somewhat "psychasthenic." She also
had the history of developing at one time a paralysis ; whether
this was of hysterical nature or not is unknown. The ambi-
tions for medicine were interfered with by the accident, and
Bailey lost some of his savings. The army service set him
further back. He was now, as one might say, on the defensive
and in the passive voice. He felt that, after all, he was not
entitled to sympathy and resented any signs of it in others.
Bailey looked with suspicion on jobs suggested for him be-
cause he did not want to take a "charitable" job.

Upon the examination table his lameness and peculiar posture
of back and legs were no longer in evidence. The whole situa-.
tion, with the exception of the hypothesis of something "peri-
organic" (the pleuritic pain above mentioned) seemed to the
physicians hysterical.

Bailey is now somewhat better ; his condition is theoretically
curable. The function of the social service is to keep him in
contact with the sources of proper psychotherapeutic sugges-
tion. The black side of the problem is merely that, after all,
he has a definite tuberculous condition of his pleura. This
can, no doubt, be cured, whereupon the whole hysterical situa-
tion would have no longer any possible organic basis. But, if
we are to give him the regime suitable to a case of tubercle.

44 THE KINGDOM OF EVILS

we must clearly somewhat alter his mental attitude, which,
though unlike that of his worrying mother, is of a somewhat
psychasthenic trend. After all, the relation of the patient to
himself is the most important point here.

We thus conclude our exposition of seven cases chosen to
illustrate the three major spheres of mental hygiene, public,
social, and individual, into which psychiatric cases (as well,
doubtless as all other cases falling within the purview of social
work) in general fall. • We do not intend to rehearse at this
point the main features of these cases, reserving such general
considerations to the main summary at the end of this book.
Briefly taken, however, our considerations descended in com-
plexity from (a) the immigration case of Agnes Jackson
through (b) three somewhat less complicated cases of Richard
Sully (the boys' club organizer), Jennie Walton (with her
peculiar thievery) and Henry Loyal (the steamfitter of psycho-
neurotic trend), a series of three cases in which but two of the
major mental hygienic spheres of interest are illustrated (Sully,
public and social ; Walton, public and individual ; Loyal, social
and individual) to (r) three cases of still simpler nature,
namely, — Nora Campbell whose offense and nature was such
as to make her dominantly a public service case with social and
individual features overshadowed by her apparent criminality;
Alfred Mack, an alcoholic, without special public-service com-
plications, with comparatively simple diseases and charac-
teristics to contend with and whose handling was a practical
matter of straight social work ; James Bailey, the subject of the
present sketch.

How can we justify placing James Bailey amongst cases that
.are chiefly individual in their mental hygienic problem? The
grounds of this claim are that Bailey's relation to the public
service was of the most tenuous, consisting merely of his rela-
tions w'ith the psychopathic hospital out-patient department,
that the social work involved was relatively obvious, and that
all the work involved led very directly back to the medical situa-
tion (injury, "functional" lameness and gait) and his char-
acter, somewhat resentful of sympathy.

The previous cases in this present group of seven have been
analyzed also briefly according to the peculiarities and special
aspects of the maladjustments or "evils" which they presented.

THE KINGDOM OF EVILS 45

The analysis of numerous cases upon this schema of evils is
to be pursued in the second part of this book and to be further
synthesized in our summary at the end. In this first part of
our analysis we have discussed cases from the standpoint of
their falling into one or other or even into two or perhaps three
of what may be called the major spheres of interest and of
authority in mental hygiene. We have in this first part of our
book discussed the practical status which the personality of a
psychopath, with all its internal and environmental complica-
tions, possesses in the existent human world, subdivided as
this world is into interests maintained by (a) organized gov-
ernment (courts, state hospital societies, etc.), (b) community
interests of a less organized character (voluntary social agen-
cies, and other efforts of citizens at large), (c) and the interests
of the individual himself (as mainly controlled by physicians
and by other personal guides endeavoring to effectuate such
changes inside of the personality as may straighten out the
entire tangle).

However, even in these cases, presented from the aspect of
the three main spheres of authority or applied influence into
which they fall, we have seen the main divisions of social mal-
adjustment stand out. To take this last case, James Bailey,
for example, we find him afflicted first with some obvious med-
ical complaints requiring rather obvious attention. But he is
much more importantly afflicted with a special attitude to life,
a definite slight defect of character requiring very particular
attention for its correction or compensation. Re educational
defect, this young Russian Jew is rather well informed, despite
his feeling that he is not as well educated as he should be. It
would be a nice point to determine whether we shall regard
Bailey's educational question as a matter of character defect
or as a matter of a true deficiency in knowledge of how a
young man in his plight ought to look upon his future. Of
course, in a general way also, Bailey is (from the so-called
middle-class standard in America) not too well informed, and
this may be regarded as an effect of his origin in the Russia
of recent years and his transplantation to the American soil
of today.

From the moral point of view, Bailey is exemplary; from
the standpoint of legal entanglements he has entangled himself

46 THE KINGDOM OF EVILS

somewhat in lawsuit preparations over his railway injury. As
for Bailey's economic plight, he groups with the so-called
"marginal" cases and would not prominently classify in the
group of poverty and resourcelessness.

Hours spent by Medical record, 7 pages

Social record, 21 pages
Physician, 3 Social work :

Visits, 14
Psychologist, 0 Interviews at hospital, 21

Telephone calls, 21
Social worker, 42 Letters, 21

BOOK II

The land of the shadozv of death,
without a}iy order.

Job, Chapter lo, Verse 22.

THE FIVE MAJOR FORMS OF EVIL
IN THE REGNUM MALORUM

Arranged for the Purposes of
General and Psychiatric Social Work

Diseases and Defects of Body and Mind Morbi (M)

Cure!
Educational Deficiencies and Misinformation Errores (E)

Teach !
Vices and Bad Habits, Non-psychopathic Vitia (V)

Train !
Legal Entanglements In and Out of Court Litigia (L)

Counsel !
Poverty and Other Forms of Resourceless- Penuriae (P)
^^ss Provide!

ANALYZED IN
THIRTY-ONE SPECIMEN PSYCHIATRIC CASES

Note. — The order of evils here adopted is proposed for the purposes
of orderly exclusion in psychiatric and other branches of social case
diagnosis. - - . ..

Intelligent sex delinquent. Difficulties in public, social, in-
dividual spheres. Medical, educational, moral, legal, economic
factors: Morhi, Err ores, Vitia, Litigia, Penuriae. Psychiatric
point of viezv.

Case. 8. Rose Talbot is one of those rare examples
amongst women of the very intelligent sex delinquent. She
is an emotional and unstable girl with strong sex desire, now
twenty-four years old, with a record of marriage at seventeen,
the contraction of syphilis from her husband (dead two months
after marriage), the birth of a syphilitic child (still living and
apparently normal after elaborate and intensive salvarsan treat-
ment), and a second marriage at twenty-two with a divorce a
year later, said divorce being procured by her new husband, a
respectable man, on account of her sex delinquency.

The immediate medical problem was the cure of the syphilis
which went forward as well as usual (or perhaps better than
usual in psychopathic cases, whom it may be difficult to make
appear at due intervals) to a practical cure, but back of the
problem of the acquired syphilis is the problem of the patient's
own emotions and will, whose disorder expresses itself from the
legal point of view as sex delinquency and comes to the clinic
for diagnosis. It is worth eternally insisting that not every
sex delinquent is by the same token necessarily a psychopath.
If psychiatry is likely some day to prove that sexual and other
delinquencies are somehow expressions of psychopathy, never-
theless psychiatry has not, up to date, proved that crime is
always and necessarily a disease. It does help the task of the
mental hygienists when overenthusiastic theorists make ex-
travagant claims to the effect that crime is always disease, and
criminology, accordingly, a part of medical science. Perhaps
more than half of all sex delinquents that come publicly to the
surface are in one way or other psychopathic (that is, either
severely or mildly psychotic or more or less feeble-minded).

How does it stand with Rose Talbot? We have mentioned
her considerable intelligence, which was eventually to be proved
by her becoming an expert telegrapher. The psychological ex-

52 THE KINGDOM OF EVILS

amination taught us at once that from the standpoint of avail-
able tests, she was of high intelligence. This mental level, thus
scientifically indicated by the psychologist, was at first sight
not at all borne out by her history when she came to the hos-
pital. She then struck the ordinary eye as a hopelessly unde-
pendable, probably incorrigible instance of an oversexed woman
with the added complication of acquired syphilis and a syphilitic
child also to be cared for. As a social problem of fitting into
some occupation. Rose Talbot was difficult. As soon as she
was a woman grown she had married ; she had learned no
trade; she was of an intelligence rather superior to the level
of the kind of work which she could readily procure ; a lapse
into sex life had been easy, and a continuation of it was to
be expected. It is a matter of interest that social conferences
held over this case left most of the conferees in a dubious
frame of mind. Upon reference to medical experts, one could
only point out the dangerous menace of the girl's syphilis to
the community, whilst another physician, upon clinical data
alone, felt inclined to think that the girl must be somehow
"feeble-minded," and still another advised a reformatory.
Rose was, in fact, for a time maintained in a home for way-
ward girls, but had such spells of violence here that she could
not be managed.

The technique of the social treatment of Rose Talbot was
briefly as follows: The girl left her husband one day in 191 5
in a temper (due to the suggestion that she live with her
mother-in-law) and tried, as a waitress, to support herself and
child. She made application to the charity authorities for the
support of her child several months later and the child was
boarded out. She was thus under the eye of social workers,
one of whom, under a misapprehension (as we now see the
problem) had her arrested as above noted. She was then put
on probation and placed in a home for wayward girls where
came those spells of violence which now began to indicate that
Rose Talbot was not to be a simple case of delinquency. At
a special conference the majority of social workers agreed that
her case was, for the present at least, a hopeless one and that
although there were definite psychopathic elements, the only
available policy was to wait for the "overt act" which would
eventually allow her commitment and internment in some recep-
tacle for delinquents. Meantime, the baby would, of coufs^.,.

THE KINGDOM OF EVILS 53

become a public charge and minor ward of the state. It was
already obvious to the social worker specializing in the man-
agement of psychopathic cases that this hopeless point of view
was logically not well founded. Not only had there been pre-
vious experience of relative, and often absolute, social read-
justment in cases of this general group of psychopathic sex
delinquents, but also there were special features (considerable
intelligence and well-developed self-respect and good general
judgment in most matters outside the sex sphere) that made
the social prognosis of Rose Talbot not absolutely dark.

Nevertheless, no psychiatric social policy was at once
adopted. Rose was still carried on the books of the probation
office. A job for her as waitress in the country was got, and
she paid her child's board. She had promiscuous sex relations
with boys about the place. (With unwarranted hope for sex
hygiene and with a technique not advocated by social workers,
an internist who had known the girl wrote a letter to the public
health authorities of the town where she was ; rather naturally
nothing came of this letter.) Social workers, without psychiat-
ric training or point of view, had previously made an endeavor
to have the girl arrested as a prostitute.

However, it happened that Rose had already become friendly
with a psychiatric social worker and had become well disposed
to the Psychopathic Hospital on account of the unexpectedly
gracious way in which she had been met by the physicians. In
friendly, unofficial correspondence, Rose would write such
sentiments as the following: —

July 24, 1916

"But perhaps I'd better tell you my honest, way-down-deep
reason for writing. You did seem to understand me so well
while I was there. Now please, Miss Carroll, I am trusting you
so thoroughly. Please don't tell. Oh, I know I shouldn't write
or tell anyone, but it does so prey on my mind. I'm trying so
hard to be good. Course it's lots easier than at first, but I want
so much to be bad. I actually get sick fighting temptation.
Why it's almost like a curse or horrible misfortune. I'm afraid
I didn't inherit a very good supply of will-power. One thing I
am learning good is to control my tongue. And that's what
puzzles me. Now, my tongue is learning to behave quite
nicely, but my passions are the most unruly I ever encountered.
And it is by the most tremendous effort that I keep good. But

54 THE KINGDOM OF EVILS

then I can be thankful that there's a Httle improvement. My first
month at Trinity House was a veritable night-mare. A most
hideous month. And I know if I give in now I shall have the
fight to do all over again, or else continue to be bad, and with
no helping hand near, it is impossible to be good, once I start
bad. But then, I shan't, because I vowed to God that I never
would. He will keep me good, won't He ? Do answer soon cause
I'm so tempted. And it's impossible to leave. I'm most
stranded and Betty's board one month in arrears. Do think
over the possibilities of my becoming a nurse and advise, your
sorely tempted, trusting friend."

July 28, 191 6

. . . "But I will be good, for if I give in I might just as
well throw up my hands. And besides, God would punish me
if I broke my oath, wouldn't He? When I was in my cell at
James Street, waiting for trial, I swore to God never to commit
adultery or fornication again. I couldn't break that, could I ?
Yet if He wishes me to be good why, oh why, will he allow me
to have such horrible unruly passions. And after all my
prayers ! I want so very much to be bad. At times I ache all
over, I feel if I only could be bad just once, awfully bad, I'd be
quite happy and satisfied. He's a student. Treats me with an
almost brotherly affection. It is such a relief to be able to tell
you everything. . . . And I'd give in so quickly only I do want
to be good, and am scared too. I was so much happier before
in my ignorance than I am now with my eyes open. I do feel
so sick and miserable all the time."

August 3, 1916

"Mrs. W. is going to send me a couple of pictures of Betty.
I can hardly wait for them. I shall be so glad when I am home
with her again. I'm just crazy about the little kiddo. I just
love to work for her now. At one time I was feeling kind of
provoked to think I could never spend much for clothes, but
since I came so near losing her, and after being confined at
Trinity House, it's just wonderful to be free and working for
her. I'm being so awfully good, not even thinking bad. You
see, it is just once in a while I have those spells, and they seem
so terrible at the time they frighten me, but now, looking back,
it was nothing and confiding in you has helped so very much.
I am so glad I have you for a friend and true confidant. It is
just like a headache (a thing I rarely have) but when I do !
think I'm killed. But there, I've troubled you long enough
with 'I.' "

THE KINGDOM OF EVILS 55

August 28, 19 16

"I've read Casqueline's (I think it is spelled) Truth about
Woman and Havelock Ellis' Psychology of Sex which quite
knocked all my good resolutions to smash. You see it was
really the religious side of me that was keeping me good, and
my fear of God. But Casqueline states that religion has nothing
to do with a woman being bad. — So you see it is not wicked to
have sexual intercourse with other men than your husband. It
is merely not the fashion.

"Now with you saying to be good and this book to give
free rein to any and all impulses and passion, what is one to do ?
Especially when there is so much bad in them, and if I was bad
it would be to satisfy my own natural cravings. And I feel so
much more fit, mentally and physically.

"But, my gracious, please don't tell Miss Ford, that I've been
talking in this strain or they'll become alarmed, which is quite
unnecessary since I've no intention of being bad yet.

"Grandma says she'll be very glad to see me and I'm going
to live with her and Betty."

September 24, 191 6

"Sometimes I'm almost tempted to marry him. Oh, dear, I
do hope I keep a level head and not do any more foolish stunts.
And besides I simply cannot marry. Anyhow, I merely like
him and am by no means fond of him. Now, aren't you pleased
to hear I'm not going to be bad, I mean, give in to sexual
desire?"

November 6, 1916

"Now, Miss Carroll, this is an honest fact, that just as soon
as I start my prayers at night and feel spiritually good, some-
thing always turns up to make me doubly bad. Last evening I
felt awfully good and said my prayers with the baby and felt
that I'd never be bad again, and behold, this morning, I awoke
worse than ever."

January 5, 191 7 ^

"I really don't think I'll be bad, maybe once in a great, great
while, but not in the promiscuous manner I have been. I just
wish I could explain. I don't think I can, yet you're the only
one to whom I could begin to explain. It is all on account of
working in the rubber shop and wearing that peachy dress you
gave me. Don't think that I'm all fussed up over myself, but
just the same, I am nicer than any worker in my department,
or in fact, that I've seen here.

56 THE KINGDOM OF EVILS

"My thoughts run ahead of my pen. Of course I couldn't
make it clear anyhow because it's not quite clear to me. I've a
great conceited bump on myself. Just a wee bit too nice to be
bad. I've thought of it a good deal and seems to me I've had
symptoms a way back, but lately they are becoming no end
developed !"

March 17, 191 7

"We have broken partnership, it really was that you know.
There we were, two perfectly mated, physically and mentally —
human beings, each desiring one of the opposite sex without the
binding and restraining tie of marriage. It really is too bad.
He was awfully decent and I liked him thoroughly, in fact could
almost say it was a good like. And again I say it is too con-
founded mean that one can't have free love, or at least until
the children come. But there, I shall have to see you to tell you
all about it."

July 4, 1917

"Am going to dress Miss Betty up and take her for a visit.
Oh, I do love her so much, so very much, that I have no room
for any one else, which is rather good, considering I have been
thru so many 'puppy loves' !"

October 14, 191 7

"Yes I do (i.e. love her divorced husband) and suppose I
always will. Time hasn't done much healing in my case, but I
do think that God has given me a pretty poor hand, perhaps in
the next deal it may be filled with brightness and I shall live and
enjoy a happy old age, that is, if I do live. I strongly contem-
plate suicide in every moody spell, and I feel quite justified for
does not our Lord say 'Come ye who are weary and heavy-laden
and I will give ye rest.' So why not accept such a wonderful
invitation. Still I rather think I am too much of a coward."

There seems to be no reason why the sentiments of these
letters should not be taken on their face value. When Rose
was dropped from the books of the Probation Office, she felt
that she still required counsel and voluntarily applied to the
Psychopathic Hospital for supervision. During a period of
two years that she has since been under the hospital's official
care her life and aims have pursued a gradual up-gradient.
She became aware that her intelligence was superior to that
of her fellow mill workers (she had betaken herself to work

THE KINGDOM OF EVILS 57

In a rubber factory, somewhat against her wish for less con-
fining work) and herself got the idea of going into telegraphy.
She is now, at the end of these two years, getting seventy-five
dollars per month, is paying for the maintenance of her child
in the (paternal) great-grandmother's home, and is living a
much more promising and orderly life than anyone could have
predicted. A peculiarity of the situation is that she is now
living with her divorced husband once more. The question
of marriage has indeed been raised, but it is the girl, rather
than her former husband, who remains in doubt of the wisdom
of the procedure. To be sure, her syphilis is as well in hand
as can be contrived; at all events, her blood serum test has
now remained normal for some time.

Let us now analyze the Talbot case in two ways. First let
us analyze it briefly, after the manner of the first part of this
book, namely, as to the existence of public, social, and indi-
vidual factors in the case, and their relative importance. We
may then follow the analysis, according to spheres of com-
munity influence, with a further analysis according to the dis-
tribution of the various evils shown by the case, thus intro-
ducing the topic of Book II. It goes almost without saying
that a case as complicated as that of Rose Talbot must have
planes of contact of both a public and a private nature. We
may count as of a public nature, for example, her arrest for
adultery, socially ill advised as that arrest may have been. As
of a social (non-public nature) we must count her promiscuity
in sex relations and her quarrelsomeness with her spouse. The
divorce complications touch both governmental authorities on
the one hand and the more private social relations on the other.
As the history of the case shows, very possibly the sex promis-
cuity and even the girl's quarrelsomeness, socially difficult prob-
lems though they are, may well be regarded as fundamentally
of a medical nature. If hypersexuality and irritability are not
regarded in the lay mind as necessarily examples either of
mental disease or of mental defect, nevertheless, from the
psychiatric standpoint and from the standpoint of the psychiat-
ric social worker, these tendencies are coming more and more
to be regarded as essentially psychopathic. Even if we, in the
end, come to regard them as eccentricity rather than psychop-
athy, nevertheless cases of sex appetite and cases of anger
instinct can best be understood in psychopathic terms. The

58 THE KINGDOM OF EVILS

public and private factors of this case, or (to use our preferred
tri-partition of factors) the pubhc, social, and individual factors
of ihis case are not only all well represented but are commingled
in such wise that it is extremely difficult to "factor" them out,
as they say in books of arithmetic. The factors unite in a
complex unit which is not the result of summation as much as
of multiplication.

Without delaying upon the further analysis of the Talbot
case from the standpoint of community influences (see, for
examples of such analyses, cases of Book I, e.g., case 4) let
us consider her from the standpoint of the evils. This is not
the place to descant either upon the completeness of our list of
evils or upon its exactitude. The appraisal of this manner of
analysis may be postponed, nor shall we be prepared to discuss
it fully until the medical data of Book III are well in mind.
As briefly in Book I, we proceed to a study of the medical,
educational, moral, legal, and economic factors, under the guise
of the evils of disease (Morbi), ignorance (Errores) vices
and bad habits (Vitia), crime and delinquency and other forms
of legal entanglements (Litigia), and poverty and other forms
of resourcelessness (Penuriae). The medical side of Rose
Talbot is evident; character defects and certain overemphases
of instinct, to say nothing of syphilis. The educational de-
ficiency in Rose Talbot is most obvious and stands out the
more clearly because she was by no means feeble-minded and,
in fact, responded notably well to the instructions given her,
at first by the psychiatrist and later by the psychiatric social
worker. It was clear, too, that in addition to an educational
deficiency (both in the matter of school life and home instruc-
tion) there was a pronounced moral deficiency It is not in-
cumbent on us to determine here (or perhaps anywhere in this
book) whether there is a distinction between intellectual and
moral education, and no doubt many of the moral deficiencies,
so obvious in these cases, are not only grounded in lack of in-
formation or in misinformation, but can be abolished, almost
at a blow, by suitable teaching of a very ex-cathedra type. But
Rose's moral deficiencies were in spheres of emotion, which
mere instruction out-of-hand could not relieve. In point of
fact a good deal of her difficulty may be assigned to disease
and not to mere inadequacy of moral training. It will be re-
membered that there was much to go upon. There was the

THE KINGDOM OF EVILS 59

girl's rather lively self-respect in all matters save those of sex;
and even in the sex sphere there was finally developed the
monogamous trend. The rather extraordinary improvement in
what one might term the individual "morale" of Rose Talbot
when a certain blue serge dress was given her (see letter in
text) cannot readily be ascribed to education of the intellectual
sort. That singularly successful step on the part of the psy-
chiatric social worker was an ethical, rather than a psycho-
logical, step.

It is clear that in trying to distinguish between the medical,
intellectual, and moral deficiencies in a case like this we ap-
proach fundamentals in the definition of medicine, education,
and ethics, definitions which are not always easy to get in text-
books of these disciplines. When we approach the fourth
group, delinquencies, we naturally find the plot to thicken
appreciably, as we have, indeed, the choice of regarding the
delinquencies of Rose as, on one hand, purely medical in origin,
and therefore not delinquencies, or on the other hand as due
purely to faulty education (and therefore hardly matters for
which she could be called to serious account), or even as mat-
ters of poor moral training (wherein again, the handling of
the case as criminal or legal would not serve the turn). But
in what consists the delinquency or legal entanglement in this
broad sense ? We are using the idea in a purely practical way.
We shall find it desirable to analyze each case in succession
from all of these standpoints. For practical purposes, no one
can deny that it is important for the psychiatrist and for the
psychiatric social worker to consider the legal entanglements
and the methods of fighting them which are brought up
by any case which demands social consideration and social
management.

So again, when we consider the economic disabilities of Rose
Talbot (with her lack of knowledge of a trade at the outset,
her syphilis to be medically and perhaps expensively treated,
and her child, also syphilitic) we need not deny that another
lot in life would have entirely altered the complications of her
particular fate, but the fact that good middle-class surroundings
would have changed this particular fate does not necessarily
mean that economics is the sole, or even the leading, feature in
the whole circumstances. Accordingly, we find in Rose Talbot,
good examples of what, upon common-sense grounds, we must

6o THE KINGDOM OF EVILS

regard as deficiencies in all five fields of evil, as we have chosen
to name them. The order in which these fields of evil have
been laid down is also, we surmise, not more ultimate than the
fields of evil themselves. In fact, in social work at large, it
has always been thought that the economic factor must take
a leading place. It is our impression that even in general social
work (and many social workers agree with us) the economic
factor is often, if not in a majority of cases, outweighed by one
or more other factors of evil that we here list.

Perhaps it is worth while to make one or two further com-
ments upon Rose Talbot. Her improvement under social-
psychiatric treatment was remarkable enough, particularly as
she had been an unsolved problem zvith no less than three agen-
cies before she was studied and treated from the psychiatric
point of view. It would be less easy to define exactly in what
the social-psychiatric treatment of Rose Talbot consisted, and
perhaps we had, at this point, best fall back on saying that the
fons et origo of the success lay just in the "point of view." It
might also be inquired how genuinely successful the treatment
has been, and no doubt the Greek warning, that we can scarcely
assign happiness to a life until it is ended, is a warning that
we should particularly heed in social work. At the risk of
repetition, let us insist again upon the extraordinary contrast
between the girl's genuine self-respect and her amoralia, or
what the old English psychiatrist Pritchard might have termed
"moral insanity."

It is of subordinate nature, perhaps, that during the years
of psychiatric social treatment, Rose has been under the per-
sonal charge of four social workers in succession and has,
nevertheless, responded properly to all four, despite their own
differences in personality. This brings out strongly the point
we above made, namely, that the success in treatment depends
more upon the point of vieiv than upon the personality of
the worker. We know that such a statement as that in the
previous sentence may well be regarded as revolutionary by
some authorities who very particularly point out the great im-
portance of the personal relation, the relation of being en
rapport in these subtle forms of psychotherapy. (Of course
another way of controverting this revolutionary point of view
of ours would be to say that all four of our workers were, as
it were, of a superior quality! This the psychiatrist might

THE KINGDOM OF EVILS 6l

be compelled to concede. Yet it is true that persons of a very
special nature are just the persons that remain in psychiatric
social work, at least in its responsible phases.) It is not so
much the point of view of the worker as it is difficulties in
effecting the new contacts entailed by the shifting. This at
least is our general experience, into which we cannot here
farther go. In point of fact, it would be singularly unlucky
if the only personal relation which the psychiatric patient could
successfully maintain with social work should be a relation with
but one human soul, since, in the nature of things, in the course
of years (and these cases are year-long in their symptoms and
demand for treatment) there must be effected a number of such
transfers of control.

Another subordinate point in the technique of social work
in the case of Rose Talbot, is the singularly small part which,
in appearance at least, the psychiatrist plays in the details of
treatment, in fact, the general course of social treatment is not,
in this case, one specially conducted by the psychiatrist; it was
rather, the duty of the psychiatric social worker, on the basis
of the medical diagnosis, to proceed to establish proper general
lines of treatment. It is entirely doubtful in our minds whether
a physician, either male or female, could have gotten into the
right relations with Rose Talbot.

Hours spent by Medical record, 23 pages

Social record, 49 pages
Physician, 4 Social work :

Visits. 37
Psychologist, l Interviews at hospital, 1 1

Telephone calls, 14
Social worker, 102 Letters, a8

FEEBLE-MINDED YOUTH

24 YEARS
(BY MENTAL TESTS 9.3)

191 5
Unemployment
Homelessness
No Income

Estrangement from Relatives
Recidivism (Larceny)
Arrest (Arson)
Probation

ig)i6
Employed
Good Home
Good Wages
Reconciled to Relatives

Stealing
Disappeared

1917
U. S. Marine

Feeble-fninded recidivist who set a fire. On probation ran
away. Later corporal of marines.

Case g. Thomas Fuller's real name was Michael Kelly.
Thomas was a reformatory boy and after he left the reforma-
tory chose to avoid its stigma by assuming his mother's name.
He was twenty-four when we first came into contact with him
after his arrest for "maliciously burning a dwelling-house."
We present him as a paradigm of evils, not quite so progressive
as his predecessor in this series, Rose Talbot, for Thomas
Fuller, despite the fact that he measured less than ten years
by the psychometric tests, got on well enough in the econornic
sphere. He showed signs, however, of trouble in each of the
other four fields, medical, educational, moral, and legal.

To be sure, there was no obvious sign of disease in Thomas.
He looked younger than his years, but was of a stocky and
well set-up build, as indeed, the United States government was
eventually to find and to exult in. But from our chosen point
of view, we must regard his low mental age as a medical
disability.

Thomas Fuller's father had long since disappeared, leaving,
at the time of our first observation of Thomas, three sisters in
the late teens. The mother, who had cared for the children
until Thomas was fifteen, had died in an almshouse; the
younger children had been left in an orphan asylum by the
father, who then vanished from the scene. Thomas got no
schooling until his twelfth year, with a little further schooling
at the age of fourteen, and with three years of reformatory
life in the late teens. The boy's moral training had suffered
throughout such a life. The marvel is that his moral adequacy
could, in the long run, be maintained. His arrest for "will-
fully and maliciously burning a dwelling-house" was but a
single episode, and unlike phenomena in some of our psycho-
paths, could not be regarded as in any case a perversion of
instinct such as may be found in pure pyromania.

66 THE KINGDOM OF EVILS

Fuller, one day, in a fit of despondency, set fire to his por-
ter's uniform which lay on the bureau in his room. He had
been discharged from his porter's job and apparently decided
to let that whole part of his life go up in smoke. The under-
standing how this might be both the first and the last episode
of this identical nature (as against the story of so many pyro-
maniacs who keep on kindling fire after fire, apparently for the
gratification of a particular instinct) is made a bit easier by a
study of sundry facts in Thomas's past life. Without going
into these in detail, we may mention that he had at times stolen
money and again clothing, and had even participated in a small
"break" into a house with companions. He was, in short, a
sort of youthful recidivist in a variety of not extremely serious
crimes. It was as if a feeble-minded boy, not educated even
up to his mental capacity, and with poor and fragmentary moral
training, had become a delinquent despite himself.

In point of fact, the case, from the legal standpoint, was
quickly resolved by the psychometric observations — Point
Scale 9.3 years, Binet 9.2 years. His deficiency of mind was
of what may be termed the truncated variety. The defect wa'^
an even and regular one, not affecting the years above the grade
registered. Whatever intellectual and moral education could
be given to Thomas Fuller must reckon with this fundamental
mind lack. There could hardly be a stronger contrast than that
between the cases of Rose Talbot and Thomas Fuller. The
one was an intelligent woman, with much to build upon, both
intellectually and morally, despite her hypersexuality and tan-
trums; the other was a moron boy, with no special sex pro-
clivities. Both enjoyed, however, good physique, and both
proved singularly accessible to social work.

Probably, in a large part because of his exemplary sex record,
the judge who dealt with the charge of "burning a dwelling-
house" did not even commit Fuller on the hospital determina-
tion of his feeble-mindedness, but on probabilities (or perhaps
as a matter of speculation) he was put on probation and proved
a ready subject of social work and remained a faithful super-
visee for the six months that he was on probation. He was
somewhat disheartened by the extension of his probationary
period for a further six months, and a month after the exten-
sion was granted he disappeared from view after a charge
(correct or false) that he had again stolen clothing. Letters

THE KINGDOM OF EVILS dj

from no address not infrequently appeared at the hospital
assuring the workers of his continued success in life.

The denouement was now to be altered by the World War.
He enlisted in the marines and he wrote that he was now "some
man" ; that he was "satisfied and at peace with the world" and
that he would "never forget his friends at the hospital."

We have a number of Thomas's letters, written in a large
round hand. Almost always he begins "I write you a few
lines 'hopping' to find you well as I am." Some extracts from
letters with the war fervor are as follows : —

September 14, 191 7

"My Dear Friend: I write you a very few lines. I hope
to find you well, as I am. And that you will time to read the
letter, or when you read it you may call it a book. I know that
you like to read books so that all right. Well I like to write to
friend's, So you are one that I could not forget. The old saying
it a treasure to have friends. Well you would like to know all
about me. Well hear gos. In the frist plase, I have maked
good without no one help. It noting like trying to make good
that me. I thought I like to be a marine, so I went in the
U. S. Marine Corps, for luck. And I have luck all the way, so
good. And I am going to tell you that I am now out off the
past, and I don't mind tell you, that I am now "some man," And
I feel like a man who has eaten a real dinner, very much satis-
fied and at peace with the world. What do you think off that.
And let me tell you my friend, that I have not forgotten your
kind advice yet. It is very indeed profitable to me. And
started out to make good, I did you know. Well the last time
that seen you, I have traveled over this world a bit, I rought it
to france. Washington D. C. and I seen the best man that the
big world of our love him, tell me the one that I mean see if you
know the one man I mean. I love him with all my heard. And
I don't mind tell you that I am now a man with some good
experience. And I have live a pretty hard life. And I've been
down pretty low, and now I am up, and that is what counts.
And I have won out, I am going to forget the methods I used
in the past life. I am going to make everybody else forget
them. I want to enjoy the remainder of my earthly existence.
"Well Dear friend I will come to a close with this letter
very. I am now in the U. S. Marine. And I am not Thomas
Fuller, but I am the Private Michael Kelly. I would like very
much to hear from a good friend like you Miss Carroll. And
the 25th of Dec. 1917 you get sum thing from me, and if I go

68 THE KINGDOM OF EVILS

to war, you will have sum thing remmber by. Write and tell
me how you are, and how very one. On my 27th birthday
not one send me a brithday card. As I have no more to say
this time I will come to a close.

"And to you My sincere appreciation to you and the good
worker at the hospital.

"Wishing you all success."

September 21, 191 7

"Well my Dear friend. I take the greates in writing to you
these few lines to you dear friend. And was very glad to hear
from you too. It was your postcard that you send to me, it is
the boston state house, some place you know. And the State
House looks very good to me, you bet. And I know that you
wrote that card. I remember your good hand off writing, that
you write, write again plase. Well dear friend I do not very
well when I will be send to france but I may go any time to
france to fight for freedom, and peace. And let me tell you
that I will fight in earnest for our be love and dear presidend
Wilson, the man off the hour. I like him with all my heart.

"And I will not forget my friends. I will think off them
when I am over in france. and now I will not forget you as
you are one off my friends. You said that they are knitting
at the hospital for the soldiers. And you asked me if I could
used and thing. Well I can used and thing that you send. I
would be glad to get anything that you send to me. Will close
hopping to hear from you."

March 29, 19 18

"I write you a few lines hopping to find you well as I am.
Well I have make good, as I am now an corporal in the U. S.
Marine Corp. that mean that I am to get $6. more an month.
So I am now getting $36. an month now. Well I am doing
the best I know how, that whi I was make an corporal in
corps. I hope that you will write me an letter and tell me how
you like the way I am making good."

Hours spent by Medical record, 25 pages

Social record, 34 pages
Physician, 4' Social work:

Visits, 18
Psychologist, i Interviews at hospital, 23

Telephone calls, 40
Social worker, 50 Letters, 45

THE KINGDOM OF EVILS 69

Hysterical sex delinquent, a persistent social problem.

Case 10. Bertha Greenwood is a case which we present
as a paradigm of troubles in the medical, educational, moral,
and economic fields. She is the second of a group of five cases
in which the troubles are fourfold. Bertha Greenwood's case
is less complex by one field of evil, according to our proposed
classification, than was Rose Talbot (case 8) whose troubles
were fivefold.. Theoretically we should be able to subtract from
the difficulties of Rose Talbot the legal entanglements and
arrive at the case of Bertha Greenwood ; so theoretically ought
we to have been able to subtract the social difficulties of eco-
nomic nature from the case of Rose Talbot and arrive at some-
thing like the degree of complication found in Thomas Fuller
(case 9). Taken another way, the phenomena of Bertha
Greenwood will have, in common with those of Thomas Fuller,
three kinds of factor, and will differ in but one factor : both
cases are fourfold with respect to their distribution of troubles;
both have difficulties in the medical, educational, and moral
fields, but whereas Fuller's difficulties were legal. Bertha
Greenwood's difficulties were economic.

Bertha Greenwood, we must confess, for the present, after
three years of social observation and attempted treatment, to
be a good deal of a failure from the standpoint of psychiatric
social work, but it is no province of this book to put necessarily
the best foot foremost. Perhaps it is better to deal with the
grounds of failure in sundry cases than to congratulate our-
selves unduly over the most striking success.

The reasons for the failure of our social methods in Bertha
Greenwood are obscure, but probably based upon our lack of
grasp upon her attitude. That attitude is, no doubt, a psycho-
pathic one. Her temperament is one of ups and downs that
are apt to occur in waves of considerable length as well as
amplitude. The term "psychopathic personality" which is, in
general, a proper designation for this, as for many other cases,
does not duly specify the peculiar difficulties, which are, per-
haps, a compound of hysterical tendencies, with a cyclothymic
(manic-depressive) tendency, expressing itself rather more in
periods of depression, of weeks' or months' standing, than in
any periods of pronounced elation.

70 THE KINGDOM OF EVILS

In her periods of comparative normality, Bertha is extremely
manageable, and amenable in some degree to suggestion, al-
though there is not much doubt whether her promiscuity of sex
life is continuously maintained; in fact, we are pretty confident
that in her periods of what we term "normality" she shows
neither any evidence of oversexedness, nor any continuation of
sex irregularities as a matter of habit. Like Rose Talbot, with
whose case, as above mentioned, that of Bertha Greenwood
falls somewhat into line. Bertha shows a kind of monogamous
trend; at all events she, for a long period, bore in mind and
descanted upon a certain married man with whom she pro-
claimed herself to have lived in sex relation. Our best evidence
is that this ideal, or paramour, of Bertha's was fictitious. At
one time she even showed a bruise of the face which she said
was got at the hands of this paramour whom, however, the
police failed to trace. We assume that her tales about him
sufficiently indicate a degree of monogamous trend. In general
she has been, and is, promiscuous in sex relations, and has even
been pregnant twice (abortions). Except at times of economic
stress, as after recovery from influenza, we believe that Bertha
Greenwood, like Rose Talbot, has shown a large degree of
self-respect, at least in the matter of not taking money for her
irregularities. She is of good physique, and of considerable
intelligence, at least of such a degree as to be able to support
herself properly in her normal periods.

Medically speaking, we might wonder whether the diagnosis
"psychopathic personality" was not, after all, far more vague
than two other diagnoses which we might be entitled to make,
namely — "hysteria" and "feeble-mindedness." To take the
latter, and simpler, hypothesis first, we find that she grades
psychometrically on the Binet Scale at 11.3 (actual age, at
the time of examination, twenty-three), but on the otiier hand
we find by the Yerkes Point Scale that she grades up to the
adult level, or at least to fifteen years plus, which was the maxi-
mum to which any person could attain by the type of test then
employed. The educational test of the Binet type probably
yielded poorer record for Bertha Greenwood than her general
efficiency would point to ; moreover, we have in our possession
a pathography or partial autobiography written by her which
exhibits much more insight into men, women, and things than
a moron is entitled to exhibit. The psychologists, it may be

THE KINGDOM OF EVILS 7I

stated, despite the Binet grade of 11.3, gave it as their opinion
from the psychological point of view that she was not feeble-
minded. It may be parenthetically stated here that persons
clearly feeble-minded (let us say in the moron division) may
be sufficiently complex to show what is termed psychopathic
personality. That issue we are not here raising ; we are claim-
ing for the concrete case of Bertha Greenwood that she is prob-
ably not at all feeble-minded and may perhaps be an uncompli-
cated case of psychopathic personality. Dismissing the idea
of feeble-mindedness in the metric sense of that term, let us
ask whether we could further define the case by stating that
Bertha Greenwood is hysterical. It is recognized, on all hands,
that the psychopathic personality may show hysterical trends;
that (as French authorities call it) there may be a forme fruste
of psychopathic personality which looks in the direction of
hysteria. We mentioned above her appearance one day with a
bruise on the face which she attributed to her ideal, but prob-
ably fictitious, paramour, a certain married man. That this
affair was an hysterical one might be thought from the fact
that she was picked up unconscious, or half unconscious. There
are other, somewhat less well-defined episodes, such as fainting
spells upon the street, and the resort in wild terror, to the house
of a woman unknown to her. One night, in Boston, in fact the
very first time that she devolved upon the medical scene, she
was in a kind of stupor, out of which she emerged telling of her
terror at a certain man. Could we see into the psychic interior
and be sure of our observations, we might think of Bertha
Greenwood as leading a sort of ideal double life, with an
idealized monogamous companion of whom she stood in a sort
of fear, that the light literature of the day is inclined to at-
tribute to the so-called "cave-woman."

It will be remembered that in the case of Rose Talbot syphilis
was early acquired. There might be more reason to suspect
the arrival of syphilis upon the docket here than in the simpler
sex life of Rose Talbot. Our serum reactions in Bertha
Greenwood have constantly been negative. This is despite the
fact that a medical consultant in private practice concluded
from his examination that Bertha was suffering from local
syphilitic disease of the pelvis of long standing. This physi-
cian went so far as to say that the nervous side of Bertha's life
was secondary to the disease of her pelvis. He counseled opera-

72 THE KINGDOM OF EVILS

tion and indeed thought such to be imperative. Another
hypothesis concerning the nervous spells in Bertha Greenwood
is that they are due to dysmenorrhea.

In point of fact, whatever be the pelvic complications in the
Greenwood case, there is ample evidence from her early life
that the psychopathic trend far antedates the immediate effects
of her sex life. As a child she had hysterical spells of rolling
upon the ground, and these began at about the tenth year and
are thought by the patient herself to have followed a criminal
sex assault. In the eleventh or twelfth year she is said to have
become subject to certain sleeping spells about which we know
little, although one of them is said to have lasted for some
two weeks. Whether these indications proved hysteria as
against some more vaguely defined psychopathic entity may
be left undecided.

Let us now take up in order the items of Bertha Green-
wood's case distributed amongst the four fields of difficulty.
It has been a classical idea, somewhat shaken by the war data,
that hysteria is essentially a hereditary disease, or, at all events,
that amongst the relatives of hysterics will be found other
psychopathic or neuropathic persons. We find in the Green-
wood girl the second of five children of a rather alcoholic
father, who worked irregularly and finally deserted the family,
and of a rather slack mother, certainly ignorant, and possibly
defective. The family was, -accordingly, constantly known to
a variety of agencies such as The Family Welfare Society, The
Society for the Prevention of Cruelty to Children, the Chil-
dren's Aid Society, and the like. In fact, we find that no less
than thirteen agencies had to do, at one time or other, with the
members of this family. With respect to heredity, we may
conclude that neither the alcoholism, nor the wandering ten-
dencies of the father, nor any actually known features of the
mother, thoroughly prove psychopathic heredity, but at least
there is a considerable ground for suspicion thereof. As for
Bertha's own mentality, we must remain in doubt whether she
is finally to be termed psychopathic, in some indefinite sense
of the term, hysterical, or something else. Probably the
psychiatric doubt which still exists as to Bertha is responsible,
in a measure, for our inability to handle the case with as much
success as the hours spent might seem to warrant.

Physically she might be regarded as an example of hyper-

THE KINGDOM OF EVILS 73

thyroidism. The thyroid is palpably enlarged, the pulse is
rapid, respiration is rapid, and there is a fine tremor of the
fingers. Whether this thyroid situation is secondary to the
sex-gland situation must remain doubtful, although modern
work upon the effects of glandular secretions upon the tem-
perament might be consistent with the idea.

If we turn to the educational field, we find Bertha's mother
ignorant and Bertha at the age of eight with three other chil-
dren placed out in various homes for some four years. There-
upon, at the age of twelve, she attended trade school for a time
and then got a job which suited her. At the age of fourteen
she began to work in factories in and about Boston and lived
in lodgings, and at this time her sex delinquency began. Some
quotations from her autobiography, which we give below, indi-
cate her present educational status. She, in practical ways, has
learned a good deal and has become able to earn twenty-five
dollars a week in hat-making, and has held a variety of posi-
tions, ranging from six dollars a week up, for various periods
of weeks or months, until such time as her alterations of tem-
perament set in. As for her moral training and status, she has
always been an affectionate, though not always truthful, girl.
She has rather made it a point to keep her promises. There
was, as is frequent with hysterics, a good deal of the histrionic
about her attitude; for example, she would, half in earnest and
half dramatically, instigate the appearance of social workers
and a detective upon Boston Common to meet the alleged man
who might be going to do her harm. Possibly this histrionic
trend is more an intellectual matter than a matter of moral at-
titude; but the trend seems to be central in her moral life. Of
course it would be possible to assert that her interest in the
Ideal Man is a gigantic bit of camouflage; but if so, this inter-
pretation would only be in line with our general suspicion that
she is, if not hysterical, at least hysteroidal in her make-up. It
is open to question how much proper moral training she got
in her placings-out ; or if she got proper training in these homes,
she may also have got much improper training. Her knowledge
of sex life she herself claimed to be practically nil at the time
of her first intercourse, said to be at the age of sixteen (of
course there was that other story of an assault at ten). If we
classify the patient as falling importantly into the group of
vices and bad habits, we ought, in all conscience, to be able to

74 THE KINGDOM OF EVILS

recommend some proper steps in moral training which might
be taken, or at the least show why further moral training would
be fruitless. As a matter of fact, we "closed" the case no less
than three times on the basis of what might be termed its social
incurability; but each time, at the patient's request, the case was
reopened.

One of our most powerful lines of management was to find
work and to secure good associates. These procedures were
singularly successful for periods of a few weeks, whereupon the
familiar lapse into depression and into the necessity or ten-
dencies of sex life would emerge once more. The facile prop-
osition for her disposal would be to place her in some sort of
new-fangled and perhaps not-yet-invented institution, which
could analyze her with absolute thoroughness and could secure
some technique for overseeing the temperamental changes that
are central in the social debacle. We can put the question
whether the irregularities of sex life are matters of poor train-
ing, to be reasoned out by better education or smoothed out by
improvements in tests, standards, companions who might be
better models, and in general the entire morale. Whatever else
be true, there can hardly be any doubt that the sex irregularity
is grounded in something somatic, something temperamental.
Whether this "something temperamental" is ingrained in the
nervous tissues themselves, i.e., in the modern medical lan-
guage an endocrine matter, is doubtful.

The situation with Bertha is somewhat like that with Rose
Talbot (case 8) ; but with Bertha there is far less of a nucleus
of self-respect and far less will-power has been yet developed
in her than in Rose who in the end was made to acquire the
idea of "success in life."

Extracts from an autobiography that Bertha wrote for the
benefit of one of the physicians are here inserted. Although
falsifying was a leading tendency with her, she sticks reason-
ably well to the truth in this story of her life : —

"It seems that life has been one hard knock after another.
If I had a few happy days there were double the days of sorrow
afterward to make up for the happy ones. And yet we must
live and endure till the end.

"My father was a good father in lots of ways, but like other
people he had his faults. One awful fault which was responsible
for all our unhappiness and the breaking up of our happy home

THE KINGDOM OF EVILS J75

was his liking for liquor. He drank terribly. I don't like to
say it, but I feel it is the truth. My mother was to blame for
my father's drinking, because she was so mean to him, always
nagging and finding fault. He got discouraged and didn't care,
then started to drink and went so far he couldn't stop it. I can
remember when my father was good and never drank. He
worked hard for us and was always kind to Mamma and us
children. Then too later I can remember how he used to come
home, at first only on Saturday nights so drunk he couldn't
find the house and all his pay gone. Then he got so he was
always drunk. Poor Dad, it was .awful and I am so sorry for
him. My mother hates him. Well, she may have reasons for
it that I don't know anything about. I don't think my father
is dead, and I have often wished I could meet him on the
street sometime, somewhere when I am out. I would love to
see him again. Poor father. That is another thing I don't
understand in this life, is why people who love each other and
should be happy together have to be separated. I will never
forget the day my father went away for good. We were all
in the house together (with the exception of my father). My
mother was sick in bed, she had just given birth to my sister
Jessie, who was only a week old then. My three brothers and
I were in the kitchen sitting around the table, telling stories. It
was early in the evening. We were right in the middle of a
story when we heard a rap on the door. We all knew it was
Dad, because he had a knock of his own, three little taps. We
all ran to the door to let him in. We hadn't seen him for a
week and we were awfully glad to see him then. My mother
cried when she saw him, and she told him to go away and never
come back, that she couldn't have him around any longer on
account of his drinking. He didn't say a word, but we begged
Mamma (as best we could) to .give him another chance. But
she wouldn't. She told him to go, so finally he started. I will
never forget it. We all clung to him crying. I know he must
have felt bad. He went away that night and none of us have
ever heard from him or seen him since. That left Mamma
with five of us children to take care of and none of us were old
enough to work. So of course it was up to my mother to
provide for us. She worked in restaurants or anywhere she
could find employment. I being the oldest girl most of the
house duties fell on me. I had to dress the others mornings
and get them off to the nursery. We were awful children and
I don't blame my mother for losing patience with us, as she
often did. She would warn us to go to school in the morning
before she went to work, and one of my brothers and I used to

76 THE KINGDOM OF EVILS

go oiif by ourselves and play all day, and then go home to
Mamma dirty at night. We never even saw the school house
from one day to another. The trwant officer was always after
us but Ma was never home to see him. Well, we were proud
kids and we did not have clothes like other children had, and
we felt bad about it, so thought we would stay away from
school. I remember one uniform I had, my mother's shoes size
six. Can you imagine a girl of eight wearing shoes of six, my
mother's skirt tied around the waist with a string and pulled up
over the top to make it short, and one of her old waists. I must
have been a picture, oh dear ! When I think of how I used
to race the streets and all the things I used to do and the places
I went, I wonder that I am even half as decent as I am today.
Besides not having clothes, we very seldom had a square meal.
We were always hungry. In the morning I always got up
(because I was made to, not from choice). I had the job of
blowing the fire to keep it going to make a cup of tea for my
mother. There was never more than one piece of wood in the
house and often only one match.

"There was a crowd of us kids who always went together on
hikes. One day my brother and I got lost and Ma found us in
Cambridge police station. I was the only girl, and there were
eight boys with me, two of them were colored. When Ma came
to take me home I didn't want to go. One of the policemen had
made a bed on one of the benches for me and the matron had
given me a doll. I felt quite at home there. It was much more
bright and cheerful than my own home, even though it was a
police station. I was always getting into mischief. One day I
stole a red and white tablecloth l)elonging to one of our neigh-
bors. They had their pulley line fastened to our window and
I took the cloth. I got arrested for it. The policeman scared
me and told me if I stole again he would put me away. We
didn't have a tal)lecloth and I thought it would be kind of nice
to have one. As long as we couldn't afford one, I thought the
next best thing was to steal it, but I decided afterwards that it
was better to do without one.

"After a while Frank and I were taken away from Ma and
put in a private family. We were very homesick. The people
were nice to us, but we missed the others at home. We were
sent to school in the morning and we went into the woods and
stayed till school was out, trying to plan how we would get back
to see Mamma. The people we lived with couldn't do anything
with us, so our guardian had to find us another place to live.
The second family we went to live with were not as nice to us
as the others were but we had to stay there. We were there

THE KINGDOM OF EVILS 77

four years. We were on a farm. We were awful lonesome
and homesick. Ma only came to see us twice in four years, and
she had tickets sent to her to go every month if she wanted to.
We went to school while with these people and helped with the
work after school, I with the house work and my brother with
the farm work. After four years we had to be separated. I
had a chance to go to Hammond School, but Ma wanted me to
go home and live with her. She cried and took on so, I felt bad
for her and said I would. (That was one step I took that I
have always regretted.) My guardian didn't want me to stay
with her, but I thought if I could help Ma I would, she had to
work so hard. I'll never forget the first day I came home, I
was so glad to see her, I ran to her and threw my arms around
her neck and was going to kiss her. She pushed me from her
and said she never kissed me when I was a baby and she
wouldn't kiss me then. I felt awful, I wanted her to love me ;
I was hungry for love. I would have done anything in order to
win her love. But she didn't care for me. I couldn't stand it to
stay with her. Everything seemed so upset and dirty to what
it had been in the country. I went to my guardian and told her
I couldn't stay. She made arrangements for me to go back and
stay with the people I had been with for so long. But when the
time came for me to go, Ma cried terribly and begged me to
stay with her. I didn't want to stay because I wanted to mak?.
something of myself and I knew I never could do it there.
But I didn't have the heart to leave her (another step in the
wrong direction). There were James, Jessie and myself at
home then. James and Jessie went to school and I worked.
Ma treated my brother James so mean he didn't want to stay
in the house in the evening. She was always nagging. He
started to go out evenings and got in with a bad crowd of boys.
They stole something one night and all got arrested. My
brother was sent to a reform school. He stayed there for a
while and ran away. They got him back and made him stay
twice as long to pay for it, and the poor kid has been in reform
schools and jails all of his life since then, up to a month or two
ago, when he enlisted. He says now that as hard as it is, it is
the happiest time he has known in his life.

"My sister Jessie started to stay out nights for the same
reason my brother did. I couldn't bear to see her have the
same thing happen to her that happened to James. I took her to
Court and she was sent to a private family to live. The people
have adopted her and as far as I know she has everything she
wants and is happy. I am glad for her.

"When I was about sixteen years old I went out of town to

yS THE KINGDOM OF EVILS

work in an institution for my board, room and clothes, just for
the summer. It was on a town farm. There were all kinds of
people there, sick, well and old. The people who ran the place
had four hired men working for them. One of them liked me
pretty well, or at least he thought he did. He tried his best to
go with me, but I wouldn't let him. I did almost as bad
though. He gave me five dollars not to say anything about it
and I didn't say anything. I didn't fully realize then what it
meant, but I realized soon afterward. I liked him and I let
him do that right along all the time I was there. When I left
there I was always lonesome for him, but wouldn't give in. I
came to New York and tried to forget him. I tried to find
someone to take his place. I was lonesome and unhappy all
the time. I lived with my mother for a while, but she was
mean to me and I left her. I met a girl that I grew very fond
of. She liked me too. She was older than L She was a bad
girl, but I didn't care, I liked her. But she didn't love me as I
wanted her to, so I had to make her love me. I didn't care
how I did it. After a time I told her I had gotten in trouble
with a fellow, so that she would sympathize with me. I knew
she would. She did, but I had to pay the price. I had to go to
bed and stay there for two weeks (until I was sick). I had all
the blankets and hot water bottles in creation on me to make me
sweat, and I had to take nasty medicine every half hour. I did
this all for love and I would not give in and tell her I had lied.
I bore it and kept quiet. She gave me the affection I longed
for and that was all I wanted. She was awfully good to me
from then on. I was quite happy while I had her to go to. She
satisfied me in every way and we loved each other. I didn't
want anybody else. Then she went away and I only hear from
her now. She is so far away I can't see her. She is in Texas.
Since then I have never found anyone to take her place, and I
am lonesome and unhappy. I have lived an awful lie and I can't
get away from it, one little lie has led to another till now it
seems as big as a mountain. I have lied to so many people I
don't know what I will ever do, and everybody thinks I am
bad."

We have chosen to regard Bertha Greenwood as a fourfold
rather than a fivefold case, and to think of her as minus the
delinquency aspect; that is, the aspect of legal entanglements.
To be sure, in one sense to be sexually aberrant is to be a delin-
quent (the terminology is still a little doubtful), but we are
talking of important spheres of contact with the law. There
were no practically important legal contacts in the case. There

THE KINGDOM OF EVILS 79

were one or two minor court appearances which have not in-
fluenced the main Hues of her social treatment by the various
agencies. It might be inquired whether the kind of authorita-
tive supervision which courts could exert would be of value in
such a case as Bertha's. We mentioned above that some sort
of institution might be devised that would help, although in
such institution we suspect cases like Bertha's would have to
be the central figures. It is doubtless unlikely that the state will
find itself able to build institutions around single figures of this
sort. We are of opinion that, despite our relative unsuccess
in handling the case, nevertheless no better results could have
been obtained by judicial methods; that is, it would not have
helped to have treated this patient as a prostitute and to have
maintained her in prisons from time to time for punitive or
correctional purposes. It must remain an open question
whether, in so difficult a case, the "iron in the velvet glove" that
might be afforded b}^ a probation system would have helped.
In some modern systems, the psychiatric viewpoint is, of course,
maintained.

We turn to the economic sphere. Getting her work was, as
above stated, one of our best lines of handling. Would Bertha
Greenwood have been another person had she been supplied
with a good-sized annuity; had she been, in short, sorriewhere
in the third estate of the well-to-do? We do not see how either
her histrionic tendencies or her depressive phases, to say nothing
of the "man crazy" trends into which she would lapse from
time to time, could have been ordered by a change of social
level. Still it must be granted that financial worries may have
had their subtle effects upon the body's functions, and in some
indirect way have changed perhaps the thyroid gland, or even
the sex life. Perhaps we should not reckon this case as very
fundamentally an economic one. For example, it appears that
no more than thirty-eight dollars were ever spent out of avail-
able funds directly upon the Greenwood girl ; still her psychop-
athy, with its phases, was continually throwing her upon the
brink of destitution.

We now turn from Bertha Greenwood to three other cases
which will in succession demonstrate the fourfold distribution
of the social evils according to our classification. From Thomas
Fuller, in whom the economic factor did not come in question,
and from Bertha Greenwood, in whom the legal contacts were

8o THE KINGDOM OF EVILS

minus or slight, we turn to case ii (Lewis Goldstein) a com-
plicated case of traumatic neurosis, in whom moral difficulties
were practically nil, to case 12 (Elsa Albrecht), a case very
possibly of dementia praecox, whom we may regard as educa-
tionally without particular social flaw, and to case 13 (Agnes
O'Brien), a case in whom the medical difficulties were subor-
dinate or exceedingly slight.

Hours spent by Medical record, 13 pages

Social record, T2. pages
Physician, 4 Social work :

Visits, 133
Psychologist, I Interviews at hospital, 19

Telephone calls, 80
Social worker, 293 Letters, 47

TRAUMATIC PSYCHOSIS
FOLLOWING INDUSTRIAL ACCIDENT

19 1 5 19 16

Industrial Disability Compensation

Insufficient Income Investment

Debts Business Failure

1917
Irregular Employment
Minor Injuries
Charitable Aid

BEFORE 191 5: illiteracy; IRREGULAR EMPLOYMENT;
BUSINESS FAILURE

Steady, illiterate workman disabled hy industrial accident.
Family case. Sloiu social recovery. Mental hygiene of in-
dustry.

Case II. We take up, in Lewis Goldstein, the third of
our five cases, showing not the full display of evils in their
fivefold distribution, but exhibiting situations in some respects
less complex, namely a fourfold distribution. Whilst Ful-
ler (case 9) showed no economic disability, and whilst
Greenwood (case 10) was not, in any important way, le-
gally entangled, the present case of Lewis Goldstein is one in
which another element or factor of evil was lacking, namely
the factor of moral disability. In fact this young Russian Jew
of twenty-three years proved to be a man of high moral stand-
ards and ambition. (It would be almost true to say, curiously
enough, that his high ambitions interfered a little with his social
cure.) Goldstein was working as a roofer's helper one day
when a twenty-five pound tar bucket fell from the fifth floor
upon his head. He sustained a compound, depressed fracture
of the skull. He lived for a time upon the weekly compensa-
tion granted him under the Industrial Accident Laws and did
no work. The Industrial Accident Board, not being sure of the
degree of disability or even of the existence of a permanent
injury, sent him to a general hospital out-patient department,
whose medical authorities assured him that he had not been
seriously injured by the tar bucket and ought to go to work
once more. In due course he was referred to the Psychopathic
Hospital by the Industrial Accident Board, coming, as is usual
with these cases, as a voluntary patient. Here the psychological
examiners found that despite his twenty-three years of actual
age, his mental age by the Binet tests was but eight and one-
fifth years. To the psychological examiners he seemed to be
a man of poor comprehension, diminished learning ability, prac-
tically no planning ability (so far as tests went), poor powers
of observation and apperception, a memory of narrow span and
retarded free associations. We mentioned these details of the

84 THE KINGDOM OF EVILS

psychological results to show how general, or as we are accus-
tomed to say, regular, was the mental loss ; in fact, the exceed-
ingly competent examiner thought that Goldstein's reactions
throughout were those of a feeble-minded person of low moron
grade.

Now such results obtained by the psychologists are, in these
cases, of extreme value, particularly when we come to com-
pare the results of one year with those of later years. Some-
times it is possible to trace the improvement of a patient recov-
ering from brain injury most precisely by means of successive,
properly spaced, psychological tests, but in the present mstance,
the psychiatric social worker examining the man's past would
have been entitled to wonder how the diagnosis of low moron
could have been made in a man who had been reasonably suc-
cessful in a variety of positions and had even, at one time,
managed a small business. He had been a steady and depend-
able fellow of good habits, cheerful, even-tempered, fond of
his family. At a pinch it would appear, however, that every-
thing he had actually undertaken to do could have been per-
formed by a moron of a high grade. It would be a pretty in-
quiry, and one which should be carried out by scientific employ-
ment managers or the administrators of business schools, to
classify types of occupation, particularly industrial occupation,
with respect to the degree of mental capacity necessary for
their carrying out. Possibly many of these industrial occupa-
tions range in their mental age capacity around ten years.
Goldstein, however, made eight and one-fifth years.

Accordingly, although the mental level and the manner of
its reduction both signify feeble-mindedness, the social inquiry
inclines us to the belief that either the accident, or some other
element in Goldstein's history, had reduced his mental level
somewhat. The psychiatrist, reporting upon Goldstein to the
Industrial Accident Board, putting together the psychological
and sociological data, said that "accordingly it seems doubtful
whether the patient could have been a low-grade moron before
his accident and that it is probable that the accident is a large
factor, if not the entire factor, in his present condition."

The medical examination showed some evidence of a skull
depression in the u])per occiput and there was a minor disorder
of the reflexes upon the right side of the body, comporting
with the probable site of the brain injury inflicted by the tar

THE KINGDOM OF EVILS 85

bucket. Upon investigation, it appeared that, after being struck
down by the bucket, he had become unconscious, was cared
for six days at the Rehef Station, became bhnd a few days,
later was cared for at a general hospital, and thereafter had
been in bed for a period of five or six weeks, so that the total
history of bed- fast debility was something like two months.

The prognosis given by the hospital was that "the patient
cannot at present work, and for some time he will be unable to
make anything like eighteen dollars a week" (his wages as a
roofer's helper).

Although this is not a textbook of psychiatry, it may be of
interest to the reader to learn how many symptoms such a
patient as Goldstein may show between eight and nine months
after injury. He came to the Psychopathic Hospital complain-
ing of insomnia, of loss of appetite, of backache, of an almost
constant headache ; his vision was greatly impaired and he was
most seriously troubled with attacks of blindness that would
last a few minutes and be attended with dizziness. He would,
under such circumstances, fall into the street and then take to
weeping. He had become restless, irritable, readily angered by
trifles, and thereafter lachrymose. His incapacity to earn
money made him depressed and apprehensive. He described
himself as having a tendency to chills and said that his memory
was impaired. Several features of this catalogue of symptoms
belong to the so-called vasomotor neuroses of certain authors,
characteristically found after injury; the facile spells of anger
perhaps belong to the so-called explosive diathesis of authors.
Upon these data, the Industrial Accident Board, after a time,
fixed a lump sum settlement, and the money awarded was put
into a small store. The business, however, failed in a few
months. Possibly its failure was due to the patient's becoming
upset by complications following his wife's pregnancy and con-
finement in a hospital. He shortly became well enough again
to work, but refused to take a job that paid less wages than
he was used to.

We had Goldstein under supervision for some three years.
By slow degrees he got back to habits of regular work in his
oH roofer's trade. About three years ago (1918) the case was
closed, partly because other cases seemed to demand more from
the social service than did Goldstein's. As a matter of the
technique of social work, it is interesting to point out that no

86 THE KINGDOM OF EVILS

fewer than eleven agencies were called upon to deal with Gold-
stein. No single relief agency was available that could supply-
all the funds necessary for his family, which was ever on the
poverty line. Steady relief for the rest of the family would
have been the ideal background for the psychiatric social worker
in the Goldstein case, but it is permissible to point out that
there would have been no family problem of moment had there
not been a central psychopathic figure on the scene, namely the
traumatic neurosis or psychosis of the bread-winner. At one
time we attempted to transfer the Goldstein family relief ques-
tion to a general relief agency, but the psychiatric features of
the whole situation failed to be grasped by that relief agency
and the case had to be reopened by us.

Certain minor psychopathic complications are worth a word.
Thus, the man's feeble-mindedness, or queer equivalent thereto,
had something to do with the temporariness of his different
jobs. Thus Goldstein might promise to apply for some
vacancy and then do nothing further about it; then again he
would, in working, run a nail into his foot, or strain his back,
or fracture his wrist, in fact have so many kinds of accident
that there can be little doubt that the complications were largely
due to his low mental capacity. It is this kind of thing which,
in industry, would go to make up a genuine problem that
might be called the nienfol hygiene problem in industry, for
it is clear that feeble-minded persons who have not had their
mentalities diminished by the fall of tar buckets on their heads,
may nevertheless very frequently be subject to accident. Of
course, throughout all this talk about Goldstein's feeble-mind-
edness, it must be remembered that he is a fairly well built, well
developed, v/ell nourished man who presented so good a gen-
eral appearance that, no doubt, any employer would be in-
clined, and properly inclined, to hire him on sight.

Our analysis of Goldstein from the standpoint of the dis-
tribution of troubles may be brief. The medical features dom-
inate, whether on the one hand we point to Goldstein's original
moronity or to his queer lack of mental capacity. The educa-
tional disability was not alone that of the feeble-minded person,
but was also that of the Russian immigrant. With respect to
vices and bad habits we can find no evidence thereof, except
phenomena that might be explained more readily on the patho-
logical, or poor education, basis. The legal entanglements with

THE KINGDOM OF EVILS 87

the Industrial Accident Board had a strong bearing upon the
rate of social "cure" and medically there is at least a strong
suspicion that the law's delay contributed not a little to the
fixation of his neurosis. Economically he was forced to drop
from eighteen or twenty dollars per week to nine dollars per
week. When the lump sum melted, Goldstein was worse off
than before. It is plain that all the phenomena in this case
are so closely bound up with one another that the cure or
removal of no single element in the complex will turn the
trick completely.

Shall we regard him as a "successful" case of psychiatric
social work ? As hinted above, we should not have, under ideal
conditions, closed Goldstein's case. At all events, we must say
that he is decidedly upon the up-gradient once more. Whether
we attribute this improvement to subtle mind changes due to
the passing of the effects of his brain injury three years before,
or whether we attribute the up-curve to environmental effects
of assiduous social work may and ought to be left undecided.
We say "ought" to be left undecided because scores more of
such cases as Goldstein's ought to be on the social work record
books of the world. Had not eleven agencies had to do with
Goldstein, and had not the thread of psychiatric insight. been
shown in the social work, it is easy to picture the collapse in
several fields of social trouble of the entire family.

Hours spent by Medical record, yj pages

Social record, 41 pages
Physician, 11 Social work:

Visits, 61
Psychologist, i Interviews at hospital, 9

Telephone calls, 50
Social worker, io6>^ Letters, 10

Mother of two illegitimate children. Mental disease sus-
pected. Referred as a ''terrible case."

Case 12. The fourth of our five cases that are less com-
plex by one element than Rose Talbot (case 8) is the case of
Elsa Albrecht, who came under our observation first at the age
of twenty-six. This case is one free from educational defi-
ciency, and is, in fact, a girl of rather superior education. She

55 THE KINGDOM OF EVILS

came to us as of the group sometimes referred to as "terrible."
During her three years in this country she had had two illegiti-
mate children. She could hold no job; she was very shifty
and undependable in her accounts of her life: her responsibil-
ity was a grave matter of question. As for the illegitimacies,
she showed little or no concern over them, nor was the truth
ever learned concerning them. To make a long story short,
she was eventually dismissed from the Psychopathic Hospital
with the diagnosis of "paranoid dementia praecox," a diagnosis
which should probably be revised on the basis of further
observation.

We find in the hospital the following evidence which under-
lay the diagnosis that we now regard as erroneous : The little
concern which she showed over the illegitimacies, irritability,
resistiveness, overemotionality, hallucinations (history of three
years' standing), double thinking (heard her own thoughts).
Psychometrically she was regarded as of adult mental age,
tested by norms for non-English-speaking persons. Perhaps
the most striking feature in the psychiatric situation was the
alleged hallucinations. She claimed to hear distinctly the voice
of some unknown woman and sometimes other voices that
were talking about her in English, French, or German. When
the question of voices was brought up with her she would grow
somewhat disturbed. Toward the close of her stay she said
that she was not now hearing these voices so much since con-
fessing about a false name that she had used. She talked more
or less about her conscience and its troubling her about this
assumption of a false name and of "voices" accusing her of
being false to herself and to God. Whether we are dealing
with definite hallucinations of hearing or whether we are deal-
ing with pseudo-hallucinations is a fine psychiatric question,
but it would not do medically to ground a diagnosis of demen-
tia praecox upon so slender a basis.

This diagnosis of dementia praecox must be accepted as a
serious thing in any social case, for once let the diagnosis
dementia praecox be grafted on any case and a sort of taint
seems to cling to the case for all time. This is no doubt largely
on account of the sweeping implications of the term "dementia."
Where the case should be put medically remains in doubt. We
are certain of many of the so-called psychogenic features, fea-
tures that are found to some extent probably in all kinds of

THE KINGDOM OF EVILS 89

mental disease, but which, when developed alone and inten-
sively, place their victim somewhere in the group of the psycho-
neuroses or the psychopathic personalities with psychogenic
features.

Rather unlike the victim of dementia praecox, and rather
more like sundry of the psychoneurotics, Elsa made friends
easily and even lay friends stuck by her through thick and
thin, and especially through the complications of the two illegiti-
mate births. Although she made Jay friends so easily, Elsa
was, in the eyes of social agencies, a good deal of a menace,
perhaps the more so as she made friends so readily. At one
time an attempt was made to deport Elsa as an undesirable alien.
However, upon investigation, it appeared that she had, after
all, taken fair care of her children for whom, indeed, she never
failed to exhibit her love. Amongst other contrasts with which
this case was so rife we should mention Elsa's own division
of mind over herself, her future, and her children. She was,
for the most part, self-confident in asserting her ability to care
for herself and her children, worked as a governess to support
them, and, for a long time, held the ideal of bringing them up
as sisters should be brought up ; namely, together. Again she
showed a deep depression, in fact, such a degree of emotionality
as was suited to her situation so that the psychiatrist would
very naturally question her being a victim of dementia praecox.
Another contrast in Elsa's case was that between her excellent
general intelligence and her inability to keep a job. It might
even be thought that a slight degree of wandering tendency
was herein shown, although the obvious cause for each loss of
a job seemed to be matters of her high temper and inability
to stand critique. As intimated above, perhaps the strongest
contrast lay between her general self-respect and her curious
light-heartedness concerning the illegitimate births. She ex-
plained that she was, in each case, engaged to her lover and
seemed to feel that these sins were comparatively minor.

The history of the social care of Elsa Albrecht is rather
unusually exciting because of factors thrust in from without.
Somehow Elsa veered from her attitude of keeping the children
together for their growing up and decided to have them both
adopted, if possible. The older girl, now four years old, was
adopted by friends. The younger one, now two years old,
went through the process of adoption, but there came about an

90 THE KINGDOM OF EVILS

annulment in the following manner : When these sudden
developments forthwith came to the attention of the social
workers, the warning was given to the intermediator for the
younger child (who happened to be a physician) that the foster
mother might properly know something of the situation. The
physician agreed readily with this idea, and in fact, set about
forthwith to have the adoption annulled. Whether Elsa had
at this time contemplated the marriage with an Oriental that
she now promptly executed is in doubt; at all events what hap-
pened was that she went to a distant city and got work. The
social technique consisted in requiring her, on moral grounds,
to come back and assume responsibility for the now unadopted
baby. She came back, took the baby, and repaired once more
to the distant city, where she married. The baby was then
placed out, and provision made for her board to be paid for by
the husband.

As a matter of the progress of psychiatric social work in the
country, it is interesting to know that we were able to get
cooperation with workers in the city where Elsa now is, so
that due attention could permanently be paid to the upbringing
of the child and to any complication which might ensue in the
married life of a woman who seems to be undoubtedly some
sort of psychopath. After an interval of two years the follow-
ing report came from the social agency : —

"We have had a report on this case within the last month
showing that the patient is fairly happy in her home which is
comfortably furnished and well kept. You must have had a

previous report on her marriage to Mr. R , her subsequent

worry over the fact that he did not make as much money as he
did prior to their marriage, and also her upset over the death
of her youngest child, Gretchen. In October, 1918, she had
frequent fits of crying and was grieving over the death of this
child and the adoption of Frieda the older one. In May, 1919,
she gave birth to a little boy, Charles. The birth of this child
has seemed to compensate her for the loss of the other two.
Her husband is now in a better financial position than formerly;
and when the patient's children were spoken of she showed no
emotion whatever and seemed to have no regret for the death
of the one nor the adoption of the other. She was very affec-
tionate to her new baby and seemed very proud of it. About
three weeks ago she wrote us that the baby was progressing

THE KINGDOM OF EVILS 9 1

satisfactorily, is now walking and talking and she herself is
getting along nicely with her husband and is in good spirits."

To sum up from the standpoint of the distribution of evils,
we have here a medical, moral, legal, and economic problem,
without important educational complications.

Hours spent by Medical record, 17 pages

Social record, 17 pages
Physician, 3^ Social work:

Visits, 7
Psychologist, i Interviews at hospital, 15

Telephone calls, 45
Social worker, 28 Letters, 31

MORON, 29
HYSTERICAL, POOR HOUSEKEEPER

1915-1916
Forced Marriage
Jealousy : Separation
Another Child

Estrangement from Relatives
Unemployed

igi6-igiy

Child with Husband'^

Relatives
Under Public Care
Reconciled
Employed

Hysterical moron, divorced, with an illegitimate child. Such
cases often known to social agencies.

Case 13. It is now our duty, for the sake of logical com-
pleteness, to describe a case without special medical complica-
tions, but one which shall show the four other types of com-
plication with which we have become familiar. In a book on
social psychiatry it is, of course, in the strict sense not proper
that we should describe any non-psychiatric, or indeed non-
medical, cases. Agnes O'Brien did show, as a perfectly proper
ground for her appearance at the Psychopathic Hospital, an
attack which it is probably safe to regard as hysterical; but
thereafter her social care contained, although many difficult, no
special medical complications.

Let us at first make her out as medical and psychiatric as
possible. When she arrived, it was with a.history that her face
had become twisted; that she was unable to chew or swallow
and that she had been crying a good deal. These things had
been going on for a day. She said she was going to commit
suicide by taking poison; she said she was going to throw a
pocketbook into the fire. Her sister-in-law thought that Agnes
hardly knew what she was doing. She was a rather frail
woman of twenty-nine who looked almost girlish. Her sister-
in-law said that five years ago, when pregnant, Agnes had had
somewhat the same symptoms. It seemed plain that they were
hysterical in part. Examination showed that the girl was
pregnant. Detailed medical examination showed the con-
tracted or tubular vision characteristic of hysterics. Although
Agnes claimed that she was unable to speak, and spoke of oc-
casional paralysis of one side of her face, it was found that,
when her attention was distracted, she could enunciate per-
fectly and showed no sign of facial paralysis whatever.

Thus, the first medical point to make is that the patient was
clearly, though mildly, hysterical. The psychological exam-
ination showed that she was a subnormal person grading at
1 1.3. Her grading was fairly even; that is, she showed the

g6 THE KINGDOM OF EVILS

"truncate" deficiency of mind which is more characteristic,
statistically speaking, of feeble-mindedness than it is of ac-
quired mental disease. Perhaps, therefore, we should classify
her as a more complicated case of social trouble ; namely, as the
fivefold case in which medical, as w^ll as educational, moral,
legal, and economic difificulties confront the social adapter.
However, we are convinced that many a social agency deals
on non-medical grounds, and certainly upon non-psychiatric
grounds, with case after case of this order. We believe that the
records of social agencies the country over will be found to
contain such cases as Agnes O'Brien's treated, and with con-
siderable or perfect success, by the usual social technique.
When perfect success is achieved in cases of this order, appar-
ently from a non-psychiatric angle, we suspect that the technique
implied is, at bottom, that of the psychiatric social worker. In
the practice of social work, and especially in the practice of
medical social work, the psychiatric viewpoint sometimes gets
implanted subconsciously in the social worker's mind. It is a
part of the program for progress in psychiatric social work to
point out the tremendous percentage of situations demanding
social work that encloses as a core some psychopath. Concern-
ing Agnes O'Brien, we then insist that her case is not an unfair
sample of cases handled sometimes successfully, perhaps more
often unsuccessfully, by agencies that employ neither the medi-
cal point of view nor the psychiatric point of view.

The social technique had to take account, for Agnes O'Brien,
of some place in wliich she could await her confinement. The
attitude of the family, especially of the in-laws, was not too
pleasant, as might be supposed when it is noted that the preg-
nancy was illegitimate. The priest's interest was enlisted.
The first pregnancy, five years before, had led to a forced
marriage, and now that the new child was on the way by
another father, there was a threat of divorce by the husband.
The legitimate child required care. This was managed by
placing the child with the husband's relatives. Prenatal care
was arranged for. Care during the confinement, care of the
baby in its early days, and placing-out of the baby, were other
steps. It was a little hard to convince the municipal authorities
that this seemingly relatively normal mother could not well take
care of the new child. However, the child was finally placed
out. There was also the important question of proper counsel

THE KINGDOM OF EVILS 97

and encouragement for the woman herself. Aside even from
the complication of her pregnancy, Agnes O'Brien was a rather
frail, inert person, a little sullen and stubborn. At the end of a
year the situation was somewhat as follows : The legitimate
child was under the care of her husband's relatives; the illegiti-
mate child was under public care ; the girl had become recon-
ciled with her own relatives, and to some extent with her hus-
band's relatives. She could, from time to time, see her child
with them. She can, of course, also see her child that is under
public care. ( Parenthetically we may remark that the monthly
or bi-monthly "pass" system by which children under public
care are allowed to come to the vision of their mothers by the
public authorities of some of these institutions may be a neces-
sary, but certainly seems a somewhat inhuman system : the bet-
ter agencies so individualize their systems that the parents who
would not be disturbing elements in the foster situations are
allowed due access.) Agnes is, for the most part, sufficiently
devoted to her children, at least to the first, or legitimate child,
yet her temperament is such that a letter of the following
description was sent to her husband : —

"Dear William : As long as you don't intend to do the
straight thing by me, I don't by you. So come up and get your
old kid or I will leave her some where on the street. I am half
dead from everything and can't stand taking care of her any
longer. Don't send that rotten old Jew up to me Saturday or
I will insult him. I can't give him any money and try to pay
back milk bills and back rent and everything. Come take your
kid quick or you will see what I will do with her. I am smash-
ing her, she is a regular pest. If I am going to live by myself
I can't have a good time with her tagging after me.

"Your neglected
"Wife."

But these sentiments oi me neglected wife are entirely incon-
sistent with her actually idolizing the child.

Shall we regard the analysis of this case as essentially free
from medical factors? It is facile enough to point out the
moronity of this girl and say that feeble-mindedness leads to
such complications as forced marriages and illegitimacies, yet
it would be more accurate to say that feeble-mindedness is not
infrequently followed by such complications. Certainly, how-

98 THE KINdDOM OF EVILS

ever, no one can fail to be aware of sundry equally moving
instances of forced marriage, illegitimacy, etc., that dot the
lives of persons that are not feeble-minded, possibly not even
psychopathic. Whatever be the truth of these contentions, we
present the case as one in which four types of factor are pre-
dominantly in evidence, whereas the fifth, or medical, factor did
not particularly influence, save in the most subtle way perhaps
the social treatment.

Hours spent by Medical record, 15 pages

Social record, s^ pages
Physician, 4^ Social work :

Visits, 43
Psychologist, i Interviews at hospital, 8

Telephone calls, 34
Social worker, 86 Letters, 25

Deaf, syphilitic, unstable. Abusive and psychopathic hus-
band.

Case 14. With case 14 we begin our group of threefold
cases ; namely, cases in which two of the five fields of social
trouble are not predominantly in evidence, and we choose, for
the first case, one with medical, educational, and moral diffi-
culties, but without special legal or economic disabilities. The
case is that of Margaret Hersey, whose social symptoms
might be listed as follows : Marital discord, seclusiveness,
deafness, suspiciousness. Margaret was an illegitimate child.
Her husband was a sex delinquent and one of her stepsons was
also a sex delinquent. It is of note ( re general progress in the
mental hygiene of the community) that Margaret Hersey came
to the attention of the social service indirectly. First came to
us the delinquent stepson who had gotten into some sex diffi-
culties, not here to our point.

Abstracting, for the moment, from the difficulties of the
rest of the family, let us consider the situation depicted in
marital discord, seclusiveness, deafness, and suspiciousness.
The psychiatric viewpoint would immediately try to connect up
some of these phenomena. Psychiatrists believe that there is
actually to be found in the world at times a so-called "psycho-

THE KINGDOM OF EVILS 99

sis of the deaf"; that is, a more or less well-defined mental
disease directly depending upon sense-deprivation, viz., deaf-
ness. But psychosis of the deaf is not actually in question with
Mrs. Hersey. The deafness was extreme enough and made
communication very difficult with other members of the family.
Mrs. Hersey may have been, to start with, a Httle paranoid;
that is, given to ideas of being put upon, of being persecuted.
If so, the at first indefinite ideas of persecution were, no doubt,
driven further into her make-up by the deafness and her lack
of power to verify or disprove sundry hypotheses about her
husband and son.

Mrs. Hersey had been married at the age of twenty and was
now thirty-eight. The very first night of her marriage, her
husband was violent and abusive, and from him she promptly
also contracted syphilis. Whether her deafness is syphilitic
remains in question. It began about eight years after her mar-
riage and grew worse some years later after her husband had
struck her a bad blow upon the head. At one time (age thirty-
three) the poor woman even attempted to commit suicide.

Medical examination showed that Mrs. Hersey had, besides
sundry minor nervous symptoms, a positive Romberg sign
and an ataxia of gait, both signs suggesting, with the rest of
her history, a syphilitic involvement of her nervous system.
In fact she had been treated at two general hospitals for this
complication of syphilis, and at the time when she came under
Psychopathic Hospital observation her spinal fluid had become
negative — a finding which does not necessarily show that there
is not still some active syphilis. There were also, in her history,
two miscarriages, which might be thought consistent with the
history of syphilis (though one of these miscarriages followed
a trolley accident).

Deafness, incommunicability, suspiciousness, seclusiveness,
formed a complex serious enough in itself ; but it appears that
from time to time she also had definite hallucinations of hear-
ing, hallucinations, however, which she quite well understood
to be perceptions of an imaginary character.

Our investigations showed that the family was economically
upon a reasonably high level and that with proper family coun-
sel that level could be well maintained. Perhaps we can indi-
cate the kind of social treatment adopted in this case by the
following notes ;—

lOO THE KINGDOM OF EVILS

9/28 Interview with husband to assist in persuasion for ex-
amination.
10/ I Interview with patient. Reassurance.
10/ 2 Interview with patient's mother. Encouragement and

advice.
10/ 7 Interview with husband. Attempt to improve insight
into patient's condition. SHght gain in cooperation.
" Interview with patient's son. Object: To appeal to his

sense of chivalry.
" Interview with patient's daughter. Object: To suggest

consideration for patient.
" Interview with husband. Object: Attempt to gain his
cooperation by agreement to assist him in making a re-
vision of his budget.
10/10 Interview with patient. Advice and encouragement.

" Interview with patient's mother. Reassurance.
10/17 Conference with entire family. Aims:

1. To straighten out difficulties in misunderstanding
over family finances.

2. To give constructive advice along this line.

3. To prompt a more friendly family relationship.

4. To have all sides of the question presented impar-
tially and thrashed out.

5. To persuade that reconstructive measures should
"let bygones be bygones."

6. To encourage patient by suggestion of lip-reading.
** Dr. Basch interviewed to enlist cooperation and acquire

possible evidence.
10/22 Conference at Horace Mann School to enlist interest of

teachers and lay constructive plans for lip-reading.
11/ 4 Patient and husband interviewed. Aims:

1. Financial advice given.

2. A dietary manual given patient to stimulate her
interest and enlist her cooperation in plan.

3. General advice and encouragement.

11/10 Patient and mother interviewed. Advice and encourage-
ment.

11/15 Patient and mother interviewed. Encouragement, ad-
vice, and reassurance.

11/22 Letter. Advice and encouragement.

11/25 Interview with patient and mother. Much reassurance.

11/30 Patient interviewed. Aims:

1. To make plain continued friendliness.

2. To encourage and advise.

3. To give patient relief of fully expressing herself.

THE KINGDOM OF EVILS lOI

12/13 Letter. Encouragement.

12/14 Mother and stepmother seen in New York. Object: To
secure cooperation.

12/23 Christmas gifts to the family.

12/28 Letter thanking patient for Christmas gifts. Encourage-
ment,

1918

1/16 Letter. Education.

1/17 Talked with husband. Cooperation.

1/24 Lip-reading teacher talked with. Education.

1/25 Telephoned. Education.

1/26 Family seen at home. Advice, encouragement, coopera-
tion, education for children, reassurance about treatment.

1/29 Letter urging treatment.

2/ 4 Same.

2/ 9 Same.

Letter to husband urging treatment.

2/12 Telephoned (same as above).

2/13 Patient at hospital. Received treatment.
Patient on wards. Encouragement.
Telephoned husband. Education.

2/15 Husband seen. Cooperation.

2/16 Son, William, seen. Education of William in attitude
toward patient.

2/18 Mother written to. Reassurance.
Letter ; arrangements for meeting.
" Mother written to. Arrangements for starting patient
on trip to New York.

2/19 Letter to husband urging generosity toward patient.

2/20 Patient taken to South Station and put on train for
New York. Reassurance.

3/1 1 Letter to patient. Object: To give her courage to tell
husband that she had lost her money.
" Daughter taken to Dental Infirmary for dental treat-
ment.

3/21 Telephoned to get patient to hospital for treatment.

4/ 3 Letter urging treatment.

4/10 Same.

4/24 Same.

4/29 Letter preparatory to visit.

5/ 2 Interview with patient and mother. Advice, encourage-
ment, education.

5/ 8 Letter to husband urging that William report at out-
patient department and that patient come for treatment.

I02 THE KINGDOM OF EVILS

5/14 Letter to patient urging treatment.

5/18 Patient and mother interviewed at hospital. Patient is

finally persuaded to take treatment. Encouragement.

Reassurance.

Let us call attention especially to the notes in the above
abstract under October 17; namely, those that deal with the
conference held with the entire family. That conference seemed
to straighten out a great many of the tangles. A very difficult
situation, the social care has now pretty well succeeded in all
respects, except in securing proper continuous treatment of Mrs.
Hersey's syphilis.

The reliance of patients upon the professional character of
the social worker irrespective of her maturity or personal ex-
perience was illustrated well in this case. The first worker
after several months of work with the Hersey family left the
department and the case fell to a young woman out of college
but a few years. The complications of marital discord with a
sex-delinquent husband might have caused the assignment of
the case to a more mature worker, if there had been a trained
and mature worker free to take it. The result, however, jus-
tified our faith in the ability of young women well trained to
deal with situations of even such deep-seated complexity as
Mrs. Hersey's. At one point Mrs. Hersey wrote the young
worker as follows : —

"You phoned Mr. Hersey last week — it had some effect, but
soon wore off, when he heard yovi had not been here. I do not
like to Imrden a young girl like you with my troubles but you
seem to know how to treat such affairs."

In analyzing this case for its distribution of difficulties, we
have tried to make it a paradigm in the threefold group. There
is no economic disability of importance. There is, in the patient
herself, no complication worthy of the term "legal entangle-
ment." Of course, the characters of the husband and son
must be taken into account; these are doubtless also, in some
ways, psychopathic and may lead to important legal complica-
tions, even to separation or divorce. Yet all the complications,
aside from purely family ones, converge upon Mrs. Hersey's
sheaf of diseases : namely, syphilis, deafness, suspiciousness,
and hallucinations. In addition to these we found her some-
what deficient in general judgment and of a certain extrava-

THE KINGDOM OF EVILS IO3

gance in managing her household, but these deficiencies were
such as to be rather corrigible by training. It would be rather
difficult to draw the line in this counsel between a belated edu-
cation, true moral training, and psychotherapy itself. So deaf
a person should, long since, have been taught lip-reading, and
her deficiency therein must be mentioned as one of Mrs. Ker-
sey's educational disabilities. As will be noted from the above
extract of the treatment records, steps were taken to teach her
lip-reading. She was something of a moral problem for us, in-
asmuch as she seemed not to have the will to stand to her treat-
ments persistently. Moreover she had been a nagging sort of
wife.

On these scores we have made her a paradigm of medical,
educational, and moral deficiency, but we regard her social
problem as centering in her diseases.

Hours spent by Medical record, 35 pages

Social record, 35 pages
Physician, io}i Social work:

Visits, 15
Psychologist, o Interviews at hospital, 24

Telephone calls, 13
Social worker, 53^ Letters, 45

^'Mystery girl" of the newspapers. Sleeping spells on the
street. Feeble-minded, hysterical.

Case 15. Bessie Polski figured in the newspapers as a
"mystery girl." The police officer found the nineteen-year-old
Polish girl in a faint and brought her to the Associated Char-
ities. Bessie said that she had been going to commit suicide.
She had a letter which reads as follows : —

"I am awfly sorry, and am a Catholic girl, and know that I
will lose my heart, but I cant help it because I am so hungry
that I dont know what to do. I'm afraid to take poison but I
cant help it because I cant live. I cant give another to my
cousin because he said I am not his cousin [untrue]. I have
not one cent and no money and I dont know how to live. I dont
know where to go, and the next day I did not eat nothing for
the whole day. I am a young girl, I dont eat nothing, only cry
all the time. I have hurt my hand and didn't work for five

I04 THE KINGDOM OF EVILS

weeks. Pleas who will help me. I am so poor that I sleep on
the street, no one knows me, and I don't eat at all."

The statement about her cousin has been noted above as
untrue and a variety of other statements failed to hold water.
The day after the police found her she was brought to the Psy-
chopathic Hospital and there was determined to be not insane
(that is, in the medico-legal sense of not being committable to
some receptacle for the insane) but to be hysterical. Bessie
said that she was subject to long attacks of unconsciousness.
Her "sleeping periods" lasted from a few hours to ten days,
with convulsive attacks of laughing and crying and a localized
anesthesia of the skin of the neck. Early in her stay at the
hospital she apparently had another psychopathic sleeping spell
which lasted about a day.

She now went from the hospital into the care of an agency,
which agency tried to have her go to a state institution for
treatment of syphilis, which she was supposed to have con-
tracted (the blood serum reaction was positive according to
the Wassermann test, and there was a slight, though distinct,
evidence of inflammatory reaction, if we are to trust the cell
count in the spinal fluid ) . Whether these findings indicate the
acquisition of syphilis by this girl, or whether they possibly
indicate that she was a victim of congenital syphilis (victims
of congenital syphilis are not infrequently without any labora-
tory sign whatever of their syphilis) must be left in doubt. In
any event, Bessie did not reach the state institution and further
blood specimens proved negative to syphilis two months and a
half later.

She went back home, and the case dropped out of social
service contacts for about two months, when a rather extraor-
dinary episode took place. ^Vhile Bessie was going along
the street, she was accosted by a man, to whom she said she
was looking for work. The man said that she might go with
him to a tenement house to meet his brother, the foreman of
a candy factory who would get work for her. What happened
in the tenement house was rape by three men. Bessie's outcries
drew the police. The men escaped. The girl was held as
witness.

Some convulsions shortly ensued and Bessie was brought
once more to the Psychopathic Hospital, whence she was dis-

THE KINGDOM OF EVILS IO5

charged, ten clays later, with the same diagnosis as before,
hysteria. She was observed in a so-called convulsion while in
the hospital. The seizure lasted three minutes, during which
she got red and gritted her teeth. She did not bite her tongue
or froth at the mouth. Her attacks would in general begin
with a feeling of pressure in the chest and a palpitation of the
heart; then there would be a choking sensation in the throat,
whereupon, apparently, unconsciousness would supervene, for
the patient could not describe the rest of the attack during
which she would laugh, cry, and toss her arms about. Curi-
ously enough, the loss of sensation observed upon her first
visit to the hospital was not now at all in evidence.

She went out to live at home, had an operation for appendi-
citis, and did not come under observation again until four
months later. Then came the following newspaper clipping
which may serve to show the attitude of newspaper men to the
so-called "mystery girl."

"girl defies doctors' efforts to waken her

"Going to Sleep for Long Periods Has Become Habit with
Bessie Polski.

"Bessie Polski, who goes to sleep for periods that vary from

a few days to several weeks, is at the Hospital in sound

slumber and puzzling the doctors. She lies in bed calmly, with
her eyes wide open, and takes food when it is offered, but
seems unconscious.

"About a year ago she had another long sleep at her home

in , and was in a far more serious condition, as she was

unable to take food, and had to be fed through the nose. Dr.

of who attended her at that time, thought she

was suffering from a form of hysteria. Her history, he says,
shows a similar sleep of several weeks' duration when she was
living in .

"She went to sleep on the sidewalk at Park and Madison
Streets and was taken to a drug store, where attempts were
made to revive her. Later she was taken to the hospital, where
one of the nurses [sic] remembered that she was brought to
the hospital several months ago in similar circumstances. At
that time she was asleep for the greater part of five days.

"It is said that she has met with several accidents in places
where she was emploved, and that about two weeks ago she fell
from a car at Street."

I06 THE KINGDOM OF EVILS

She was again observed at the Psychopathic Hospital, but
had no longer any seizures and showed no further sleeping
periods. There were no stigmata of hysteria. It was, how-
ever, decided that she might best be committed to a state hos-
pital. The basis for such commitment was, not so much the
hysteria, as the feeble-mindedness which she showed upon psy-
chological examination. There were no marked irregularities
in this examination, which gave her a Point Scale age of nine
years, actual age nineteen years. Her attention was unstable
and she was oversuggestible by the tests employed. In other
respects she was rather generally deficient.

After a time she was released from the state hospital and
placed out, but she could make very poor wages and was even-
tually allowed to go back to her family whom she aided by
working in a restaurant. At last accounts she was earning a
little money by working in a restaurant.

This case we present as a paradigm of triple disorder, medi-
cal, educational, and legal. The medical fraction of the count
is clear : the two years' history of hysteria and the low mental
capacity, not necessarily in alliance with one another in all
cases, are no doubt combined in Bessie Polski to confuse results
of social treatment and to complicate the economic situation.
The educational deficiency was a marked one, centering chiefly
upon a language difficulty, which was not merely the girl's own
but was shared by all her relatives. A galaxy of Polish-
speaking social workers might have been necessary to have
made all the points desirable with Bessie's relatives. The
legal complications with the police by reason of the rape at-
tempts were dominant. It is perhaps well to say that not all
the "mystery girls" who form so striking, if so small, a part
of the psychopathic hospital clinic are feeble-minded. It might
be inquired whether this girl, a probable victim of rape, a pos-
sible sex delinquent prior to her first period of observation at
the Psychopathic Hospital, should not be considered as some-
what of a moral problem. Our evidence is, however, that she
was, in general, not immoral in the popular sense of this term.
We are not even sure that syphilis was ever acquired. In any
event the problem of social care did not seem at any time to
involve moral training. Bessie's "immorality," if such we may
call it, was no doubt a matter of ignorance, and the total prob-
lem here was one of adjustment to the community, with due

THE KINGDOM OF EVILS IO7

regard to the feeble-mindedness and hysteria on the one side,
and the language difficuhy and educational deficiency on the
other.

There was no proper guardian for Bessie save the public
institution from whose iron she might be saved by the velvet
glove of social service. The only relative of this girl in this
country was a well-meaning, friendly, but ignorant cousin,
whose wife could, of course, not understand Bessie's feeble-
mindedness, to say nothing of her hysteria, and assumed a
rather hostile attitude to her. The proper answer to the Bessie
Polski question was evident resort from time to time to a pub-
lic institution. Obviously we cannot count this case as one of
highly successful social practice, yet it is as well to demonstrate
failures and negative results from time to time as always to
put the very best foot forward. We above spoke of the desir-
ability of public institutional care ; but it is worth further speci-
fying that the public institution in question should uncondi-
tionally be a medical institution and not of the prison system.
The chief social service contribution in the case of Bessie Pol-
ski, then, may be summed up in the words "public care and
supervision under medical auspices."

Hours spent by Medical record, 34 pages

Social record, 8 pages
Physician, 9 Social work :

Visits, 6
Psychologist, I Interviews at hospital, 3

Telephone calls, 3
Social worker, 11 Letters, 10

Grown-up "spoiled child." A motherly landlady found.

Case 16. Mark White is now nearing thirty-one years,
but strikes one still as a rather overgrown boy. He is rather
an inferior-looking shipping clerk, who came of his own initia-
tive to the Psychopathic Hospital. He said he was afraid of
crowds and that his memory was not as good as it had been.
He dated his troubles from a time when his express wagon
had run into a street car and stunned him. Pie had a darnage
suit brought after this accident. He told of hallucinations of
several sorts, the absurdity of which he said he now realized.

Io8 THE KINGDOM OF EVILS

Once he had thought a doctor had hypnotized him. He had
very pecuhar ideas about masturbation, which he said that he
had done as a rebel against God and to displease God. The
patient was a Roman Catholic. We found him to grade at 16.5
years on the Point Scale and to show few failures except in the
memory tests; but in his memory he was more erratic than
actually deficient. The question was raised whether he might
be a psychoneurotic, or possibly a victim of dementia praecox.

A study of his family relations showed that he had been for
many years rather ext'"aordinarily dependent upon his doting
mother's care; but she had died four months before he came
to us. Up to this time he had been thrown only in the society
of women of his mother's age and had made no friends amongst
his own sex or amongst younger women. He was a sort of
overgrown, spoiled child, a rather seclusive and very self -accusa-
tory person. As for the hallucinations above mentioned, it is
a question how gravely they are to be taken in the matter of
the diagnosis of schizophrenia ( dementia praecox). Certainly
the notions about hypnotism and about masturbation are
peculiar enough to suggest schizophrenia, and the so-called
ideas of reference (people pursuing him on the street) might
be used in building up that diagnosis.

He was discharged to the social service without a definitive
diagnosis between schizophrenia and psychoneurosis. The
ideal in such a case as that of Mark White might be to give
him, in a popular phrase, some sort of "sublimation." The
best social service could do appears to have been to give him
compensation. A landlady of maternal type was secured
through a room registry. Upon due explanation of Mark's
plight, the landlady undertook his care. A position was found.
The end crowned the landlady's work. Mark is now at least as
well off as ever, perhaps better. Latterly he has even developed
some fresh contiguities and interest in women of his own age.
He became particularly interested in the nurse who took him
through influenza. Formerly made fun of where he worked,
he has now become well liked and sociable both with men and
women of his own age. The socializing problem is going
apace with the aid of church measures, the community chorus
and the like. Aside from irritabilities at the doctors, Mark
White seems to be approximating the normal.

Briefly analyzed, Mark White appears to be a threefold case

THE KINGDOM OF EVILS IO9

of social difficulty in which neither moral nor legal difficulties
appear. His medical category must remain in doubt ; but there
can be no doubt that he is in some sense psychopathic. His
curious up-bringing and maternal spoiling form an equally
prominent part of the story; indeed some might claim that the
medical difficulty traced absolutely and entirely back to his
curious home environment. He was economically in the need
of aid during the first months of observation, coming to us as
an object of charity, with the history of being in debt and of
having received aid from a relief society.

Hours spent by Medical record, 42 pages

Social record, 38 pages
Physician, 9^ Social work :

Visits, 26
Psychologist, i Interviews at hospital, 13

Telephone calls, 55
Social worker, 57^ Letters, 25

Alcoholic and syphilitic woman under the influence of di-
vorced delinquent husband. Refused treatment. Ahoulia
( weak-willedness ) .

Case 17. Eva Collins, a sales clerk, thirty-one years old.
is presented to illustrate the threefold combination of social
difficulties : medical, moral, and legal — the educational and
economic elements being absent or negligible. The prime medi-
cal reasons for her hospital observation were alcoholism and
neurosyphilis. Indeed, her first diagnosis was that of locomo-
tor ataxia (now universally recognized to be a syphilitic dis-
ease) and a "psychotic episode" due to alcohol. Mrs. Collins
had acquired her syphilis from a sex delinquent and otherwise
criminal (forger) husband, whom she had married twelve years
before our observation of her, namely at the age of nineteen.
It is probable that we must regard her as a rather indecisive
and weak-willed person, and this native hypoboulia was at last
to interfere gravely with her fate. She was for various medi-
cal reasons regarded as a most promising case for antisyphilitic
treatment; but, owing to her indecisiveness of character and to
a more or less ill-grounded desire to get away from the Psycho-

no THE KINGDOM OF EVILS

pathic Hospital atmosphere and sundry drawbacks of its pub-
licity, she continued for but ten months under our social care
and medical treatment. Despite continual efforts our contacts
with her grew fewer and fewer during the last few months
before her case was closed on the score of her recalcitrance.

It is interesting to note that a poorer patient who could not
have begun to pay for antisyphilitic treatment would doubtless
have remained under our care despite objections on her part
to being hospitalized.

Doubtless under ideal conditions of social work, recalcitrant
cases of this sort would be pertinaciously pursued into the com-
munity so far as the rights of privacy of the individual would
permit. Relative to these selfsame rights of privacy, it is of
course a modern point of view that syphilitics of whatever sort
are hardly entitled to so much privacy as that which normal
persons enjoy. The house of a syphilitic is not his castle.
Moreover, we have to deal with a delinquent and vicious hus-
band. It has for years been plain that only the very poor and
very rich get adequate medical treatment. Here Mrs. Collins
offers a peculiar instance of failure on the part of the moder-
ately well-to-do person to get continued treatment from a mix-
ture of pride motives, indecision of character, and husband's
influence.

Mrs. Collins felt that she was well-to-do enough to employ
a private physician, and this was no doubt the case, but in our
experience the proper tenacity of antisyphilitic treatment is
rarely shown in private practice partly for reasons grounded
in the old-time attitude of physicians to the syphilis problem
and partly because a patient without marked symptoms slackens
his interest in treatments that are on the whole rather annoying.

We have noted that the difficulties of moral adjustment
here were perhaps grounded in a degree of psychopathic inde-
cision and perhaps also in part in the neurosyphilis itself.
There were also sundry divorce complications. When Mrs.
Collins first reached the hospital, she was endeavoring to secure
a divorce. Although she was prevailed upon to abstain from
her husband's company for a period of six months and although
the divorce proceedings were carried through, she reversed her
attitude shortly and began to get her alimony at the personal
hand of her former husband. How intimate her relations with

THE KINGDOM OF EVILS III

the former husband now became is ar matter of doubt. Before
we lost track of her, however, she had lost contact with her
former husband and announced to us that she was now keeping
company with another man, to whom she said she was to be
married. Permanent loyalty to husband, relatives, physicians,
or hospitals was apparently inconsistent with Mrs. Collins' char-
acter. These shifts in allegiance were regarded as probably
part and parcel of the weak-willedness (aboulia) noted through-
out, but it may be that there is a slight general tendency in
Mrs. Collins of the sort sometimes termed paranoic, a tendency,
that is to say, to the development of delusions of persecution.
She was rather childlike in her attitude to ordinary affairs
such as her money. After she was in straits about money, she
fell into a sort of depression and thence into alcoholism. She
drank with her husband. This lapse into drinking became in-
grained and what might be called a conditioned reflex upon
seeing her husband. Seeing him would precipitate a bout.

We have not up to this time mentioned the hereditary taint
in Mrs. Collins; but when we put together the medical and
moral features of her case, we are not unprepared to find that
her mother and a sister had actually been committed cases to an
institution for the chronic insane. The mother had suffered
from involution melancholia and the sister from dementia prae-
cox. Other brothers and sisters were normal enough. We
have spoken of her as childlike in worldly reactions, yet she
made an exceedingly high score upon her psychometric test,
namely i8-\-', with a score of 93 points on the Point Scale.
The only item of her psychometric record at all noteworthy
was a certain degree of oversuggestibility. How far "over-
suggestibility" of routine psychometric tests can be correlated
with Vv^eak-willedness (aboulia) remains doubtful, and it is a
stock and justified complaint that routine psychological tests
have so far not quite measured up to our hopes of definite
means of judgment concerning moral capacities and poten-
tialities.

To justify our calling this case a combination not only of
medical and moral troubles but of serious legal ones, we need
refer only to the divorce complication. As a sample of record
of social treatment we insert the following entries for three
months : —

112 THE KINGDOM OF EVILS

I917 . . . , ..

8/30 Interview for purpose of enlisting patient's cooperation

for future treatment by appealing to her intelligence
and for purpose of bracing her up to point of decision of
living away from husband. Friendliness of patient
clinched by offer of visit to mother with view of arrang-
ing her treatment at home and incidentally gaining access
in natural manner to patient's relatives.

8/31 Purpose of visit to patient's mother carried out. Family
cooperation enlisted largely through offer of medical
assistance to mother. Investigation made easy through
this method.

9/ 5 Letter to patient to show continued friendly interest.

9/ 6 Encouragement of patient continued.

9/ 8 Patient's confidence strengthened by friendly advice
which leads naturally to frank discussion on the subject
of patient's use of alcoholics.

9/1 1 Lawyer interviewed for purpose of establishing good
working cooperation with him and with idea of clearing
his mind of any misapprehensions in regard to social
service connection with case. Cooperation secured and
constructive plan leading toward future change of work
outlined.

9/12 Encouragement.

9/18 Evening call on patient for purpose of showing social
friendliness as well as for purpose of sizing up patient's
living conditions.

9/21 Visit to Mrs. Smith (an acquaintance of visitor) in hope
of connecting her up with patient on friendly basis.

9/25 Letter to lawyer for purpose of keeping him informed
in regard to social service interest.

9/29 Encouragement.

10/ I Encouragement and advice in regard to patient's family
situation which is reacting upon patient.

10/15 Business course started according to plan of 9/1 1.

10/18 Encouragement.

10/20 Arrangement made for outside examination of patient
by oculist in order to save working time and make exam-
ination as little of a nervous strain as possible to patient.

10/22 Encouragement and advice.

THE KINGDOM OF EVILS 1 13

10/29 Call to show friendly interest.

11/ 3 Encouragement and reassurance in regard to situation in
family of patient's sister.

11/12 Call for purpose of friendly advice and encouragement.

11/21 Conference with Visiting Nursing Association in order
to gain their cooperation through explanation of mother's
eccentricities.

11/23 Visit to patient's sister for purpose of getting over to her
the fact that there is an intelligent and constructive treat-
ment possible to use in the case of a boy of the make-up
of her son. Patient reassured by this interview and co-
operation of sister gained in making better plan for her
nephew. Opportunity taken to straighten out situation
existing between district nurse and mother.

11/27 Arrangements made with Dr. Jones in order to insure
interest and reliable medical advice for patient's nephew,
on which to base future social action.

Hours spent, by Medical record, 30 pages

Social record, 2)1 pages
Physician, 4 Social work :

Visits, 27
Psychologist, i Interviews at hospital, 16

Telephone calls, 30
Social worker, 46^ Letters, 25

Psychasthenic atmosphere about an eye trouble. Alcoholic,
spoiled child.

Case 18, Hamilton Green, a rather under-sized, boyish-
looking man of twenty-nine, came voluntarily to the Psycho-
pathic Hospital at the suggestion of the social service of a gen-
eral hospital. It was plain that he was in some important diffi-
cult way an "eye case," but the medical story would sound a
good deal more complex if one took into account the indigestion,
constipation, headache, dizziness, nervousness, fearfulness on
the street, whisperings heard when going to sleep, temporary
drinking to excess, "gas on the heart," and the like. Compe-
tent ophthalmological examination showed the man, who had
recently been a porter and elevator boy, to have an actually
severe astigmatism, such that exceedingly strong lenses were

114 "^^^ KINGDOM OF EVILS

required. There was no small degree of hereditary taint;
namely, a question of mental or nervous disease in the father,
epilepsy in certain paternal cousins, and stammering in ma-
ternal relatives.

The second element in Green's case is the moral one. He
was at times excessively alcoholic. But a more fundamental
moral deficiency lay in his irresponsibility to his mother. Per-
haps this is to be laid in part to his being a spoiled child. He
was an only child. His mother helped him financially. Other
relatives helped out also. Yet applications to the Associated
Charities were from time to time made, but had to be refused
because of these family resources. Finally, however, the
mother ran through the small capital sunk in their house and
mother and son became partial public charges. That there was
a necessity, therefore, in Green's mental or medical condition
is not likely. There was a question of moral attitude involved.
This moral deficiency has now been in part made up through
the counsels and insistence of the social workers. At this time
it is fair to say that Green's own interior ambition has been
aroused so that the social service splint may not for all time
be necessary for him.

As for the economic deficiency, we have discussed it in gen-
eral terms in the above paragraphs. After some two months of
handling by the social service, no further grants of money were
required for Green.

The situation now shows in the foreground the eye trouble,
which is not only objectively somewhat serious, but has shown
no signs of disappearing as an object of careful subjective con-
cern. Green continually complains of the drawing of his
glasses, of his not desiring to walk up a hill for fear of its
rising to strike him, of his often misjudging distances, and so
on. However, he has been prevailed upon to stick closely to a
single eye clinic, and no doubt in the long run the subjective con-
cerns, which now seem almost obsessive, will atrophy or gradu-
ally retire. Here we have an example of what is sometimes
termed a "periorganic" situation. The term periorganic refers
to the actual objective existence of a serious somatic trouble
(in this instance astigmatism) around which develop by almost
natural processes an obsessive or a psychasthenic atmosphere.
Reference to the first paragraph of our discussion gives a cata-
logue of complaints forming this psychasthenic atmosphere.

THE KINGDOM OF EVILS II 5

Remarkable therein are the actual hallucinations, the hearing of
whispers as he goes to sleep. These so-called hypnagogic hallu-
cinations of hearing are interesting also in connection with the
flashes of light which Green says he imagined after he had
been dreaming about his landlady, whose rent was two months
past due. Whether these phenomena are to be regarded as
genuine hallucinations or as vivid fancies of a dreamlike world
remains still in doubt. Some observers of Green have thought
of him as possibly a victim of schizophrenia (dementia praecox)
and would no doubt look upon these hallucinations or pseudo-
hallucinations as consistent with that far more serious disease,
schizophrenia, than the one we have elected to ascribe to this
man. However this may be, practically all of the constellation
of symptoms first set forth has now vanished, leaving astigma-
tism and its immediate sequelae in the center of the stage. We
should make one exception. Green will still occasionally lose
a job through getting drunk. Green claims that his drinking
is somehow connected with his eye trouble, or at all events
that the drinking habit is in general a matter of the last five
years during which time the astigmatism came to the surface
of his life.

Hours spent by Medical record, 9 pages

Social record, 17 pages
Physician, 5I/2 Social work :

Visits, 16
Psychologist, 0 Interviews at hospital, 3

Telephone calls, 9
Social worker, 28J/2 Letters, 12

Industrial traumatic neurosis in a competent steady family
man. Family problem. Slow recovery with graded light work.

Case 19. John Flynn we present as combining medical,
legal, and economic elements of trouble.

The legal elements in question are Industrial Accident Board
complications. Although we have all along stressed the cen-
trality of the individual in social psychiatric cases, we have not
intended to give the impression that the family group is not
equally in the practical eye of the social worker. John Flynn's
problem would, no doubt, be very properly regarded as a fam.-
ily problem by the non-psychiatric social workers. The psy-

Il6 THE KINGDOM OF EVILS

chiatric social worker regards it also as a family problem
(with even sundry psychiatric complications produced by the
wife's ignorance or feeble-mindedness as indicated by her
rating of 11.6 by the Point Scale) but finds the hub of the diffi-
culty, after all, to lie in the psychopathic central figure.

The psychopathy in question was traumatic neurosis. By
neurosis we mean a functional, that is, a theoretically curable
disease, which, under proper treatment, ought to revert to the
normality of the man before his accident. (It may be as well
to say that traumatic psychosis, also at times suspected in John
Flynn, means a disease of more serious character, often a con-
dition of defect directly consequent upon brain injury, and
hence, not to such a degree recoverable ; and the rather poor
prognosis early offered by the physicians for John Flynn him-
self was probably due to the suspicion that, in addition to trau-
matic neurosis, there might be some irrecoverable brain defect
in him. The traumatic neuroses may be best classified under
the psychoneuroses, though the traumatic forms of psycho-
neurosis offer rather special features.

A hundred pound weight struck a glancing blow on Flynn's
head, causing a scalp wound. Flynn was not made unconscious
by the blow. He has always stuck to the idea that the weight
hit not only his head, but his back, and explains the persistence
of pains in the head and back from that circumstance. Flynn
was, at the time, in the midst of some rather complicated ma-
chinery. He saved liimself by dropping some thirty or forty
feet to another part of the machinery. He was able to work
a day or two, but then had to give it up by reason of severe
headaches and dizziness. The dizziness passed, and to some
extent the headache, but he could not work, or felt that he
could not work, on account of persistent backache. He did not
arrive for treatment at the Psychopathic Hospital until seven
months after the accident.

Meantime he had been in contact with the Industrial Acci-
dent Board, through which compensation was granted him at
the rate of ten dollars a week, being six dollars less than his
previous earnings. Some small savings he quickly used up.

There was no mauvaisc volontc about Flynn. He wanted
to be cured and made several unsuccessful attempts to work.
The background was not bad. He had once been a hatter,
earning as much as twenty-four dollars a week at one time.

THE KINGDOM CF EVILS 11/

Later he had become a machine oiler. He was interested in
machinery, had been ambitious enough to attend evening classes
for firemen, read and studied a good deal and had saved several
hundred dollars. He was a good family man, amiable in dis-
position, energetic, and strong. Now, since the accident, he
had become apathetic and seclusive. He read no more and was
apt to be irritable when approached. His sleep was poor. He
felt tremblings all over his body and felt sometimes as if his
legs were going out from under him.

Meantime pressure was being brought upon the Industrial
Accident Board to have his compensation stopped, as the medi-
cal examination by the company's insurer led to the view that
there was no reason why he should not work. It appeared to
his examiner that there was, or might be, a fixed idea of in-
ability to work. Accordingly he was sent to the Psychopathic
Hospital. There it was found that he showed some tubular
vision, or so-called limitation of visual fields, a condition which
seemed to us to indicate that he was either hysterical or inclined
to hysteria.

The idea that he was suffering from a traumatic hysteria,
that is, a traumatic neurosis of a rather particular nature, was
also supported by finding evidence in him of sudden spells of
sweating, sometimes confined sharply to one side of the body.
This so-called "vasomotor neurosis" was another point looking
in the direction of traumatic hysteria. There was also some
evidence of diminution of sensory power, although no definite
anesthesia. On the more psychic side of the man, his irritabil-
ity, his fear of falling, and a newly acquired fear of walking
in the open, to say nothing of a reluctance to working further
with machinery, were other points fairly consistent with the
idea of a traumatic neurosis. In short, John Flynn showed sun-
dry features with which we have become so familiar in the so-
called shell-shock group of war cases, cases in which, either
with or without actual direct violence to a part of the body,
symptoms of a general or special nature occur (the war neu-
roses, war hysteria, war-shock, shell-shock) and as in many
of the war cases, the symptoms were somehow determined to
a side of the body on which or near which the blow (windage)
or sound occurred.

The medical diagnostician's impression of a case as psycho-
genic is, of course, tremendously heightened by the determina-

Il8 THE KINGDOM OF EVILS

tion of symptoms to the side on or near which the exciting
cause was delivered, since, by and large, a blow on one side
(say the left) of the head, with injury to underlying tissues,
should ordinarily lead to symptoms on the other side (say the
right) of the body. This is not the place in which to go into
the question of the so-called "mechanisms" of hysteria, yet it
is of importance for the psychiatric social worker to know upon
what a delicate knife-blade the diagnostic decision now and
then depends. Another obvious point, here worth mentioning,
is that amongst physicians themselves all such cases as John
Flynn's deserve attention by special physicians.

As in all Industrial Accident cases, (particularly in view of
their later possible improvement), the psychometric level was
determined. He was not regarded as feeble-minded or as
having shown intellectual deterioration, grading at 11.3 by the
Binet Scale and 12.5 upon the Point Scale. (These differences
are due to certain differences in the tests, which do not argue
any fundamental divergence of opinion as to psychometric
rating, but simply go to show that the methods of determining
psychic levels are not yet absolutely established. The results
are found trustworthy within certainly a year or so of the
figure given. It is, of course, worth while eternally insisting
that the determination of even a low level of intellectual capac-
ity does not argue that the status is original ; that is, that the
patient is a feeble-minded person. The decision whether we
are dealing with inborn lack or acquired loss of mind remains
a delicate one, based upon psychiatric estimate of symptoms that
pull down the patient's memory capacity below his normal level
and of course must depend upon data as to the patient's social
status. No doubt the previous record of John Flynn's life
would absolutely prove that he was not feeble-minded in any
ordinary sense of that term, in fact we felt that it was a cer-
tain psychopathic depression that pulled Flynn down even to
the 12.5 level at the time he was examined.)

The prognosis was rendered that John Flynn would spon-
taneously clear to a large extent "within an unknown period,"
and it was added that our tests indicate that his feeling of in-
adequacy was rather an objective one, despite the fact that he
had subjectively added a great deal of what the old books used
to term "hypochondria." This suggestion of an actual objec-
tive feeling of inadequacy meant to show that the insurer's

THE KINGDOM OF EVILS II9

physician was, perhaps, not right in thinking that the patient
was objectively able to work to full capacity. A diagnosis of
plain traumatic neurosis would, on the contrary, have meant
that Flynn would have been set down as a man objectively able
to work though subjectively unable. There was, consequently,
between the physicians, no issue as to adequacy for work at
the moment subjectively.

The insurer would appropriately take the attitude that a man
objectively able to work might soon become subjectively able
(that is with the proper social or medical technique) and thus
relieve the insurance company from its burden. There was,
of course, no question throughout of simulation or a conscious
"faking," as the man in the street has it. We are therefore
dealing with a most delicate question of diagnosis, wherein
the personal equation and acquired professional slant of the
diagnostician must inevitably operate. But whether the pa-
tient is objectively unable to work, subjectively unable to work,
or even (as in not a few Industrial Accident Board cases) ac-
tually simulating, at all events, the man is not at work. The
Industrial Accident Board itself, having semi-judicial powers
and impartiality of view (all sides of the compensation ques-
tion being represented as a rule in its make-up) of course acts
as a stabilized social service mechanism ; that is, as a bit of pub-
lic machinery that has rather recently grown out of the de-
mands of modern social service. As is now familiarty known.
the Industrial Accident Board representatives can be of direct
community help and individual help in the advice they offer
to the victim of injury as to whether he should or should not
take a "lump sum" settlement or continued compensation.
Which of these lines is technically better depends upon the case,
and "dependence upon the case" means that adequate modern
social investigation has to be before long undertaken.

A decision was made in John Flynn's case, whether for bet-
ter or for worse, (and whether permanently for better or worse
remains still in question), to grant continuing compensation
decreasing with his wages. So judicial and authoritative is the
Industrial Accident Board that an admixture of social work
not of quite such public nature is often advisable in cases like
John Flynn's. We at first sent him, whilst still in a state of
almost complete inability to work, to a cement shop conducted
on principles of occupational therapy at a near-by hospital.

I20 THE KINGDOM OF EVILS

Here he was able to work for only a quarter of an hour at a
time. He was rather irritable when others were about and
had to be given work by himself. The occupational therapy
was so far successful that at the end of three months he had
become ready for light employment. He became an elevator
man in a college dormitory. He told his employer about his
dizzy spells and gave the impression that he was likely to faint
rather often. At first the prospective employer was fearful.
The social workers explained the man's exaggeration of his
own trend, and he got the job. With the help of one of the
college boys he was kept under constant supervision, for he
needed daily encouragement. The work was light and the boss
favored him as much as possible. Days when he felt he could
not go to work alternated with more hopeful days. He suffered
from nausea, weakness of legs, dimness of vision. By almost
imperceptible degrees he has improved, until now a year and
seven months since he came under treatment, he is almost
restored to a firm industrial footing.

He did not lose confidence when the college dormitory closed
for the summer, but with guidance found another suitable job
running an elevator in an apartment house. Recently his tene-
ment was burned, and he lost many of his household goods; but
he met the situation competently and with the help of relatives
has gotten together another home. For over a year he has
been in great anxiety about his baby, who is threatened with a
serious illness. He still has spells of stomach trouble, which
has improved under treatment.

In spite of all these difficulties he is practically well, except
for minor pains and feelings of discomfort, and slight spells
of irritability, symptoms which he has learned how to control.

That this case is a psychiatric one in the sense of a psycho-
neurosis there can be no doubt. It is worth the social worker's
while to remember that all depends upon the point of view of
the physician whether certain psychiatric cases are regarded
as psychiatric. For instance, the nausea and indigestion of
John Flynn secure treatment for him at a high-grade general
hospital under the diagnostic terms "hyperacidity and gastropto-
sis." No doubt, good clinical proof was available for said hy-
peracidity and gastroptosis, but no doubt also, the bull's-eye
was hardly punctured by the treatment.

The general lines of treatment in John Flynn's case may be

THE KINGDOM OF EVILS 121

summed up as follows : — First in line comes encouragement.
Work of graded difficulty to comport with the terraces in his
improvement was indispensable ; correlative arrangements with
the Industrial Accident Board had always to be examined;
Flynn's eyes had to be examined and payment arranged for by
the Industrial Accident Board, to say nothing of the treatment
just mentioned and payment therefor at reduced rates. No
less than sixteen visits to the wife in her household were made
in the period of thirty-two months. The wife we found to be a
woman of even, pleasant disposition, well-meaning, but rather
ignorant (her mental level stood, on examination, at about
1 1.6), a good and thrifty housekeeper. There were two chil-
dren. A third came for whom some arrangements had to be
made with the Milk and Baby Hygiene Association. Advice
had to be given about the confinement, and a visiting house-
keeper was called in.

It is unnecessary to rehearse the evidence for placing this
case amongst cases of medical, legal, and economic difficulty.
It might be questioned whether Flynn should not also be re-
garded as belonging in the group of educational difficulties.
Certainly more or less advice had to be given to him and his
family along lines of everyday information. Nevertheless, the
educational defect in Flynn himself was no doubt directly
medical ; that is to say, traumatic in origin. Morally speaking,
Flynn was throughout a good risk. Our latest advices about
him are that he has now undertaken a more complex and diffi-
cult job, which he performs successfully.

Hours spent by Medical record, z^4 pages

Social record, 63 pages
Physician, 14 Social work :

Visits, 32
Psychologist, i Interviews at hospital, 34

Telephone calls, 137
Social worker, 89 Letters, 15

Intelligent sex delinquent. High empathic index. Six months
in a state hospital. Voluntary institution care.

Case 20. Dora Hadley, like Rose Talbot (case 8), be-
longs to that relatively small group of persons, the intelligent
sex delinquents, — at least we may speak of them as relatively
rare from their toll in clinic records.

122 THE KINGDOM OF EVILS

We classified Rose Talbot as a psychopath. Presumably she
would fit in the heterogeneous group known as psychopathic
personalities. Perhaps we should classify Dora Hadley also
here. It is clear that the term sex delinquent, like the term
delinquent in general, makes no kind of psychiatric diagnosis.
There are delinquents and delinquents, and it helps to solve no
problem to call all delinquents a priori psychopathic. The plane
which separates cases like Talbot from cases like Hadley is
perhaps imaginary. Nevertheless around the circle of obvious
psychopaths is another circle (or is it a matter of wider and
wider circles?) containing persons who are merely in some
sense eccentric and to a lesser degree off-center than the
acknowledged psychopaths.

We are endeavoring in this section of cases to report all
tertiary combinations of social symptoms. If we stretch a
point in regarding Dora as unmedical, we shall not damage the
main contention, which is that Dora Hadley presents no par-
ticular economic problem but is predominantly a moral problem
with a train of legal entanglements (eventually leading to state
hospital care for six months) and with the problem of moral
and, perhaps more important still, intellectual instruction in
the mid-center of the picture.

We shall give below the rather long summary of Dora's case
as a sample of actual case records which the student may use
for analytic purposes in preparation for the still more difficult
analyses of original records on which such summaries are based
(at the end of this book are examples of such complete records
for analytical purposes), l)ut before presenting the summaries
we may give a still briefer resume of Dora Hadley's case as
follows : —

Dora Hadley was a girl of respectable family of fairly good
New England stock. Dora's mother died in childbirth. Al-
though very intelligent (her own psychometric tests gave her
an adult age level) she got expelled from school for insubordi-
nation. She was an inmate of many homes which were scarcely
"homes" to her. She lost jobs, ran bills, and resorted to prosti-
tution. Under psychiatric social treatment there was at first
little progress. She remained a slack worker and mischief-
maker. She still lost jobs which were got for her. She re-
mained promiscuous in sex relations. She even took to drink-
ing. She rather naturally got blue at times over her plight.

THE KINGDOM OF EVILS 12^

The Story would not be properly told if Dora's beauty of
physique and vivacity of behavior should not figure therein.
Everybody's empathic index (as someone has called it) for
Dora was high — one somehow liked to see oneself in such a
guise.

Here follows the summary of her history quoted from the
social record : —

Social History:

Patient is a girl of nineteen, of American birth and parentage.
Her father works in an eyelet factory. Her mother died when
patient was one week old. From that age to two years, she was
brought up by paternal grandmother, where she remained until
fifteen. There were two half-sisters only a little younger than
herself. From the age of fifteen to nineteen patient tried
high school, but flirted with boys, whispered and did not do
her work, so that she was asked to leave. She lived with sev-
eral different relatives, and two families in which she worked.
She spent six months at the Middlesex State Hospital. She
tried factory work three times but was discharged for poor
work and bad conduct, singing, talking, and disturbing others.
In the spring of 1914 she became acquainted with Elsie Rich
(also a patient here) of the State Reform School, who taught
her prostitution. She and the other girl met men in a ravine
and had intercourse for money. Went to hotels in Worcester
for dinners. This period was of several weeks duration. Dur-
ing the summer, while working in a family she formed an
acquaintance of a Harvard student of good reputation which
lasted all summer. One time she was found in a dark hall
dressed in a kimono sitting in his lap. In January she was
sent to Trinity House by the Children's Society who had been
trying to help patient's family to care for her in the past two
years.

Physical History:

Patient was a seven months' baby but developed normally.
She was six months in care of Middlesex State Hospital as a
voluntary patient in 1912. Was in Psychopathic Hospital
January 27 to February 15, 191 5.

Her mother died of "peritonitis" ten days after her birth.
She is reported to have had "queer spells" every few weeks,
when she did not lose consciousness but was unable to speak.
The attacks were preceded by a vision of her mother or hearing
the voice of her mother. An aunt on the maternal side was

124 "rHE KINGDOM OF EVILS

demented before her death in old age. The paternal grand-
mother was said to be a "gossip and trouble-maker."

The patient is lazy, but nervously active. She is strong and
in good health, but is very susceptible to pain.

Mental History:

Patient went to school from six to fifteen years. When in
the ninth grade she whispered and disturbed other students so
much that she had to sit in the sixth-grade room because that
teacher was better able to control her. She had one year of
piano lessons. Reads some good classics.

She has been unsuccessful at work because she cannot apply
herself continuously to one task. In housework she failed be-
cause she was unsystematic and careless. She bothers others
at work by talking or singing or direct conversation. The
patient has no trade but wishes to be a nurse.

She takes very strong likes and dislikes but is fickle and
turns against a person as soon as she finds he is no longer
useful to her own ends. She is extremely vindictive and spends
a great deal of thought on how she can "get it back" at anyone
for a supposed injury. She says she must have excitement.

She is untidy in her personal appearance and takes no care
of her clothes or room. She is nervous and fidgety, quick to
anger and very fluent in expressing her anger. She is com-
pletely wrapped up in herself and her own pleasures and ends,
and considers no one else's feelings. The patient holds lewd
telephone conversations with men. picks up men, deceives, and
lies. She runs up bills. She spends her earnings on clothes.

From infancy she has had crying spells and when younger
would hold her breath until she was blue in the face. She has
always shown a brutal strain and a desire to torment someone
or something — pinched a baby she cared for till he was black
and blue. In the same way she makes up stories to injure
people she knows. Insinuated to a woman for whom she
worked that her husband made advances to her.

Patient thinks she has been ill treated and that her half-sisters
have been given more privileges than she. Everyone has
knocked her about she thinks. Has no fondness for parents,
whom she considers hypocrites.

There seemed to be no change in her at time menses began,
but a gradual development of this character from early child-
hood.

In the light of most of the story above given the following
letter, restrained and stable as it plainly is, is a bit astounding,

THE KINGDOM OF EVILS I25

the more so as Dora actually did make good her promises
therein.

"My Dear Miss Adams :

"I'm very sorry I went away from you as I did Wednesday
afternoon. I was feeling bad, and rather cross too, because of
the way things had turned out in the last week. You'll forgive
me, won't you?

"I have made up my mind at last, Miss Adams. I am tired
of leading the life I have led for the last month. Now I have
given up my freedom, my friends (?) and am going to put in
six months here at Trinity House. I want to be good. I simply
cannot trust myself as much as I hate everything immoral. I'm
not immoral, Miss Adams, — I hate it. I've been unmoral, that's
all. You understand me, don't you? And I think you believe
in me. I want to be a real, true woman. I'm going to be one.
I'm going to try so hard to please everyone. Miss Ellis is
beautiful and good. I love her and Miss Mansfield and I want
to be like them, just the kind of a girl they want me to be. I
can do it.

"I shall miss heaps of things. I want to see someone but can-
not. I shall be lonesome too — but I'll stick it out, if it will only
help me to be what I want to be.

"I want you to come out and see me, and surely you will
write to me ?

"Sincerely,
"Dora,"

She not only at our suggestion made voluntary resort to an
institutional home, putting herself under its control for six
months, but stayed with the home for six months longer than
she promised. The Psychopathic Hospital social service was
then emboldened to close her case. She is now doing well as
a nurse in training. In a period of eighteen months or, if we
count the state hospital term as sharing in her progress, two
years, Dora climbed a considerable terrace educationally and
morally. Lest we be regarded as over-optimistic, we may
remind the reader that the White Slave Traffic Investigation in
Massachusetts some years since — an investigation headed by
Dr. Walter E. Fernald — gavt a number of examples of prosti-
tutes who if not highly intelligent were at all events not feeble-
minded. In fact the obviously feeble-minded among the pros-
titutes of that investigation were but slightly over fifty per
cent of those examined by strict mental tests. We are informed

126 THE KINGDOM OF EVILS

by Dr. Fernald that the woman of intelhgence who resorts to
prostitution and whose case is not otherwise complex is very
often to be fomid in the course of a few years outside the tem-
porary field. Many known prostitutes of this intelhgent group
have settled into stable married lives.

Hours spent by IMedical record, 39 pages

Social record, 31 pages
Physician, li Social work:

Visits, 21
Psychologist, i Interviews at hospital. 32

Telephone calls, 43
Social worker, 54 Letters, 13

Unstable Jewish girl with obsessive ambition for education.

Case 21. Bessie Silverman, a nineteen-year-old Russian
Jewess, came to the out-patient department of the Psychopathic
Hospital of her own volition. She came by herself and said
that she wanted to find out her mental ability. She gave her
own history. Her family in Russia had been fairly well-to-do,
the mother was dead, and her father had married again, and
emigrated to America leaving Bessie in Russia. In her four-
teenth year Bessie herself came over and interspersed factory
work, which she shortly undertook, with periods of schooling.
The dominant issue with Bessie was to get an education. It
was rather a sharper issue with Bessie than with the typical
Russian Jew of the recent American scene. Bessie must needs
get an education and must go through college, and the issue was
still sharper when her ambitions were compared with those of
her father and stepmother, for the Silverman family had in a
sense come down in the world since their immigration to
America. Upon examination we found her to make a score
of 17.5 years with 87 points. There were no special features
in the examination to throw clearer light upon her character.
Her afiswers were rather slow and she seemed to be rather less
self-confident than most persons teking these tests. Physically
we found her to be negative except for a spinal curvature. On
the whole the best large category in which to place her seemed
to be that of the psychoneuroses. One of our reports speaks of
her showing a kind of fundamental disharmony in life, a dis-

THE KINGDOM OF EVILS 12^

harmony based on the incompatibiHty of her ambitions with
her immediate opportunities and perhaps with her own mental
capacity.

The principal of a high school became interested in her upon
our proffering him the case. He wrote that he thought he had
succeeded in arranging a reasonable program for her and found
her in a good frame of mind for work. Carrying this school
work (in which she really needed a private tutor according
to the school view), wearing a plaster cast for her lateral curva-
ture, and earning money outside formed a triple weight which
she was hardly able to carry. All the while she seemed to re-
sent the social crutch, and her nervous make-up never failed to
be in evidence.

The procedure was beset with difficulties. The central idea,
that of going to college, we eventually decided to indulge. She
must of course go through preparatory school first. A man
of means who had taken an interest in the Silverman girl (she
was rather adept at making friends) undertook to finance her
going to a suitable and expensive preparatory school. This
plan must needs fail on account of Bessie's determination not
to accept charity. We seem to have reached an impasse. She
says that if she only had money she could win in life, but as
she has not enough money and will not take it she therefore
denounces the American situation, particularly the school situa-
tion. In point of fact, the school work with the heavy col-
lateral burden had proved too much for her. She has now
reached a level of what we might from the general standpoint
call compensation. She is doing housework for weeks or
months at a time in different places.

We have not ticketed Bessie Silverman as distinctly a med-
ical case, finding her problem to be one of moral training and
of economic difficulty. Yet if pushed to explain her case we
should be inclined to think that in a very tenuous way there
are sundry medical difficulties at bottom. At all events there
are temperamental faults which can best be understood by
looking in the psychiatric direction. The social service and
the school authorities, to say nothing of her general American
experience, are teaching her, if not her level, then some poten-
tialities in the present world. It might be easy to charge up
her plight to something racial and it is indeed true that sundry
Russian Jews do appear from time to time upon the social scene

128 THE KINGDOM OF EVILS

who have some features of Bessie Silverman. We are inchned,
however, to think of her as rather specially affected by a psycho-
neurotic trend. Whether her general disabling through incon-
sistent ambition is so much an educative as a moral affair is
also doubtful. The economic evidences are plain enough, but
the attitude toward them which Bessie assumes is still more
troublesome. It is easy to speculate upon the outcome.

Hours spent by Medical record, 12 pages

Social record, ^-J pages
Physician, 4 Social work :

Visits. 38
Psychologist, i Interviews at hospital, 64

Telephone calls, 123
Social worker, 139 Letters, 40

" Little fiend ," a neglected child, becomes "the pet" of a foster
household.

Case 22. Elliot Calderwood was brought to us as a "lit-
tle fiend." He came through the court. His aunt had found
him unmanageable and was so incensed with this boy of eight
years that she refused even to telephone to learn our findings
and refused to have him in her house another night. His aunt
told us that Elliot was wild in every way, could not eat like a
decent boy, shuffled his feet, ate like a gourmand, and was a
frequent and sometimes open masturbator who had attempted
sex relations with his four-year-old girl cousin. One reason
why the aunt felt so desperately concerning her nephew was
a variety of facts which she knew concerning his father and
mother, who both had somewhat checkered sex histories.

The small boy, observed in the hospital, was found to be a
likable afifectionate small boy, who admitted much, if not all
that his aunt maintained. He was. however, so far as we could
make out, in no sense a medical case. He measured up to nor-
mal psychologically. He had learned his sex practices from
various adults and said that he had been taught also by them
to steal.

The need of a careful education was represented to a chil-
dren's agency which assumed responsibility for the boy's sup-
port and thus avoided his becoming a public charge. There

THE KINGDOM OF EVILS 129

was some likelihood that the father, who was now in the Cana-
dian Army, might perhaps be reached to help in payments.
(The father was located and actually did make an allotment.)
At all events, the children's agency's decision was greatly justi-
fied by the outcome in the Calderwood case. The boy was
circumcised and placed in a country town with a kind woman
who became very fond of him. With her he gave no trouble,
ceased masturbating and became the "pet" of the household.
We present this case as one of threefold disorder, minus the
medical, and curiously enough, the moral complication. We
say "curiously enough" because a case brought to us as a sort
of fiend of immorality might, perhaps, be regarded as one of
distinctly moral disorder. To be sure, the moral question had,
forthwith, to be brought up for discussion, but the mental tests
and the general hospital observation, to say nothing of his
smooth history on placing out, will not allow his being classi-
fied in the moral group. The whole situation seemed to be one
rather of education, and upon proper intellectual training, the
moral pseudo-difficulty disappeared. We place him in the legal
group because he came to the hospital through the court. He
was a neglected child and an economic charge.

Hours spent by Medical record, 12 pages

Social record, 3 pages
Physician, 3 Social work:

Visits, 2
Psychologist, i Interviews at hospital, I

Telephone calls, 7
Social worker, 5 Letters, 2

WOMAN. 43, LR'IXG AS MAN
12 YEARS

IQI6

. 1916-18

Man's Dress

Woman's Dress

Inebriate

Drinking Spells

Irregular Work

Steady Job

Bisexual Delinq

uency

Books and a Pipe

Early History:

Married,

Deserted

Abandoned Child

Put on

Disguise

Woman who lived as a man. Psychopathic sexualis. Alco-
holism. Became a steady worker, consoled by pipe and book.

Case 23. Julia Brown was a woman who lived as a man.
She was probably in the late thirties when she first came to
medical attention. Of old New England stock, she had lived
with her family, father, mother, and two sisters in country
towns to the age of eleven, whereupon Julia's mother died and
her father married again. Julia went to live with her aunt.
She left high school at the end of her second year to work in a
mill. After a year in the mill she married a hard-drinking man
who left her shortly after the birth of a baby boy. Putting
the baby (whom she was never to see again) in her aunt's care,
she went back to the mill and worked three years. In the late
teens or early twenties, Julia Brown put on men's clothes and
from that day forward never wore women's clothes again until
she came under care. According to her story she was con-
stantly teased for looking so much like a man. She thought
she could get work more easily and get better pay as a man.
Moreover she was very fond of girls. After donning rnen's
attire she assumed the name of Alfred Mansfield. She began
to drink and to smoke a pipe incessantly. She lost a series of
jobs on account of her drinking habit. There were no other
delinquencies except that she was once accused of stealing
fifteen dollars. To all public observation she was well behaved
and was seldom actually seen drunk. In general she led a
happy life according to her own conceptions, and was accepted
as a man, fitted into the social life on the chosen level, and sang
in a quartet with three men, etc. For a year she kept house
with a girl who for a time thought that Alfred Mansfield was
a man, but in general, according to her story, she lived alone.

About a year before our observation she came to Boston
with a clairvoyant for whom she had worked in another city.
She helped the clairvoyant for some weeks. When he left the
city she got work as painter and odd- job man, and then worked
as a press-feeder.

133

134 'f'HE KINGDOM OF EVILS

Early In December, 191 5, Alfred Mansfield was overcome
by gas and next day found herself in a general hospital. She
had been unconscious in the interval. She denied that she
had turned on the gas with suicidal intent. The examination
at the general hospital revealed that Alfred Mansfield was really
a woman. She was shortly sent to the Psychopathic Hospital,
no doubt in part because of the history of concealment of sex,
but also because she had buzzings in the ear and complained
of hearing children's voices. There was never, at the Psycho-
pathic Hospital, any behavior which would suggest hallucina-
tions and no further complaint of voices.

We found her a tallish, well-developed, and rather poorly
nourished woman with somewhat heavy, masculine features,
short coarse hair, some slight evidence of beard, and a low
voice. She had a sizable scar on the left jaw. Her teeth were
in very poor condition. She suffered from flat feet but other-
wise showed little that was abnormal. There were striae of
her pregnancy. Her gait was masculine.

The gynecological examination proved bacteriologically
negative. She talked readily without reticence and gave a
fairly consistent story whose dates we have not been able in
all details to verify, but there was clearly no general tendency
to concealment of her vital record.

Psychometrically she stood by the point scale at 12.5 years
and by the Binet Scale at a slightly lower level; namely, 11 3/5
years. After the details of these tests, it seemed that her free
associations were retarded and her interpretative powers (in
the tests employed) rather poor. On the other hand, her
memory span was fairly wide and she exhibited a fair degree of
comprehension and powers of observation. Her learning ability
and perception of form proved good and her attention fairly
stable. She was noted as oversuggestible. The psychologist
concluded from the psychological standpoint at least she could
not be regarded as feeble-minded.

There was never any sign of a definite psychosis or of any
progressive condition suggesting mental disease. It was clear
that she belonged amongst the psychopathias or psychopathic
personalities, or possibly she could be put in a group of eccen-
tric persons that are not clearly psychopathic ; that is to say,
amongst a group of mild psychic anomalies. From her own
standpoint, however, her life was fairly self -consistent. She

THE KINGDOM OF EVILS 135

on the whole felt that she had lived a happier life in her disguise
and had more money. She was certain, and quite tranquil in
her assertion, that she would forthwith go back to her life as
Alfred Mansfield.

Psychiatrically we found her without active symptoms of
any sort. She remained under observation at the Psychopathic
Hospital for a month. She then had to be transferred to a
general hospital owing to a throat culture positive for diph-
theria. She remained technically under our care for a few
more days, and was then discharged by court order to herself
and to our social service. We determined that she was not
insane and not feeble-minded, and expressed a question as to
her being a victim of psychopathic personality.

The situation was on the whole rather more pathetic than
ludicrous. The net result of the social work in her case is that
Alfred Mansfield has gone back into Julia Brown who so far
as we know (she was lost to notice for three months at one
time) has constantly worked and has betrayed no masculine
tendencies, unless persistence in smoking a pipe be so regarded.
It is true that she has for the most part lived in somewhat
questionable lodgings and that she has not been finically neat
in her life there. She has had a number of drinking spells.
One night she came home drunk. The next day a lodger missed
fifteen dollars and charged her with the theft. At all events,
the landlady turned her out. That morning she staggered away
drunk with two suitcases. She sat down upon a doorstep to
rest. Someone noted a pipe sticking out of her pocket. When
the police arrived, Julia had vanished, leaving the suitcase
wherein the police found men's underwear and quantities of
strong tobacco. There was no proof of the alleged theft, the
police on investigation found that she was giving satisfaction
in her mill work (she had become a checker of stock and was
well liked, even having been made secretary of an employees'
war savings stamp club) and dropped the case.

With the social service, Julia Brown has been on the whole
rather friendly and rather passive under treatment. When
she gets into a fix she calls upon the department to help her.
For example, her drinking at one time badly frightened her as
to its possible outcome and upon her desire for aid, arrange-
ments were made for sending her to a state hospital as an
inebriate. There she stayed for some three months and

136 THE KINGDOM OF EVILS

emerged greatly improved. We feel that she has been restored
to that level of normality, or subnormality, which could in all
reasonableness be hoped for.

Apparently during her life as Alfred Mansfield this woman
was rather sociable. Now she is a good deal more seclusiye.
She reads classical fiction, smokes strong tobacco, and cannot
be broken of a desire for spirits which she drinks at home alone
We have closed the case so far as all active steps are concerned,
but naturally expect from time to time that she will resort to
the department for aid. She has developed an ambition for
learning some technical sort of work which can be performed
at home, the textile products of which could be sold by the
piece. The point seems to be that she wants to make a home
of her own.

A number of rather human questions might be raised by this
case. On the whole we feel that the present approximation of
normality is a good deal superior to the previous plight despite
the seclusiveness which has developed. A question might be
raised as to whether she should be put in contact with her son,
whom, as above stated, she has not seen since he was a few
weeks old. For the sake of the individual happiness of her
son, it has been for better or worse decided that no special
efforts were imperative to bring mother and son together. In
the course of a few years the mother's status may be so far
improved and the boy's character sufficiently stabilized to war-
rant a set attempt at reestablishing relations. The woman is
herself turning her thoughts to the boy and the family relation.
Recently one of the hospital social workers met Mrs. Brown
on the street. She seemed pleased by the encounter and stopped
for a chat. She was looking well in a new spring hat and
she seemed quite satisfied with life. One of her favorite ex-
pressions is : "Life is sweet to me."

We have presented the case as one of non-medical and non-
educational nature, although it would be easy to say that she
is so far a victim of psychopathic personality that medicine has
an important part in the plot, and it will also be easy to show
that her life has been such that a part of her plight was due
to ignorance. Nevertheless, we are not prepared to say that
she is definitely a psychopath in the sense of sundry cases of
overdeveloped instincts or of a definite psychopathia sexualis.
She may beloner as hinted in that wide and vague circle of

THE KINGDOM OF EVILS 1 37

eccentrics and cranks that lie in the Umbo outside the circle of
the psychopathias. Educationally, the woman is well informed
and writes a good letter ; there is no obvious gap in education to
make up. On the other hand there was, of course, a large
moral problem and the question of readjustment of the entire
attitude of this woman to her life. We have purposely laid
little stress upon the sex delinquencies, heterosexual and homo-
sexual, which are suspected or implicit in some parts of Julia
Brown's history. With a case of congenital psychopathia
sexualis we question whether our social treatment would have
been so relatively successful and so quickly productive of re-
sults as the above account indicates. In short, the readjust-
ment problem was more a moral than a psychiatric one despite
the fact that the psychiatric point of view was no doubt of the
utmost service in picking the situation to pieces and parting
out the moral from the distinctly psychopathic elements of
Julia Brown. The element of delinquency needs no further
analysis than what the history reveals and the economic prob-
lem, though never desperate, required a good deal of help and
indeed from time to time actual money grants.

Hours spent by Medical record, 27 pages

Social record, 48 pages
Physician, 5 Social work :

Visits, 49
Psychologist, I Interviews at hospital, 14

Telephone calls, 53
Social worker, gs^i Letters, 21

Depressed cigar-maker; could not work; feared open spaces.
Low standard of living ; family problem.

Case 24. We now undertake a new group, the binary
combinations of social trouble. We shall find ten binary com-
binations, the first four of which will be combinations of dis-
ease with some other form of social trouble.

David Stone was a Russian Jewish cigar-maker who came
to this country at the age of five. We medically placed him in
the psychoneurotic group.

By way of exemplifying the routine summaries of social,
physical, and mental conditions with their results, we here

138 THE KINGDOM OF EVILS

insert the actual text (as usual with the names and certain other
features changed) from the social record. The reader should
bear in mind that the summary is of the social records and not
of the medical records.

RESULTS : February 25-July 3, 1918

Social:

Work was found for patient in the stock room of a wholesale
cigar plant at fifteen dollars a week. Patient worked there
about three months and then he obtained work from the Stand-
ard Life Insurance Company, as an agent, on a commission
basis, earning about twenty dollars a week. Patient's wife has
not been working ; two hundred and twenty-five dollars security
for patient's new job had to be raised, patient's wife getting
this through the Jewish Free Loan, and by pawning a few arti-
cles as well as by borrowing from relatives. Patient is paying
back at the rate of five dollars a week on this.

After urging by social service family moved into better
quarters.

Patient's son Arnold was ill for a short time at the county
hospital. Made a good recovery, though he is still to report to
the out-patient department here.

Patient's wife has complained of a uterine disturbance for
which a private physician has treated her. Social service re-
ferred her to the county hospital for this.

Physical:

Nothing of note.

Mental:

Patient likes his new insurance work. Has grown less and
less timid about going about alone, declaring himself cured the
beginning of July, 1918, Dr. Myer saying he need not report to
the out-patient department unless he wanted to. He took this
new work as he saw in it more chance of advancement. Patient
has reported to the out-patient department several times.

July 3-October 3, 1 91 8
Social:

Family have moved to 47 Wall Street, Roxbury, a better
section, where they have three large rooms ; the rent being nine
dollars.

Patient's niece is wife of a cosmetic specialist who uses the

THE KINGDOM OF EVILS 1,39

fourth room in front of the tenement as a store for his wares,
and reduces the rent to nine dollars in return for occasional
services of patient's wife in the store. Patient's wife is not
doing any other work. Social service arranged for her and the
children to have a vacation during the summer, which benefited
them considerably.

Patient's wife puts off her own treatment at the county hos-
pital or by her physician. She has not taken Arnold to the
county hospital as she should.

Patient is still working for the Standard Insurance Company,
earning twenty-one dollars a week. He works mornings, rests
in the afternoon, and finishes work in the evening. Patient is
still paying back at the rate of five dollars a week for the
amount borrowed for security.

Physical:

Patient's condition is about the same. He was overcome by
the heat in the summer but is able to do his work now.

Mental:

Patient's son or wife frequently accompanied patient at his
work, the heat having made patient afraid to go out alone for
fear of fainting. He has reported a few times to the out-patient
department. His work is still that of agent at the Standard Life
Insurance Company, which he enjoys very much.

October 3, 1918-January 3, 1919
Social:

Patient is still working for the Standard Life Insurance
Company as agent, earning twenty-three dollars for the past
quarter, which is almost up. He is still paying back his money
borrowed at the rate of five dollars a week, and is paying one
dollar a week on a fifty-dollar Liberty Bond recently taken out.

The family are still living at 47 Wall Street, Roxbury, which
is proving a very satisfactory home considering the cheapness of
the rent. They were very appreciative of the second-hand bed
and mattress provided through the social service.

Patient's wife still has not had adequate medical attention for
herself. She refused treatment in the county hospital because
she does not approve of the medical students being present in
clinic, and defers visiting the Norton Hospital on one ground or
another. She and the three children have had influenza recently
but did not have serious attacks.

140 THE KINGDOM OF EVILS

Physical:

Patient probably had influenza in October, but did not have a
serious attack. Since then he has been feeling stronger than he
has for several months.

Mental:

Patient has been steadily improving in his ability to go out
alone, his wife accompanying him less and less frequently. Now
he goes to work alone practically all the time. For the past two
months he has worked very hard to make up for the time he
lost in the heat of summer. He works overtime when he takes
a holiday, such as Thanksgiving and Christmas. He is very
enthusiastic about his work and pleased with his increase in
salary. Patient has been in out-patient department once. Seen
by Dr. Jones, who prescribed medicine as a nerve tonic, which
Dr. Jones felt sure would have immediate results.

January 3-May 3, 1919

Social:

Patient continues to work for the Standard Life Insurance
Company from twenty-five dollars to forty dollars a week. His
debts are almost paid ofif. He still lives at the same address. His
wife has been examined In' the physician who attended her in
the first confinement. She thought she could afiford this luxury.
The doctor told her that she was in good condition, the only
pathological finding being a nervous stomach which she could
disregard. She is anxious to arrange a good vacation for the
children in some way and thinks it would help patient if they
could find a cheap summer home from which he could commute.

Physical:

Conditions are negative.

Mental:

Patient had one somewhat depressed spell in February, Dr.
Jones, out-patient department, thinking it pointed possibly to
manic depressive insanity as patient's real diagnosis. Patient's
wife explained it as his usual reaction when seasons change, and
as due also to the fact that his salary was not increased as much
as he had been led to believe by a mistake on his employer's part.
This did not keep him from work, however, and after a few
days he was as well as ever. He says his own mental attitude
has been his salvation since he came to the hospital.

THE KINGDOM OF EVILS I4I

He is concerned lest he be unable to give his children a good
education. He came in willingly to be presented at a clinic for
employment managers in April, and impressed the group as a
fully recovered man. He says he likes to do anything he can tor
the hospital and for others ill as he has been, and he has inquired
with interest for a patient to whom he gave vocational advice
here six months ago.

We present this case as a combination of medical and educa-
tional difficulty. There is obviously very little actual character
disorder save that which is involved in the psychoneurosis it-
self : On this account we do not classify Stone as a case in
which moral measures need systematically to be explained. Nor
were there any legal complications of note. The observer who
found them living in their four dark rooms (five sleeping in
one room whose window had to be kept closed on account of
an odorous alley) might at first sight suspect moral difficulty.
This, however, was not at all in evidence save for the facts
noted above. The social symptoms summarized were as fol-
lows : spouse working, housing bad, employment irregular,
failure in business, debts, and selfishness. If it be objected that
"selfishness" is not in itself a social symptom in the strict sense,
nevertheless selfishness has such a marked social effect that it
may well stand for a whole sheaf of social symptoms.

David Stone's medical deficiency is plain. How can we
define the deficiency we regard as educational ? Here was a not
infrequent family type, strongly anticapitalistic and socialis-
tically well-read, yet their living and housing conditions were
bad (perhaps one ought not to say bad deliberately but bad
through a kind of lack of social sense, through a mind of
social apathy or thoughtlessness). Such living and housing
conditions obviously combined with David Stone's psycho-
neurosis to form in some sense a new compound sort of social
defect. Neither psychotherapy alone however skillfully leveled
at the psychoneurosis nor the cleverest neighborhood work di-
rected at the cubical contents of the Stone tenement would, by
itself, afTect that social cure of the family plight. It is the
obvious thing to say that David's fear of open spaces and the
family habit of living in a sort of crevice in the world is some-
how racial and a matter of the ghetto. How ingrained or how
superficial the alleged ghetto loves of this race really are, we
are not competent to discuss. Suffice it to say that not every-

142 THE KINGDOM OF EVILS

body in the ghetto is psychoneurotic and that many a Russian
Jewish point of view gets in a rather brief time complete illumi-
nation on these and other matters in our American scene. Be
all this as it may, the low educational level of a family like the
Stone family was something social to be wrestled with.

Throughout these binary combinations of social trouble we
shall find ourselves inquiring whether the two conditions each
time in evidence are intimately or loosely combined. We shall
ask whether they are combined so intimately as to form, as it
were, a new compound such that the social treatment entailed
is not merely a subtraction, one by one, of the two problems
from the patient's life, but requires a novel form of handling.
It is clear in Stone's case that a strict agoraphobia or fear of
open spaces was primary in his psychoneurosis, was in some
sense identical with the intentions or motives underlying a
strictly unnecessary life in a tenement. We are tempted, there-
fore, to say that the Stone compound of disease and ignorance
was a rather intimate product of the two factors working upon
each other.

The Stone problem is now happily almost settled. Curiously
enough the main problem that exercises the mind of the now
stabilized paterfamilias is the education of his children.

Hours spent by Medical record, 6 pages

Social record, 21 pages
Physician, 14^ Social work :

Visits, 19
Psychologist^ o Interviews at hospital, 10

Telephone calls, 46
Social worker, 37^/2 Letters, 13

Steady employee of good character who pilfered. Epileptic
wife: marital discord. Social treatment depends upon correct-
ness of medical diagnosis.

Case 25. Alfred Stevens is, no doubt, a case of the so-
called cyclothymia group. He has been three times voluntarily
a patient at the Psychopathic Hospital and although the first
time there was a question between manic-depressive psychosis
and psychoneurosis the settled diagnosis was manic-depressive
psychosis. We are not in this book discussing the medical

THE KINGDOM OF EVILS 1 43

aspects of psychiatry, yet it is important for the psychiatric
social worker to remember that the cyclothymic (manic-de-
pressive) group of disorders is on the whole theoretically quite
separate from the group of psychoneuroses. The psycho-
neuroses (hysteria, neurasthenia, psychasthenia) are on the
whole diseases both theoretically, and very often practically,
influenceable by psychotherapeutic methods. It would be al-
most safe to generalize that the psychoneurotic group is the
psychotherapeutic group par excellence. The cyclothymic
(manic-depressive) group of disorders is theoretically non-
influencable by the psychotherapeutic technique, although
cycloth3^mics, like all other persons normal or subnormal, are
to some degree influenceable in subordinate features. On the
whole the attacks of emotional disorder that characterize
cyclothymia and are expressed in its Greek designation are self-
limited in their course and not controllable in the degrees of
their severity. The typical cyclothymia (manic-depressive
psychosis) will show attacks of emotional disorder sometimes
depressive and sometimes maniacal (the medical denotation of
this term maniacal covers all degrees of excitement down to
mere psychopathic illusion or hypomania), but not all cyclo-
thymics show maniacal attacks and some of them never show
any phenomena that are not clearly depressive. Alfred Stevens
was in point of fact the victim of a sort of a constitutional
melancholia. He was of a brooding and seclusive tempera-
ment without outside interests. He was, however, not of a
complaining sort and had no tendency to feel persecuted.

For years he held a good job in a dry-goods firm, and, as
transpired in the sequel, he was given to continual small pil-
ferings, a habit of over ten years' duration. A moral compli-
cation of the Stevens case was that beyond question the wife
knew of these pilferings but on some ground condoned them,
A trunkful of ribbons, laces, collars, etc., was found in the
house. The firm did not press the pilfering issue but discharged
Stevens on another pretext. He was not without some sense of
the real reason of the discharge.

Can we connect the pilfering with the man's cyclothymic
temperament? Pilfering might on an oversimple schematic
basis be regarded as a sort of overdevelopment of the acquisi-
tive instinct. The acquisitive instinct might stand out in relief
on the general background. This at least is the hypothesis for

144 THE KINGDOM OF EVILS

sundry of the special forms of psychopathia (kleptomania,
wanderlust, etc.) with which we are familiar. In this instance,
however, we are not so much inclined to attribute the pilfering
to any trend toward kleptomania as to the effects of a certain
weak-zvilledness or hypohiilia more closely related with the
man's general make-up.

He was a rather effeminate and timid man. Without sug-
gestion of homosexuality, he has always been "a regular sissy,"
had been unduly finical about his clothing, had not smoked or
drunk, had no sense of humor, had no interest in religion, had
always preferred to be alone, made little sexual demands (sex
interest absent for ten years), and did not want guests about
the house. However, he did want to please his wife, and doted
on his little girl. The wife was frankly an epileptic and had
sundry seizures upon the street and elsewhere. Despite his
kindliness with his wife, there was a good deal of irritability
in the home, no doubt largely due to the wife's temperament.
Indeed this epileptic wife has twice left Stevens and had in fact
shortly before Stevens' appearance at the hospital definitely de-
cided to leave him for good.

Psychometrically Stevens stood at 11.3, making a general
intelligence score of 68 upon the Yerkes scale. At the time of
examination his chronological age was forty-six, the irregular-
ity in the tests stood at nineteen points, and the irregularities
stood out especially upon the supplementary tests. He made at
the time a very poor score on tests of immediate memory and
upon the construction puzzles, despite the fact that his coopera-
tion, interest, and attention were very good. The irregularity
of his examination was interpreted as suggesting psychosis
rather than inborn feeble-mindedness.

Manic-depressive psychoses and the cyclothymias in general
are rather characteristically hereditary in the sense that there
are frequently two or more relatives of a cyclothymic patient
that also show psychopathy; often indeed the psychopathy of
the relative is also cyclothymic. In point of fact, Stevens'
father had died in an English hospital for the insane, and a
sister's child has been fifteen or more years insane in an Eng-
lish hospital. However, two brothers are in the English Army
and so far as known normal, and there is a second sister who
is apparently without taint. The mother's cancer is, so far
as we know, without significance for heredity.

THE KINGDOM OF EVILS I45

With respect to social treatment, it will be remembered that
the medical diagnosis upon his first appearance upon the hos-
pital scene lay in doubt between cyclothymia and psycho-
neurosis. Indeed the man's general appearance was rather
suggestive of psychoneurosis, and the constitutional melan-
cholia shown in his history got rather easily an interpretation
as psychoneurosis. Stevens' finicalness bore some resemblance
to the psychasthenic obsessions of that form of psychoneurosis
known as psychasthenia. He would sit in the out-patient de-
partment weeping, and strike the observer as greatly in need
of comfort and counsel along lines that might be called psycho-
therapeutic or common-sense lines, according to the termi-
nology preferred. Comfort and counsel would indeed cause
him somewhat to brace up, though the underlying tempera-
ment obviously persisted.

The first idea of the social work was to rationalize the atti-
tude of this supposed psychoneurotic pilferer to his stealing.
Some progress was made in this rationalization process. De-
spite minor successes of our counsel, on the whole no progress
was made in altering the man's entire attitude to his life, espe-
cially as to steadiness in employment and attitude to wife and
child. Before he came to the hospital he had had no less than
twelve jobs in eight months.

As soon as the medical diagnosis clearly pointed to cyclo-
thymia instead of psychoneurosis, hospital care could rationally
be advocated rather than out-patient counsel. He was sent, or
rather voluntarily went, to a state hospital and the situation in
the course of a few weeks "was so altered that although he left
against advice he had gotten upon another temperamental level
and was prepared for steady work. In fact, he found such
steady work for himself. Since this time no further special
steps in social treatment have been necessary, his wife has come
back, and a new home has been started. As to the pilfering
history, Stevens' conscience does not now trouble him. He
has rationalized the pilfering as due to his mental disease.
Whether this is profoundly true or not, a solid readjustment
toward his past has accrued.

It is plain that the treatment is not in any sense an "elabo-
ration of the obvious." The differential medical diagnosis
betwixt cyclothymia and psychoneurosis proved a most
important one for Stevens' quick restoration to self-sup-

1^6 THE KINGDOM OF EVILS

port. Medical practitioners as a group are not too well-in-
formed with what they are rather apt to think a superfine dis-
tinction between mild degrees of mental disease. Many a
case of mild cyclothymia (manic depressive) and even of
mild schizophrenia (dementia praecox) has been diagnos-
ticated psychoneurosis over periods of months and years.
Close observation, psychological examination, and social his-
tory (including points got from the non-effect of some of the
early steps in social treatment) here combined in a compara-
tively brief period to assure the correct diagnosis, and the cor-
rectness of this diagnosis meant shifting the whole front of
treatment.

In summing up the analysis of Alfred Stevens, we need dwell
no further upon the importance of the medical side. There
was no important gap of ignorance to fill. Luckily the pilfer-
ing never reached a legal phase, the economic difficulties were
implaced in the medical situation, and on the whole rather
easily met. Whether Stevens is, narrowly speaking, an ethical
case might stand in question; yet we do not regard his pilfer-
ing as either implaced in the manic-depressive psychosis or in
any plain psychopathic trend. There was distinctively a moral
attitude assumed by him and by his wife toward pilfering
habits of ten years' duration. A new moral attitude toward
stealing had to be instilled.

Hours spent by Medical record, 53 pages

Social record, 36 pages
Physician, 10 Social work:

Visits, 21
Psychologist, 2 Interviews at hospital, 23

Telephone calls, 28
Social worker, 52 Letters, 9

Arrested under "work or fight" law; a case of mental disease.
Commitment. Provision for the family.

Case 26. Kevork Ardinian was suddenly arrested under
the "work or fight" law, but was shortly thereafter sent to
the Psychopathic Hospital, being committed from the court
for observation. The situation was somewhat strange.
Ardinian was an open-faced, smiling young Armenian who

THE KINGDOM OF EVILS 147

had, until very recently, been a hospital porter. He worked
alongside his wife in a general hospital and he had saved a
little money so that they could be classed as "independent"
rather than marginal in our economic classification. Ardinian's
wife was already advanced in pregnancy when he was dis-
charged for refusing to do part of his assigned work. He
said that he had headaches, and stood about complaining on
the streets in an Armenian neighborhood. He occasionally
smiled to himself. (This causeless, silly smiling is a char-
acteristic symptom of the disease schizophrenia-dementia prae-
cox — from which Ardinian was later thought to be suffering,
but it does not do to draw definite conclusions from any single
symptom in mental disease.) As for any adequate reason
for his suddenly ceasing to work, Ardinian could give none,
but simply replied gently that he did not need to work as he
had enough money in the bank for a time. He said that more
money would come to him, possibly from the government. In
line with his silly smiling, he was observed to be rather de-
tached in manner and a bit playful, although not saucy, with
women. He had a somewhat oversweet manner with them.
He fell into silence when reproved, kept to himself, and was
inclined to tease his neighbors, for example, leaving laundry
baskets in the aisle for the fun of making the people walk
around them.

That a man could be both smiling and stubborn, as was
Ardinian, seemed to argue an abnormal mixture or compound
of emotions. Such queerly mixed emotions (sometimes termed
by the psychiatrists "parathymia" or even "schizothymia" hav-
ing reference to the dissociation or split in emotions found in
schizophrenia) would rarely appear in any other disease group
than the schizophrenia group.

Psychologically they found Ardinian to rate at 13.3. The
non-English norms were used, and an interpreter was present.
The psychologist reported that Ardinian would perhaps have
done better if he had not refused altogether to do the form
association test and the three-words-in-a-sentence test. His co-
operation was rather poor. When non-English norms are used
in determining the psychological level, the practice, of course,
is to allow sundry points for the supposed inability to do some
of the tests that require certain educational capacities. Ac-
cordingly it is always possible to allow too much or too little

148 THE KINGDOM OF EVILS

to patients who are tested by the non-EngHsh norms. There
was no question, in any case, of moronity or feeble-mindedness,
which would argue a mental age from nine to eleven inclusive.
Here was a man with some deficiency on test. We are prob-
ably able to argue from his social history that he was not, at
the outset, feeble-minded even in the slight degree that lies
above moronity and below normality.

We are not, in this book, discussing psychological levels or
their determination, but it is clear that the social worker, like
the psychiatrist, must never view the psychological level as
determined completely out of its social-psychiatric setting.
Viewed in the social and psychiatric setting, these psychological
level determinations are amongst the most powerful agents we
possess in diagnosis.

Physically we found no special signs of disease or abnor-
mality. It would not do to regard overactive knee jerks and
irregular pupillary margins as of great importance. There
was, however, a slight protusion of the eyeballs that his friends
had latterly noted as unusual. Whether this slight exophthal-
mos could be regarded as pointing to some slight degree of
Graves' disease is doubtful. The thyroid was not palpable,
and the pulse was not increased. There were, however, some
tremors of hands and tongue.

Psychiatrically he proved, for the most part, normal. There
were of course the free, broad smiles upon insufficient occasion.
There was a certain resistiveness at times, though whether
Ardinian's refusal to have a bath on entrance should be re-
garded as suggestive of dementia praecox must be doubted.
He said that he ought not to be compelled to do anything he
did not want to do. That there was a certain delusional trend
seems possible if not probable. The government had not
treated him right. He should not be made to work unless he
wanted to. On being asked several times over why he had
refused to work, he replied "me too much work."

It seems that he had been born in Armenia twenty-five years
before; that one brother was an elevator boy at the hospital
where he himself had worked, and that another was in Russia.
He had worked in mills as a laundry helper. He had once gone
back to Russia and come around the world in returning. He
had been making eleven dollars a week. When he had first

THE KINGDOM OF EVILS 149

come to Boston he had been remarkably ambitious and went
to night school a few months so that he might read and write
English. Although he was better coaxed than driven, he had
never shown stubbornness or lost his temper with his employer.
On the other hand, it appears that he was not at all liked by
his fellow employees as he was rude to them and swore at them.
On the whole, he was inclined to keep by himself. After he
brought his new wife back from Russia his employer noticed
a change. He had become moody, had begun to tease and irri-
tate other workers and refused to do anything beyond the bare
routine of his job. He "did not feel good," had shaking at-
tacks at night, and his eyes began to stare. The fact that his
wife was still working, although far advanced in pregnancy,
shamed him not at all.

At this time Armenians of the neighborhood arrested him
under the "work or fight" law. Ardinian was rather care-
fully examined and his case was placed before two staff confer-
ences at the Psychopathic Hospital. There seemed to be no
doubt that he was a victim of schizophrenia (dementia praecox)
yet the disease was of such slight degree that Ardinian was
not at first regarded as committable. It was thought that some
kind of close and effective social supervision might encourage
him to work. Supervision was imperative, however.

The fact that he had in the late teens or early twenties been
able to teach school, but had in recent years lost his capacity
to do more than such work as dish-washing, seemed to warrant
the assumption that there had been a slow-moving loss of
mental capacity over a longer period than recent facts indi-
cated. In short, the schizophrenia process may have been going
on even before Ardinian's marriage.

Ardinian showed, under social treatment, a somewhat pe-
culiar attitude to work. He took a great deal of interest in
the occupational worker (a graduate of one of the courses in
occupational therapy established for war work) and worked
rather effectively at weaving for her. He said that he would
work to please her, but that she was making him a great deal
of trouble. The moment the pilot was dropped, so to speak,
that moment he refused to work further. There was thus a
sort of psychopathic altruism of small dimensions, but there
was no ambition or effective egoism which could be worked

150 THE KINGDOM OF EVILS

on. If the worker said "please" to him he replied "do not say
'please.' If you say 'please' I have to make and I cannot
make."

Ardinian became mildly but annoyingly flirtatious at the
end of three months. He asked his wife to go out and work
for him. He was making no progress in work for himself.
He got excited at times and even struck his wife. In playing
with the baby he swung it wildly about.

The money the Ardinians had saved was now practically
exhausted and no progress was likely toward immediate cure
or self-support. The psychopathic altruism which allowed
Ardinian to work a little on the immediate suggestion of the
worker was too tenuous to build upon in community life. That
Ardinian might become a fair worker under hospital condi-
tions was possible. The answer to the questions on this case
seemed to be "commitment." Ardinian was committed four-
teen weeks after he left the hospital. Looking back upon this
case, one might wonder whether Ardinian should not have
been committed to a state hospital forthwith upon his first
period of observation. There was no change in the medical
diagnosis during the fourteen weeks that elapsed between hos-
pital observation and eventual commitment. No doubt much
time now proves to have been wasted by the occupational
worker, who, save for her own experience, secured nothing in
exchange for her time, either for the world at large or for the
Ardinian family in particular.

The problem facing the court in a case like Ardinian's would
be exceedingly difficult if there were not adequate social super-
vision available, for the court would, on the one hand, not be
able to find enough in Ardinian's record to warrant commit-
ment. To be sure, he received from an acute medical observer
the diagnosis "dementia praecox," but this would not in itself
indicate commitment forthwith. On the other hand, the ex-
perienced court would bear in mind numerous cases in which
mild dementia praecox had blossomed into exceedingly dan-
gerous excitement, violence, or destructiveness. Such "waiting
for an overt act" is unfortunately the rule in sundry communi-
ties. Here, with the proper social supervision, there was less
likelihood that the advance of Ardinian's process would go
unobserved and catastrophes would very probably largely be
avoided.

THE KINGDOM OF EVILS I5I

IMeantime, as a matter of social technique, the social care
of the wife and arrangements for her pregnancy and confine-
ment and for her offspring were carried out by a family agency.
Upon his commitment the family was then turned over to the
family agency on the ground that the psychiatric part of the
problem had been removed or sufficiently disposed of.

•\Ve have put the case of Ardinian amongst the binary com-
binations and classify him as a combination of medical and
le^al difficulty. The medical difficulty we have sufficiently
analyzed. Legally. Ardmian came to an arrest and was com-
mitted to the Psychopathic Hospital under a special law for
observation. He was thus a court case of mild mental disorder
whose problem got its solution in commitment to a permanent
receptacle for the insane. There were no special legal compli-
cations attending this commitment. Had Ardinian committed
some overt act of violence or destructiveness before his first
appearance in court and his observation at the Psychopathic
Hospital, no doubt he would have been forthwith committed.
His mental disease was such a peculiar one and in one sense
so mild at the outset, that this solution of commitment was de-
layed. In the long history of legal process, however, no doubt
we may think of Ardinian as a relatively simple case of a man
arrested under the "work or fight" law on the ground of be-
havior for which he was quite irresponsible.

Hours spent by ^iledical record, 30 pages

Social record, 21 pages
Physician, 5J/2 Social work:

Visits, 22
Psychologist, i Interviews at hospital, 6

Telephone calls, ^y
Social worker, 35 Letters, 7

Intelligent dothes-presser disabled by occupational neurosis.
Large family in Russia to support.

Case 27. Herman Simonson left his family in a little
village of Russia ten years ago and came to iVmerica to advance
his fortunes. He lived frugally and uprightly and was a man
of high character and some education. The work he found
to do, clothes-pressing, paid good wages, but yet not more than

152 THE KINGDOM OF EVILS

enough to keep him and support the family in Russia — his
wife, six daughters, and the wife's aged parents. As the years
passed, he began to fear that he could not earn enough to bring
them over; they were growing restless and hard feeling began
to creep into their letters.

In the end Simonson acquired a severe neurosis with pains
in the legs that became unbearable when he worked at his trade,
and deprived him of strength to operate his pressing-machine.
When he came to our out-patient department he had been the
rounds of a number of general hospital clinics without im-
provement. His legs were cold and blue in spite of the five
pairs of stockings he wore. His mental state was one of utter
despondency; if he could not get well he could never see his
children again; he had lived for them and now they had not
enough to eat in that little Russian village and he could earn
nothing to send them ; would it not be best for him to commit
suicide while his life insurance was paid up? H he could not
be cured, almshouse life, never to see his wife or children
again, was a fate tragic enough. He was cured after three
years of persistent work. He first and last resisted treatment,
wanted to try another doctor, objected to every kind of light
work suggested and found fault with everything the social
workers did for him, but was restored to competency, one might
say, in spite of himself.

It was decided that the best prospect of making the patient
self-supporting lay in setting him up in business in a small
store, and a sum of money was raised for this purpose. After
many attempts to find a store that would be a safe investment,
an opportunity for trading in coal was arranged. Meanwhile
a number of temporary occupations were tried, which the
patient would give up after a brief effort. He was under treat-
ment as an out-patient continually, and for six weeks was in
the hospital as a voluntary patient. He complained that the
doctors did not help him ; thought that the lodge members who
were obtaining financial support for him were adding to their
reputation as charitable individuals by helping him ; claimed
that the money raised for him belonged to him and sb.ould be
given to him unconditionally ; repeatedly said he suffered "every
minute of the day" but had not the courage to kill himself,
though he would if it were not for his children.

As the pains in the legs decreased and he admitted feeling

THE KINGDOM OF EVILS 153

better, we insisted that he take a position as porter in a small
factory in order to prevent his becoming completely disused to
work. This was a job that he considered beneath him, and
it paid only ten dollars a week, but it was the only thing open
that he could do. He still holds on to this job at higher wages,
although he has since developed the coal business. In the fac-
tory he is regarded as a man who must be humored, for every-
body near him must hold his opinion or none. The foreman
sums him up, "Well, you know, he's Simonson !" He has
been elected president of a benefit organization to which he
belongs. He is said to be "as cranky as ever" but is alert and
in good spirits.

We analyze Herman Simonson as a binary combination of
medical and economic disorder. W^e regard him medically as
belonging to the psychoneurotic group of disorders. His fleet-
ing pains, his rounder's history in several hospitals without
relief, and his constipation were features. Whilst in hospital
he woke up five or six times in the night worrying about his
family in Russia. He felt cold sensations in the legs and
sometimes had prickling sensations in the calves of both legs.
Sometimes his hands were overwarm and sweating. He com-
plained of a bad headache. He was neurologically normal.

The impression which Simonson conveyed to the physicians
was one of relatively hopeless psychoneurosis. Accordingly,
when it proved possible to get several hundred dollars to set
Simonson up in business there was considerable concern ex-
pressed by the physicians lest the money was being thrown into
the sea. The results above described speak for themselves.

It is worthy of particular medical inquiry whether there is
any adequate and obvious physical cause for such a psycho-
neurosis as Simonson's. Cases numerous enough in this col-
lection yield no such physical cause, but the failure to find such
on the surface does not mean that such may not really exist.
Moreover, there may be a kind of psychoneurosis due to spe-
cial physical causes working directly or indirectly upon the
mind. Thus in Simonson's case it may be inquired whether
the steady, hard work and confining work at clothes-pressing
with its persistent cramped postures may not have worked
after the manner of the so-called occupation neurosis. The best
example of occupation neurosis is, of course, the familiar
writer's cramp, but even in writer's cramp there is an admix-

154

THE KINGDOM OF EVILS

ture of physical with psychic conditions, a mixture not always
easy to analyze.

Some authorities who have gone very deeply into the mat-
ter of occupational neurosis find physical causes in not a few.
We give below a partial list of occupations which have given
rise to occupation neurosis (Southard and Solomon in Kober
and Hanson's Diseases of Occupation and Vocational Hygiene,
1916)

Auctioneer

BicycHst

'Cellist

Cigar-roller

Clarionetist

Compositor

Cornetist

Dancer

Diamond-cutter

Enameler

Engraver

Flower-maker

Flutist

Gold-worker

Hammerman

Harpist

Knitter

Laborer

Lathe-turner

Letter-sorter

Lithographer

Locksmith

Mason

Microscopist

Milker

Miner's nystagmus

Money-counter

Nail-maker

Organist

Painter

Pianist

Preacher

Sailor

Sawyer

Scissors-sharpener

Seamstress

Sewing-machinist

Shaver

Shoemaker

Singer

Smith

Tailor

Tawer

Telegrapher

Tennis-player

Tinker

Trap-drummer

Treadler

Trumpeter

Turner

Walker

Watchmaker

Zitherist

Hours spent by
Physician, 55^-2
Psychologist, 0
Social worker, 35

Medical record, 18 pages
Social record, 22 pages
Social work :

Visits, 15

Interviews at hospital, 14

Telephone calls, 15

Letters, 12

Series of feigned suicides. Psychopathic girl who desired
to be some sort of heroine.

Case 28. Aimee Prevost stands on the Psychopathic Hos-
pital books as a psychopathic personality. Her history, with
its series of feigned suicides, some of them most neatly staged,
is possibly in some sense a history of instincts unchecked.
Aimee constantly saw herself in other people's eyes and re-

THE KINGDOM OF EVILS 155

lentlessly tried a variety of expedients to succeed. The desire
to be some sort of heroine was Aimee's desire. We confess to
some hesitation in taking all such as psychopathic! In any
event, we have classified her as virtually non-medical in her
display of troubles and have regarded her as a combination of
educational and moral difficulty.

When Aimee first appeared on the hospital scene, she seemed
rather illiterate. In due time she was examined psychologically
on four different occasions, at periods about a year apart. It
was clear from the examinations that she was not feeble-minded
and had good native ability, yet in all four examinations the
variability of her attention and her lack of effort in carrying
out the tests were striking. So far as the mental tests went,
her difficulties looked in the general direction of a disorder of
the will.

If we choose to disregard the vague aspects of psychopathy
in the Prevost case, we shall see her problem as virtually the
combined problem of reeducation intellectually and retraining
morally. The legal contacts and even the economic problems
remain minor.

Aimee Prevost was the oldest of four children in a French
Canadian family living in a Massachusetts town. By the time
she was eight years old both parents had gone to hospitals for
the insane in Canada, and the children were scattered. Aimee
went to live with an aunt. At sixteen she was working in a
mill in another city and had begun her life of independence
with little or no knowledge of her family. She came to Boston
at seventeen and worked for periods from a few weeks to sev-
eral months in hotels, restaurants, and hospitals.

She was twenty when we first knew her in 191 3. A pre-
tended attempt at suicide brought her to the Psychopathic Hos-
pital. She had taken iodine and then gone to the police for
safety, no doubt reassured by a similar experience six months
before when she had sought the police after drinking chloro-
form liniment. Some months before she had swallowed a
corrosive tablet in the presence of a medical student, who had
carried her to an emergency hospital for treatment. She now
said that she was despondent because this same student, who
had lived with her as his wife, and whom she had expected
to' marry her, had left her. She said that she would "get re-
venge if it should take ten years." She had already written

156 THE KINGDOM OF EVILS

with vindictive intent to his father and a girl he knew at
home.

When Aimee left the hospital the social service undertook
supervision. She was a likable girl with a certain sweetness
of disposition in her good moods, and with ability to reason
intelligently. She had a rather touching desire for refined
and attractive surroundings and surprising discrimination in
recognizing educated tastes and manners. She prided herself
upon holding a reputation for always having "classy fellows,"
and was never without one or more students to take her about.
Her desire for "good times" was insatiable. Although the ex-
tent of her sex delinquencies could never be learned, by her
own admission they were many. She had had two gynecolog-
ical operations during the last three years, and was even now
in need of treatment for gonorrhea. The blood test for
syphilis was positive.

It was clear that the girl had had a poor chance in life, and
she herself felt bitter about her lack of opportunity. She said
she wanted "to take a fresh start" and to try with help pro-
vided by the social service "to make something of herself." A
comprehensive program was planned, for work, recreation, a
church connection through a sympathetic priest, treatment for
gonorrhea, and a good boarding place. The social workers
saw her frequently. Attempts to find recreation to compete
with the "good times" of the past fell flat. Jobs were found
and at once lost through the girl's incompetency. "We don't
want her type of girl," the report would be. She ignored the
church, found excuses for not Hving in the boarding places
chosen, and neglected her treatments. She refused to go into
an industrial school, to which there was no way of committing
her against her will. Untrained for any work that might ap-
peal to her intelligence and satisfy her ambition, she was
despondent because she had "no future." So after a few
months it was arranged for her to attend a trade school. Her
board was paid by a friend of the social worker, who had had
experience with girls in similar plights and undertook to help
in the reeducation of Aimee. For a few weeks she was happy,
but her work proved unsatisfactory, and in the second month
she gave it up. A commercial school was tried (to learn type-
writing and the use of the billing machine) and, when she was
discharged for f^oor work itnd bad conduct, a second school

THE KINGDOM OF EVILS 157

was tried with the same resuh. "She made almost no prog-
ress, and was inattentive and troublesome, taking other stu-
dents' attention and not following rules or instructions. Her
personal appearance was much against her, as she was untidy
as well as painted." The three school attempts covered a year.
Meanwhile Aimee had improved a good deal in appearance
and manners. She took better care of her clothes and person,
although she was still rather inclined to be dirty. She had a
series of admirers, and "good times" continued. She was asked
to leave the girls' lodging house where she had been placed be-
cause she was "a bad influence on the girls."

Aimee had now to look again for an uncongenial job. She
was discouraged and unhappy, and wanted to be with her own
people. A sister had been located, well married and living in
comfortable circumstances in a rural neighborhood in Canada.
Aimee was sent to visit her. After a few days her brother-
in-law in righteous indignation turned her out of his home and
found her a refuge in the almshouse. We brought her back
and found her a position at housework.

Soon she announced that she was to be married to a college
senior, the son of wealthy parents from another state. The
boy came at once in response to a letter asking him to call and
said he did intend to be married to Aimee, and that, although
he had believed that he was the first man to have sexual inter-
course with her, he did not think the knowledge that he was
not would miake any difference. He said that he was willing to
"break it off," but Aimee seemed so unhappy at the idea of his
leaving her that he felt he ought to marry her, though he did
not exactly love her. He was a fine-looking lad with nice man-
ners. Learning that he was about to leave town, Aimee had
him arrested for breach of promise, but agreed to drop the case
under advice from the boy's lawyer. In compensation his
father gave her five hundred dollars, and she fitted herself out
at once with new clothes in remarkably good taste. The young
man on release from jail went directly to her room and spent
the night with her, again offering to marry her. He departed,
however, and Aimee followed him to New York and threatened
to bring another suit. But she came back and arranged the
most dramatic of her suicidal episodes. She left by the river
bank an old hat and coat with a note to the hospital saying that
she would be drowned when it was received, and later leturned

158 THE KINGDOM OF EVILS

to the spot to join the crowd watching the river dragged. Two
days later the poHce, who had been notified, found her draw-
ing the last of her five hundred dollars from the bank and
brought her to the hospital. She was amused by the success
of her "frame-up," and somewhat consoled for the loss of her
lover by the newspaper notoriety she had gained, but she still
swore vengeance upon him.

After this Aimee refused to keep in touch with us and we
felt that our supervision would alter but little the course of
her life. She was clever enough to find work and make friends
and to keep out of court. The life of the professional prosti-
tute disgusted her and she would probably continue to have
promiscuous sex relations of a private nature and to work
intermittently.

We heard of her six months later as nurse in training in a
hospital for mental diseases in another state. A social worker
there who had known her said that she was doing well in her
work and seemed greatly changed. She appeared ambitious to
lead a regular life and intelligently interested in her work. But
soon she gave up the training and left claiming that she
was afraid her history would be known, since she had been
recognized.

Hours spent by Medical record, 33 pages

Social record, 51 pages
Physician, 9 Social work :

Visits, 35
Psychologist, 4 Interviews at hospital, 61

Telephone calls, 91
Social worker, 100 Letters, 75

Portuguese ivho got into a tangle over his draft papers and
was arrested for "desertion." Epilepsy.

Case 29, We found it hard to get a good example of
the binary combination of educational and legal troubles. It
actually seems as if this particular dyad of evils is statistically
very infrequent. At all events this is true for the Psychopathic
Hospital group of cases. Yet if we think of the matter in the
most general way, can the world be otherwise built than to
show many instances of persons who through ignorance are
unable to cope with legal difficulties? Naturally, plain com-

THE KINGDOM OF EVILS I59

binations of educational and legal difficulty without psycho-
pathic or moral twists would not in the first instance get to the
Psychopathic Hospital clinic.

The Portuguese, John Manaos, whom we choose, was a
man of about thirty years, who may have been somewhat
feeble-minded, though there is no definite evidence of this.
He could speak English, but spoke it very imperfectly. Though
he had forgotten most of his Portuguese, he was fairly well
Americanized. Yet he got into a tangle concerning draft
papers in connection with his war service and apparently quite
through ignorance was unable to straighten out the techni-
calities. He was arrested and put in a guardhouse for failure
to fill out his draft paper. The fact was that he had really filled
out a draft paper and returned it. A second blank was given
him which he returned, saying that he had already filled out a
blank. Thereafter came the arrest, technically for "desertion."

At the police station he began to show a psychosis. In the
midst of normal talk with his relatives he would all of a sud-
den become mute and tense, staring fixedly at the wall. He was
tense and staring on admission to the Psychopathic Hospital
and was very resistive during the process of undressing. He
said he had been in the hospital ten minutes and immediately
afterwards said that he had been there all night. When asked
the date he said "January 5, era first year, that is what they
keep saying." He told of having fainting spells every week
with loss of consciousness. Something dropped in his throat,
he said. At other times he had been unable to talk. He said,
"My mind is getting blank." He had had influenza about
three weeks before admission. His eyes were somewhat prom-
inent, hands tremulous, and his knee jerks hyperactive.

Under observation he was at times overactive and talkative,
at times quiet and mute, at times hallucinated (women were
talking about him and voices called his name). After about
ten days he became pretty clear and began to take an interest
in time, place, and persons. Asked about his phrase concern-
ing the new era, he said : "They say the world is changing.
They were talking amongst themselves. There was the first era,
the Babylonian, Syrian, and Greek. I thought this was going
to be the German or something like that, you know." About
this time he seemed a case not only committable but deserving
commitment forthwith. He was accordingly committed Feb-

l60 THE KINGDOM OF EVILS

ruary 5 (about three weeks after admission), but was suffi-
ciently well to be dismissed about seven weeks after admission
in a condition "improved." The diagnosis was epileptic psy-
chosis (clouded state).

Like so many psychopaths of various sorts, Manaos had
the reputation of being a nervous and delicate fellow. His
work record was studied rather intensively by a worker em-
ployed in industrial researches, and we therein find a history
of many jobs dropped for a variety of reasons, no one of them
particularly suspicious of psychopathy, yet taken on the whole
suggestive of general inadequacy. In less than three years he
had worked in ten different places as porter, car-cleaner, kitchen
boy, milling-worker, machinist's helper, etc. Manaos had the
idea of being a machinist. The bare record of condensed en-
tries concerning the various jobs and the periods spent on them
during the last three years fill five typewritten pages.

A record was found of his having been arrested as idle
and disorderly for hanging about street corners at the age of
twenty. The difficulty again seems to have been one of igno-
rance rather than of any moral defect. Of course, the hypothe-
sis might be raised that he was already epileptic at that time,
and if we felt that these episodes of arrest for idleness and for
"desertion" were really arrests of a man who was in a clouded
state of mind, then we should perforce have to regard Manaos
not as a combination of ignorance and legal trouble but as a
combination of disease and legal trouble. After giving due
prominence to the hypothesis of epilepsy and its accompanying
clouded states as a cause of Manaos's difficulties, we are still
inclined to think that he is a man who could be and can be
taught to do much better. For example, he was once employed
as a night watchman. The owner found him sitting with his
lantern on a curbstone outside. Upon being told that this was
not proper watching, Manaos was thereafter (so long as em-
ployed) a perfectly good watchman. He had not been a stupid
boy at school. He had started school late and left it at the age
of fifteen in the eighth grade.

This is of course a case whose outcome cannot be stated.
Many epileptics remain in this community doing perfectly good
work throughout their lives. Indeed, there are no doubt many
epileptics who accomplish unusual things and are actually emi-
nent men. This Portuguese was actually committed (although

THE KINGDOM OF EVILS l6l

released after a few days) as a victim of epileptic psychosis,
and it may be thought that he will finally be committed once
more. In the intervals, however, aside from the persistence
for a few hours or days of a clouded state, Manaos is to our
minds much more of an educational than a medical problem.

A community that should elaborate its mental hygiene to the
last point would no doubt devise a means for light and non-dis-
turbing contact with Manaos for a period of many years and
no doubt the entire cost of such mental hygienic measures
w^ould be amply compensated for by the preserving of another
industrial life from undue interference either by his lack of
information or by the complications of epilepsy.

For a further account of epileptic phenomena, see Section
III in Book III.

Hours spent by Medical record, ii pages

Social record, ii pages
Physician, 6^4 Social work:

Visits, II
Psychologist, o Interviews at hospital, 4

Telephone calls, 9
Social worker, 23J/2 Letters, 7

Overworked young mother harassed by scolding husband.

Case 30. Emma Marburg came to the out-patient depart-
ment by the advice of another patient because she felt she
would not "be able to hold out much longer." She had married
at seventeen John Marburg, a Pole, ten years older than her-
self, and had never been happy with him. She was now twenty-
six and had five children. The family lived in three dark
rooms at the back of a ground floor tenement. Mr. Marburg
had earned only ten dollars a week as a mechanic until recently
when he began to make fifteen to nineteen dollars a week. He
had kept out of debt and his wife even suspected him of having
some small savings; but as the weekly expenses for mainten-
ance were between sixteen and seventeen dollars a week, their
life was a struggle for existence. A legacy of several hundred
dollars from Mrs. Marburg's father a few years earlier had
helped out.

Mrs. Marburg was frail and lacked vitality. Her chief

l62 THE KINGDOM OF EVILS

symptoms according to the medical record were "fatigue, un-
happiness, and worry." She felt hopeless about her ability to
give the children proper care, and was terrified at the thought
of having more children. She had lost all ambition to keep the
house in order (it was unspeakably disorderly and filthy), for
their tenement was unwholesome and even the necessary house-
hold utensils were lacking. More fundamental than this ma-
terial resourcelessness was the poverty of her relations with
her husband, a man of good but peculiar disposition. He had
always "nagged her" and quarreled with her, complaining of
the disorder of the house and the poor quality of the food, and
blaming her for having so many children, which he attributed
to "her laziness." He suspected her of relations with other
men (without justification) and a year before had openly
accused her of sex relations with the godfather of one of the
babies, who left the house and never returned. He seemed
afraid of his wife : at night he would bolt the door of his bed-
room, he would make the children taste the food before he ate,
would move away if she came near, and look around if she
passed behind him. At one time he complained to a children's
agency that she neglected the children. No action was taken,
but Mrs. Marburg was deeply mortified, as she said she had
always tried to do her best by the children and stayed with her
husband only on their account.

Mr. Marburg had come to our out-patient department three
years before complaining of "nervousness and sleeplessness."
The examination showed no evidence of mental defect or psy-
chosis ; and his symptoms were attributed to excessive use of
coffee and tobacco.

The marital discord seemed to center around the question
of thrift. Mr. Marburg came of a family of frugal, successful
workmen and his mother had kept a clean, comfortable house in
Austria. Both he and his brother were disappointed in the bad
housekeeping of their American wives. Marburg wished to
live well and also to save money. He wanted his wife to take
lodgers, and to go out and work to earn stil! more money. He
could not understand her refusal nor her inability to give him
nourishing food and provide a clean home with the ten dollars
a week he gave her. He was fond of the children and helped
at times with their care; and he was fond of his wife to the
extent of saying that he could care for no other wom.an, but

THE KINGDOM OF EVILS 163

he said that "the man must come first" and he was not so much
worried by the fact that the children were thin and undernour-
ished and the failure of his ambitions to have "a good home"
as he was by his inability to save. He was the only well-fed
member of the family. Yet he was a well-meaning man and
sincerely troubled about the state of his family affairs. He
had been many times to his physician with his tale of woe,
until he had become "a pest." He offered to pay a fee for these
social calls, which was not accepted, and finally the physician
had to refuse to see him.

Mrs. Marburg had not had a happy life up to the time of
her marriage at seventeen. Her mother died when she was a
baby and her stepmother was unkind to her and her sister and
fed them scantily, for the most part on bread and tea. She was
kept out of school to help at home, so that when she was taken
out of school at fourteen to be put to work she was in the
seventh grade. She graded well in the psychological examina-
tion. After three years in a rubber factory she married to get
rid of the "nagging" at home. Six years later her father com-
mitted suicide.

The social problem here was one ot educational and financial
deficiency, an untrained woman with an income insufficient for
the needs of her family, li Mrs. Marburg could be taught
good standards of living and educated in good housekeeping
and sufficient funds could be provided to maintain the family
suitably, it seemed probable that there would be no medical dif-
ficulty, and that the marital dissension would subside to a nor-
mal level. No question of conflict with public authorities ever
arose in this case. Our efforts were directed then toward the
better education of Emma Marburg and a more provident use
of John's wages. In time he should be earning more. Al-
though he sought to give the impression that he had saved a few
hundred dollars, it was pretty sure that he had only about sev-
enty-five dollars stored away.

The first steps toward this end were to secure John's sym-
pathy and cooperation, which he yielded fairly readily, with
occasional changes of mind ; to keep Emma's courage up ; and
to rally around the family the friendly interest of relatives,
physicians, teachers, and priest. A new tenement was found,
whereupon Mr. Marburg committed the extravagance of fur-
nishing a parlor in mission style, a hopeful sign we felt in a

164 THE KINGDOM OF EVILS

man with habits of excessive thrift. Some gifts of household
goods and clothing were used to cheer Mrs. Marburg. There
was not enough clothing in the house to dress all the children
completely at the same time and Mrs. Marburg's apparel was
depressingly shabby. The children were taken to a hospital for
examination, and a tonsil operation was performed upon four
of them. The baby's feeding was regulated also. After tre-
mendous efforts to overcome Mr. Marburg's opposition to the
novelty of the idea, Emma was sent to a convalescent home for
a four weeks' vacation, while the children were boarded. In-
cidentally she acquired some housekeeping notions and brought
back a sheaf of recipes. A visiting housekeeper was secured
to undertake her instruction. Unfortunately one of the chil-
dren brought home an infection of scabies which ran through
the family and interrupted education ; and Emma was laid up
with a scalded foot. Then came the discovery that she was
again pregnant. In spite of the terror she had shown when
she first came to us a year before, she accepted the fact calmly.
She had become somewhat happier and more reconciled to her
husband, who showed a very much better disposition and took
more responsibility for making the home comfortable. He had
an occasional relapse into his scolding habits, but on the whole
had become fairly considerate. The case was left in the care
of a prenatal clinic. We felt that at least another year of inten-
sive social treatment would be required to effect any lasting
improvement in so deep-seated a case of ignorance and povertv,
but we could not carry the case longer because (according to
prevailing custom) our staff of social workers is not large
enough to carry one-half of the current work of the hospital,
and urgent and acute cases demand for the most part first
attention.

Hours spent by Medical record, 9 pages

Social record, 39 pages
Physician, 434 Social work :

Visits, 62
Psychologist, l Interviews at hospital, 6

Telephone calls, 18
Social worker, 100 Letters, 12

SYPHILITIC DELINQUENT— I
GIRL, 21

1915

Poor Stock (Alcohol, Sex Delinquency)
Placed Out, 3 (Troublesome)
Kidnapped Home, 12 (Incest)
Reform School, 13 (Good Work)
Parole, 18 (Lewdness, Temper, Blues)
Suicidal Attempts

(syphilis congenital?)

SYPHILITIC DELINQUENT— II

GIRL, 21-24

ipiyiQiS

Good Work at a Job but —
Unmanageable

Suddenly Married a Black Sheep-
Kept House Well

Baby Took a Prize

Illness — in Hospital

Discord

Another Baby Sick

Husband in Prison — Paroled

Third Pregnancy

Improvement Under In-Law's Care!

Wayward, syphilitic girl married to a black sheep. In the
end a devoted mother.

Case 31. Alice Nardini, an American girl of twenty-one,
married in haste to Joseph Nardini, an Italian youth about her
own age (the "black sheep" of a good family) is presented as a
case whose outstanding features were moral and legal. She
had received a fair education, and although her early training
was of the poorest, a term in an industrial school had taught
her the essentials. Financially she could always "get along"
although fairly near the margin of poverty. Strictly speaking,
she was not without medical difficulties (presumably every case
under care at the Psychopathic Hospital has some medical
complication), but the positive Wassermann test probably due
to congenital syphilis and the psychopathic aspect of her quick-
tempered, moody disposition were less conspicuous in her case
than her unreliable conduct. Legal complications appear from
time to time. She seems to be one of those persons who are
always on the verge of association with the court.

When Alice was three years old she was taken by the court
from her parents, both of whom were alcoholic and sexually
delinquent, and placed in the care of a children's agency. She
was boarded in homes of the best sort, and given up by one
after another because she was troublesome. When she was
about thirteen her parents kidnapped her. They became drunk
and quarreled, and the father after having the mother arrested
took the child to a shack in the country where he practiced
incest. She was rescued by the police and committed to an
industrial school as "a wayward child, grov/ing up in circum-
stances exposing her to lead an immoral, vicious, and criminal
life." At the school she made a fairly good record and was
a great help in the sewing room as long as she was allowed
to be prominent. She would do almost anything to attract
attention.

In childhood she had fits of temper when she would scream
for an hour at a time. She showed such a tendency to vulgarity

167

1 68 THE KINGDOM OF EVILS

that she could not be allowed to play with the neighbors' chil-
dren in the respectable homes where she was boarded. If
crossed she became sullen, refused to eat, threatened to kill her-
self, and finally got into a state of nervous excitement that
alarmed her friends. A physician who saw her thought that
she should be kept under restraint for the public safety.

When she was allowed to leave the industrial school to do
housework in private families she used obscene language and
was lewd in her manner with men upon the street.

Alice was sent to the Psychopathic Hospital because she
threatened suicide when a girl whom she had known at the
school spread stories about her in the town where she was
working. Five months later she was returned after an at-
tempt to take poison. On this occasion she had been allowec'
to visit her mother, now married a second time to a steady,
respectable man, and no longer alcoholic. Her mother accused
Alice of being in league with her stepfather to run the house
and a quarrel arose that led to Alice's attempt to kill herself.
The medical diagnosis the first time was "not psychotic." The
girl was distinctly not feeble-minded, according to the psycho-
logical examiner. She appeared bright and quick. The second
time she was in the hospital the final conclusion of the medical
staff was that there was a question of early dementia praecox.
The Wassermann reaction was positive and antisyphilitic treat-
ment was given. As the mother had syphilis, the presumption
was in favor of the opinion that Alice was a case of congenital
syphilis.

The family chart of this girl is very black. Her mother is
a high-grade moron ; both parents were alcoholic and sex
delinquents. On the father's side the grandfather was criminal-
istic, the grandmother hysterical, the great-grandfather a sex
delinquent. On her mother's side, the grandfather and great-
grandfather were alcoholic, the grandmother was feeble-
minded, had tuberculosis and was alcoholic, and sex delinquency
appeared among the great-aunts and uncles, a cousin was
insane. Ten of the family were confined in institutions of one
sort or another.

When Alice left the hospital the second time, she had become
of age and could therefore no longer remain under the authority
and care of the industrial school, so she was taken under super-
vision by our social service. In the position found for her she

THE KINGDOM OF EVILS 169

did satisfactory work but was unmanageable because of her
pert and independent manner. It was impossible to tell what
she did in her leisure time; but she could not live at home
because she and her mother could not keep the peace when long
together. Soon without warning she announced her marriage
to Joseph Nardini, who had been given to drink and the use of
morphine, but for a while had been sober and industrious,
working as a grocer's clerk. The results of our supervision
until a year and a half later, when the family moved to another
state where Alice's stepfather had found promising work foi
Joseph, are summarized in the social record as follows : —

May 28, 1914-March II, 1 9 16

Social:

After leaving the hospital in June, 1914, a position at the
Roxbury General Hospital was secured for her where she
remained until October, 1914. She left without serving notice
and was married without visitor's knowledge to Joseph Nar-
dini, an Italian of good family. Just before this, she was
going out with two different men, both of whom she alleges
made improper suggestions to her. Boy was born July 24, 191 5.

With the exception of a month in the fall of 191 5, when
the patient lived with her mother in Westbridge while husband
was working in Eastboro, they have lived in the South End.
Patient's husband has worked in a grocery store, for a roofing
company, driving an automobile, cleaning streets, and as porter
in a bank, earning from ten to sixteen dollars a week. The
family has been in debt most of the time, and while they have
made regular payments, one debt would no sooner be paid
than another would be contracted. The parents of both patient
and husband have regularly supplied them with money and
with clothes. Of a bill of thirty dollars at the Maternity Hos-
pital, five dollars was obtained through the efforts of Miss
Fuller, a visitor to the Nardinis ' from the Charity Organiza-
tion Society. When the family went to New York state,
March, 1916, they were in debt over one hundred dollars.

Patient's husband has had periods of drinking, and for over
a year before marriage used cocaine and morphine. He and
patient quarrel. When husband is intoxicated, he is ugly and
will strike patient. But since baby was born, July, 191 5, he
has treated patient better. He seems devoted to the baby.

For a time patient's mother and patient's husband were not
on friendly terms, and patient did not dare let her husband

170

THE KINGDOM OF EVILS

know when she had seen her mother. Husband's parents have
tried to hold up to both patient and husband a high standard
of conduct. They have a strong sense of responsibiHty for
patient since she has married into the family.

Physical:

Patient was given antisyphilitic treatment here the first sum-
mer and has been under observation of Dr. Scott since. When
the baby was born in the Maternity Hospital patient was given
ether. The delivery was normal. Patient had trichaniasis and
was in the Roxbury General Hospital twice in fall of _ 1915.
She is not living according to the diet prescribed. Patient is
looking fairly well, but has lost weight since leaving the hos-
pital. Is kept awake at night with the baby.

Mental:

She is fond of her husband and craves affection from him,
and is devoted to the baby although she does not wish any more
children. There has been a gradual change from the high-
tempered, self-willed disposition to a more docile and obedient
bending to husband's wishes, so that there is less quarreling at
home. In February, 1916, threatened to leave husband, but
after quarreling one half day and sending for visitor, went back
to him. In December, 191 5. had a noisy quarrel with mother
at her home. Other less important squabbles occur.

Patient is a poor housekeeper, but mother says she is im-
proving. She depends upon her mother to do a good deal for
her.

When they returned to Boston after two or three months we
reopened the case and results during a period of nine months
follow : —

June I, 1915-February 29, 1917
Social:

Familv returned to former address in the South End because
they found it impossible to live on husband's wages. Husband
has worked more regularly since his return and makes from
twelve to sixteen dollars a week. He has straightened out and
no longer drinks or abuses patient. Debts are paid except
fifteen dollars at the Maternity Hospital. Second boy born
December 28, 1916.

Physical:

Patient no longer requires antisyphilitic treatment. Two
weeks' rest in the country was urged before confinement, but
she could not be persuaded to go.

THE KINGDOM OF EVILS I7I

Mental:

Patient shows marked improvement in housekeeping and
personal appearance. She takes a real pride in her home and
has shown marked ability in sewing for the children, even
making some dresses for her husband's young sisters.

She is less impulsive and seldom quarrels. She allows her-
self to be ruled by her husband, and seems happy and content
with her life. Her voice is subdued and she has poise and
dignity of a grown woman.

She is now stated as not psychotic. She is considered a
psychopathic individual who has been compensated socially.

Alice was much improved and the case was again closed as
the supervision of the in-laws seemed adequate. But a friendly
call three months later brought to light the fact that Joseph
had been sentenced to the house of correction for a year and a
half for drawing a revolver upon an officer who interfered in
the advances of himself and his companions to some girls upon
the street. Apparently Joseph had no malicious intentions, but
the law had its way with him. Alice was being supported by
public aid and her father-in-law. We joined Mr. Nardini in
an effort to bring about the release of Joseph, who after serv-
ing six months of his sentence was paroled. By this time the
original problem of the training of a somewhat psychopathic
girl had been eclipsed by the "family problem" of the Nardinis,
and we asked a family agency to take the case. When we
heard of the Nardinis recently, Joseph had been drafted into
the army. Before he went he had been drinking and taking
morphine and had been abusive to his wife. He had gone about
openly with a woman whom Alice styles "a regular bum." She
is now endeavoring to discover an opportunity for the police
to arrest the woman ; and is thinking of going to court for sep-
arate maintenance when Joseph comes home.

The improvement in Alice herself (aside from the condition
of the family) during the four years we have known her is a
matter of some surprise. Considering her bad heredity, and
unfortunate early experiences, and her unstable character, we
did not expect as much stability as she has developed. In spite
of many handicaps she has shown continued progress. Joseph,
while he has had his good spells, has been a difficult husband to
manage even with the help of able in-laws. Alice's mother,
though kind and helpful for the most part, has an uncertain

1^2 THE KINGDOM OF EVILS

temper and once at least was intoxicated and "disgraced" her
daughter in the eyes of the Nardini family. Alice herself has
had a good deal of sickness and the first baby had ear abscesses
and the second child was in a hospital at eleven months for
feeding troubles. The third child was never well and died
at three months. The uncertainty of their income has been
another burden upon Alice, for although funds have always
been forthcoming, Joseph's irregular habits of work and ten-
dency to gamble as well as drink have kept the family most ol
the time in debt.

During the first pregnancy Alice was given antisyphilitic
treatment regularly, and the baby was a fine child. Before the
birth of the second child she was under medical observation,
but treatment was not considered necessary. This baby also is
well and sturdy. When we referred Alice to a general hospital
for treatment for syphilis, the diagnosis upon our medical
record "question of early dementia praecox" proved to be a
snag, for the superintendent of the hospital to which we wished
to refer her replied that in view of the diagnosis "the patient
was directed to return" to our hospital, since if there was "any
question of mental disease in her case" he felt she belonged
in the care of our hospital. The matter was finally adjusted,
with some difficulty, upon a statement from one of our physi-
cians that Alice Nardini was "not a mental case."

Hours spent by IMedical record, 17 pages

Social record, 31 pages
Physician, 5%. Social work :

Visits, 48
Psychologist, i Interviews at hospital, 1 1

Telephone calls, 6
Social worker, 76^4 Letters, 16

Incompetent young wife quarrels with in-lazvs, then quarrels
zvith husband, who deserts.

Case 32. Although Catherine O'Connor by psychological
tests would be classed among high-grade morons (she graded
at II. 6 years by the Point Scale and was twenty-three years
old when tested), she was bright and teachable, fairly intelli-

THE KINGDOM OF EVILS 173

gent, and even capable when she exerted herself. She was not
mentally different from many women coming to social agencjes
whose intelligence is never questioned to the extent of psycho-
logical tests. While her case might be regarded as presenting
difficulties in the group of morbi, owing to her somewhat defec-
tive intelligence, yet the factor of intelligence defect played a
relatively small part in her treatment, and the main difficulties
to be dealt with lay in the moral and financial fields. After
the desertion of her husband the question of support for herself
and the children was the pressing consideration. Her moral
difficulties were faults of "temper." Up to the time of her
marriage she showed an easy-going disposition and had no
particular trouble. As a child, however, she was somewhat
peculiar, having sullen spells when she would go two and three
weeks at a time without speaking to anyone in the house.
After the birth of her first child, she quarreled continually with
her husband and lost no opportunity to be rude to his family,
whom she disliked. She would burn presents that they sent
to the baby. At times she had thrown dishes at her husband
and refused to cook his meals. She never did justice to her
housekeeping, and was slack and untidy. The husband also
was of an easy-going disposition and quick temper and bore
up his end of the family quarrels. After one particularly violent
scene, in which Catherine became very much excited and
obsessed with the idea that her sister-in-law intended to take
her baby away, a doctor was called, who advised sending her to
the Psychopathic Hospital for observation. She said he told
her "the hospital would be a good place to rest in" and she was
willing to come.

The story of social treatment during two years and nine
months is briefly told in a summary from our record prepared
for the Associated Charities in another city to whom the case
was referred after Mr. O'Connor had returned and the family
had been transplanted to a new neighborhood. We asked that
a friendly visitor keep in touch with them. Both Mr. and Mrs.
O'Connor had shown marked improvement apart, but it re-
mained to see whether they could attain stability in their corn-
mon life. A copy of the summary follows : — ■■

174 THE KINGDOM OF EVILS

SUMMARY

Social History:

Patient is an American born woman, twenty-six years old.
of Irish parentage. She is a pretty woman, short and sHght,
has pleasing manners and an attractive smile. Patient was
married six years ago to Frank O'Connor. For a time they
were happy together, but after the birth of the first child, 191 3.
there was constant friction. The husband earned fourteen
dollars per week, and patient had great difficulty in making
both ends meet. Patient also did not get along well with her
husband's family. She felt that they were trying to take her
child from her. Finally the husband had patient sent to this
hospital, June, 191 5. They were advised to separate, but
decided not to and apparently were happier. Five months a f tcr
birth of second child, January, 191 6, patient's husband deserted
her. Patient was sent to Peterboro for a vacation. She en-
joyed the place so much that she decided to remain.

For fourteen months she and her l^aby Marion, now a year
and a half old. lived in Peterboro. where the patient worked as
stitcher in one of the Fox & Blake shoe factories. Patient
earned between seven and ten dollars per week with which,
together with the small amount given her by her sister Mary,
she supported Marion and herself. Patient was well liked by
her employers and made many friends in Peterboro. While
there she lived in three different places in each of which there
was someone to care for Marion during the time patient was
working. Patient's older child, Winifred, four years old, is
well cared for Ijy Mrs. Edward O'Connor, 36 Troy Street,
Foxbridge, mother-in-law of patient.

Early in the spring of 191 7, patient heard that her husband
had deserted from the army in which he had enlisted under an
assumed name. In June he returned to Boston and went to
see patient several times. He gave himself up and served a
sentence of eight months at Blackport Island.

In October, 191 7, patient was not able to work more than
three or four days a week because of fatigue, due to preg-
nancy. November 13, she and Marion went to board at 12
Ford Street, where they had an attractive bedroom, a sitting
room, opening on an enclosed porch, together with board for
nine dollars a week.

Patient's board was paid by the Red Cross until February
9, 19 1 8, at which time the sentence of patient's husband ex-
pired, and he returned to Boston. Previously patient's husband

THE KINGDOM OF EVILS I75

had been an unstable, irresponsible young man, lacking in am-
bition. Since his return, however, his entire attitude has
changed. He at once sought work and secured a position as
meat-cutter at fifteen dollars per week. The second week he
was raised to sixteen dollars. He was desirous of leaving this
city and making a new start. He chose Lawrence, went to the
Y. M. C. A. there, secured employment at seventeen dollars
per week in a factory and in addition worked as meat-cutter
for Saturday afternoon and evenings. Eighteen dollars was
lent him to pay patient's board for two weeks ; of this he has
already paid back sixteen dollars. Three dollars additional
was given to patient, so husband now owes this hospital five
dollars.

On February 28 patient was confined at the Maternity Hos-
pital, where she gave birth to a boy weighing six pounds, four
ounces, and where she remained eleven days. She then returned
to 12 Ford Street for two weeks, her board being paid by
Country Week. Patient and baby then spent a few days with
patient's sister Mary, in Arlington. March 30 patient joined
her husband in Lawrence.

During patient's confinement, baby Marion came down with
scarlet fever and is now in the Contagious Hospital doing
fairly well.

Physical History:

Patient had a normal birth and development. Her children's
births were normal. While her husband was in, she became
pregnant and was confined in February. During early part of
last pregnancy patient was examined at Suffolk General Hos-
pital and while at 12 Ford Street attended a prenatal clinic.
There was nothing unusual during her confinement.

Mental History:

Patient went to the seventh grade in school. She is fond
of reading and dancing, but had had little recreation since
marriage. She is untidy and slack as a housekeeper, but when
she tries she keeps herself and her baby neat and clean.

Patient's psychological examination at this hospital showed
that she graded at 11. 6 years. Diagnosis was: Not insane.
Since leaving hospital in 191 5, patient has been under the care
of the social service. She has done her best to carry out sug-
gestions made to her, especially recently, and is always appre-
ciative of what is done for her.

Patient is optimistic about the future and greatly pleased

1/6 THE KINGDOM OF EVILS

because of the change in her husband's attitude. She is eager
to have a happy home and reaHzes that she must do her share
to make it so. She also has become more interested in hygiene
and in the health of her children. At present she is greatly
worried about Marion, to whom she is devoted. She is amen-
able to social treatment.

A year after the family left Boston, one of the social workers
who had dealt with them (three social workers had in turn
charge of the case) happened to be near their new home and
called. She found Mr. O'Connor doing well, and Mrs. O'Con-
nor happy in a good, well-kept home. The whole family had
been sick with the influenza during the epidemic and Mr. O'Con-
nor had nursed them. The oldest child, a beautiful little girl,
died. Even under the strain of this grief, Mrs. O'Connor has
remained reliable. Mr. O'Connor is still going "up the ladder"
as he expresses it, in a letter we quote below :

"My Dear IMiss Goode:

"Received your letter last week sometime, but as I am not
much of a hand at writing it took me until today to answer
it. I hope that you have thoroughly recovered from your ill-
ness. I suppose that you will be mad at me for writing to
Catherine and having her come up here. I found two nice
rooms near my work and I also thought that it would be better
for Catherine to be here because she was worrying over Marion.
Being up here might take her mind off thinking of her. Now
of course I know she will be all right at the hospital under
the conditions. As I understand from Catherine I have got to
pay for her board and treatment there, also the other expense
of two visits of the doctors. I am doing all I can to make
good. I have secured a position in a market for Saturday
afternoons and evenings. So you can see that I am trying my
best to get up the ladder as soon as I can and I hope to con-
tinue. I am in hopes that nothing more will come up to
greaten the expense any more. I am very thankful for all of
the good things you have done for both Catherine and myself.
I will never forget them you have been my friend. Now as
soon as I can I will try and straighten out all matters with you.
I would like very much to see you but it is almost asking too
much to call up to see me. I want to keep in touch with both
you and the Y. M. C. A.

"Sincerely,

"Frank O'Connor."

THE KINGDOM OF EVILS I77

Hours spent by Medical record, 39 pages

Social record, 53 pages
Physician, 5 Social work :

Visits, 49
Psychologist, i Interviews at hospital, 18

Telephone calls, 75
Social worker, 100 Letters, 45

Persistent forger and "ne'er-do-well/'

Case 33. Ignatz Simanski forged a number of worthless
checks totaling $176 all within a period of eight days. Siman-
ski was an American-born Polish Jew who had gone back o
Berlin in his teens, worked with various firms, and was an in-
terpreter seven years. Apparently he lived very well in Europe,
but never sent money to his mother or sister. He kept mis-
tresses in Europe. He did not want to enlist in the war, was
ashamed not to, and finally left Europe to keep out of the war.
An artist divorcee with whom he became infatuated used up
his money. The forging then began. He got out of prison
in eleven months, without money or clothes. A friend of
Simanski's sister advised him to go to the Psychopathic Hos-
pital suspecting that, with his record, he might be a victim of
psychopathic personality. He came and was put under a sort
of supervision. Assistance was given him — a week's board
and shoes. A job was got for him in a munition factory.
Three months after there had to be a tonsil operation which
was arranged for. Upon emerging from the hospital he was
again destitute. That Simanski was in any psychopathic (ex-
cept under that extreme view of delinquents which regards
them as all in some sense psychopathic) was very doubtful. He
was referred to an agency for homeless men and the case was,
from the Psychopathic Hospital point of view, closed. It ap-
peared from recent advices that Simanski was married and is
making good in a small way. Of course, he is not cutting the
rather wide figure which apparently he cut in Europe and
shortly after his return. Whether, in the long run, he will turn
out again a more markedly delinquent, or whether he will be-
come obviously psychopathic is a question. Of a psychopathic
trend we found no sign.

178 THE KINGDOM OF EVILS

We have described Ignatz Simanski as a case without pre-
dominant or certain medical disorder. Perhaps we should re-
gard him as a moral problem and lay stress upon his irrespon-
sibility and selfishness, which we ascribe to educational defi-
ciency. Superficially viewed, this man has developed sundry
vices, but whether he is accessible to moral treatment in the
ordinary sense of that treatment is to be doubted. Just as some
authorities view crime as a sort of disease, so others view crime
as a sort of vice. We do not wish to enter the lists to argue
these views. In any event, the problem of Simanski is one
of low moral standards combined with economics.

Hours spent by Medical record, 4 pages

Social record, 8 pages
Physician, 3% Social work :

Visits, 3
Psychologist, o Interviews at hospital, 7

Telephone calls, 21
Social worker, isJ/2 Letters, 20

Psychoneurotic plumber unable to zvork for six years.
Afraid to go out alone.

Case 34. Daniel Griffin is a case we choose to analyze as
one of almost purely medical difficulty. Educationally he was
rather unusually without blemish, achieving the highest mental
age level consistent with the scales in use and achieving a gen-
eral intelligence score of 97. The psychologist noted that
Griffin's performance was exceedingly good in the construction
puzzles for example, but that he took much longer time on a
second trial than on the first, since he became very nervous
and feared that the second trial would fall off in excellence, al-
though he cooperated well and showed great interest in both
tests. He afterward complained of being greatly fatigued as
he had not slept at all the night before.

Thus, although psychological tests are not as a rule extremely
good sources of psychiatric data (as we cannot carry over a
specific deficiency in given tests, such as one for oversuggesti-
bility for instance, to argue a general psychiatric oversuggesti-
bility), yet Griffin's behavior during the tests suggested the
disease of which we think him the victim. Beyond question

THE KINGDOM OF EVILS 1 79

he belongs to the psychoneurotic group-. He came voluntarily
to the Psychopathic Hospital, complaining of feeling tired. He
had had, he averred, a nervous dread for some five years. It
was not a particular dread, but there was a feeling that some-
thing terrible was going to happen. He was worried because
he could not get on his feet and could not make a man of him-
self. He himself called his disease "neurasthenia."

He had been a plumber and said that he had contracted lead
poisoning, which was the cause of his disorder. However, at
another time he explained the beginning of his disorder in
a bout of rivalry over some bit of technique in the plumber's
trade with a man who beat him in performance. All this he
had taken much to heart. Whenever that particular thing was
to be done in plumbing he kept having precisely the same creepy
feeling that ran over him the day his fellow workman over-
reached him.

For some six years Griffin had not worked. Mornings he
felt shaky and trembly, was without ambition, and could not
seem to "get started." He felt a dread that "something might
happen" to him if he were alone. Evenings he would feel
better and might then take a solitary walk. Day times, how-
ever, he could never prevail upon himself to go out. Day
times he read or helped his mother about the house. He was
interested in lectures, in studying, and in serious conversation.
He spurned moving pictures. Whereas he had for a long time
been very fond of athletics, he now had no stomach for any-
thing except treatment for his nervous trouble. His brothers
and sister, he said, had ostracized him. He was angry with
one brother, though in point of fact at least a part of his
feeling might be attributed to his vexation at not having his
doctor's bills paid by the family. There appeared to be no
religious or sex concern in Griffin.

Griffin presented a good general appearance, though his
manner was a bit effeminate. He was not sad but anxious in
expression and, though for the most part agreeable, became
at other times petulant. He had been referred from the out-
patient department into the wards of the Psychopathic Hos-
pital. As soon as he entered the wards he wanted to know how
soon he could go home. Nevertheless, he stayed, being funda-
mentally willing enough. His fault-finding would run after
this fashion : "This has been a strenuous evening for me," he

l80 THE KINGDOM OF EVILS

would say. "I just got. through with the lady with the puzzles
and it has affected me."

Nothing psychiatrically other than the above was found
in Griffin's rather short stay (six days) in the wards, whence
he was discharged (as the clinic slang has it) "to self and to
the out-patient department."

He has been under observation for a good part of a year
and is perhaps a bit better. He is now being got to take more
interest in housework and repairs about the house, upon which
he spends several hours a day. He thinks, or at least states,
that his visits to the department are of little avail. He insists
that physicians should tell him concretely what will make him
well. He would rather like to have his excellent psychological
rating on paper to present to friends as evidence that he is men-
tally normal. In all the visits that he has made to the out-
patient department, he had never yet been able to go alone
although he has from time to time made elaborate plans to get
to the hospital alone. Evidently the brief trip seems to him a
compHcated tour. He protests that he must not come in the
car with a social worker because he will "look awkward." The
family's attitude to Griffin is altered again to one of affection.

This case we have picked as one of relatively uncomplicated
medical interest. As above noted, he is psychologically on a
rather superior level. Morally one might lay up to him as a
kind of vice or bad habit the attitude towards work which he
has assumed. It is somewhat a question of terminology,
whether we shall regard this psychoneurotic attitude as dis-
tinctly a kind of vice or bad mental habit. To be sure, the
effects of the psychoneurosis are found in the moral sphere
and affect both emotions and the will. But probably that ana-
lyst would go quite wrong who should feel that, by those moral
measures that aid the normal person who falls into moral
difficulties, he could restore Daniel Griffin. Naturally the
proof of the pudding in this case, as in many others, lies in the
eating.

Nor would we deny that some cases called psychoneurosis
have been cured by the usual moral measures at the conmiand of
the adult person of common sense who knows something about
the world and has a modicum of personality. Of course, too,
in some wide sense of the term, these common-sense moral
measures might be regarded as a form of psychotherapy. On

THE RiNGDOM OF EVILS ,l8l

this extremely wide (and we think excessively wide) interpre-
tation, even the processes of normal education as well as those
of moral training would fall under the caption psychotherapy.
But psychotherapy, strictly speaking, is a form of therapy, and
the term therapy has come to be used as signifying treatment
of disease or defect. No doubt, then, in a case like that of
Daniel Griffin, ordinary measures must be used just as ordi-
nary devices of education and instruction must be used. But
the stock moral measures of the community will not serve
and (as Daniel Griffin's five or six years of proper contacts
with an excellent family prove) have not served to turn the
trick.

To be sure, our own efforts have not been crowned with
complete success — nor may they ever be, despite the uninter-
rupted up-curve which we have in the past months noted.
What the real cause of psychoneurosis actually is remains to
medical minds a question. We do not need here to mention the
various psychogenic explanations which have been offered.
Griffin was in charge of a competent physician fully cognizant
of various modern suggestions as to the mental origin of sun-
dry kinds of psychoneurosis. Whether psychogenic causes
were absent or whether they simply were not discovered, at all
events, no single or removable cause has ever been alleged for
Griffin. AH legal and virtually all economic difficulties fail to
complicate the case. There was indeed nothing in Griffin's
life or history, as so far brought out, which could combine with
his psychoneurosis to form a picture like many of those before
described.

Griffin is the first of five cases, in which we are attempting
to display comparatively uncomplicated instances of medical
(Daniel Griffin), educational (John Henry), moral (Clara
Perkins), legal (Nathan Blumberg), and economic (Margaret
Dolan) disability. Thus the cases of slightly greater com-
plexity with which Griffin's case could readily be compared,
are cases 24 to 27. Of these four cases of medical trouble
combined with one or other type of non-medical trouble, two
(case 24, David Stone, and case 27, Herman Simonson) are
also cases of psychoneurosis. The case of David Stone we
regarded as a binary combination of medical and educational
deficiency, whereas Herman Simonson we regarded as a com-
bination of medical and economic trouble.

182 THE KINGDOM OF EViLS

In passing it may be noted that case 25, Alfred Stevens, was
also at first thought to be a case of psychoneurosis. That case
of Alfred Stevens was in fact, the striking case in which altera-
tion of the physician's estimate from psychoneurosis to cyclo-
thymic constitution (constitutional slight melancholia) made so
profound a difference to the man's happiness and self-support-
ing power.

Hours spent by Medical record, 19 pages

Social record, 23 pages
Physician, 4^ Social work:

Visits, 22
Psychologist, i Interviews at hospital, 4

Telephone calls, 20
Social worker, 453/^ Letters, 45

Boy kept a prisoner by insane mother. Enforced seclusion
did not prevent 'intellectual development.

Case 35. John Henry was a nine days' wonder in the
newspapers. He was a fifteen-year-old boy who was "rescued"
from a dark cellar where his mother had kept him five months.
The older medical textbooks used to tell of certain "wolf
boys," of whom the celebrated Caspar Hanser was one of the
first to bring up the problem whether an absolute lack of normal
education would so dull or retard development as to produce
in itself insanity or feeble-mindedness. The wolf-boy question
hardly admits a general answer. No doubt many of the wild
waifs picked up in the woods are actually feeble-minded or
victims of dementia praecox. John Henry was not in that
sense a wolf boy. He had been kept in his cellar on 1 strange
hypothesis. His mother had kept him back in school ; she
persuaded the teachers to hold John back on the score of his
feeble-mindedness.

Naturally, after John's somewhat picturesque rescue, he be-
came the especial object of the psychologist's attention. Mira-
bile dictu, John graded virtually at normal. At a chronological
age of fifteen and a half years, his Point Scale level stood at
16, and his level on the Stanford scale stood at 15.5.

This case so well illustrates the peculiar and critical advan-
tages of mental tests in certain instances, that we here trans-

THE KINGDOM OF EVILS 183

cribe a large portion of a special report made by the psycholo-
gist at the Psychopathic Hospital, Dr. Josephine Foster.^ This
report includes some notes upon John's present situation and
progress.

REPORT OF A CASE IN WHICH ENFORCED SECLUSION DID NOT
PREVENT INTELLECTUAL DEVELOPMENT

The psychologist who gives "mental tests" is frequently met
by the statement : "This low mental age means nothing because
the child has been sick and has not been a regular attendant
at school" or by : "You can't expect a child who has lived on
a lonely farm and who has had no playmates to test at age."
In vain may the psychologist answer : "I admit that inability
to read may lower the mental age with a scale like the Binet
or the Point Scale. In other respects, however, school training
has little influence on the outcome of psychological examina-
tions." Such a reply usually fails to carry conviction to one
who is not an experienced examiner. Instead, an objector is
likely to depart, thinking that the psychologist is grossly ex-
aggerating the importance of the tests, resolving to take mental
ages in the future with as large a grain of salt as ever, and
continuing to consider the mental age only when it agrees with
his personal opinion of the case.

In our work at this hospital we have come to use the answer :
"Let me tell you about a fifteen-year old boy we examined some
months ago." The illustration has been so successful that we
offer it here to other psychologists for similar use.

John Henry (this, of course, is not the real name, but it is
like it in having the same second name, which the boy spelled
Henery) was born in a rather poor district of a New England
city on August 13, 1902. Of his remote ancestors we know
comparatively little. Presumably his paternal grandparents
were natives of Ireland. His maternal grandparents are said
by one of our informants to have come from England and
Scotland, and by another to have been born in Nova Scotia
and Maine. We have one history which says that a maternal
uncle died in an insane asylum. Another maternal uncle, who
came to the hospital upon request, is reported to have been
insane, and appeared to be very unintelligent and was consid-

1 Foster, Josephine Curtis. A Case in Which Enforced Seclusion Did Not Pre-
vent Intellectual Development. In Journal of Applied Psychology, June, 19 19.

184 THE KINGDOM OF EVILS

ered as "probably untrustworthy in his statements." This uncle
denied mental illnesses in the family, but at the same time
showed such familiarity with hospitals for the insane as to
suggest personal acquaintance. Of the boy's immediate family,
the father was born in Ireland, and was probably a horse-
trainer. He was heavily alcoholic, abused the children, and
some five years ago deserted the family. John's mother was
born in New England. She was at this hospital for a time,
and is now an inmate of a state hospital for the insane with a
diagnosis of dementia praecox, paranoid. Four of John's
siblings are said to have died of starvation in the first year.
An older half-sister is apparently normal.

The schooling of John and this half-sister Julia was decidedly
meager. They were allowed to attend school occasionally, but
although both of them learned to read, they acquired little else.
If we could add together all the days John spent in school, they
might come to three years. We know that the family moved so
frequently (at least eleven times in five years) that he could
seldom have spent a full term in any one school. John was
last in the fourth grade. He attended school in this grade
irregularly for some years. Apparently he was not held from
advancement on account of dullness, but because the mother
went to the teacher and said : "Don't waste any time over this
boy of mine. He is feeble-minded and will never learn, no
matter how much effort you expend on him." Apparently,
also, the teacher believed the mother who was so candid about
the failings of her son, accepted her advice, and spent her
energies on the other children.

As might be expected under the guidance of such a mother,
home life was not an aid to John's mental development. Julia
says that her earliest remembrances are of squalid surround-
ings, a room or two with the poorest of furnishings, which
were never anything but filthy. She had very little clothing,
and at times such a small amount that she was forced to stay
indoors. John says that his mother would buy him new clothes
and then lock them up till he had outgrown them. Moreover,
there was never enough food, and the children were continually
hungry. The mother and stepfather beat Julia and obliged her
to chop wood and do all the work. In her presence they also
indulged in perverse sexual practices. John was not abused to
the same extent, probably because he was the father's own

THE KINGDOM OF EVILS 1 85

child. However, the only attempt to teach him anything was
his father's instruction in obscene verses and songs.

John and Julia had not even the opportunity to learn from
contact with other children. Their mother often kept them in
the house, and this happened still more frequently after the
father deserted. Even when the mother was away scrubbing
in the middle of the day, the children dared not venture out for
fear there might be some truth in their mother's statements
that "there was a God overhead who would do various things
to them, that the policeman would get them and do terrible
things, that people would kill them," and later, when Julia
was living elsewhere, the mother told John that "they would
jatch him in the draft," — a hazy, but horrible fate.

John's story of his life is of a succession of moves from
house after house, with periods of confinement varying from
a few days to one that lasted thirteen months. Most of the
day time he slept or amused himself by reading the Bible, the
few religious books, and the few Indian stories which they
owned. When the mother returned from her work, he seems
to have been occupied with endeavoring to escape her wrath.
He says that she would ask him questions and then answer
them herself. H he attempted a reply, she usually slapped his
face. She talked continually of the references which the news-
papers made to her, and of the pictures the moving-picture men
were taking of her. They had no regular meals. The mother
probably ate something at the restaurant where she did scrub-
bing, but all she brought home to John was bologna sausage,
milk, crackers, and bread. When he came to this hospital, the
boy had not had a hot meal in months. At night he was often
kept awake by his mother's talking, by what he called "mother's
lies."

Things went from bad to worse with John, but they im-
proved for Julia in the spring of 191 7. At that time the mother
accepted a position as "an experienced cook" and took the
children with her. On the third day she was discharged as
dirty and hopelessly incompetent. Julia, however, was retained
and since that time has had normal surroundings. John and
his mother returned to their squalid living, and the boy was
confined even more closely until early in 1918, when the police
and one of the children's societies found them and brought
them both to this hospital.

1 86 THE KINGDOM OF EVILS

When John was examined here, he was a large, overgrown
boy, sallow and anemic. His voice was husky and uncertain.
He did not know how to meet strangers, and was shy and
reserved. His face was a little sober, but almost expressionless.
He smiled slightly and then only after many interviews. He
answered all questions as briefly as possible. The most sur-
prising thing about his attitude was that he took practically
no interest in his surroundings or in what was to happen to him.
John's ignorance of the world about him was astounding. He
could name the president, the governor, and several recent
mayors, but when asked for the capital of Massachusetts he
did not understand what was meant. He knew nothing what-
ever of geography. With the exception of reading, arithmetic
was the only school subject in which his performance was at all
creditable. He had never seen a moving picture or a baseball
game.

We have here, then, a boy of fifteen and a half, who has
had practically no school training, practically no contact with
other children, and no home education save what he may have
picked up from the reading of a few religious books, and per-
haps a stray copy of a newspaper.

In spite of this overwhelming lack of information and of
training, when given a psychological examination, John re-
ceived a mental age of 16.0 (I. O., 104) on the Yerkes-
Bridges Point Scale, and a mental age of 15 yr. i mo. (I. Q.,
.98) on the Stanford Revision of the Binet. There is nothing
in the examinations that would be unusual in a normal boy of
his age. On the Point Scale the errors he made were in : repe-
tition of seven digits, repetition of the longest sentence, failure
to give interpretation for two of the pictures, failure to give
definitions in terms of classification, acceptance of the line sug-
gestion, failure in one of the memory drawings, in one of
the definitions of abstract terms, and in one analogy. On the
Stanford Scale, he passed all the 9 year tests, failed in designs
from memory in year 10, an interpretation of pictures in year
12, in the vocabulary in year 14 and the succeeding years, in
giving differences between abstract words, in repeating back-
wards, and in the code in year 16, and in the repetition of digits
forwards and backwards and in giving the thought of a passage
in year 18. His arithmetical ability is particularly evident in

THE KINGDOM OF EVILS 187

the Stanford examination. He did the Healy Construction
Puzzle A in seven moves in fifteen seconds and Construction
Puzzle B in twelve moves in thirty seconds. His attitude dur-
ing the psychological examination was somewhat listless and
a bit childish, but he cooperated well and showed occasional
interest and pleasure.

The conclusion must be that, in this case, at least, lack of
school education, lack of home training, and lack of normal
intercourse with other children have not prevented a normal
rating on intelligence scales.

John's subsequent history, while not of consequence for our
purpose, is, nevertheless, interesting. He was discharged from
this hospital with the diagnosis "not insane, not feeble-minded."
We hoped that it would be possible to give an examination at
the expiration of his first year of living in normal surround-
ings. This proved inadvisable because the boy is doing good
work on a farm, and a trip to the city might encourage his
present ambition to work in a store, a job which doubtless
would not fit him just now. The society, however, sent us a
detailed report of a "visit" made, and we give the substance of
that report here : —

John is living on a farm with a family who understand his
case and are anxious to assist him in every way possible. He
has gained in weight since last year and he looks physically
well. However, he is very slow in his movements, and appears
to take no interest in his surroundings. He seemed little af-
fected by the fact that the visitor had come from Boston to see
him, and the family say that this is his usual attitude. In the
year that he has been with them, he has never spoken of his
mother and sister, has never asked questions about places to
which he has been taken in the automobile, or shown any inter-
est in them. The only exception was one trip to the ocean
when he asked, "Why can't you see the other side?" He has
never spoken of the trip since. His typical day is as follows:
Rises at six without being called, feeds the horses without
being told, milks three cows, comes into the house for breakfast
without being called, eats a hearty breakfast, then, without any.
comment, returns to work, waters the cows, and cleans up the
barn. He comes back to the house about meal time, gets the
mail from a box at the end of the lane without reading any
addresses or ever asking if there is a letter for him. After the

1 88 THE KINGDOM OF EVILS

noon meal he takes care of the hens and does odd jobs. In the
summer time he goes for the cows. After supper he reads the
jokes in the daily paper and Farm Journal, sometimes smiling
a little. He never grumbles while doing anything he is asked,
never asks a question, very seldom speaks without being spoken
to, goes to bed without being told to at six-thirty and is per-
fectly willing to do this day in and day out. In fact, far from
disliking routine, he is somewhat disturbed when rain prevents
the performance of some of his usual chores. He shows no
interest in anything. He is good to the animals but never pets
them and the dog and cat never ask him for food. He never
notices anything unusual. If. for example, a cow were in great
distress and he had not been told to notice whether or not the
cow was sick, he would make no comment. Neither is he at
all interested in the fact that the farmer is willing to give him
fifty dollars if he remains with him a full year. Besides this
total indifiference, the farmer and his wife have reported sev-
eral facts which are of importance in the prognosis of the case.
He has recently been smiling more often, and occasionally
laughs heartily when alone at his work. When asked what
he was amused at, he insists that he did not laugh. He has
never made any attempt to play with a boy who lives in the
next house, a quarter of a mile away. It seems likely that the
boy may end by having dementia praecox, like his mother.

From the above account as published by Dr. Foster, it will
be seen that our initial idea in presenting John Henry ; namely,
that he might be regarded as an instance of purely educational
deficiency minus all four other forms of social defect that we
classified in this book, medical, moral, legal, and economic, is
destined to prove unsound. Perhaps, in short, we did regard
John Henry as a combination of psychopathic trend and educa-
tional defect. He brings out so purely and picturesquely, how-
ever, what lack of education cannot do that we have determined
to keep him in his place in the series to portray a singularly
simple instance of educational deficiency.

Hours spent by Medical record, 25 pages

Social record, 0 pages
Physician, 4V2 Social work:

Visits, 0
Psychologist, 1 Interviews at hospital, o

Telephone calls, o
Social worker, o Letters, o

THE KINGDOM OF EVILS 189

Girl who fabricated and ran away from home. Mother of
two illegitimate children.

Case 36. Clara Perkins' difficulties are all in the moral
sphere. She was an average scholar, graduating from the
grammar school at fourteen; and she qualified for entrance to
a nurses' training school, where she spent a few months in
training. She had had no difficulty in supporting herself ; and
her family, although they find it hard to make both ends meet,
manage to keep out of debt. With public authorities Clara has
had no contact. When she was under observation in the Psy-
chopathic Hospital at the age of eighteeen, the diagnosis made
was psychopathic personality ; but after she had been under
supervision for a year and a half, the opinion of the physician
in charge of the out-patient department was that this diagnosis
was a mistake. He considered her normal and sufficiently
stable to undertake nurse's training. By psychological tests
she graded at adult age and did still better in the supplemen-
tary tests upon another examination a year after the first.

The cause of her examination at the Psychopathic Hospital
was a series of fabrications that began about a year earlier.
The following account is taken from the social record : —

Since January, 191 5, patient has systematically and success-
fully deceived her mother and associates as to the work she has
been doing. To her employer and fellow employees she told
stories of being engaged, of the abuses of her parents who had
"sold her into virtual slavery" at fifteen to a man by whom
she had a child. She told of being an illegitimate child herself.
To her dentist she told elaborate tales of abuses by her parents
and the discovery of her real father. She maintained the
family were trying to force her to marry someone she did not
want to. To her family and neighborhood friends she gave
minute details of her nurse's training course and the visiting
nursing among the poor which she was doing. She stayed
away from home, ten days at Hotel Cambridge and three or
four days at Tremont Street lodging house, on a pretext of
being "on cases." She wrote two long letters to her dentist
and once sent for him to see her at Hotel Cambridge which he
did. To her family and to employers' children she introduced
some man by different names. She explains later this was a
chauffeur friend of a girl working in neighborhood. No other
suggestion or positive history of sex delinquency.

IQO THE KINGDOM OF EVILS

During this period of lying patient's habits were as regular as
before. She left her place of employment to be married she
said, and her mother's telephoning there to find out where she
was disclosed the truth. Patient went constantly to moving
pictures and could remember a film a year back as vividly as
though she had just seen it. They affected her so much that
she imagined herself as playing some of the parts.

Clara's father had been alcoholic for a time and her paternal
grandfather and great-grandfather were insane. Her mother
comes of good stock, but is a delicate "nervous" woman. The
other children, three little brothers, are well. A half-sister and
a half-brother, who live in the city, are married and successful,
and take a good deal of interest in Clara. Except for the
narrow limits of the family income (Mr. Perkins earned about
fifteen dollars in a garage) Clara's home life should have been
on the whole comfortable and happy. They had been in more
comfortable circumstances in Nova Scotia, but Mr. Perkins
lost his position through drink, and so nine years before they
had come to Boston for a new start. Mrs. Perkins had always
"kept a girl" and had not been used to the heavy work in the
house that she now had to do. Mr. Perkins no longer drank
to the point of intoxication, but enough to affect his disposition
at home. Clara was very fond of her family but afraid of her
father and jealous of his attention to the younger children.
She was very affectionate and would sometimes cry if she did
not receive the attention she desired. With her mother she
often got into little quarrels, as both were quick-tempered, and
Clara was apt to feel that her mother did not understand her.
She never went out in the evening and had no girl friends ex-
cept her half-sister and sister-in-law; and she had never "gone
out" with young men. The home was neat and pleasant, but
she was ashamed of it, because "the stair carpet had been taken
up" and not replaced.

After leaving school Clara worked in eight different places
within four years as bundle girl, laundry worker, and nurse-
maid. She was never discharged but changed about from rest-
lessness. She had no ambition except a vague desire to become
a nurse.

When she left the hospital she was taken to a general hos-
pital for the removal of tonsils and adenoids and after some
weeks in a convalescent home was gotten a position in a laun-

THE KINGDOM OF EVILS IQI

dry. Her eyes were examined for glasses and a fallen arch
was strapped at a general dispensary. After a few months she
left her position when a raise of wages was refused, and for
several days went about the city looking for work and conceal-
ing her unemployment. After this she seemed physically tired
and could give no clear account of how she had spent the time.
This was the only recurrence of her deceptiveness until over
three years later, when, a year after the case had been closed,
her mother came to us in alarm because Clara had "begun her
fabrications" again. She had been telling extravagant false
stories about her half-sister with whom she was living, which
stopped at once when she heard that her mother had consulted
the hospital.

Work away from home was tried next and a position as
maid in a small out-of-town hospital obtained for her. She
gave satisfaction in her work and was advanced to greater
responsibility. Her conduct was satisfactory also. Two young
men whom she met in the town proposed to her and her attitude
toward them seemed to be sensible and dignified. To one of
them she was about to become engaged when he enlisted and
was sent to France. Clara decided not to be formally engaged
to him until his return. She wanted very much to enter a train-
ing school for nurses and was not opposed. After a few months
she was doing so well that we felt we could close the case. We
were influenced in this decision by the fact that the social
worker who had dealt with Clara's case from the beginning was
leaving. Although we felt that another year of supervision
would be required before we could feel satisfied that Clara was
in a stable condition, between the difficulty of introducing a
new social worker to the case and the pressure of new work,
we decided to close the case, unwisely as the event showed.
We inquired of Mrs. Perkins in December, 1918, and were
told that Clara was doing well; that she had given up the
nurse's training which proved to be too hard for her, but was
working in a mill and living with her half-sister, and that she
heard from the young man in France who had asked her "to
wait for him." When three months later the family were
alarmed at signs of a returning tendency to fabricate and Mrs.
Perkins came to us for advice, she told the real reason for
Clara's leaving the training school — she had become pregnant.

When she left the maternity home where she was confined,

192 THE KINGDOM OF EVILS

she boarded the baby with a friend of her mother and went to
live with her half-sister, whose husband was willing to have
the baby come, too, when it should be a little older and less
care. Clara claimed that she had written the whole story to a
soldier in France to whom she was "half engaged" and that he
had replied in a fashion that led her to hope he still expected
that they would be married. The case was reopened for super-
vision of the baby's health (the child was found to be in poor
condition), of Clara's health (for she had been having more
trouble with the arches of her feet), and to steady Clara during
this period, while she was expecting the return of her fiance.

When the soldier returned, however, he disclaimed an
engagement to Clara and married another girl. In the mean-
time Clara had become pregnant again. The only account of
the parenthood of this child that could be obtained was her
story of an assault. The first baby she placed for adoption
against our advice, and with the second baby she went to nurse
during confinement the wife of the young soldier to whom she
had claimed to be engaged. She filled this position with a
good deal of ability, and when her services were no longer
needed, she went with her baby to keep house for a small
family at their summer home in the country. Here she is
well liked and is highly commended for her ability in cooking
and managing.

Hours spent by Medical record, 38 pages

Social record, 54 pages
Physician, 7 Social work:

Visits, 38
Psychologist, 2 Interviews at hospital, 53

Telephone calls, 15
Social worker, 69 Letters, 13

Overfrugal tailor in court for non-support. Attention of
legal authorities to social and medical facts.

Case 37. Perhaps the Psychopathic Hospital should not
have handled such a case as Nathan Blumberg, presented as a
paradigm of relatively pure legal difficulty. Yet we can readily
show a dark reflex of legal trouble upon several other sides of
the man's life. In no sense of heroic proportions, just such

THE KINGDOM OF EVILS 193

gray or drab difficulties form the stock-in-life of a number of
"normal enough" persons, whose best aid will probably turn
out to be aid from social psychiatry. As in novels of Balzac
the characteristic legal troubles not unreadily find a psycho-
pathic figure in their midst or at least a figure which has a
soitpgon of mental disease about it, so in cases like Blumberg's.
Blumberg was even at one time provisionally classified as
falling in the group of psychoneurotics, but on the v/hole no
satisfactory diagnosis of the sort can be offered, or perhaps
any psychiatric diagnosis.

Amongst the social symptoms in case Blumberg we find such
items as the following : arrest, separation from family, partial
industrial disability, unemployment, family dissension. In
point of fact, Blumberg was never seriously disabled, indus-
trially speaking, save as the immediate result of his legal
tangles.

Blumberg was a Russian Jew, one of twelve siblings. There
were apparently no psychopathic or especially neurotic features
in his family. He had not attended school in Russia and main-
tained that there were no schools where he was born. Never-
theless, he had in America learned to read English. He had
learned tailoring from his father in Russia. He had been in
the Russian Army before the Russo-Japanese War and came
to America in 1904 to escape service in the army. He had
already married at the age of twenty-six a quarrelsome wife,
from (as he said) a quarrelsome family. He came to America
without his wife. Finally, in the course of eighteen months,
he sent for his wife. He had now become a bushelman tailor.
Soon, however, the wife's complaints about money and her
extravagance began to grate on Blumberg, who himself had
an ambition to save every cent. He loaned money to a pros-
perous brother-in-law, but when he tried to get the money back
a year later, he found that his wife was spending some of it.
By the time the whole of the money was returned, Mrs. Blum-
berg had bought a fur coat with two hundred dollars of the
sum.

Then came quarrels. Once the Blumbergs came to blows.
According to Blumberg, his wife struck him first, as she
"would not take him right." Blumberg was forthwith arrested
and was triumphantly informed by his wife that "in this coun-
try a lady can do as she pleases." The case was filed, but he

194 THE KINGDOM OF EVILS

moved to another city whither his wife followed him some
months later. With Blumberg's money Mrs. Blumberg started
to run a shop with one of the boarders that she had been
taking. Blumberg became suspicious that his wife was not
true to him, but the suspicion was rather of her general loyalty
than of any sex delinquency. Now shortly the wife began a
suit for separate maintenance, and the newspaper publicity
caused him again to remove, this time with two of his children,
to a relative's farm. Then came the decree that he pay fifteen
dollars a week for the support and care of his children and
that meantime all the children should live with the wife, but
visit Blumberg with reasonable frequency.

Blumberg had not of late been working steadily. He finally
appeared at the Psychopathic Hospital out-patient department,
coming alone and complaining that for the past year he had
often been chilly all over, that he had had pains in all his bones
and dizziness in his head which was worse on windy days, that
he had slept poorly, that he had had bad dreams and was sweat-
ing profusely at night.

Upon investigation it appeared that the cause of the legal
entanglements was chiefly financial, due to a conflict between
Blumberg's ambition to save and Mrs. Blumberg's contrary
ideal. Blumberg could not pay the maintenance allowance. It
is somewhat edifying, though not amusing, to find that when
Blumberg could not pay the allowance, he was adjudged (after
some correspondence) to be under contempt of court and
actually was committed to jail until he should pay one hundred
dollars. He was bailed out two days later and fled to New
York City. He wrote asking what he should do next, was
advised to return and try to make it up with the court and
did, in fact, come back to Boston; but before he could be seen
by the physician with whom he was on friendly terms, he
walked out and has not since been heard of.

It is a question in our minds whether what might be termed
the "frightfulness" of the jail order has not tended to sever con-
nections completely between Blumberg and his family. Some-
times inexperienced courts talk about "these cases" without, so
far as we are aware, defining to what group ''these cases" ac-
tually belong. We are not ourselves sure that we are dealing
fundamentally with a "case," medically speaking. A case with
such indefinite mental symptoms or features suggests that pro-

THE KINGDOM OF EVILS I95

found allowances should be made for errors in handling; much
hangs on whether Blumberg is psychoneurotic or is not psycho-
neurotic. It seems clear that his legal handling has not been
based upon as thorough a knowledge of the everyday facts as
lay directly at the hand of the court.

It is not that the wife's story was particularly appealing in
contrast to Blumberg's, for no one has asserted that Mrs.
Blumberg's moral attitude was of the most exquisite. Our
present point simply reduces to the feeling that proper atten-
tion is not always paid by legal authorities to social and medi-
cal facts. Nor will it much longer serve for the legal authorities
in these modern days to justify themselves by the vague gener-
ality that we lawyers understand these things whereas you lay-
men exist in the penumbra. We are bound to say that some-
times these matters are not attended to in extcnso and in all
their profundities by the judges themselves, but rather by the
clerks of courts and probation officers, some of whom are not
yet educated (even by prolonged "practical" experience) in
psychiatric social work.

Hours spent by Medical record, 6 pages

Social record, 16 pages
Physician, 4Y2 Social work:

Visits, I
Psychologist, o Interviews at hospital, 6

Telephone calls, i
Social worker, 9 Letters, 24

Poor old woman, zvorried and overworked.

Case 38. Though Margaret Dolan came to us as a patient,
her difficulties were almost entirely financial. The medical
opinion after she had been observed for ten days in the hospital
was "not psychotic." Her mental condition was the result of
well-founded worry. For nine months she had been in con-
siderable anxiety about debts, doctors' bills, and even the
means of subsistence. She suffered from indigestion, which
four doctors in turn had not been able to relieve, and was
afraid to eat for fear of increasing her stomach trouble. She
was afraid that she would go insane and spoke of feelings of
unreality, saying "I feel I am way ofif in some other world."

196 THE KINGDOM OF EVILS

Educationally Margaret was not lacking, — after graduating
from high school, she had studied bookkeeping; and she was
far removed from conflict with public authorities. But her
financial difficulties loomed large.

She was fifty-two years old, and her sister Annie, with whom
she lived, was fifty-nine. They were two gentle little old ladies,
of frail physique and brave hearts. Annie was the more
optimistic and had "always looked on the bright side of things"
but Margaret always worried a bit. They took two lodgers in
their tiny apartment and while Margaret did the housework
Annie worked in a shoe factory, getting from seven to twelve
dollars a week. In this way they were able to have a more
comfortable home than if Margaret, too, had gone to the shoe
factory. She had expected to be a bookkeeper, but soon after
she took her first position she was called back home to nurse
■her mother through an illness of years, and again after working
for a short time went home to nurse her father until his death.
■fifteen years ago. Then she and her sister came to the city
to keep house for their brother. He drank heavily and finally
eight years before had disappeared. The sisters continued to
keep their home and got along comfortably, until Annie was
laid ofif during a slack season, one of the lodgers left, and Mar-
garet began to have indigestion. For doctors' bills for Mar-
garet and living expenses they had gradually borrowed two
hundred and fifty dollars and they could barely meet their living
expenses. They could not afiford to pay for the refitting of
Margaret's artificial teeth, which did not fit properly and
caused her difficulty in chewing.

After reassurance and three weeks' rest in the country, and
a new plate for the teeth, Margaret had gained fourteen pounds
and felt much better. It was several months before she would
venture alone on the street. She held two hundred and fifty
dollars life insurance for her brother, whom the sisters
believed to be dead. This money was finally secured through
a friendly lawyer to pay ofif the debt that was worrying them.
Lighter work was to be found for Annie, as army shoes made
heavy work for the frail little woman ; but she developed cancer
and soon had to be sent to a hospital where she died in a few
months. Aid from a relief society was obtained for Margaret,
who kept the home and visited her sister every day in the
hospital. After Annie's death, she was well enough to take

THE KINGDOM OF EVILS I97

a position at housework. During her sister's illness many of
her old friends renewed their interest in her. She no longer
had a sense of unreality or feared to go about alone and seemed
quite capable of taking care of herself.

Hours spent by Medical record, 17 pages

Social record, 27 pages
Physician, 8 Social work:

Visits, 47
Psychologist, o Interviews at hospital, 10

Telephone calls, 64
Social worker, 90J/2 Letters, 25

BOOK III

Oh that my vexation were hut weighed,
And all my calamity laid in the balances.

Job, Chapter 6, Verse 2.

ELEVEN MAJOR GROUPS OF MENTAL DISEASES

Illustrated in Sixty-two Specimen Cases of
Psychiatric Social Work

I. General paresis, juvenile

paresis, etc.
II. Feeble-mindedness of vari-
ous forms.

III. Epilepsies.

IV. Alcoholic, drug, and

poison cases.
V. Focal brain lesion cases

(mental).
VI. "Symptomatic" mental
cases (bodily origin).
VII. Senile, senescent, pre-
senile cases (old age
group).
VIII. Dementia praecox; para-
phrenia.
IX. Manic-depressive psy-

choses ; cyclothymic.
X. Hysteria, neurasthenia,
psychasthenia.
XL Dubious and special psy-
chopathias.

Syphilopsychoses

Hypophrenoses

Epileptoses
Pharmacopsychoses

Encephalopsychoses

Somatopsychoses
Geriopsychoses

Schizophrenoses
Cyclothymoses
Psychoneuroses
Psychopathoses

Note. — This book is intended to give the physician a general view of
the social-psychiatric problems in the main mental disease groups.

SECTION I

SYPHILOPSYCHOSES ( NEUROSYPHILIS)

Costly delay of diagnosis in a case of general paresis that
looked like neurasthenia. Industrial disability for five years.
Social work — free treatment and home care.

Case 39. We begin now to present social cases from the
medical point of view. The psychiatric social worker (and
eventually the layman too) must learn that insanity is not a
unit. There can be no better way of grasping the fact that
insanit)', though legally a unit, is not medically a unit, than
by considering cases of syphilis of the nervous system (briefly
put, neurosyphilis) giving rise to mental symptoms.

We may begin with the case of Greeley Harrison, a case
already presented from the medical point of view in the case
history, Neurosyphilis by Southard and Solomon, 191 7 (case
9 in that collection). These authorities put Greeley Harrison
first in every account of the systematic diagnosis of the main
forms of neurosyphilis because they desired to impress the med-
ical profession with the costly delay of diagnosis in that form
of neurosyphilis known as general paresis.

''W^hy was not I told that my disease was syphilis five years
ago?" Harrison was wont to say after he had come under medi-
cal treatment at the Psychopathic Hospital at the age of forty-
six. In point of fact, we found that for a number of years
past there had been symptoms which should have attracted
medical attention. Five years before he came to our observa-
tion, namely, at the age of fort\'-one, Harrison had been ap-
parently overcome when working near a stove, and afterwards
went upstairs, talking incoherently. However, he recovered
shortly, and nothing was thought of the episode. Spells oc-
curred almost every month for a time, and later still more
frequently. Finally these spells became associated with uncon-
sciousness and with loss of memory.

It is no part of the task of this book to give the details of

203

204 THE KINGDOM OF EVILS

medical diagnosis or treatment. From the standpoint of the lay
observer, the fact was outstanding that Harrison had for five
years been unable to do regular work. What misled the medical
inquirer, and this is a lesson for physicians and laymen in all
forms of mental disease as well as in the present form, was
that Harrison's constant complaining would set him down as a
kind of neurasthenic or psychasthenic. It would be stretching
a point to say that his ideas were delusions, that is, demonstra-
bly false beliefs, but he continually dwelt upon bodily symp-
toms, after the manner of the psychoneurotic (under the so-
called psychoneuroses the psychiatrist is apt to include neuras-
thenia and hysteria). Harrison approached sundry physicians
for aid, complaining of nervous indigestion of years' standing,
of headache, of insomnia, of nervousness, of failing memory,
and of deafness. After one knew that Harrison was a neuro-
syphilitic it was, of course, easy to point out that headache and
failing memory might well have suggested syphilis. However,
a number of physicians told him that he was a neurasthenic,
and when he arrived at the Psychopathic Hospital he announced
that neurasthenia was the disease from which he was suffering
and that he had been treated for this disease by hypophosphites.
The so-called six tests (blood serum Wassermann, spinal fluid
Wassermann, globulin and albumen reactions of spinal fluid,
cell count and gold sol. on spinal fluid) proved positive. The
medical diagnosis seemed, beyond much question, to be that
of general paresis.

The medical lessons of this case are: —

I. Neurosyphilis, even in its paretic form (so-called general
paresis or "softening of the brain") may look to the physi-
cians like that purely functional disease, neurasthenia.
(For an example of pure neurasthenia see below, case 87.)
2. Neurosyphilis, in its paretic form, is not necessarily com-
pletely intractable to treatment. (This is a most important
conception, not yet well established in the medical mind.)
And on account of the doubt which prevails concerning
general paresis and its inevitable non-responsiveness to
treatment, we shall need to look further into the medical
history of. case Harrison.

. Harrison has had a great deal of antisyphilitic treatment
including mjections into the ventricles of the brain. He has
continued in about the same state mentally : that is, there is a

THE KINGDOM OF EVILS 205

considerable degree of deterioration and he has occasional
seizures. He is in a state hospital where he has charge of the
patients' dining-room. Physically he is in rather good condi-
tion. His laboratory tests are now quite normal. He seems
to have been held stationary for the past four years.

The social work consisted in getting Harrison free treatment,
encouraging his mother, and seeing for how long he could
receive suitable care at home. His mother and sister worked
and supported him. He had used up considerable savings
when he came to us and had nothing of value left except a fur
coat.

Hours spent by Medical record, 55 pages

Social record, i page
Physician, 23^2 Social work:

Visits, o
Psychologist, I Interviews at hospital, 6

Telephone calls, o
Social worker, 3 Letters, 0

Widow with syphilis contracted from an abusive husband.
Well for fourteen years. Now marked depression. Treatment,
rest, employment.

Case 40. Another case from Southard and Solomon's
Neurosyphilis, Greta Meyer, (107 of that collection) is one
of neurosyphilis, not of the type of so-called general paresis or
"softening of the brain" but of a more diffuse type of disease,
or, as commonly termed in medicine, "cerebrospinal syphilis."

This widow of fifty-one came of her own volition to the
Psychopathic Hospital wanting aid from the physicians for a
marked depression. It seems that she had lain down one day
for a nap and on waking up found that she could move her
right arm and leg only with great difficulty. She got much bet-
ter in a few days.

Going back in her history, it appeared that two years before,
at forty-nine, a small swelling had appeared on the right side
of the forehead near the hair line, a swelling that was firm and
not sore. Treatment, evidently antisyphilitic, reduced this
swelling but left a hollow space in the bone.

Going still farther back in her history, it appeared that

206 THE KINGDOM OF EVILS

some sixteen years before her coming to the Psychopathic
Hospital, namely at the age of thirty-five, she had developed
some red spots on her hand which she learned at a hospital
were due to syphilis. She was treated rather faithfully for
these spots for a year's time, whereupon she seemed perfectly
well and, in fact, remained perfectly well for fourteen years.
Going still farther back in Mrs. Meyer's history, it seems that
she was married at sixteen and lived with her husband until
twenty-nine, but at this time she left him on account of his
being alcoholic and abusing her, and on account of her dis-
covering, through his physician, that he was sufifering from a
venereal disease.

As is mentioned more in exfenso in the Neurosyphilis case
history book, the diagnosis of a diffuse neurosyphilis, possibly
associated with a plugging of arteries, was then made.

After she had improved under salvarsan treatment, she then
became also a problem for social workers in certain respects.
She was referred to the social workers for employment and
rest. She was accordingly given some three weeks of rest in a
convalescent home. Some temporary jobs were then secured.
The depression for which she had originally consulted the hos-
pital was greatly diminished during this treatment by rest and
employment. The case could then, for a period of about a
year, be closed by the social workers and then referred to the
follow-up division of our department to insure the proper con-
tinuance of medical treatment. An incident of her care was
that about six months after her original treatment for syphilis
she slipped on a wet floor and fell, fracturing the pelvis. (The
bones of some syphilitics are well known to be rather more
susceptible to fracture than those of normal persons.)

From the standpoint of social case analysis, the case of
Greta Meyer seems then, comparatively simple ; namely, a case
of practically pure medical disorder. Not even the economic
factor came specially into evidence.

Hours spent by Medical record, 22 pages

Social record, 6 pages
Physician, 14 Social work:

Visits, 0
Psychologist, o Interviews at hospital, 5

Telephone calls, i
Social worker, 3j/< Letters, 2

THE KINGDOM OF EVILS 'lQ>']

Familial syphilis. Routine examination of "wife and children:
positive blood test in all. No other indications of syphilis:
source of infection unknown.

Case 41. We borrow the case of Walter Heinmas from
the medical, legal, and social part of the Southard and Solomon
book on Neurosyphilis, (in that collection case 97), not because
either he or his family ever came to the point of social treat-
ment, but because the problem of familial syphilis seems ex-
quisitely exemplified in the children. The situation is one
which rather astounds even medical men who are not al-
ways too well aware of the caprice with which syphilis shows
itself.

Heinmas himself was a case of general paresis of a classical
type, with marked feeling of well-being (the so-called euphoria)
and characteristic grandiosity.

It is the routine procedure of the Psychopathic Hospital to
look into the families of syphilitic patients. The Heinmas
family consisted of the parents and two daughters aged nine
and seven respectively. Both the patient himself and his wife
denied all knowledge of syphilitic infection, nor was the wife
able to support the idea that she had ever had any primary,
secondary, or tertiary symptoms; especially there had been no
abortions, miscarriages, or stillbirths. Both children had
been born at term and had been absolutely healthy. Upon
examination, the mother had no physical signs which could be
referred to syphilis. Both daughters were well endowed in
mind, were of very good physique and showed no stigmata of
congenital syphilis, yet the blood tests of all three (the mother
and two children) proved positive. These tests were repeated
several times with the children (both with and without sal-
varsan injections) and their bloods remained consistently
positive.

In the Southard and Solomon series it has been found that
about 15 per cent of the marriages wherein one spouse develops
paresis result in sterility, in 18 per cent there are abortions,
miscarriages, or stillbirths, in 15 per cent there are positive-
Wassermann reactions in one or other members of the family.
The rather obvious motto can be adopted: "The families of
paretics are the families of syphilitics."

20h THE KINGDOM OF EVILS

Hours spent by , Medical record, 2 pages

Social record, i page
Physician, 3^^ Social work:

Visits, 5
Psychologist, o Interviews at hospital, 3

. Telephone calls, 13

Social worker, 9 Letters, 19

GENERAL PARESIS
IN A MACHINIST

October, ipi6

Disabled for Work

Inebriety

Marital Discord

No Income

Debts

No Money for Therapy

January, ipi/
Employed
Sobriety
Happiness
Adequate Wages
Debts Reduced
Treatment

Paretic machinist, alcoholic, neglected treatment: on the verge
of complete breakdown. Restored in three months to industrial
efficiency through combined medical and social treatment. Pro-
moted to foreman.

Case 42. David Collins we present as a good example of
social problems in that common form of syphilitic mental dis-
ease known as general paresis.

General paresis is a kind of mental disease long known by
psychiatrists and has always been thought to have a fatal prog-
nosis in a period ranging say from three to five years from the
onset of symptoms. Patients surviving that period for any
considerable length of time would ordinarily be regarded as
either not cases of general paresis at all or very non-typical
ones. Accordingly the psychiatrist and the medical man in
general would feel very skeptical as to the value of spending
overmuch time or money upon social work designed to bring
out earning abilities or develop valuable changes of character in
victims of general paresis. No doubt this skepticism is statis-
tically rather well founded. Yet modern work seems to show
that neither mental and nervous symptoms nor laboratory signs
(blood serum, spinal fluid, etc.) alone, nor any combination of
these symptoms and signs, will invariably suffice to establish
the diagnosis of general paresis in the early months or, let us
say, in the first year of its symptoms.

If a mental disease looking like general paresis is not going
to prove to be general paresis, what form of disease is likely
to develop? There is another form of syphilis of the nervous
system ( for which the abbreviated term neurosyphilis has come
into general use) called cerebral syphilis or cerebrospinal syphi-
lis or diffuse neurosyphilis, which form has a much more favor-
able prognosis with respect to duration and a much more fav-
orable prognosis with respect to the self-supporting capacity
and manageability of the victim. It may accordingly make a
crucial difference to the man and his family whether he is dis-
govered eventually to have the paretic form of neurosyphilis

2.U

212 THE KINGDOM OF EVILS

(i.e., general paresis) or the diffuse form of neurosyphilis
(commonly called cerebrospinal syphilis). The medical man
should not, and the medical social worker cannot, neglect the
other members of the paretic's family. The children of a
paretic, are, of course, the children of a syphilitic (examples
of the value of this slogan are given elsewhere in Section I of
this book) and accordingly various steps in mental and physical
hygiene must be taken. These latter we do not discuss under
the case of David Collins, but call attention rather to the value
of psychiatric social work for the family.

Disabled for work in October, 1916, David Collins had, in
three months, found work with the firm that had previously
employed him. From a condition of inebriety he had, under
the social service influence, become sober. A state of serious
marital discord had been replaced with domestic happiness.
The family which had had no income in October had, by Jan-
uary, the advantage of adequate wages. The debts previously
incurred had been reduced, and treatment for the man's neuro-
syphilis had been arranged for. The case had been an appealing
one to the social service, and it proved easy to raise money
by newspaper advertising (under "Divers Good Causes") on
the ground that he was in dire need of medical treatment and
would otherwise lose his mind. It must also be noted that
within the first three months of social work the wife had also
gone under treatment (blood test of a child proved negative).

Collins, at forty-five, had had to give up his machine shop
work on account of becoming tremulous and sometimes con-
fused about his work. He fell down unconscious a number
of times. When he arrived at the Psychopathic Hospital out-
patient department with his wife, they had nothing but return
carfare upon them, and it was found that they had no means
of income whatever.

Already two years of possible treatment had been lost, since
the patient had two years before been brought to the hospital
by the police who had found him in convulsions on the street.
At that time he had refused to return for treatment. Such a
refusal is, of course, a matter of great regret to the ardent
believer in social work and intensive medical treatment for
neurosyphilis. No doubt, in an ideal mental hygiene situation
enough force and ingenuity could be brought to bear to bring
all such cases, even when like Collins exceedingly recalcitrant,

THE KINGDOM OF EVILS 213

under medical and social care. He had always been a hard
drinker and was still drinking.

It seems that he had had three jobs in two years which he
had been forced to leave, finding each one too hard for him.
By arrangement with the social service, the manufacturing
firm that had previously employed him allowed him two morn-
ings ofif a week to come for his treatment, on condition that
he make up the time at night. On this basis he got his full
pay, twelve dollars a week. He was influenced to stop drink-
ing, the wife becoming immediately reconciled with him again
and said it was the best day of her life when she brought him,
two years after his first hospital appearance, to the out-patient
department. Now, she said, they had become "like sweethearts
again." Besides obtaining treatment for the wife, work was
found for her by the social service. Ordinarily it vvould be
considered rather poor social work to cause the wife to go
out to work but in this particular situation it seemed advisable,
so that the debts of the family might be paid off. Shortly Col-
lins himself obtained a raise of pay. Later on he was promoted
to the position of foreman.

In some ways this case of Collins might seem a schematically
simple one. We find in our notes, however, that the investiga-
tion entailed inquiries of (i) Mrs. Collins, (2) the priest, (3)
previous employers, (4) neighborhood storekeeper, (5) daugh-
ter's teacher, (6) the landlord, (7) previous landlady, (8) a
neighbor, (9) the social service of a hospital where Collins
had once been treated. Valuable data were obtained from prac-
tically all of these sources. It is plain that without a consider-
able social service staff this kind of work cannot be done and
that it is entirely out of the question to suppose that the admin-
istrative officer, whether medical or social, who sits at his desk
in however well appointed an institution, can obtain these data
in such quantity as to permit valuable work.

Let us remark, too, in passing, upon the tremendous change
in the attitude of public and private charitable institutions
toward such problems as these. Time was when each institu-
tion "passed the buck" to some other institution and hardly
any board of trustees would advocate "borrowing trouble" by
seeking cases to treat in the community. Yet we believe we
are safe in asserting that this modern attitude toward the hid-
den sources of disease in the community is the only attitude

214 THE KINGDOM OF EVILS

which, in the long run, turns the trick of eradicathig either
venereal disease or any other form of widespread social
disease.

Yet with all the rather optimistic features present in the
early progress of Collins' social care, under pressure of work
the case was too early closed and not followed up as it might
and should have been. It was again reopened through the
vigilance of officers having in mind the tremendous value of
this program of social work in neurosyphilis, and Collins went
again under treatment. He was particularly difficult on ac-
count of his alcoholic tendencies and on account of the usual
story on the part of these patients, namely their tendency, as
soon as they feel rather well again, to drop treatment and re-
fuse to report. This is the story not alone in the social care
of neurosyphilis but in that of many other forms of chronic
disease. All in all, Collins received regular treatment by sal-
varsan for a continuous period of nineteen months and subse-
quently for further periods. He is one of the cases under
systematic therapeutic investigation by the Massachusetts Com-
mission on Mental Diseases. What is to be the outcome of
that investigation which began in 19 14 and has under observa-
tion several hundred neurosyphilitics can doubtless not be said
until the period of a decade has elapsed.

Here, then, is a sample of mental disease clearly syphilitic
in origin, clearly chronic in its course, if not likely to pass
rapidly into dementia and death; yet by combined efforts of
the medical and social service, a reasonably good front to the
disease on the one hand and the world on the other was pro-
vided. We now have a history of five years since his first
appearance in the hospital after falling into convulsions on
the street, and we have a history of three years since the initia-
tion of a period of regular treatment. Whatever be the patho-
logical fate of David Collins, whether it be early or late, at all
events partial or temporary cure by social service must be scored
for the Collins family, as well as for its central psychopathic
figure. His case is by no means an isolated one in our experi-
ence. We feel ourselves entitled to crave most earnestly the
concession by medical men that social service energy shall be
duly expended even upon these cases of such (statistically
founded) unfavorable prognosis. It is, perhaps, also worth
while to insist that neither the intensive medical care nor the

THE KINGDOM OF EVILS 215

elaborate social care undertaken in the case of David Collins
would have been vv^arrantable by itself alone.

Hours spent by Medical record, 11 pages

Social record, 26 pages
Physician, 8 Social work :

Visits, 2."]
Psychologist, o Interviews at hospital, 15

Telephone calls, 5
Social worker, 51 Letters, 9

General paresis in a soldier; at first thought to be dementia
praecox.

Case 43. Carl Spindler came from a public health hos-
pital with the diagnosis of dementia praecox. His case was
found to be one of general paresis requiring commitment. He
was incoherent, and very talkative, to the efifect that he was
going to Washington to take the President's place, that the
girls were all crazy about him, and that he had plenty of money.
He was a well-built man of thirty-three of German descent.
He had worked in packing houses until he enlisted in the army.
He had seen service in France, where he had got a number
of shrapnel wounds and had been gassed. He was transferred
to a state hospital for prolonged care.

Hours spent by Medical record, 7 pages

Social record, i page
Physician, 314 Social work :

Visits, o
Psychologist, o Interviews at hospital, 2

Telephone calls, o
Social worker, lYz Letters, 2

Steady young soldier who began to sing, dance, and fight.
Taboparesis. Symptoms following his mother's death.

Case 44. Thomas Scannell was drafted at the age of
twenty-one and had been in the army fifteen months (of which
seven months' service in France) before he was sent to an
A. E. F. hospital. He passed through three hospitals in this
country where he was thought in turn to be suffering from (a)

2l6 THE KINGDOM OF EVILS

dementia praecox, (b) general paresis, and (c) manic-depres-
sive psychosis. He was excited and talkative (threatening,
e.g., to write to the President for a better room), sang, danced,
and fought. In the Psychopathic Hospital he proved definitely
a paretic (taboparetic form). Accordingly commitment was
recommended. But his sister and her husband, both plainly of
low mentality, insisted upon taking him home, saying that they
should never feel satisfied if he were not given a chance at
home. He is now receiving treatment as an out-patient only.
His mother died while he was in France, and he himself at-
tributes his illness to nervousness resulting from worry over
her death.

He is the illegitimate child of a hard-working respectable
woman married to a worthy man who died when the boy was
eight years old. Scannell was a steady young man with a pleas-
ant disposition. He "was crazy about his sister's baby." He
did not use alcohol and had held one job for five years.

Hours spent by Medical record, lO pages

Social record, 2 pages
Physician, 2% Social work :

Visits, o
Psychologist, o Interviews at hospital, 3

Telephone calls, 6
Social worker, 31/2 Letters, 6

Boy with congenital syphilis (juvenile tabes). Dropped
behind in school at eleven. Difficulty of getting parents to have
treatment for him.

Case 45. The physician's point in presenting Archibald
Sherry, the twelve-year-old victim of congenital locomotor
ataxia (juvenile tabes) would be to show special pride in his
therapeutic results in a rare disease. The case has been pre-
sented briefly from the medical point of view as case 38 in
Southard and Solomon's case history collection Neurosyphilis.
We may here omit the medical details. The layman would,
of course, readily observe the unsteadiness of the boy's gait,
and would come upon certain oddities in his teeth (typical
Hutchinsonian teeth). The psychiatric social worker, like
other lay observers, should bring notes concerning superficial

THE KINGDOM OF EVILS 21/

oddities of teeth for the physician's consideration and now
and again the worker will be able to throw considerable light
upon obscure cases under direct medical observation by retriev-
ing sundry dental facts concerning relatives of the patient,
superficially examined in the course of taking histories in the
patient's home.

The Sherry boy, after the diagnosis of his syphilis had been
thoroughly proved in hospital, was treated and certain pains
of his, certain attacks of confusion, and trouble with his speech
disappeared upon salvarsan injections, and his gait became
steadier.

From the standpoint of social psychiatry, Sherry's family
history was of interest. On the father's side there was nerv-
ousness (as well as alcoholism and degeneracy). The number
of things which "nervousness" may at bottom be is legion; of
course no conclusion as to syphilis in the family could be drawn
either from a history of nervousness or of degeneracy. The
fact that the maternal grandmother had cancer is, no doubt, of
no importance. A sister, four years older than Archibald, was
also thought to be "nervous" and unstable. One task of social
psychiatry was to have this girl examined for syphilis and
especially to have her blood and spinal fluid examined. Both
blood and spinal fluid failed to yield signs of syphilis.

Instructive also is the fact that Archibald, although always
a weak and sickly child, did well in school to the end of his
eleventh year, when his capacity to keep up with the other chil-
dren dropped and he became no longer so amiable and sociable.
An odd thing in the case was that the eye-lashes of the boy had
turned white during the year.

It was, of course, also the duty of the social service to se-
cure blood reactions of father and mother, who denied syphilis.
The reactions of both father and mother proved, in fact, nega-
tive, and also, as above noted, that of the older sister. The
medical observers remained in doubt as to whether the case
was one of syphilitic disease handed down from father or
mother, or whether the case was one of a rare or unique con-
dition, namely — "acquired" juvenile tabes. (Concerning the
true meanings of the terms hereditary, congenital, and ac-
quired, the psychiatric social worker should make absolutely
sure.)

Social work in this case proved difficult by reason of lack of

2l8

THE KINGDOM OF EVILS

cooperation on the part of Archibald's mother. Treatment
could not, in fact, be consistently continued. However, social
workers from time to time visited the boy in his home, and he
has apparently shown no setback since his initial improvement
following a few injections of salvarsan into the blood that were
made some six years ago.

Hours spent by
Physician, 5^/3
Psychologist, o
Social worker, 4254

Medical record, 9 pages
Social record, 18 pages
Social work :

Visits, 24

Interviews at hospital, 3

Telephone calls, 18

Letters, 14

Industrial disability caused by syphilis. Under treatment
returned to work.

Case 46. The full text of Harold Gordon's social record
is given in Appendix A.

SECTION II

HYPOPHRENOSES ( FEEBLE-MINDEDNESS)

High-grade moron, daughter of a good family. Stealing,
sex irregularity. "Football of environment." Institutional
care. Need of psychiatrist, psychologist, and social worker.

Case 47. Florence Warner, nineteen, brought to the
Psychopathic Hospital for observation at the family physi-
cian's suggestion, turned out to be a moron, measuring 11.5
years by the Point Scale and 10 1/5 years by the Binet Scale.

It is worth while to premise that these minor differences in.
the mental test levels, as is clear from the data of many previous
cases in this book, allow no doubt whatever that the girl so
tested was a moron, — provided always that the tests were car-
ried on under favorable conditions without (a) fatigue on
the part of the examiner, or (&) on the part of the patient,
without (c) any clouding of consciousness, such as infectious
disease, alcohol, drugs or other condition might produce and
{d) without any trace of stupor or dullness of mental facul-
ties incident to many forms of the frank psychoses. None of
these latter phenomena were shown by Florence Warner. She
was at the time of examination perfectly clear-headed and
capable of a very fair amount of attention to the tests. In fact
we find from the report recorded that her comprehension was
good and that she had a very excellent power of reasoning in
the examples set for her. Her memory, to be sure, was only
fair and her anal3^ical power limited. Her loss of points in
the mental tests accordingly was a rather general one and the
separate items were valued from rather poor to fairly good or
even good — being for the most part only fair.

We may further take occasion at this point to say that the
detailed procedures of the mental tests, whether by the various
revisions of Binet or by the Point Scale, are entirely within the
scope of a social worker to learn and even to use, as (in point
of fact) these procedures are within the scope of any well edu-

219

220 THE KINGDOM OF EVILS

cated person. But we do not need to exhibit the prejudices of
an overspecializing psychologist when we insist that these tests
are not to be trifled with, and are not to be valued highly save
when performed by an examiner of considerable skill and ex-
perience who "has his hand in" and who for the most part is
doing little else in life. This is not to say that what Professor
James called the Ph.D. octopus need dominate the field of
practical mental examination, although for our part we feel
that every laboratory executing routine tests in important cases
should be managed by an expert psychologist who shall stand
sponsor for the results. Those not familiar with the situation
in applied psychology may not bear in mind how rapidly the
field is changing and how numerous the modifications and im-
provements in psychometric tests will be before at last we reach
the ideal set of tests. On the other hand, the time is past when
anyone can safely doubt the present-day value of the tests we
have within ordinary limits of variation and under the special
safe-guarding conditions enumerated above.

The problem in the Warner case was stealing and sex irregu-
larity. While we are discussing the psychometric tests it may
be worth while to insist that these tests throw little or no light
upon the causes of such bad habits or vices. The mental tests,
being almost exclusively intcUigcnce tests, throw little light
upon either the quality or the level of the emotional or voli-
tional sides of the person examined. To be sure Florence War-
ner was somewhat "suggestible" to test; but this "suggesti-
bility" is a very specific one which does not necessarily argue
that the one who shows it steals or enters into irregular sex
relations on account of it. Tlie chances are that Florence was
the "football of environment" ; but it would require a far more
elaborate analysis by psychiatrists (or by persons otherwise
expert in the world's ways) to prove that' her irregularities
were phenomena of weak will or suggestibility. How, we may
ask, shall such analysis of all sides of the mentality be made
as will throw the needed light upon the causes of stealing, sex
irregularity, and the like? There is no certain answer to this
question, although various psychiatrists and psychologists have
suggested schemata for analyzing personality under various
headings.

It seems that Florence had been in the habit of stealing from
members of her family and from friends ever since she wa.s vj

THE KINGDOM OF EVILS 221

small child. She could now no longer live in her brother's
family unless means were found by which she could support
herself. But, as she was given to stealing, she could not be
recommended to any employers. To add to the difficulty she
had recently begun sex relations with various men. It seems
she had gone to a distant state to work as a telephone operator
and had there fallen into bad habits — drinking, smoking, and
irregular sex living.

Upon the discovery of her level as a high-grade moron, in-
stitutional care was recommended, on the particular grounds
that she was a high-grade moron of such a trend that she might
benefit by institutional care and would otherwise be in consider-
able danger of becoming a source of venereal infection. In
point of fact Florence was still negative to test as to venereal
disease, but was already being strongly urged by a girl friend
to join the prostitute group.

As is the situation in most of our states in the present phase
of mental hygiene, the waiting lists at the schools for feeble-
minded were extremely long. However, upon the Psycho-
pathic Hospital's representation, Florence was listed amongst
the urgent cases. She was in the meantime sent to a small pri-
vate institution which agreed to make exception to its general
rule not to receive mental cases. The institution must have
regretted its step at the end of three months since Florence
had plotted to escape with another girl and had a bad influence
on the other girls.

The feeble-minded schools' waiting lists were still long and
in the interval Florence was sent to the state infirmary, i.e.,
the big almshouse hospital of Massachusetts. She promptly
took a violent dislike to the women she was there thrown with
and was given night work so that she might avoid them. After
three almshouse months she was eventually admitted to a state
school for feeble-minded. She immediately began to mingle
with the older girls and seemed to become perhaps more happy
than could be reasonably expected.

It may be remarked that Florence's family was on rather a
high level. It was naturally rather hard to persuade her rela-
tives to let her go to a state institution. Of course the general
level of mental hygiene in Massachusetts, as in a few other
states, is such that we may hope that the general prejudices
against all state institutions will at last melt away.

222 THE KINGDOM OF EVILS

Could such a case be handled by the social worker in com-
bination with a competent psychiatrist ■mithout the aid of a
psychologist f The psychiatric examination determined her to
be not insane. The positive evidence for the moronity in Flor-
ence is derived almost wholly from the mental tests. The phys-
ical examination was largely negative; still it may be of some
importance to the girl that diseased tonsils and a functional
heart murmur were found. The medical examination also was
of value to her in showing that she was not as yet a "venereal"
case. It is especially important to her that the psychiatrist
could find no evidence of a definite acquired psychosis. We
feel that it is of the greatest importance to exclude psychosis
from these cases of feeble-mindedness. We are familiar with
numerous cases in which moronity has been confused with ac-
quired and progressive psychosis. In short, we hold that the
psychiatric examination in these cases has extraordinary nega-
tive values.

While we are comparing the practical values of the psycholo-
gist whose data made the positive diagnosis "moronity" and
of the psychiatrist whose examination was exclusive of any
such disease as dementia praecox, let us inquire whether the
psychiatrist and the psychologist combined could have handled
this case effectively, without a social worker. It will be noted
that the eventual success in getting Florence into the right in-
stitution was a matter of very time-consuming and ingenious
persuasive work. The more competent the psychologist the
more valuable his work in the laboratory and the less likely
he or she would be inclined to "hug the telephone" and do the
traveling necessary. The same holds for the psychiatrists.
Moreover, as those acquainted with social service technique
are well aware, neither the psychologist nor the psychiatrist
has a knowledge of the institutional equivalents, institutional
and other personalities, community and neighborhood habits
and peculiarities, and the technical facts which training and
experience give to the social worker. Happily we are able to
say that, as the years pass, the psychiatrists and psychologists
are becoming less willing to say that, just because they under-
stand every social service device employed, therefore they can
perform the steps effectively in proper sequence and without
loss of time.

With respect to the relations of the general medical social

THE KINGDOM OF EVILS 223

worker to the general problem of medicine, there is no longer
any doubt of the necessity of a medical social worker in any
community with high health standards. But if this is true for
general medicine and the medical social worker in general, it is
one-hundred fold truer still for the complicated relations of
the psychiatric social worker. In fact we do not need to argue
upon this line for those who have had any practical experience
in the field. But we take occasion in discussing this first of
our group of feeble-minded cases to insist upon a point which
stands out most clearly in a case like that of Florence Warner.
Of course we do not know what the eventual outcome in
Florence Warner's case may be, granted that the psychometric
diagnosis of feeble-mindedness is correct (and there seems to
be no doubt of the accuracy of the diagnosis in this case). Pos-
sibly it will be in some respects easier to handle a moron who
steals and has sex irregularity than to handle a person of per-
fectly normal mentality with precisely the same trends; but
there is no general rule to this effect.

Hours spent by Medical record, i8 pages

Social record, 5 pages
Physician, 3^ Social work :

Visits, 2
Psychologist, I Interviews at hospital, 2

Telephone calls, 4
Social worker, 7 Letters, 4

A psychopathic family. Each member (parents and eight
children) an indimdual problem. Syphilitic, feeble-minded
father. Distinction between hereditary and congenital.

Case 48. The family is today, in many social service quar-
ters, the unit of interest in social work. We do not deny that
the family ought to be the object of social work, yet we feel
that the psychiatric viewpoint has gone far to prove that every
family should be analyzed in the first instance, not so much
from any supposed general family tendency, and not so much
from the standpoint of the family income as from that of the
social situation presented by each member of the family taken
as an individual. We are aware that many social workers will
feel that this plan is carrying individualization to an absurd
degree. Particularly in the case of the Newman family, whose

224 THE KINGDOM OF EVILS

plight we hang- upon the individual case of Bessie, but which
contained ten members (parents and eight children), it would
seem a little preposterous to consider technically every member.
But let us consider the situation of each member.

Bessie, the third child, nineteen years of age as we now
write, is a case of feeble-mindedness belonging in the moron
group, measuring psychometrically 94/12 years by the Stan-
ford-Binet method and 9.7 by the Point Scale. Bessie whom
we first observed at the age of fifteen was at once determined
to be suitable for a state school for the feeble-minded. The
waiting lists were too long, however, and she could not be
admitted. She remained at home, finally became pregnant,
altered her character somewhat thereafter so that she became
something of a runaway and was delivered of a child which
became a public charge (because of Bessie's obvious inability
to take care of it and because the family otherwise had already
too much on its hands). Bessie remains at home a good deal
of a problem. There was at one time a question whether
Bessie might not be a victim of schizophrenia (dementia
praecox) partly on account of the history of her going over
to New York to visit a prostitute girl friend and an episode
of throwing clothes out of the window. Technically, however,
on the whole no convincing proof of schizophrenia could be
found. In any event such a process would have been one
grafted upon an original feeble-mindedness.

It was not Bessie, but a sister Rachel, seven years younger,
who first came to the hospital's attention. She was sent by
her teacher for falling out of her chair, one day as often as
three times in an hour. Rachel was found to grade approxi-
mately at her age (eight) at the time of examination, although
there was the hint of subnormality in her comprehension,
emotional control, and power of concentration. No definite
psychosis was determined for Rachel ; but a certain hyper-
kinetic tendency on her part might look in the direction of
some form of psychopathic personality.

She came under hospital observation two years later, a
nail-biter and thumb-sucker, still suffering from the hyper-
kinetic tendency which was termed "nervousness" and "insta-
bility." Under hospital observation, as is so frequent, the
girl showed no sign of the hyperkinesis noted outside but
when she returned home she was as bad as ever.

THE KINGDOM OF EVILS 225

The most important individual problem next in order
amongst the children is that of Isaac, the oldest son, now
twenty-three. He is definitely feeble-minded, grading 9.7
years by Point Scale when observed at the age of eighteen
and a half. Icaac's record shows a general leveling down of
his mental capacities although his power of attention and his
emotional control are more prominently affected than the other
faculties (recalling the situation with Rachel). Isaac was
unable to read or write but made five dollars a week. He
was a domestic nuisance because he, without provocation, ad-
ministered heavy blows to the children. At the present time
he is working with fair regularity for a relative and gives no
trouble, though he "knows it all." He often sits for long
periods without talking and cannot eat if the other children
are about.

His next younger sister, Molly, two years older than the
third child Bessie, seems to be absolutely normal in every
respect, is physically something of an athlete, and was found
upon the Psychopathic Hospital observation to be normal in-
tellectually. Were it not for the abnormality of all the other
members of this family of ten, we should regard Molly's
having an illegitimate child as not especially suggestive of
psychopathy. Perhaps it is safer not to guess psychopathy
even against the heavy atmosphere of the Newman family.
Molly has also a so-called "doubtful" Wassermann serum reac-
tion of the blood which so often turns positive later on and
is always suspicious. (The father of the family was syphilitic
to test.) Molly, with the aid of one of the children's agencies,
made some effort to take care of her child but eventually had
it placed for adoption. She later made what seemed to be
a promising marriage. When her husband returned from
army service, he failed to support her and became sexually
abusive. Now she is back with her own family seeking a
divorce. She claims that one of the reasons for her quarrels
with her husband is his failure to keep the agreement he made
when they married that he would take steps to find and recover
her first child.

Having considered, first Isaac, second Molly, third Bessie,
we come now to the fourth, Louis, two years younger than
Bessie and five years older than Rachel. He tested, when
his actual age was thirteen, ten years by the Binet and 11. 3

226 THE KINGDOM OF EVILS

by the Point Scale. He was a boy with an uncontrollable
temper and hyperkinetic in various ways, making grimaces and
jerky movements of the limbs. He is now in a special class
at a business school but is doing very unsatisfactory work and
will no doubt shortly drop out.

Daniel two years younger than Louis, is bright in school,
a nervous, irritable boy with a positive Wassermann serum
test. He seemed to be always in a fight. His brother, two
years older (Louis) and his father were especial irritants for
him. He was quite uncontrollable by his mother. This boy
Daniel graded a few points higher than his actual age, eleven
and a half, by both the Point Scale (11.8) and the Binet
(11 3/5 ) . He may be regarded as in a general way somewhat
precocious and to test was deficient only in his learning ability
and in a certain oversuggestibility.

Of the two remaining children, Leo, now eleven, is a good
deal of a problem. He is also, like his brother Daniel, not
feeble-minded. He is a restless, quarrelsome, and excitable
boy who cannot sit still and (resembling Rachel's falling from
her chair at school) often falls down when playing or walking.
He has recently developed hysteria and has already had two
sufficiently pronounced attacks with paralysis of a leg. This
paralysis combined with pain in the back of the knee has at
times been cured for the moment through persuasion and
command by the psychiatrist.

Sally, now seven years of age and the youngest, was at
three years regarded as a bright little girl and passed most of
the four-year-old tests. She even now grades approximately
to her actual age. She cries continually, has a violent temper,
is given to biting herself when angry, hits herself against the
wall and, like Leo and Rachel, has the falling tendency noted
for them.

What kind of parents did these eight children possess? The
father Jacob, examined at forty-four, proved to have a mental
age of some 9 years. His blood serum showed a suggestively
positive reaction for syphilis (three years later a test proved
definitely positive). At the earlier age it was thought that
some organic mental disease, presumably a form of neuro-
syphilis, was developing. Jacob makes many complaints at
home, grows easily angry but has not in three years of obser-
vation yet developed any progressive mental disease. What-

THE KINGDOM OF EVILS 2.2^

ever he may develop, it seems likely that he is feeble-minded.
It might be inquired whether Jacob acquired his syphilis or
was perhaps the victim of congenital syphilis. He has no
marked stigmata to external observation. There is appar-
ently some enlargement of the right lobe of the thyroid. A
heart examination taken in connection with the positive serum
test suggests aortic disease. There was some tendency to
clubbing of the finger nails and there was a pronounced
cyanosis of both hands. He sometimes complains of attacks,
which taken into association with his syphilis, might seem to
suggest organic disease of the nervous system. Yet it is pos-
sible that many of these phenomena in Jacob are hysterical.

His wife, Sadie Newman, although a woman of somewhat
limited intelligence (not tested but almost certainly not defec-
tive; has efficient brothers known to the social service) has
some psychoneurotic symptoms (heat flashes, nervous spells
with chin quivering and inability to speak, feeling of general
weakness). Almost all the other features in Sadie's life are
extraordinarily to her advantage. She has naturally had a
most difficult life but has brought the afflicted family through
more difficulties than a normal mother would like to face.
Mrs. Newman has had in all twelve pregnancies. The first
was a miscarriage and the second child died young (thought
to be feeble-minded). Then came Isaac, the definitely feeble-
minded boy. These first three pregnancies form the clinical
ascending scale of improvement found in the syphilitic family
and the fourth child, athletic Molly, might be regarded as
showing that the syphilitic taint had run itself out. However,
next came a definitely feeble-minded child, Bessie, an ugly,
pugnacious child. After Bessie came the second and last
miscarriage. Then came the grimacing, high-tempered Louis,
followed by nervous Daniel with his positive serum test ; then
came Rachel, Leo, and Sally with their overactivity and falling
tendencies, but between Leo and Sally came a boy that died
four days after birth.

We spoke of Molly as possibly terminating the syphilitic
taint shown in the first three pregnancies but will remind the
reader that this good child (the best in the family) herself
had a doubtful Wassermann reaction of the serum. Three
members of the family, Molly, Daniel, and the father Jacob,
have suggestive or positive Wassermann serum tests.

228 THE KINGDOM OF EVILS

Of course if we should construct a chart of the mental and
nervous diseases and defects in this family we might make
out a strong case for so-called "heredity" if we, for the mo-
ment, forgot the syphilis in the situation. It is worth while
for the social worker to remember that, after all, we must
regard many of the phenomena in this family as preventable
in view of the fact that most of these phenomena accord very
well with our idea of what syphilis can produce. To be sure
we do not know why the father Jacob was feeble-minded and
it may be that the expert eugenist could trace the separate
threads of inherited feeble-minded and syphilitic infection in
the Newman group. We do not at all know that the father
Jacob was a congenital syphilitic. It may be that he was a
feeble-minded person who acquired syphilis. Furthermore we
must point out a number of psychoneurotic traits in Mrs.
Newman, though it would be almost fair to inquire whether
many of these traits were not a rather natural acquisition for
a housewife in her plight. At all events, as we have repeat-
edly insisted elsewhere in this book, the social worker should
not confuse the hereditary with the congenital. What the
feeble-minded part of Jacob transmitted may perhaps be hered-
itary. What the syphilitic part of Jacob contributed was, no
doubt, congenital. We would not bore the reader to under-
stand the distinction between hereditary and congenital by this
repeated insistence ; however we have heard some relatively
expert social workers on the platform using in their propa-
ganda terms which signify that for them at least at the mo-
ment, tJie distinction between hereditary and congenital did not
seem to be a worth-while distinction. It will be observed that
this distinction is a very important one psychologically and even
from the standpoint of the budget. The philanthropist who
wants to stop hereditary mental disease and defect may per-
haps best proceed by endowing eugenic researches and propa-
gandas. The man who has in mind the prevention of certain
preventable forms of mental disease and effect (by well-known
public health methods, now being rounded into marked ef-
ficiency) would raise money on the venereal disease propa-
ganda supported by research.

Let us briefly sum up the social treatment of the Newman
group : I . Financial assistance was got so that household goods
might be procured with which more decent standards could

THE KINGDOM OF EVILS 229

be maintained, with the result that while six years ago the
family lived in dirty and dilapidated surroundings (there was
not even a bed for one of the sisters) now they live in a fairly
well appointed apartment.

2. Numerous and changing arrangements had to be made
from time to time for different children. Three of the chil-
dren have been boarded out for periods of some two years
each. To be sure these children were neither "dependent" nor
"neglected" children in the technical sense of those terms so
that the fact that a public agency was got to give them better
care must be scored as a triumph of prevention.

3. Arrangements had to be made for two confinements
(illegitimacy in both), and for the care of the illegitimate
children.

4. The father had to be instructed concerning work and his
attitude to the family.

5. Advice and encouragement was given to the mother in
regard to the father and in regard to each of her children in
turn.

6. The relatives had to be advised with respect to the
mental condition of the family so that their cooperation might
be maintained. It was natural that from time to time they
should lose patience.

It may be noted that twenty-six medical and social agencies
have been found so far on the records as dealing with the ten
surviving members of the Newman family.

Hours spent by Medical record, 145 pages

Social record, 99 pages
Physician, 491/^ Social work:

Visits, 95
Psychologist, 15 Interviews at hospital, 38

Telephone calls, 105
Social worker, 180 Letters, 98

Imbecile boy kept at work by frequent changes. Trained
in special class. Feeble-minded father gotten a job: sick mother
treated.

Case 49. The Rosenthal family pales into insignificance
beside the Newman family. Yet amongst five members three
are definitely psychopathic up to date. The boy, Nathan, was

236 THE KINGDOM OF EVILS

the first to appear under hospital observation. He was sent
by a school teacher with a question as to his mental defect
and yielded a Binet rating of 6 with an actual age of twelve
years. Once later he tested at a rather lower level but at the
last examination definitely tested at 6 3/5 by the Binet and
5.9 the Point Scale. He is accordingly classified as an im-
becile.

It was plain that he should be sent to a school for the feeble-
minded. There was for the moment no vacancy to allow his
admission. Concerning the possibility of couunituient it may
be noted that the family refused to allow commitment; even
had the family entertained the idea of commitment, no doubt
the committed child would have been released from the insti-
tution forthwith on the ground that there were other case?
more suitable for schooling. Nathan had, therefore, to be
supervised at home. He was hard to manage, irritable, quar-
relsome, and if crossed, disagreeable. He threatened with a
toy pistol persons who, he thought, had injured him. He
would wait behind a door with this pistol to shoot a boy who
had hit him. He attended a special class at school and his
conduct improved a little after his teacher obtained for him
a newsboy's license. Nathan is now working irregularly; his
mother finds fresh jobs for him when he decides to leave one.
He is very sensitive to children's taunts and comes home to
his mother crying because somebody has teased him.

Nathan's two siblings, a boy two years younger and a girl
three years younger, are regarded as very "smart'' and are
in the high school and grammar school respectively in proper
grades (tested at the hospital their age levels are well up to
normal).

The social service work in the case of Nathan shortly
brought out the fact that his mother Sarah (forty-three) had
bad headaches and so-called "rheumatism" with numbness of
the arms. She was examined in the out-patient department,
took hydrotherapeutic treatment and gradually improved.

Mrs. Rosenthal had to take care of the family finances
because her husband Abram, also examined in the out-patient
department, proved to be nine years of mental age (actual
age forty-seven). Mr. Rosenthal, a painter, seems to have
had a fall upon his head at about the age of twenty-four. He
had come from Russia at the age of nineteen. He was still

THE KINGDOM OF EVILS 23 1

unable to read English. Rosenthal's friends thought that he
had not been normal since his fall. He had been getting
gradually worse and had begun to suffer from spells of dizzi-
ness. He accordingly had to give up his painting. At his
first examination in the out-patient department there were
some signs of lead poisoning. He was sent to a general
hospital for treatment (the same general hospital where he
had been treated twenty-three years before for "concussion
with question of laceration of the brain," evidently the basis
of his traumatic defect-condition). At this general hospital
he was operated upon for appendicitis. Aid had to be given
to the family in the meanwhile by two charitable agencies.
Dental work was arranged for. Upon recovery he was helped
to get a city position. His general health had by this time
much improved.

At the present time, what with the father's improvement
in general health and the mother's improvement as to head-
aches, the general situation is as good as might be expected.
Once when out of a job Rosenthal came to the hospital for
aid in getting another city job. Of course it is naturally not
advisable for any agency, and above all a public agency, to
cause patients to lean financially upon it; but a little aid ap-
plied at a critical time to help restore physical or mental health
does not necessarily encourage a dependent attitude. Our
assistance is often sought in finding work when there is no
thought of money help.

Concerning heredity in this family complex, we know noth-
ing concerning Rosenthal except that he was one of six chil-
dren, one of whom died at twenty-five years but the others
of whom lived to more advanced ages. The like holds true
for the mother who was one of some nine children, all of
whom are said to have lived to a considerable age. Both
father and mother are the only ones of their siblings that
survive. A niece of the mother has epilepsy. The data, as
in the case of many immigrants, are of no particular value
from the eugenic side. We do not know of any hereditary or
syphilitic features in the family, li Rosenthal is a true case
of traumatic defect-condition (that is with mental symptoms
due to definite structural lesion of brain tissue caused by the
accident) then we should have no reason for thinking that
the boy could have inherited his feeble-mindedness from the

232 THE KINGDOM OF EVILS

father, but of course, we do not know whether Rosenthal
graded to normal at the time of his accident.

Hours spent by Medical record, 39 pages

Social record, 45 pages
Physician, i6j4 Social work:

Visits, 31
Psychologist, 5 Interviews at hospital, 23

Telephone calls, 20
Social worker, 64 Letters, 10

Street car conductor, steady quiet fellow; moron. Enlisted
in the navy. Sex obsessions and delusions.

Case 50. Bernard Bornstein, a moron, seventeen years
old, wanted to enlist in the navy to see the world. His parents
refused permission because the father was out of work and
the family dependent on the boy's wages (he was earning
between fifteen and twenty dollars a week as a street car
conductor). So Bernard ran away and enlisted. His first
day on shipboard he met another Jewish boy, who became his
chum and in the course of time told him that the other sailors
intended to make him commit sodomy. Bernard believed this.
In the hospital he insisted that there had been about a hundred
and fifty of his shipmates who had followed him around so
that he could not do anything ; write a letter, or take a bath, or
get to sleep. He said he would wrap the blankets about him in
his hammock and they would come and tear them off. He had
in fact complained to the officers, who sent him to the hospital
with a statement that there was no basis in fact for his ideas.

This boy had attended the public schools in New York until
he was fourteen, made there {though a moron) a fair record,
and had then worked regularly earning increasingly good
wages. He lived with his parents and gave his weekly pay
to his mother, to whom he was much attached. He was a quiet
fellow who spent his evenings at home and went about very lit-
tle with other boys. In this protected environment he was con-
tented and useful, until a sudden impulse to see the world car-
ried him into a life of responsibilities beyond his capacity.

Hours spent by Medical record, 29 pages

Social record, o
Physician, 4]4 Social work, 0

Visits, 0
Psychologist, i Interviews at hospital, O

Telephone calls, o
Social worker, o Letters, o

THE KINGDOM OF EVILS 233

Feeble-minded recidivist. Honorable discharge from the
army.

Case 51. Howard Driscoll by psychological tests showed
a mental age a little over ten years (twenty-one at the time
he was examined). He had enlisted in the artillery at sixteen
and had been after three years in camp sent to England for
guard duty, and later to France where he was wounded several
times and gassed. His army record was sprinkled with
A.W.O.L.'s but in the end he got his honorable discharge. He
came home but after a short time vanished, turning up only
at intervals for a few days. He was even arrested once for
vagrancy and served a reformatory sentence. Again, he broke
into the house of an aunt and stole jewelry for which he was
given three months in jail.

He now enlisted in the navy and was soon discharged for
mental incapacity. Some months later he joined the state
guard and was assigned to a machine-gun company. A week
later, whilst guarding ammunition, he offered to relieve an-
other guard so that the latter could get his dinner. When the
other man had been gone for several hours, Driscoll got angry,
left his post, and went off for four days. He was then sent
to the Psychopathic Hospital for examination, where he was
pronounced feeble-minded as above.

The family gave an account of a change of character at
the age of nine when the boy had a fractured skull. After
this he lied and stole and fought. He had been twice in a
reform school. He never kept at a job for more than a few
days or a few weeks, with the exception of a position as
moving-picture operator which he held off and on for two
years, leaving five separate times because he did not like the
"boss" who "called him down." Two months after discharge
from hospital, he was again admitted, sent in by the court
on a charge of larceny. His mother was distracted, fearing
that the boy might do some terrible thing that would bring
harm to him and disgrace to the family. During the two
months' interval between his admissions to the hospital, he
married a girl whom he met on the street after a week's
acquaintance and in the full knowledge that she was preg-
nant by another man. This girl, as it chanced, had alsO' been
at one time a patient at the Psychopathic Hospital, a moron

234 I'HE KINGDOM OF EVILS

suffering from chorea sent in from a reformatory where she

had made an attempt at suicide.

For lack of suitable hospital provision for such defectives

as Driscoll, the chances are that the rest of his life will be

spent in intermittent penal sentences. The girl he married

is a similar problem.

Hours spent by Medical record, 13 pages

Social record, i page
Physician, 3^ Social work:

Visits, o
Psychologist, i Interviews at hospital, 2

Telephone calls, o
Social worker, i^ Letters, i

Subnormal psychopathic girl. Illegitimate child that died.
Unhappy, quarreling. Family known to twenty-four social
agencies.

Case 52. Beatrice Cellini has never been in the wards of
the Psychopathic Hospital. She has been handled as an out-
patient and under the social service. She came to us alone,
crying and telling about her unhappiness. We found that she
had been sent from another out-patient department with the
idea that she might be a mental case such as could properly be
treated at the Psychopathic Hospital. It proved that she came
of a family that had been the subject of attention by no less
than twenty-four social agencies in the City of Boston before
she came to the Psychopathic Hospital as the twenty-fifth.

She said her home conditions were poor and that she cried
a great deal. It was partly her own fault. A man had been
attentive to her whom she wanted to marry, but "how could
a girl who has had an illegitimate child marry." She said she
had never gotten along with her mother, who had nagged her.
Moreover she quarreled with her brother and disliked her step-
father, (There were five stepsiblings.) She had worked in
candy factories not earning more than eight dollars a week.
At sixteen she had run away to another state with a man who,
according to her story, assaulted her. This man afterwards
went to prison. At the age of twenty, according to her story,
she was raped; at all events she became pregnant and the off-
spring, turned over to the state, shortly died. It was this
past that she had so much upon her mind. A brother was
dying of tuberculosis in a hospital.

Beatrice was given the psychometric tests (non-English) and

THE KINGDOM OF EVILS 235

was found to grade at 13.4 years. The examination was a
so-called regular one. She appeared to be overhasty and
thoughtless in answers though she cooperated perfectly well
in the tests. No doubt Beatrice is to be regarded as some-
what subnormal or perhaps amongst the upper third of the
morons. Accordingly only a relative adaptability to the social
milieu is to be expected. The expected success was scored.
Beatrice was got to canvass for a magazine and this work
appealed to her. She went out amongst friends and acquired
a more cheerful attitude to the world. Through the counsels
of the social service and otherwise she got upon much better
terms with her mother. In some way, either through the
passage of time or the friendly conversations with visitors, the
history of her rapes and of the illegitimacy was either erased
from her memory or, as the phrase goes, "rationalized." We are
inclined to insist upon the value of what may be called the "psy-
chiatric touch" or attitude. One of the general social workers
who had come in contact with Beatrice had fired the following
adjectives at her; "vain, idle, lazy, selfish, untruthful, immoral."
The innermost nature of the psychopathic personality re-
mains to be worked out (see Book III, Section XI) and the
relation of subnormality and moronity to psychopathic per-
sonality is a little unclear (see, for example, comments under
the case of Marian Spring, Case 63, and elsewhere). Beatrice
varied much in her attitude to the worker. Upon one visit she
would be perfectly amiable and compliant, upon another, sullen
and disagreeable; even within the space of a single visit her
mood might well vary from sullen to amiable. On the whole
the variation was almost always polarized towards the more
pleasing mood ; that is, she responded well to friendly contact.
It was noted above that she disliked her home atmosphere;
nevertheless she could not be persuaded of the value of going
away from this disagreeable home. Whether these moods
correspond with a slight tendency on the part of Beatrice to
the so-called cyclothymic constitution (see Book III, Section
IX) we may suspect but leave doubtful.

Hours spent by Medical record, 11 pages

Social record, 17 pages
Physician, 3^ Social work:

Visits, 6
Psychologist, I Interviews at hospital, 3

Telephone calls, 13
Social worker, 15 Letters, 7

SECTION III

EPILEPTOSES (epilepsies)

A reliable zuorkman for tivo years past disabled by epileptic
seizures. Drinking debauch after mother's death: attack of
violence. Doing well at work on relative's farm.

Case 53. Luigi Silva was brought to the Psychopathic
Hospital by the poHce. He had had a fit and become violent
and destructive during a heavy drinking debauch. He was
still noisy and excited upon his entrance, unclear as to mental
processes, and quite inaccessible to the examiner. When seen
he was trying to break windows ; looked as though he saw
animals and seemed to be trying to pick up some things and
avoid others. He would cry out : "Why don't you take that
thing off of my shoulder?" or again "It is a lie!"

Two days later he was perfectly clear. He remembered
having hallucinations of hearing and had a proper insight
concerning them. He was quite vague as to his time in the
hospital. He seemed on the whole rather dull. Psychometri-
cally he graded at 9.2 years; the grading was rather irregular,
suggestive, that is to say, of an acquired deterioration. He
was rather effective with the construction puzzles and fair upon
the memory tests. Physically the only positive points of note
were moderate impairment in hearing of both ears, slight
nystagmus, and slightly excessive reflexes on the left side of
the body.

Silva had been born in Boston of Italian parents, left school
at the age of fourteen to go to work, and had sometimes earned
(doing heavy nickel and brass work) as much as ten dollars a
week. Later he earned as much as twelve to fifteen dollars
a week. He had been a reliable workman, not especially
alcoholic. At about the age of thirty-one he had had his first
attacks of an epileptic nature, coming every three or four
weeks. For the past two years he had been unable to work
on account of the seizures. Of late he had begun to drink a

236

THE KINGDOM OF EVILS 237

good deal of whisky. Two weeks before his arrival at the
hospital, his mother died, and after her death he had a very
heavy drinking debauch whereupon ensued the violent and
destructive attack above mentioned.

Upon his discharge from the hospital he went to live with
a relative on a farm. The plan was to keep Silva away from
the temptation of liquor. Now and then he was to come to
town to go to the hospital clinic. This plan was carried out.
The patient helped about the farm, doing light carpentry,
feeding animals, and cutting ice. The cousin brought him to
the hospital from time to time. Immediately after his dis-
charge the attacks grew for a period more frequent and severe.
He is still having attacks which for the time are of milder
nature. He is said to be improved mentally, which improve-
ment presumably means that there are fewer after-effects of
the now somewhat mitigated attacks.

There are a number of medical problems in the Silva case
still unsolved. Like all but a small minority of epileptics he
exhibits a number of signs of structural disease of the nervous
system. We do not know why the epilepsy began, as it is
said to have begun, after the age of thirty. We have so far
found no evidence of epilepsy in other members of the family.

Perhaps we might use our ignorance of certain features in
the epileptic Silva to insist upon the importance of the whole
problem of the epilepsies. Perhaps nothing is more harmful to
the victims than to lump them all under one term "epilepsy."
It is just as true that there are numerous forms of epilepsy
as that there are various forms of mental disease. The rela-
tions of alcohol to epilepsy are particularly intriguing. It
seems to have proved that alcohol tends to produce more fre-
quent and possibly more severe attacks of epilepsy in con-
firmed epileptics. There are also cases to prove that alcohol
'Can de novo produce epilepsy in a person without hereditary
soil or acquired taint, and that this epilepsy may then persist
even without the stimuli of further alcoholism. But these
relations between alcohol and epilepsy cannot be said to be
thoroughly established in such a way as to offer clear prin-
ciples of prognosis. Alcohol is only one cause or complication
of the epilepsies. Following, on page 467, is a grouping of the
major kinds of epilepsy; without going into their special
natures, it can be readily seen that in the field of epileptology,

238 THE KINGDOM OF EVILS

the social worker, to say nothing of the psychiatrist himself,
must step gingerly.

Hours spent by Medical record, 19 pages

Social record, 6 pages
Physician, 5^ Social work:

Visits, 10
Psychologist, i Interviews at hospital, o

Telephone calls, 6
Social worker, 17^4 Letters, 3

Epileptic who killed his mother. Convulsions after head
injury.

Case 54. Patrick Donovan, thirty-six, killed his mother
and an indictment was found against him for murder in the
first degree. Patrick had given himself up to the police, say-
ing that the beer he had drunk the night before had been
drugged and he did not know what he was doing. His sister
thought he had had convulsions the night before the murder.
These convulsions were not necessarily "epilepsy." It is im-
portant for the social worker not to confuse every fit of con-
vulsions with the disease, epilepsy. But these particular fits
turned out to be verv^ definitely epilepsy, due to an injury ten
years before.

Patrick had never had any serious illness before the age of
twenty-six, although he was said to have been always very
quiet, sullen, and quick-tempered — more quick-tempered with
members of his family than with strangers. In short even
before the fracture of his skull at the age of twenty-six he
might be thought to have shown somewhat of an epileptic
temperament, at all events a psychopathic temperament. Pat-
rick's brothers were all alcoholic ; his paternal great-grand-
father had had a mental disease ; his father had become insane
at the age of forty.

The patient was struck on the head by a ledge weighing
sixty pounds and was in the hospital for some thirteen weeks.
On the day of the accident there were nineteen convulsions.
From that time forward convulsions occurred frequently
throughout his life, as a rule at night. Patrick drank heavily
of water and had a large appetite. He grew very jealous
and was unsociable in his family.

THE KINGDOM OF EVILS 239

There could be hardly any doubt that Patrick's action was
epileptic. His mother's body was badly mutilated. Some
time before, it now transpired, Patrick had assaulted also his
sister, breaking her jawbone. He had at that time also been
drinking.

The psychiatrists found Patrick well oriented as to time,
place, and person, nor could much impairment of memory be
determined. He told of times when his heart stopped beating
for long periods whilst he was lying in bed. He told how he
had a queer, shivery sensation in his body. Often he felt he
was falling when he was not falling.

The psychologists found Patrick of the mental level of
thirteen years. There were no irregularities in his mental
tests (that is to say, no marked examples of his passing tests
of high year levels while failing to pass the tests of earlier
years). His associative processes proved to be slow, as well as
all of his responses, although he cooperated well. His vision
had been somewhat diminished since the accident and the
psychologists felt that his rating was thereby somewhat
lowered. It seemed accordingly that Patrick was not to be
regarded as feeble-minded by the mental tests.

Physically there were signs of the old head injury. There
was no marked evidence of heart disease. Neurologically he
showed sundry effects of his old fracture in the shape of
elimination of the fields of vision of the right side and some
visual impairment. The X-ray confirmed the history of the
fracture.

Here is a case in which the sphere of authority was in the
sense of our Book I almost purely public — indicted for crime
he could almost at once be determined to be irresponsible for
an act done at the time of epileptic seizures. He could there-
fore promptly be sent to an institution for the criminal insane,
where no doubt he will lead a tranquil enough life punctuated
by occasional epileptic seizures. In certain epileptic cases there
is a possibility of surgical aid. But in this instance the medical
details of the examination were such that surgery was not
recommended.

What is the province of the social worker in a case like
that of Patrick Donovan? The social worker's task is prac-
tically confined to the collection of data of value in the medical
and psychiatric judgment of the case. In this case various

240

THE KINGDOM OF EVILS

points concerning heredity were obtained. Thirteen agencies,
relatives, friends, and employers were consulted by letter, tele-
phone, or interview.

There is no special tendency to epilepsy in the offspring of
the injured patient. It is often of value to reassure the rela-
tives of traumatic epileptics upon just this point. The theory
is that the injury to the brain which brings on cerebral con-
vulsions does not injure the germ plasm and accordingly has
no effect upon heredity. In this instance there were no epilep-
tics in the family tree, but there was mental disease on the
father's side and there the patient's brothers were alcoholic.
Besides this his somewhat psychopathic temperament must be
considered.

Hours spent by
Physician, 5
Psychologist, i
Social worker, 5

Medical record, 15 pages
Social record, 4 pages
Social work :

Visits, 2

Interviews at hospital, o

Telephone calls, 6

Letters, 6

Drafted but discharged because of epilepsy. Beginning of
symptoms after industrial accident.

Case 55. Charles Lovell was sent from the National
Guard camp with the statement that he was depressed, appre-
hensive, and excited. He seemed to be trying to give an im-
pression of more mental trouble than existed. He said he
"was crazy a year ago," that his "mind gives way under
strain." He was twenty-seven years old and had lived with
his mother in a small town, where he worked for a florist.
In school he went to the sixth grade, leaving at the age of
sixteen. By psychological tests he graded irregularly at 11. 8.

Five years before, it was learned, while at work in a foundry
he had been hit on the head, had lain unconscious two hours,
and next day became "raving crazy" and attempted suicide.
He was in bed several months and according to his mother
did not get "right in his head" for a year. Thereafter had
had occasional dazed spells and lapses of memory, such as for-
getting how he came by money that his mother had lent him.

THE KINGDOM OF EVILS 24I

The diagnosis was epilepsy (no doubt traumatic). The pa-
tient was discharged from the army and returned to his old
job. Two months later his mother wrote a frantic letter to
the social service to ask advice as Charlie had received another
draft paper to fill out. A statement of the examination here
was sent her, and a local physician was obtained to take over-
sight of the case.

Hours spent by Medical record, 17 pages

Social record, i page
Physician, 3J4 Social work:

Visits, 0
Psychologist, i Interviews at hospital, I

Telephone calls, o
Social worker, i34 Letters, 4

Soldier in whom seizures follozved vaccine inoculation.
Always siihnormal, hut a steady lad.

Case 56. Frank Wayne was helping his father on the
farm in a southern state when he enlisted at the age of nine-
teen, in the coast artillery, in the spring of 191 7. Ten months
later, following several vaccine inoculations, he began to have
"fits." These attacks came on at night, while he was asleep.
He would run about, without regard to the danger of hurting
himself and would sometimes bellow and froth at the mouth.
He was discharged from the service after a period in an
army hospital and sent home. His seizures now became so
frequent (he had as many as eight in ten hours) that his
father could not control him, and he was returned tO' the
government hospital and then sent here for a period of
observation.

Before enlistment Wayne seems to have been a simple-
minded lad of good habits and few interests. He went to
school irregularly because of work on the farm and left at
seventeen. He was considered by his father to have "good
health" and to be "sound mentally." A year and nine months
after his first seizure his mental rating was 8 by the Point
Scale. There had evidently been some mental deterioration,
though he was probably always subnormal in intelligence. He
had a speech impedirnent and $eemed dull, but otherwise

242 THE KINGDOM OF EVILS

showed no peculiarities while in the hospital. After a few
weeks in the public health hospital he demanded his discharge
and was again sent back home. The diagnosis in both hos-
pitals was epilepsy with deterioration.

Hours spent by Medical record, 12 pages

Socfal record, i page
Physician, 334 Social work:

Visits, o
Psychologist, i Interviews at hospital, 2

Telephone callSj o
Social worker, 2^ Letters, i

Policeman who enlisted and had night attacks after first
typhoid inocidation. Epilepsy or hysteria f

Case 57. John Bristol had been on the Boston police force
before he enlisted, and was taken on again after his discharge
from service, but lost his position during the police strike of
1919. While in the army he was boxing instructor in a train-
ing camp.

After his first typhoid injection he had a queer attack in
the night. These attacks continued to occur nearly every
night, always coming during the night, always alike, and num-
bering from six to fifteen in a night. He would suddenly turn
over in bed, bury his face and head in the pillow until he lost
his breath, then lift his head to get air and awake partly
conscious. During the attack he knew what was going on
about him, but could not control himself. He would jerk
about and sometimes hit himself in the face.

He came into the hospital as a voluntary patient because
these nocturnal episodes kept him from feeling up to regular
work. He was single and made his home with his family.
The father had died in an alcoholic psychosis. His case was
left undiagnosed, for although it was felt that the trouble was
probably epilepsy, the possibility of hysteria could not be
positively excluded. An X-ray showed a slight clouding in
the pituitary area, but there was no positive evidence of glan-
dular trouble as the cause of the attacks.

After four months' treatment in the out-patient department,
the attacks fell in number to five or six a night, and Bristol

THE KINGDOM OF EVILS 243

felt encouraged and ready for regular work. He said if he
could ever get the attacks down to four a night he should feel
that he was completely cured.

Hours spent by Medical record, 9 pages

Social record, 8 pages
Physician, 3^4 Social work:

Visits, o
Psychologist, o Interviews at hospital, 7

Telephone calls, 4
Social worker, sH Letters, 10

SECTION IV

PHARMACOPSYCHOSES ( MENTAL DISEASES CAUSED BY ALCOHOL

AND drugs)

Expert physicist: invahtablc employee. Drinking spells
when violent and abusive. Evidence of character anomaly.
His fault mental or moral?

Case 58. John Logan, thirty-nine, is a very competent
advertising man in a business wherein a certain technical
knowledge of physics is of importance. Logan was born in
Ireland and had an excellent technical education there. He
had come to America in his thirty-seventh year, having at that
time been married four years and having two children. Within
a year of his marriage he l^egan to drink, and he drank con-
tinuously for seven months, during which time he was under
the care of male attendants. From time to time he had spells
of drinking in which he would become abusive and even violent.
His wife even left him at one time, but went back with him
to his father's house in Ireland, where he recovered. Several
more spells of drinking followed. After one very bad attack,
his wife again left him, carrying with her the two children,.-
and consulted a lawyer. Upon this, Logan sold his house,
came to America, got a good position where his technical
ability counted, and eventually persuaded his wife to join him
once more.

Work piled up and, in the course of some six months, Logan
again began to drink on the ground that he was helped in his
work thereby. He again jjecame abusive with his wife, and
the landlord gave him notice to quit. He turned upon the
landlord, finally said he was going to hire a man to shoot the
landlord, and was brought by the police to the Psychopathic
Hospital,

According to Logan's wife, her husband was, as a rule,
considerate enough yet objected to her making friends or hav-
ing any other associations save with himself and the children

244

THE KINGDOM OF EVILS 245

He would not take her out of an evening, being content to
stay at home, reading or talking. He had never allov^^ed a
door to be unlocked at night, or a window to stand open even
in the hottest weather. He was apt to become irritable at
any trifling noise or disturbance. If his wife complained, he
would threaten to go away and drink. In point of fact, had
it not been for the children, Mrs. Logan said she would not
live a moment with her husband.

After two weeks' observation in the hospital, Logan was
discharged and went back to his position. He was regarded
as "not insane" ; he was thought to have been a victim of acute
alcoholism and not of any alcoholic psychosis. The question
of his being a delinquent was left unresolved.

Is it worth while to try to clear up a point or two concern-
ing the respective place in diagnosis of "delinquency," "alco-
holism," and "alcoholic psychosis"? As we have repeatedly
hinted in other parts of this book, it may well be that the
psychiatrists and the criminologists of the future will show
that all delinquents are in some sense psychopathic ; but so far
as we are aware, this proof has not been brought. Even in
those instances in which the character anomaly of a delin-
quent is so outspoken that the term psychopathic fits pretty
well, nevertheless from the legal and even from the moral
points of view, this anomalous character may remain per-
fectly "responsible." Naturally, it is not here our duty to
inquire the meaning of the term "responsible." We leave the
issue at this, namely, that delinquency is not a psychiatric
diagnosis. The question of psychopathy remains to be deter-
mined whenever delinquency of whatever type is asserted.

Somewhat the same situation holds with respect to "alcohol-
ism." Alcoholism is obviously a social diagnosis. It is very
possibly a medical diagnosis. Sir Patrick Manson has spoken
of alcoholism as a disease due to the toxin developed from
yeast ! But assuredly alcoholism is not a psychiatric diagnosis.
It is especially important for the psychiatric social worker to
bear in mind that acute and chronic alcoholism are two forms
of social condition which are not at all necessarily mental
diseases.

Logan was dismissed the first time from the Psychopathic
Hospital without a psychiatric diagnosis. That he was a
victim of acute alcoholism was obvious. That he might pos-

246 THE KINGDOM OF EVILS

sibly be a delinquent (from his abusiveness, violence, and
threats of homicide) was obvious. That his character was a
bit eccentric might also be alleged. But then the "benefit of
the doubt'' had also to be extended to Logan.

Logan's employer had supposed that the man would have
to be discharged. The situation was explained to the employer,
who remarked that Logan's work was of so much value to
the firm that an occasional leave of absence might be granted
to him if necessary. The patient readily agreed to do no more
overtime work, to give up alcohol, and to take more interest
in his wife's happiness and amusement. Logan began to take
a great interest in the Men's Club. (For a brief description
of this club, see case 6, Alfred Mack.) Logan in fact even
undertook to act as its president. However, within four
months he began to neglect the club, grew resentful of the
hospital's continuing to take an interest in him, even threatened
to leave the state, said he could not be dictated to, and began
to think that everybody in his office was jealous of him and
working against him. He began again to drink heavily and
to abuse his wife, and even once threatened to choke her.
Upon this his wife notified the social service and Logan was
brought back to the Psychopathic Hospital by the police. The
next day he said he was rather glad he had come. He said
he could not believe that he had been dangerous, and it was
with some difficulty that he could be convinced of his change
of character.

He was discharged once more after a period of ten days,
again with the diagnosis of acute alcoholism (not a psychi-
atric diagnosis), yet the notes show that this man's character
anomaly stood out somewhat in relief, so that a suggestion
of the diagnosis of paraphrenia was offered by some observers.
This condition termed paraphrenia is a disease rather closely
similar to the so-called paranoia, a condition with which even
the laity has become more or less familiar. It is a disease in
which to all external appearances the patient acts quite nor-
mally. Neither his will nor his emotions are at all out of
keeping with his ideas. It is these ideas which are at fault.
Characteristically, the disease runs a course through (i) a
somewhat indefinite early phase to (2) a phase of feeling per-
secuted. In typical cases, the phase of persecutory delusions
passes insensibly over into (3J a phase of grandiose delu-

THE KINGDOM OF EVILS 247

sions in which the patient feels himself superior to or domi-
nant in his family and surroundings. There was in point of
fact in Logan's case no very striking sign of any grandiose
trend, but his complainings, jealousies, and ideas of persecu-
tion by his working associates and his wife seem consistent
enough with this diagnosis. On the whole, however, there
was no sufficient argument for paraphrenia. Upon discharge,
Logan seemed "amiable though rather peculiar." He came a
number of times to the Men's Club; then he begged to be
excused, disliking, as he said, the hospital associations and
feeling that his fellow employees would see him on the way
to the hospital. In point of fact, so skillfully had hia hospital
stays been guarded from knowledge that only four or five
persons amongst his working associates knew at all of his
having been treated in hospital for alcoholism.

Four years followed in which Logan's family life was rea-
sonably successful. To be sure, he remained capricious and
unreasonable, haggling over every slight expenditure and giv-
ing his wife money for food only. However, he drank not
at all, enjoyed his work, sent his family on good vacation;
when his wife was away himself did some work about the
house, and all went well. A third child had been born. The
family had moved to pleasant suburbs, where garden work
was the center of interest.

It is to be noted, however, that the prognosis by the medical
staff upon his second discharge remained a bit dubious. That
he might return some day to the hospital was an opinion that
stood for four years in the records without confirmation.
Even when the old situation recurred and he was again a fit
subject for the Psychopathic Hospital, there was a good deal
of doubt whether a man who had never received a psychiatric
diagnosis was suitable for reception. Could the Psychopathic
Hospital dogmatically advise the family or the police to bring
a man like John Logan back under care ? Here lodges a large
arid important question in the mental hygiene of the com-
munity. We make no doubt that in the end such advice prop-
erly supported by medical, psychological, and social data will
be proffered in cases far less dangerous than John Logan's.
However, we are aware that in vast communities of the United
States no such interference with personal liberty and an
alcoholic's privilege of the pursuit of happiness would be

248 THE KINGDOM OF EVILS

tolerated. No doubt sundry representatives of the judiciary,
even in our own community, might raise their eyebrows at
this kind of reaching out from government to the citizenry.
Looked at from another point of view, however, we are sure
that progress will be in the line of such "interference."' If it
be "interference" to preserve a man from his own anomalies
(to say nothing of his wife and children), then one might say.
Make the most of it ! The ideal day when psychopathic hos-
pitals throughout civilized communities shall be as open to
the mental sick as general hospitals are open to the somati-
cally sick, will see far milder cases than John Logan's brought
to the examining table. No matter what the cake of custom
fixates in the minds of uncivilized communities, the Psycho-
pathic Hospital movement must and will irresistibly go for-
ward, and perchance engulf those very superconservatives that
everywhere block progress.

We wrote the above words before the critical first of July,
1919, upon which day national prohibition in our country
began. As a matter of history, Logan, it appears, was influ-
enced to start drinking again by the suggestion that July i
was upon us and that a few last drinks might well be in order.
He took these drinks, and during the next fortnight at home
drank more and more until he became again in the familiar
way excited, noisy, threatening, and abusive. Aside from
trembling of his hands and tongue, he was quite normal physi-
cally. As always, he was psychometrically on a high level,
getting the maximum year level that our tests permitted.
Again he received the medical or social diagnosis "alcohol-
ism," was regarded as non-psychotic, and was discharged.
What is Logan's prognosis? National prohibition may settle
his fate. If, however, his spells of excitement and abusive-
ness are really not socially alcoholic in their origin but repre-
sent some profound wave of emotional change in Logan, then
perhaps a new picture will unroll itself.

What has the social work accomplished in the case of John
Logan? Such cases have not been at all frequent. Physi-
cians might well be entitled to doubt whether such cases be-
longed to the medical, and particularly to the psychiatric, field
at all. The question has been raised several times whether
John Logan was really a proper subject for the Psychopathic
Hospital. Would he not perhaps have been straightened out

THE KINGDOM OF EVILS 249

as effectively by treatment in some other form of hospital, or
even as a delinquent? We are personally, however, strongly
of the opinion that the psychiatric point of view is the best
available for the elucidation even of such mild character dis-
order as we find in Logan. Logan himself, especially after
he had been drinking for some time, no doubt felt that the
Psychopathic Hospital cast somewhat of a stigma upon him.
He was always polite enough to the particular worker set over
him; but his behavior was unmistakably that of a somewhat
complaining, resentful man. His wife, on the other hand,
felt that John Logan's fault was far more mental than moral.
Perhaps she was taught by our social workers so to think.
In any event, without the aegis of some hospital, and perhaps
without the particular aegis of our own in this community,
Mrs. Logan would have felt quite at a loss. No one would
have picked up the loose ends of the family plight; and we
feel that an enormous debacle might well have ensued in this
family without the support afforded by social work.

The only alternative that we can think of to the sort of
support afforded by the Psychopathic Hospital social service
would be a similar type of support that one might ideally
think of as possible under a greatly reformed criminological
system. Should it ever be possible for the present system so
to develop a fine system of extramural threads running to all
parts of the community of delinquents and near-delinquents,
then we can ideally conceive that an extension of the proba-
tional system along preventive lines might turn the same trick
that was turned by the Psychopathic social service in the
Logan case. But we may be permitted to point out that, if
it remains doubtful whether the Psychopathic Hospital has
any right to spread its wings over John Logan, then it is per-
haps more doubtful whether a benevolent and reformed prison
system could quite so readily spread its wings. Moreover, we
think that the wings of the Psychopathic Hospital will always
be of whiter hue than the wings of any prison system.

For the administrator of such a beneficent system, whether
it stretches its wings from a commission on mental diseases or
from a bureau of prisons, the problem presented by such a
man as John Logan is always a bit difficult. Shall he or shall
he not be admitted as virtually a psychopath when much doubt
rules whether he is demonstrably a psychopath? Whatever

250 THE KINGDOM OF EVILS

the system, all depends, as is ever the case, upon the operator
of the system. Imagine a stickler upon fine technical obstacles
and you will imagine an operator who will fail whatever the
general virtues of the system. Wherever possible the com-
munity should be given the benefit of the doubt, and in our
experience, giving the community that benefit incidentally
inures to the good of the central figure in the tragedy.

Hours spent by Medical record, 11 pages

Social record, 22 pages
Physician, 4 Social work:

Visits, 12
Psychologist, i Interviews at hospital, 8

Telephone calls, 16
Social worker, 29 Letters, 16

First attack of delirium tremens. Drank to excess while
wife was in hospital.

Case 59. Patrick Nolan, forty, is presented as a case of
delirium tremens, that most frequent of the alcoholic psychoses.
(In the discussion of the next case, John Sullivan, we make
some note of the differences between delirium tremens and
alcoholic hallucinosis so far as these are of importance to the
social worker.) This man was, according to the mental tests
made by the psychological examiners, of a very high rating,
namely 15.5 years of mental age (close to the limit of age that
can be tested by present-day psychometric tests) and scored
in other ways his intelligence was high. This test was made
November 19 and the patient cooperated well though he was
at that time impatient to get to his family waiting upstairs.
He had been admitted to the hospital four days before, namely
on November 15.

Nolan was an Irishman, alcoholic from the age of twenty-
two years. He had been drinking to great excess for some
days and had l^ecome very nervous and tremulous. Two
nights before admission, that is on the night of November 12,
Patrick waked up a family that lived near him and asked the
head of the house to come to the Nolan home and stay with
him as he was nervous and afraid he would die. His wife was
in hospital for a slight operation and he had resorted to whisky
for companionship. He himself said that while he and whisky
had always been good friends before that, after his wife had

THE KINGDOM OF EVILS 25 1

gone to the hospital he and whisky had become inseparable.
His friend, Mr. Doherty, stayed with Patrick all night. Pat-
rick slept not at all but wandered from room to room. He
seemed a little better next day but in the afternoon talked
about seeing his dead brother. Accordingly a physician was
called who found all the lights in the house lighted and the
doors locked. Patrick refused to see the doctor ; the police
came ; Patrick then opened the door and went with them talk-
ing about devils who were getting him. So far as his friends
knew or at least would say, Patrick had never had a similar
state before.

For two nights in the hospital he continued to see devils
under his bed. He was "somewhat depressed" but the line
between depression and a proper sadness is naturally hard to
draw. When he told his story he had become humorous. All
are familiar with the humor of the Irish but it would appear
from medical observations in alcoholic psychoses that the so-
called "humorism" is not merely an Irish trend but is found
as a somewhat differential effect of alcoholism in a variety of
races.

Patrick Nolan failed to see the "animals" which one is sup-
posed to see if a victim of delirium tremens. Perhaps "devils"
will serve in their place. It is just as well, however, that the
case we here choose to illustrate delirium tremens is a case
without the so-called zoopsia or hallucinations of animals.

Physically Patrick was a muscular, gray-haired, ruddy-faced
man having the somewhat characteristic weather-beaten alco-
holic facies. Aside from a flushed face and widely dilated
pupils, there was nothing of note in the physical examination
save very active knee jerks. The victim of delirium tremens
is rather apt to look more "sick," that is, physically sick, than
the victim of alcoholic hallucinosis (to be considered in the
next case, John Sullivan). The facial flush, the tremulous-
ness, the dilated pupils, the look of a certain confusion and
perhaps fear combine to give this impression of a delirium
tremens victim as looking "sick." "Nervousness" is a term
the layman is apt to use about this state ; but the term is used
for so many other states that it is of little or no value from
a standpoint of diagnosis. He was discharged recovered on
the seventh day and his frank psychosis had thus lasted appar-
ently some nine or ten days in all.

252 THE KINGDOM OF EVILS

Patrick was now referred to the social service. He was a
married man without children who lived on the top floor of
a three family house. He was an unskilled laborer earning
fifteen dollars a week. Both he and his wife were church
members. In Ireland he had had schooling until his thirteenth
year and had worked on a farm until he was twenty- four. A
brother had died at forty of cirrhosis of the liver, a condition
which many books describe as of alcoholic origin, and which,
no doubt, is often alcoholic in origin though other factors must
probably enter. Another brother had died at the same age,
forty, of heart disease. Still another had died of tuberculosis
at thirty-six, and the fifth of the five brothers had been a vic-
tim of delirium tremens at one time at the Psychopathic
Hospital.

An arrangement was made for the patient to come to the
Men's Club but this proved not feasible. However, without
this aid, through the very light supervision necessary, the
patient ceased to drink and it was possible to close the case
two months and a half after he first came under observation.
It may be queried whether this case was not closed too early
and this must be admitted, though no doubt with the experi-
ence in hand any renewed resort to alcohol on Patrick's part
would have been quickly called to the hospital's attention on
account of the relations established with the wife.

Hours spent by Medical record, 13 pages

Social record, 2 pages
Physician, 3J/2 Social work:

Visits, 2
Psychologist, i Interviews at hospital, i

Telephone calls, 0
Social worker, 5 Letters, i

Alcoholic hallucinosis in discharged real estate agent. Other
forms of alcoholic psychoses. Temporary care law.

Case 60. John Sullivan, forty-seven, was a victim of a
so-called alcoholic hallucinosis, a condition which somewhat
resembles the condition well known to the laity under the
name delirium tremens and not always easily told from de-
lirium tremens on the one hand and from various other forms
of alcoholic mental disease on the other hand. Before the

THE KINGDOM OF EVILS 253

era of national prohibition both alcoholic hallucinosis and
delirium tremens formed so important a group of diseases that
no social worker could fail to take an intimate interest in their
nature, especially touching their prognosis.

It is worth while stressing the fact that the alcoholic mental
diseases do not vary in severity in proportion with the alco-
holism which is indispensable to their production. Whether
there are not some other more essential factors that lie at the
basis of alcoholic mental disease in its various forms is, at
present, unknown. By the administration of alcohol one
coidd not promise the production of an alcoholic psychosis.
To be sure there are some pseudonormal forms of alcoholic
mental disease that seem somewhat closely allied to drunken-
ness, a condition which is not ordinarily, or perhaps properly,
termed a mental disease. The periodic form of uncontrolled
drinking called dipsomania and the rare disease known as
pathological intoxication are two conditions which require the
most thorough observation and expert judgment to diagnosti-
cate. The victim of genuine dipsomania is, no doubt, as a
rule, a psychopath on some broader and deeper basis than the
mere alcoholic habit. . The basis of the strange disease, patho-
logic intoxication, is perfectly obscure, though the condition
may suggest, in its suddenness and relation with perfectly in-
significant intakes of alcohol, some peculiar condition of sensi-
tization that may finally be explained when all such matters
as shellfish poisoning, strawberry skin eruptions and the like
are explained. We insist rather upon these points because
there is an almost irresistible tendency for the lay worker and
for the inexperienced physician to regard the alcoholic psy-
choses as, after all, probably somehow based on the intake of
greater and greater amounts of alcohol. While upon the gen-
eral topic we may add that despite sundry assumptions to
the contrary, it is doubtful whether particular kinds of alco-
holic beverages have very especial outcomes in relation to
mental disease. (The experimental absinthe convulsions form
an important exception.)

But the great bulk of the alcoholic mental diseases with
which the social worker or the court officer comes in contact
is, no doubt, composed of the disease delirium tremens, an
example of which is the case of Patrick Nolan given above.
Some authors even deny that a differentiation can be made

254 THE KINGDOM OF EVILS

between the two conditions, delirium tremens and alcoholic
hallucinosis, and they can point out numerous transitional and
intergrading forms of alcoholic mental disease. Some cases
looking like delirium tremens may run along for several weeks
after the manner of alcoholic hallucinosis. Some cases of
delirium tremens, instead of presenting the hallucinations of
vision that are typical thereof, present hallucinations of hear-
ing such as we may ordinarily find in alcoholic hallucinosis.
On the other hand, alcoholic hallucinosis, though it is less
likely to run the brief course of less than a fortnight which
delirium tremens runs, may not seldom show hallucinations
of sight like those of delirium tremens. It is easy to see
that the lay mind would here run too readily upon diagnostic
rocks. To illustrate this fact we may point out that owing to
certain details in the Massachusetts law, the Psychopathic Hos-
pital was not expected to take cases of delirium tremens any
more than it was expected to care for cases of real drunken-
ness. Nevertheless, every year scores of cases of delirium
tremens were admitted to the hospital under the false assump-
tion that they were cases of alcohohc hallucinosis. To be sure
humanity entered here to cloud the issue. No other institution
in Boston was so well equipped materially or diagnostically
to handle the alcoholic psychoses as was the Psychopathic Hos-
pital. (It is to this day a sad commentary on the progress of
the so-called general hospitals that they have not equipped
themselves with baths, isolation rooms, corps of skilled at-
tendants, and proper diagnostic specialists to meet the com-
plications of alcoholism, with the result that the jails have
had to serve as hospitals in states not properly equipped with
psychopathic units.) Accordingly we were in the habit of re-
ceiving, on the ground of humanity, sundry cases that seemed
to be in extremis but which turned out to be cases of delirium
tremens. When all is said and done, the differential diagnosis,
even in this group of mental diseases which the layman is apt
to think he understands fairly well, is not easy.

The prognosis of these cases is particularly hard, not to
say often impossible to lay down, and some cases of a disease,
ordinarily fairly acute, turn inexplicably into chronic cases
requiring institutional care or its equivalent, and persisting
with a batch of hallucinations and delusions like those with
which the disease began, or else subsiding into a deterioration

THE KINGDOM OF EVILS ^55

or dementia in the midst of which any very definite alcoholic
features are hard to descry.

Before dismissing this topic of the alcoholic psychoses in
general, we may mention the existence of a third group of
alcoholic psychoses of an insidious onset and a chronic course,
cases that do not necessarily begin with any acute form of
mental disease (though they may do so) but do not charac-
teristically "hallucinate" (a slang phrase of the clinic having
reference to the process of having hallucinations ; that is, false
perceptions in some field of sense, notably in the alcoholic
psychoses in the spheres of vision and hearing). We offer a
case of this third group in that of Michael Piso, a case of
jealousy psychosis.

John Sullivan was a real estate sales agent. He said his
business had been going wrong for some time, that he had
gone up to Canada one day and returned on the next train,
having the idea that a detective was following him; in fact
he said he saw someone following him and that he heard some
men on the train talking about him. Even after entering the
hospital he said he heard people remarking about how he
was using other people's money.

Technically the fact that Sullivan had an idea that a detec-
tive was following him would be regarded as a delusion or
false belief. If, however, he actually saw real men and, not-
ing their whispers, conceived that they were talking about him,
then his status would be technically regarded as one of the
so-called delusions or ideas "of reference."

Whether Sullivan actually had hallucinations is a matter of
some doubt, though he admitted hearing voices of no visible
source, but he heard them rather vaguely. The victim of a
typical alcoholic hallucinosis should, perhaps, have heard voices
much more definitely than did Sullivan. The theoretical line
of separation between ideas "of reference" and hallucinations
is sharp enough, seeing that the latter must be definite false
perceptions, whereas the former are a kind of erroneous idea ;
yet the practical claim of separation between these two symp-
toms wavers tremendously.

He had had a history of several weeks of such delusions,
believing that the police were after him because he had held
back his rent, that people had scoffed at him, that he was
ruined (he had actually lost money in recent sales). He said

256 THE KINGDOM OF EVILS

that his mind had become rather confused of late and that he
could not think. In fact, he "must have been insane." He
had once even gone so far as to threaten suicide.

With all this it may seem strange that Sullivan had actually
come to the hospital as a voluntary patient. When it came
to signing the application for his admission he, however, be-
came suspicious and refused to sign. He was accordingly
admitted under the Temporary Care Law (see Appendix C for
discussion of the Massachusetts Temporary Care Law, one of
the measures without which extensive state work with non-
committable psychopaths is impossible). As he admitted hav-
ing hallucinations or other symptoms of a frankly psychopathic
nature, it was perfectly proper to have a medical officer (not
upon the stafif of the hospital) make application for his ad-
mission. Upon these preliminaries, Sullivan went to the ward
without protest. This was on May 23 and by June 29 it was
possible for him to be discharged, as recovered, to the outt
patient department. He had had seven days of so-called "tem-
porary care," that is, of care under the law which did not carry
him to the probate court, but upon the seventh day, that is,
May 29, he was actually "committed," that is, his case was
carried to the probate court upon the evidence of two expert
physicians not connected with the Psychopathic Hospital.

He was then carried upon the books until December 29.
Already by May 29 he had improved a great deal so that the
commitment to the hospital was really a measure on the pa-
tient's behalf, to the end that he could have hospital care until
his disease was over. He was under hospital care, therefore,
for a period of about five weeks. At some time in the third
week he got good insight into his past condition. At this
point the social service took control, although the term "con-
trol" might seem a rather heavy one for this particular case.
Sullivan was a very amiable sort of man with what may be
termed a rather high empathic index. ^ The technique of
this social care consisted in utilizing the Men's Club for hos-
pital and human contacts and in counsel and encouragement.

John's mother had been for two months at a hospital for
the insane some years before, also the victim of alcoholic men-
tal disease. One of three brothers was also a very heavy

* Southard, E. E., M.D. : "The Empathic Index in the Diagnosis of Mental Dis-
eases," Journal of Abnormal Psychology, October, 1918.

THE KINGDOM OF EVILS 257

drinker though all three brothers and four sisters were physi-
cally well. John's father had died of accident. John had
had little schooling but had educated himself. Though he
had been a gardener in England he had become a real estate
agent in America. His business had been good until it had
gone downhill during the last year, obviously the result of his
alcoholism. So far as the history was frank, it would seem
that before that time he had been drinking more moderately
though all through the twenties and early thirties he had been
a very heavy drinker, apparently without any mental effects
of a nature to interfere with self-support.

Physically he proved entirely normal save his thinness, and
psychiatrically there were no abnormalities save those men-
tioned. He explained that he had taken the trip to Canada with
a vague idea that he was going to start anew there.

We find medical notes of reports in July, August, Septem-
ber, November, February, March, May. These notes show
that there was no return of symptoms and that Sullivan was
making a good deal of headway with his debts and with his
business. Pari passu with these medical notes we find social
service notes in February, March, April, and May of the year
following his attack and, in fact, in May the case was closed
by the social service. The social-service notes had told of
visits at Sullivan's home and of advice concerning his coming
to the Men's Club. The economic problem was not in the
foreground, as the wife kept a lodging house.

Hours spent by Medical record, lo pages

Social record, i page
Physician, 7% Social work:

Visits, 3
Psychologist, o Interviews at hospital, 2

Telephone calls, I
Social worker, 5^/^ Letters^ 4

Root of family dissension may be disease /)f one member.
Acute alcoholic hallucinosis; chronic inebriety; morbid temper-
ament.

Case 61. If we examine a social case card-catalogue, we
shall find case after case of so-called family dissension. We
say "so-called" not because the term is meaningless, but be-
cause cases left with the designation family dissension are,

258 THE KINGDOM OF EVILS

we believe, cases not properly analyzed as to the form of evil
at work. That form of evil may as readily be disease in one
or other member of the family as any other of our major
groups of evil. Thus Margaret Murray, a Scotch woman of
thirty-nine, was living in New Hampshire with her six-year-
old daughter Pearl, apart from her very reputable husband,
an iron-worker earning some thirty dollars a week. The
"symptom'' catalogue stood as follows :

Social symptoms:

Inebriety (chronic)

(?) Insane commitment

( ?) Neglect of child

(?) Immoral influence on child

Marital discord

Arrest
Social diagnosis:

Family dissension
Medical diagnosis:

Acute alcoholic hallucinosis

We hold that the medical diagnosis in this case is the social
diagnosis and that family dissension, though a perfectly cor-
rect term for the social conditions found, is not the caption
most helpful in determining social treatment. Chronic in-
ebriety is set down as one of the social factors : a fortiori,
acute alcoholic hallucinosis is another and even more command-
ing factor, since (a) this disease brought Mrs. Murray to the
Psychopathic Hospital and (b) its prognosis and treatment
(whether by costing confinement in a state hospital or not)
will influence every social step taken. In short we would pre-
fer to place this case among the Morbi rather than among the
Vitia where family dissension would tend to leave it. Let the
morbid factor be removed, and the moral factor can remain —
i.e., Mrs. Murray would then have her chronic inebriety to
face (provided that in her case the habit is not itself a disease).
Let the inebriety be removed, and there might still be a basis
in morbid temperament or bad habits for family discord.

Let us examine enough of the facts to demonstrate the
issue. Mrs. Murray had drunk to excess and had been twice
arrested for drunkenness (chronic inebriety). She came to
Boston and, whilst working in an institution, developed the
symptoms that brought her to the Psychopathic Hospital.

THE KINGDOM OF EVILS 259

There she had hallucinations of hearing and told (delusional)
stories of her husband's abuse of her. There was even raised
the question of commitment. The husband was by now dis-
heartened and antagonized and had begun to regard his wife
as irresponsible. There was discord over the question whether
she should live with husband and daughter, should take the
daughter with her, or leave the daughter with her father.
Mr. Murray felt that daughter Pearl might suffer immoral
influences from her drunken mother. Upon study of the case
it appeared to the social workers that the child could hardly
be unaware of her mother's drunkenness. It was on this
account that the list of social symptoms contained the two
questions "neglect of child?" and "immoral influence on
child?"

The efforts of the social service were summed up as fol-
lows : —

1. In arranging for temporary care for patient and child
upon the former's discharge from the hospital until the hus-
band could be located and until employment was found for her.

2. In making an investigation of the family situation to
understand the facts.

3. To give advice and cooperation to both the patient and
her husband as they are working out their readjustment.

If we take the phrase "working out their readjustment"
upon the simple basis of family dissension, we should hardly
avoid being influenced by the phrase itself. Family dissen-
sion clearly points to moral difficulties within the sphere of
what we have in this book termed Vitia. Family dissension
does not at all necessarily point to disease (Morbi). The man
in the street and the social worker can hardly help feeling that
family dissension is a matter of ingrained temperament dif-
ficult to train by moral methods, difficult or impossible to
reeducate by the intellectual route alone and, even if psycho-
pathic, by the same token harder than ever to meet. In short,
the social worker, should she content herself with the social
diagnosis family dissension, might believe that she was doing
the charitable thing by her patient. Family dissension as a
moral matter sounds less heinous than family dissension as
a matter of disease.

But let us look into the facts. As a matter of the actual
situation and its outcome, the social condition family dissen-

26o THE KINGDOM OF EVILS

sion proved to be almost entirely, if not quite, fear of a rather
acute mental disease or the so-called hallucinosis. That there
was any deep underlying psychopathic trend of temperament
is extremely doubtful. Even if Mrs. Murray became alco-
holic through some deep trend of her nature, there is no proof,
theoretical or practical, that this temperamental trend would,
in and by itself, lead to family dissension. Accordingly, we
hold that our proof is positive, that the social diagnosis in
the case of Mrs. Margaret Murray should be alcoholic mental
disease, in particular acute alcoholic hallucinosis. We hold
that the social prognosis depends upon the medical diagnosis
and prognosis. We hold that family dissension is an effect
rather than a cause and is probably removable. We hold that
the questions raised concerning neglect of child and immoral
influence upon the child by her mother are questions which
would be removed by a solution of the mother's alcoholic
problem. Likewise we hold that the arrest and the question
of commitment of Mrs. Murray to a chronic institution (a
question raised during her temporary care whilst she was
recovering from the acute effects of her alcoholic psychosis)
are likewise purely secondary products of the situation.

We should also like to call attention to the fact that the
phrase "chronic inebriety'' which stands at the head of the
list of social symptoms in this case is likewise somewhat mis-
leading. To be sure the acute mental disease known as alco-
holic hallucinosis was, in this case, incidental to a chronic in-
ebriety. It is also true, no doubt, that alcoholic hallucinosis
is, as a rule, incidental to a chronic inebriety, but it is not at
all clear that chronic inebriety must necessarily or in any
large proportion of cases lead to alcoholic hallucinosis. • As
one author rather paradoxically said, "The causes of delirium
tremens are still obscure." The same holds for the allied
disease, alcoholic hallucinosis, the causes of which are per-
haps still more obscure than those of delirium tremens itself.
Neither of these diseases is at all proportional to the amount
of alcohol consumed by the victims nor to the duration of
the habits of inebriety. Nor can we say that the prognosis
of cases of delirium tremens or of alcoholic hallucinosis at
all varies with the duration or severity of the alcoholic bad
habit. We may be permitted to add that chronic inebriety
shares with family dissension the pretty distinct intimation

THE KINGDOM OF EVILS 26 1

that we are dealing with bad habits and vices rather than with
deficiencies in the patient's education or psychopathic tempera-
mental tendencies.

The general social worker must bear in mind these intima-
tions of the social phrase. The psychiatric social worker
quickly learns the more obvious pitfalls of phraseology, but
each type of social worker and the physician himself must
guard against throwing all cases of family dissension and oil
cases of chronic inebriety over into the disease group. It
must be plain from the general drift of our contentions in
this book that disease must be considered as a primary hy-
pothesis and not necessarily as a statistical probability. De-
ficiencies in education leading to family dissension or to chronic
inebriety are even less statistically probable as a matter of
actual fact — still, we must consider the hypothesis of faulty
education. Nevertheless, if we are entitled to give over the
psychopathic hypothesis and the maleducational hypothesis,
then we shall be reduced to the hypothesis of moral deficiency
or perversion. If we are reduced to this hypothesis, we shall
find, far more trouble in the process of readjustment for every-
body,— as some might say nine parts of internal readjustment
to one part of external and merely social readaptation. Family
dissension might conceivably be an almost purely legal diffi-
culty owing to perfectly logical disagreements on the part
of different members of the family concerning (let us say)
financial arrangements ; but of that rare possibility there was
no question in the Murray case. Nor \yas there any question
of a purely economic basis for the dissension in this family.

The social analysis of the Murray case leads us, in the end,
to placing an acute and curable alcoholic mental disease sharply
in the foreground. The social prognosis becomes extraordi-
narily brighter than it would be if we took family dissension
prima facie as the root difficulty. We are dealing with an-
other sample of the well-known, though somewhat paradoxical,
plight, the situation that it is rather better to be sick than
to be vicious.

Hours spent by Medical record, 6 pages

Social record, 7 pages
Physician, 3^ Social work:

Visits, o
Psychologist, o Interviews at hospital, 2

Telephone calls, 22
Social worker, 7 Letters, 15

262 THE KINGDOM OF EVILS

Feeble-minded teamster ten years married to a good wife,
suffers from alcoholic "jealousy-psychosis." Violent, abusive.
Improvement. Family difficulties: poverty, sickness.

Case 62. There are hardly more intriguing cases than
those of jealousy in alcoholics. Psychiatrists recognize a pe-
culiar alcoholic "jealousy psychosis," sometimes conceiving
that the onset of sexual impotence on the part of the alcoholic
leads up by somewhat natural steps to the belief that the spouse
is in love with a rival. Now there is, perhaps, especially in
alcoholic families, always a possibility that there is some ac-
tual fire under the delusional smoke. The psychiatrist, and
even the social worker who comes in close contact with family
conditions, may be for a long time in doubt as to the actual
facts. In alcoholic communities the psychiatrist often feels
himself entitled to suspect alcohol in any case of delusions of
jealousy. Yet the psychiatrist has constantly in the back of
his mind sundry exceptional instances in which jealousy delu-
sions appear in wo;2-alcoholic persons, for example in victims
of schizophrenia (dementia praecox). The social worker's
data become of prime importance in making exactly this deci-
sion between alcoholic jealousy-psychosis and dementia prae-
cox with sex ideas.

Michael Piso had been jealous of his wife, according to
his history, ever since their marriage. As a jealous husband
he questioned her about everything — at one time accusing her
of immorality with a lad of nineteen years. They had been
married for ten years, and his wife was in point of fact an
exceptionally good woman. There were three living children.
Michael had been alcoholic for some fifteen years. He always
made excessive sex demands upon his wife and twice tried to
choke her when these demands were not met. He was a team-
ster and worked in one place throughout his married life. At
one time he developed an abscess in the right ear and com-
plained of severe headaches. The psychiatrist brought up a
question, upon his arrival at the hospital, of organic brain
disease but was even then convinced (by such portion of the
story as was available) that he was probably a case of alco-
holic psychosis and was at the same time feeble-minded. This
combination of diagnoses proved in fact the final one, and
he was discharged as a high-grade moron with alcoholic
psychosis.

THE KINGDOM OF EVILS 263

Just before entering the hospital he threatened to buy a
pistol and attacked his wife. He had left work about a week
before entering the hospital and had grown increasingly jeal-
ous of his wife and imperious as to sex. A year before he
had had a severe headache which had thrown him out of work
for ten days, and at that time he vomited and had blurring of
the eyes. As to heredity, one of his children had had convul-
sions and a cousin died insane in a state hospital.

The psychologist could find no marked irregularity in
Michael's reactions; and, finding his mental age according to
the Point Scale to stand at 11.6 (Binet 103/5) years, made
the diagnosis of feeble-mindedness. It might be inquired
whether this feeble-mindedness was more apparent than real.
Seeing that Michael had been heavily alcoholic for fifteen
years, we might regard him as a victim of alcoholic deteriora-
tion. Some victims of alcoholic deterioration do give a low
test of this sort, even without marked irregularities ; on the
whole, however, a victim of acquired psychosis is very likely
to show some traces of inability to pass tests of the earlier
years of the scale {e.g., seven-year-old tests) at the same time
that he passes the tests of the higher scale years {e.g., eleven-
year-old tests). Michael was a teamster, and his work no
doubt did not as a rule require behavior more complicated than
that of the mental age level of 1 1.6.

The psychiatrists could upon physical examination find no
sign of brain tumor, nor, with the exception of pyorrhea, was
there any marked condition of disease in the body.

There was considerable doubt whether he had ever had
hallucinations, although there was a possibility of auditory
ones. The delusion of infidelity on the part of his wife he
now very well concealed. After some three weeks in the hos-
.pital he grew quieter, remarked that he had one night heard
a voice about his wife, saying, "Do not trust her" — a voice
which he knew to be imaginary, — and now claimed he had
never suspected his wife of anything and that he trusted her
absolutely. Upon his discharge he seemed to be quite normal
except for slight sidewise movements of both eyes (nystag-
mus), which were however held very quietly when looking at
some definite point. He was now discharged to the social
service, which had to face family conditions of some compli-
cation. The picture of the results obtained may be got from

264 THE KINGDOM OF EVILS

the following transcript (names, as always, changed). See
below for general comment on these results.

July 8-October 8, 1916

Social:

Patient has been steadily at work earning thirteen dollars a
week. Expected to go to Men's Club, but did not come to
September or October meetings.

Physical:

Patient has only once had headache of late. Has worn
glasses for four years and will have eyes reexamined.

Mental:

Patient has not been drinking except once. Wife still com-
plains of sexual demands but commends him in every other
way.

October 8, 1916-January 8, 191 7

Social:

Family visited five times. Mrs. Piso pregnant and without
clothes to get outdoors in. Children's shoes worn out and no
warm clothes. Clothes taken and arrangements made to send
wife to Boston Lying-in Hospital as free patient with permission
of own doctor. Dr. McDonald. Patient could not be per-
suaded to let wife go, so visitor arranged to have district nurse
give prenatal care. Patient is working steadily and brings
home wages every -w^eek, and comes in every night at six
o'clock. Patient has walked to Boston two evenings with wife
and about Charlestown once or twice. Wife is anxious to have
everything in good order around the house before confinement.
There is nothing abnormal in wife's condition and she feels
well. Children are well now and have had no colds since they
have been able to go outdoors. Dr. McDonald to take confine-
ment case.

Physical:

Patient is well.

Mental:

Patient, is not drinking now, at least wife sees no signs of it.
He was very firm about not letting wife go to hospital.

THE KINGDOM OF EVILS 265

January 8-April 8, 191 7
Social:

A baby girl was born January 23 and baby and mother did
well in care of Dr. McDonald and the district nurse. Patient
has worked steadily and brought money home. Patient has
had no recreation except to visit his father who is ill. He
spends his leisure at home with the children of whom he is
very fond. Wife took cold in her breast and had to stop nurs-
ing the baby for a few days, but recovered satisfactorily. Is
having teeth treated. The baby has some stomach trouble
and has not gained very fast, but dispensary doctor says she is
all right.

Physical:

Patient has been well except for trouble with hemorrhoids
which lasted about two weeks in March,

Mental:

Patient drank about a week after birth of baby but stopped
because it was so hard on family. He is very agreeable and
helpful at home. He came once to Men's Club meeting and
would have come two other months but his wife was ill and
the distance great.

April 8, 1917-July 8, 1917

Social:

Patient worked steadily and was kind and devoted to the
family during April and the early part of May, Patient's
father died May 12, and he drank steadily for a month. For
the last four weeks he has drunk nothing. Wife and children
are rather tired and run down and have been registered at the
Country Week for a two weeks' vacation. The baby has been
under dispensary care and is doing well.

Physical:

Patient's work has tired him and he has suffered from head-
ache occasionally but has not been induced to have his eyes
examined. He has not worn his first glasses faithfully.

Mental-
While patient was drinking he became exceedingly jealous
and irritable. His sexual demands were excessive. When not
drinking he has been agreeable and helpful at home. At-
tended the Men's Club.

266 THE KINGDOM OF EVILS

July 8, 1917-October 8, 1 91 7
Social:

Patient has been working steadily in spite of heavy work
and long hours. His pay has been raised to seventeen dollars
per week. He has not been drinking for four months. After
Mary recovered from diphtheria, patient's wife and children
had a Country Week vacation for two weeks, which was very
beneficial to them all. Mrs. Martin kept house for patient
while they were gone. Patient and his wife go to Boston
together Saturday nights to do their shopping now, instead of
patient's going alone and getting drunk. Patient and all the
family are in need of warm clothes.

Physical:

Nothing of note.

Mental:

Patient has been very kind to and considerate of his wife.
He missed the family greatly while they were away on their
vacation, and met them at the station with his express team
when they returned. He is very fond of the children, and says
that he prefers to spend all he earns for his wife and them,
"instead of wasting it for drink."

Thus, medically the health of the wife and children was
supervised and a vacation procured for them. It proved pos-
sible also to improve the housekeeping by concrete advice as
to procedure. The wife was told "to be nice" to her husband,
to "dress up" Saturdays for the purpose of taking her hus-
band shopping. She let him buy a derby hat, saying, "You
have to let them have something when they work so hard."

On the economic side she was discouraged from working to
supplement the family income, so that Michael should not be
dissuaded from trying to get a better paying job. Economi-
cally also the family was helped out by means of clothing, be-
cause after all Michael's wages were too small for the familv
needs. This case showed all the forms of evil discussed in
this book except the legal. No doubt the mental issue was
the dominant one and the economic probably stood next; but
in the family adjustment the social worker employed means
quite beyond the merely psychiatric and economic range, to
teach the housewife much of value to the family specifically
and to improve the moral situation between the spouses.

THE KINGDOM OF EVILS 267

Hours spent by Medical record, 36 pages

Social record, 33 pages
Physician, 6j4 Social work:

Visits, 46
Psychologist, i Interviews at hospital, 8

Telephone calls, 17
Social worker, 78 Letters, 27

Morphinism and alcoholism in a woman of psychopathic
personality. Fantastic story of a murder. A social service
failure.

Case 63. Marian Spring we present to illustrate morphin-
ism, though there is hardly any doubt that she is an example
of a so-called psychopathic personality (see Book III, Section
XI for other examples).

Marian had been brought up in her middle-class family and
upon leaving school at fourteen had spent two years in a con-
vent. Then after living some years at home, at nineteen she
began to work in mills. While she was a mill operative, she
began, in her twenty-first or twenty-second year, to drink with
another girl, and apparently this drinking began after the
death of her mother. Finally she got to drinking hard enough
to interfere with her work, and at last began to make her rather
checkered round of institutions, spending two years in an in-
sane hospital from the beginning of her twenty-fifth year, and
then being confined in three reformatories up to a period of
four months before her admission to the Psychopathic Hos-
pital. In the brief intervals between these institutional deten-
tions she worked at housework which she did very capably
and nicely. Marian, however, had few friends and apparently
had chosen her associates from amongst the most undesirable
of the mill workers. These associates were so undesirable that
they were not allowed at home and the family had become
quite discouraged with Marian.

She was a well-developed and nourished woman with rather
prominent eyes and a certain asymmetry of face. She was
physically energetic and sturdy, but said she was somewhat
unusually susceptible to pain. She had always been healthy,
she said, with the exception of having every year a sore throat.

According to her story and various inquiries she was capable
enough in all places that she undertook to fill but lost them

268 THE KINGDOM OF EVILS

through alcohoHsm and the morphine habit which she had
acquired very shortly after beginning to drink. She was a
rather winning sort of person and very successful in getting
help for herself by various subterfuges. Thus she had the
usual skill in getting morphine by surreptitious routes and
she could, on occasion, obtain help in getting out of hospitals
or institutions. At one of these institutions she had been
destructive and quite unmanageable. She told at the hospital
a very striking story about seeing a girl friend murdered by
a certain doctor who, as she said, had great influence over her
own life and with whom she had had sex relations. This story
remains quite unverified and is, no doubt, an example of the
fantastic lying which not only morphine patients are apt to
indulge in but which is likely to be shown by sundry psycho-
pathic personalities without the influence of morphine.

She came to the hospital technically "left by herself" but
was, as a matter of fact, brought in in a disheveled state by a
man and a woman. The man had found her somewhere drunk
and had brought her in an automobile to the hospital, where
she had told the man she wished to come. She was quite inco-
ordinated, excited, and restive and apparently was hallucinat-
ing. (She said: "Oh, how it stares me in the face. If he had
only killed me instead of her.") It remains, we suppose, a
question whether she was actually a victim of false perceptions
or whether she was embroidering after the manner of the
morphinist or psychopathic liar.

The diagnostic question at once arises whether Marian was
not feeble-minded. The term feeble-mindedness can, as has
been constantly shown above, be used in various ways and
some authors speak of a pure defect of will and emotions (the
so-called amoralia of authors in which intelligence is entirely
preserved or at a normal level) as feeble-mindedness. This
use of the term feeble-mindedness would, then, have reference
to social rather than demonstrable psychical defect. The im-
pression of certain psychiatrists who saw her when she first
went to the hospital for the insane was that she was a feeble-
minded person but at that time no special tests were made.
When these tests were performed she was found to be some-
what deteriorated, but the detail of the tests seemed to indicate
that she was really not fundamentally feeble-minded. As we
insist elsewhere, the things Marian did that brought her to

THE KINGDOM OF EVILS 269

social attention would not be explained by a low intelligence
rating even had she shown such demonstrable defect outside
the zone of will and emotion. Put briefly, the psychopathic
personality may be feeble-minded to test or may test out not
at all feeble-minded ; the psychotic trends remain somewhat in-
dependent of the intellectual level, though no doubt the patient's
degree of responsibility must hang somewhat upon her intel-
lectual powers of judgment.

This case might be counted as a social-service failure. No
doubt the social worker will, until the end of time, have cer-
tain failures to score. Supervision has failed to reform Marian
despite her capabilities in the line of work and despite a high
"empathic index" or attractiveness which means that she will,
no doubt, always have friends. Unfortunately she makes
friends amongst other psychopaths. The well-known gregari-
ousness of morphinists may play a part here and this
gregariousness of drug addicts has always to be borne in the
social worker's mind. How much this gregariousness is a
matter of morphinism or heroinism and how much it is a mat-
ter of a certain mild integrating psychopathic trend must be
left to the future to decide.

Marian Spring will be what the English call an "in and out"
for many years. Such forces as national prohibition and an
effective Harrison law and other devices for the successful
removal of alcohol and drugs from her habitat will, perhaps, in
the end, leave her a not very socially dangerous character.

Hours spent by Medical record, ^,2 pages

Social record, 16 pages
Physician, 6^2 Social work:

Visits, 9
Psychologist, o Interviews at hospital, 3

Telephone calls, 7
Social worker, 20^ Letters, 18

SECTION V

ENCEPHALOPSYCHOSES ( BRAIN DISEASE)

Psychoses of old age. Prognosis in arteriosclerosis. Sales-
man with moments when he "lost himself." State hospital care
or private measures?

Case 64. A psychiatric social worker always has to con-
tend with the feeling on the part of many physicians, many
fellow social workers, and the majority of laymen that mental
disease is incurable. Even if something by experience has
been done to diminish this feeling for sundry types of mental
disease, the feeling of poor prognosis and of probable incura-
bility still hangs about most patients developing mental symp-
toms in the fifties, sixties, or seventies. We give two instances
later in this book, those of Catherine Cudahy (case 69 and
Jeanette Burroughs, case 68), in which psychoses developing
in old age were still not inconsistent with remarkable ameliora-
tion and easy accessibility to social-service measures.

A very firmly fixed medical prejudice is that "one is as old
as his arteries." Accordingly a victim of the hardening of the
arteries (arteriosclerosis) is assumed to be by the same token
a victim of old age or its equivalent. Since old age has uni-
versally so poor a prognosis, then hardening of the arteries is
dropped into the same basket of poor prognoses. Now, in
point of fact, there are various kinds of arteriosclerosis, only
some of which characterize old age, and many forms of arterio-
sclerosis are not in any respect characteristically senile. One
of the greatest surprises of the youthful physician is to see
cases of severe arteriosclerosis, looking to be at the point of
death, come around in the course of weeks or months to a
phase of comparative normality and even capacity of self-
support.

Thomas Warren, sixty-four, received the diagnosis of
arteriosclerotic dementia at the Psychopathic Hospital, whence

270

THE KINGDOM OP EVILS 2.^1

he could be discharged somewhat improved after about three
weeks' observation, for the most part as a voluntary patient.
The term "dementia" has almost invariably, to a physician as
well as to a layman, the suggestion of permanence and in-
curability, although there is nothing about the prefix de in this
word dementia which necessarily signifies that the deterioration
is either permanent or temporary (in fact some of the older
psychiatric textbooks talk of certain acute dementias which
often led to complete recovery). Sometimes the term "deterio-
ration" is used for milder degrees of "dementia." Perhaps it
would have been safer to call the case of Thomas Warren
(with some of the physicians) a case of arteriosclerotic
"psychosis," thereby dodging the suggestion of permanence
that now sticks to the term "dementia." At all events, as above
stated, Thomas Warren was discharged somewhat improved.

Little is known of Warren's early history. His father had
died of a shock. Warren himself had worked as a salesman
and buyer from youth up and had never had any symptoms of
nervous disease until some six or seven months before admis-
sion, when a hemorrhage of the eye had occurred and he had
found some difficulty in working. He kept at work, but began
to lose his memory. At times during this period of six months
he completely lost himself for a few minutes at a time. He
made mistakes in his work and knew that he had to be watched
on this account.

These spells of losing oneself are amongst the most sug-
gestive features of arteriosclerosis in men of his age, especially
so when associated with gradual loss of memory and other
signs of deterioration. (The layman should not, however,
feel too great assurance as to the nature of such spells, since
epileptic and epileptoid conditions might likewise bring them
about.) It is worth while to insist that these "seizures" are
not signs of senile dementia, but are signs of either arterio-
sclerosis or some other form of disease not necessarily senile.
The important point we here try to make is that they do not
necessarily argue an invariably down-grade process on the
part of the patient. They may very well correspond with ex-
ceedingly slight destructive processes, due to blood-vessel dis-
ease, in the brain and may very well go alongside an almost
complete normality of the whole brain mechanism. Moreover,
the progress of these cases is not seldom highly irregular.

272 THE KINGDOM OF EVILS

Persons with very definite and severe apoplectic seizures, in-
volving the paralysis of an entire side, may not only recover
to a large extent the functions lost at the time of the so-called
"stroke," but may live to perform important functions in life
and even to carry on complex business affairs. In short, let us
insist that no very definite prognosis, either of regular or
irregular down grade or of improvement should be offered.
Nevertheless, it will be in the interest of the patient from the
social standpoint to give him the benefit of the doubt with
respect to his outcome. Not rarely will the worker be rewarded
by a very fair compensation in the patient's life as a result of
the execution of right social measures.

Warren was still a rather well-developed and nourished man,
with a slightly increased blood pressure. His gait was un-
steady and rather stiff. There was a certain incoordination
also in the movements of his arms, and with eyes closed he
would fall to the ground. Both fingers and toes were tremu-
lous at the time of his hospital observation. He had been rather
depressed before coming to the hospital. It would, of course,
seem natural to the normal observer for a man thus affected
to be depressed, and it might seem that the depression was a
perfectly normal sadness; yet depression and emotionality with
a tendency to rather disproportionate weeping have been ob-
served to be symptoms in arteriosclerotic brain disease. The
depression is often much more a symptom due to sundry stimuli
working directly in the tissues or from the juices of the body
than a rational effect of deliberate thinking about one's des-
perate situation.

It became a question whether Warren should not be sent to
a state hospital for permanent care, partly on account of his
dementia, which might be better cared for at a hospital than
at home, and partly on account of the low state of his savings.
It becomes a delicate question of some practical difficulty
whether to advise that such rather gradually deteriorating per-
sons shall remain in the community or be committed to a state
hospital. On the whole, in most communities of a proper de-
gree of civilization, the state hospital will prove to offer better
facilities at a less total cost to all concerned than private meas-
ures can readily equal. It is of course possible with these cases,
as with almost all others, to construct an "institutional equiva-
lent" by turning some home into a hospital. Some years ago

THE KINGDOM OF EVILS 2/3

public authorities upon the insane used to bring up the question
whether the state might not soon be asked to take care of many
persons who could as readily exist outside the institutions. If
we look at the subject from the standpoint of the total cost to
the community, regardless of its exact and temporary source,
we shall probably be compelled to agree that on the whole the
modern trend toward state hospital care of persons hard to
manage outside is the right trend and one to encourage. On
the whole, there is an invisible, but none the less actual, insur-
ance in the community, through the processes of state care,
over against all manner of friction, wasted time, energy, and
money spent by inexpert relatives of mentally sick persons. As
the almshouse stigma disappears from state hospitals, as the
insanity stigma diminishes to a hardly visible point, the trend
toward state care of unfortunates of this group will no doubt
become stronger still. Sentiment will turn into sentiment for,
instead of sentiment against, state care.

Hours spent by Medical record, 19 pages

Social record, 11 pages
Physician, 8^ Social work:

Visits, 10
Psychologist, o Interviews at hospital, 8

Telephone calls, 14
Social worker, 23 Letters, 4

Chordc girl with illegitimate child. Outbursts of temper;
lying. Improvement in maternity home. Persistent social
problem.

Case 65. Though from the psychiatric side Helen Fitz-
patrick gave somewhat the effect of a psychopathic personality,
she was a victim of chorea. Her mental symptoms accordingly
gave rise to the question whether she was not what psychiat-
rists call a "symptomatic" psychosis. These "symptomatic"
mental diseases appear incidentally in the midst of other well-
recognized diseases of a somatic nature, for example, typhoid
fever or pneumonia. Chorea, in the form in which Helen
Fitzpatrick showed it, is itself probably an infectious disease,

274 THE KINGDOM OF EVILS

Looking at the Fitzpatrick girl from the side of social
factors, we find the following list: —

Stealing
Lying

Sex delinquency
Outbursts of temper
Industrial disability
Family discord
Separation from family
Lack of early training
Insufficient income

The major social diagnosis was set down as delinquency.

Upon her admission to the Psychopathic Hospital Helen re-
marked, "We are all a high-strung bunch, the whole of us at
home, and that is all the trouble. We get on each other's
nerves." It seems that, a fortnight before, a probation officer
was called in by Helen's father, because she had cut up her
sister's hair ribbon and thrown flatirons about. Her choreic
movements were very marked while she was in the receiving
ward. She explained she was untidy in dress because she had
been taken from her house at five o'clock in the morning. In
point of fact she had refused to dress at all.

Physically she was found to have, besides choreic movements,
slight heart trouble (often found in choreics). All the re-
flexes were very active. Mentally she was quite inaccessible
to the examiner, although she was plainly oriented in every
way and very emotional. Later she grew more accessible and
rated by psychological tests pretty evenly at fifteen (she rated
at good or very good in the supplementary tests, except in those
for motor coordination wherein she was fair and in those for
voluntary attention where she was poor). While in the hos-
pital she grew quieter and the chorea was even somewhat
lessened.

The court, on representation that supervision for Helen
should be undertaken, readily accepted the offer of supervision
for Helen by our social service. After a few weeks in a con-
valescent home, where it was determined that she had become
pregnant, she was sent to a maternity home and remained until
after the birth of her baby three months later. She Improved
in health and recovered from the chorea. Her mental attitude
improved and she took a mature and sensible view of her situa-

THE KINGDOM OF EVILS 275

tion. She was brighter than most girls in the home. She
showed no conduct irregularities or signs of bad temper while
there.

Her marriage with the child's father, a boy, Thomas Lynch,
was seriously considered. In the beginning her father insisted
that they should be married, but, as the shiftlessness of Lynch
and the rather low standard of his family came to light, Helen's
parents became persuaded that the marriage would be an addi-
tional misfortune. Lynch was willing to marry, but left the
decision to his mother. Mrs. Lynch objected to having her son
"tied for life to a girl like Helen." As the boy was under age,
his mother's consent was necessary, and in the end she flatly
refused to give it, although she did agree that Thomas should
support the baby. The final conclusion of all concerned was
that a marriage between the two would lead only to further
unhappiness. The priest cooperated by advising against the
marriage.

When Helen was ready to leave the maternity home, she
was referred to a children's agency with the understanding
that she and her baby should be boarded in a family where
Helen might be trained in the care of the child. She was fond
of the baby and proud of her. Her attitude in general was
so much improved that she was allowed instead to go home,
but, though she took good care of her baby, she shirked all
other responsibilities and got on so poorly at home that she
was sent to board with the baby in a country home. The baby
after being weaned was boarded separately, and Helen was
placed in another family to do housework. This she did not at
all like, and she proved unsatisfactory to her employer because
she was untruthful and untidy. After three months she was
allowed to go to a relative, who conducted a small sanatorium
and who undertook to be responsible for her. Mrs. Fitzpatrick
took the baby home.

Here then is a case which promises to be a persistent and
year-long problem.

Hours spent by Medical record, 21 pages

Social record, 20 pages
Physician, 3^ Social work:

Visits, 2.2
Psychologist, l Interviews at hospital, 6

Telephone calls, 10
Social worker, 34 Letters, 18

SECTION VI

SOMATOPSYCHOSES ( BODILY DISEASE)

Mother of illegitimate child, with dubious mild psychosis.

Case 66. Ethel Murphy, twenty-seven, had been somewhat
depressed, or at all events sad, since having an illegitimate child
two months before admission. Her eyes were somewhat promi-
nent, her thyroid gland was enlarged, her pulse was rapid.
She thus presented many of the features of a Graves' disease
which was, however, of mild degree. She had never expressed
any suicidal ideas. It was suspected that at one time she had
had auditory hallucinations.

The social worker at the hospital where she was confined
brought her to the Psychopathic Hospital on the ground that
as the baby was to be adopted it was important to have the
mother examined for her mentality, so as to reassure the foster
mother.

The psychologists found that Ethel graded very irregularly
at II. 3 years. She cooperated very well but she made several
illogical errors in the picture puzzle test. The irregularity
(see discussion under case 19) presumably signifies an ac-
quired psychosis rather than an original subnormality, but
there is really no evidence of a definite psychosis unless we
are to think of her as a victim of a slight or minor psychosis
due to hyperthyroidism. Various diagnoses suggested were
subnormality of mind, hyperthyroidism, epilepsy, and exhaus-
tion, but the psychological examination appears to dispose of
the subnormality of mind, at least as a fundamental and origi-
nal state. There was no good evidence of epilepsy. The re-
maining suggestions of hyperthyroidism and exhaustion place
her in an undefined group of mental diseases due to bodily dis-
ease. (See remarks under the case of Helen Fitzpatrick, case
65.) The child was, at the suggestion of the physician, placed
under state care and separated from the mother,

27O

THE KINGDOM OF EVILS 277

The case was followed by the social service and Ethel is

now at work in a contented frame of mind. That the social
service had positively something to do with this result cannot
be contended; although only the usual technique of counsel and
assurance was followed. The earlier difficulties of technique
had centered about getting this girl, who was (in her own
judgment) only slightly ill to take the step of going into the
wards of the Psychopathic Hospital from the out-patient de-
partment from which she had been first referred. Xo doubt
the advance of psychiatry in the far future will bring more
and more of these exceedingly dubious and (from the ordinary
medical viewpoint) extremely mild cases under early suitable
observation.

Hours spent by ^.ledical record, 25 pages

Social record, 9 pages
Physician, 5 Social work:

Visits, 20
Psychologist, i Interviews at hospital, 4

Telephone calls, 9
Social worker, 34V2 Letters, 16

Attack of mental disease follozi'ing influenza.

Case 67. Joseph O'Brien is an example of influenza psy-
chosis incidental to the influenza epidemic in Boston in 191 8.
He was a case of toxic delirium. His mental symptoms de-
veloped in the period of defervescence, in fact seven days after
the temperature fell. It seems that his mind became affected
immediately thereafter. He wanted to wander about, thought
he was on board ship, did not recognize his family and had
to be restrained by his relatives, would fall down, once set
fire to a bureau. He himself said that he had been taking a
good deal of alcohol but this was denied by his relatives.

Upon admission he seemed to be confused and was probably
hallucinated as he reached out his hands to grasp imaginary
objects, apparently looked at the object, and then began pick-
ing at the mattress. His hands were tremulous. He remained
in the hospital four days short of two months and was dis-
charged in greatly improved physical condition. His periods
of confusion kept recurring for three weeks after admission

278 THE KINGDOM OF EVILS

and he developed from time to time a temperature which
reached 103 degrees on the fourth and fifth days after admis-
sion. For the rest, the physical examination proved negative.
The task of the social service is here simple. It is a ques-
tion of follow-iip. The return of symptoms in influenza psy-
chosis is naturally a matter of research at the present time.
Letters are from time to time received from O'Brien showing
that he is getting on well and, in fact, "could not be any better."

Hours spent by Medical record, 11 pages

Social record, o
Physician, 5^ Social work:

Visits, o
Psychologist, o Interviews at hospital, I

Telephone calls, o
Social worker, i Letters, 4

SECTION VII

GERIOPSYCHOSES (OLD AGE)

Senile psychosis. Widow sazv her son zvho had been dead
forty years. Improvement: proper care arranged.

Case 68. Jeanette Burroughs, a widow of seventy-two,
was found getting her meals on a gas heater and doing needle-
work for an art society, with her son paying the board bill.
She went to church and to the movies and called upon her
friends from time to time. She entered the wards of the
Psychopathic Hospital from the out-patient department. She
had had dizzy spells for two or three years, though she had
never fallen down. Sometimes she had a peculiar feeling in
her head like rushing water. She was in many respects very
well preserved, looking younger than her age. She had at one
time been treated for diabetes. Just before coming to the out-
patient department, she had imagined that a son, now forty
years dead, had sat beside her and talked to her. A man in
black had walked up and down in front of her house. She
felt, she said, prostrated with grief, and her sleep had become
disturbed and fitful. She was a voluntary patient at the hos-
pital, but there could be no doubt that she was legally com-
mittable on the score of the clear hallucinations and delusions.

Physically she was well developed and nourished. There
were no obvious lesions of the heart and lungs, and there was
no special disturbance of blood pressure. There were no evi-
dences in the neuromuscular examination that there had ever
been any degree of destructive brain disease. A certain emo-
tionality and a feeling of loss of memory were the most out-
standing mental symptoms, except the ideas revolving about
the resurrection of her dead son.

Admitted April i6, 191 7, it was not until June i that she
gave up her delusions, admitting at that time that, though the
ideas still did "come up at times," she was now "able after
struggling always to put them down." She said she was less

279

28o THE KINGDOM OF EVILS

collected in the evening than in the morning and night, perhaps
better be spoken to earher rather than later in the day.

The only point concerning the discharge of Mrs. Burroughs
now lay in the question whether she would have proper care
on leaving the hospital. This became the province of the social
service to accomplish. During the period of a year the social
service was able to keep her properly boarded out (with some
aid from charitable organizations) and saw to it that she was
visited by friends from time to time. She resumed her habit
of attending church and the movies. She fell and injured her
hip one winter's day — an accident which in an old person is
ordinarily very dangerous. The hip trouble proved to be merely
a contusion, and Mrs. Burroughs recovered. At the end of
this time the case could be closed so far as the Psychopathic
Hospital social service was concerned. She was left under the
care of a non-psychiatric social agency. She has throughout
continued to make a little money by needlework but so far as
can be seen must remain for the rest of her life somewhat of a
charge.

Is Mrs. Burroughs mentally normal? She is at all events
now not a victim of any acute delusional psychosis, whether
senile in causation or of any other origin. Nevertheless from
time to time it appears that she still sees her dead son, and it
is probable that she still bears inside some traces of the former
psychosis. However, if she had never shown more psychop-
athy than she now shows, no doubt, she would never have
appeared on the records of an institution for mental diseases.

Hours spent by Medical record, 28 pages

Social record, 10 pages
Physician, 8 Social work:

Visits, 16
Psychologist, o Interviews at hospital, 0

Telephone calls, 12
Social worker, 21^ Letters, 2

PRESENILE PSYCHOSIS

WOMAN, 55

February June

Unoccupied Occupied

No Pleasures Friends Call

Outbursts of Temper Husband Told Why

Presenile psychosis. Scolded by the clock. Home life al-
tered: improvement.

Case 69. Catherine Cudahy, fifty-five, kept hearing the
big clock on the mantelpiece ticking at her vindictively. She
had become violently enraged by this ticking at least twice in
a period of two months. At last her husband had to send her
to the Psychopathic Hospital. She thought a Holy Father
was on the roof.

Her case was put by the psychiatrists in the presenile group
and was called involutional psychosis. They found her a vic-
tim of hallucinations of hearing, but found that her delusion
about the Holy Father was not very definite or fixed. She
finally admitted that the ticking of the clock at her was only
imaginary. She had not heard the clock ticking after the ar-
rival at the hospital. Her memory seemed to be poor for
details both of recent and remote events, but she could remem-
ber excellently the main events in her life. She was physically
rather obese and, since an operation two years before, had
not been able to go to church. She had begun to feel tired all
the time and had been hearing the clock talking for about five
months. Mrs. Cudahy did not use alcohol (an important nega-
tive fact for the psychiatrists).

The problem for the social worker came upon her discharge
"improved." She was somehow to alter her home life; she
was not to be left alone so much or spend so much time unem-
ployed. These suggestions were carried out and she was made
to take daily exercise outdoors. The relatives were persuaded
to cooperate. They visited her and kept her busy. She re-
ported regularly at the out-patient department every fortnight,
and the clock went definitively out of her life.

Hours spent by Medical record, 11 pages

Social record, 3 pages
Physician, '7 Social work:

Visits, 3
Psychologist, o ■ Interviews at hospital, 6

.. .., r« w . Telephone calls, i

S6cial worker, 7% Letters, 5

283

SECTION VIII

SCHIZOPHRENOSES (DEMENTIA PRAECOX)

Cose of dementia simplex self-supporting in the community.
May look like feehle-mindedness. Training. Simple environ-
ment provided.

Case 70. There is a form of schizophrenia (dementia
praecox) to which the adjective simplex is added. In this form
of the disease there is a certain deterioration and dulHng of
the emotional hfe which fails to be accompanied by the vari-
ous so-called catatonic ( formerly termed cataleptic) symptoms
or by the delusions which are so frequent in most cases of
schizophrenia. Moreover, in these so-called simplex cases the
emotional deterioration may itself be slight, and it is commonly
thought by psychiatrists that a great number of these cases
of dementia simplex are found in the community at large, per-
haps self-supporting or nearly self-supporting, with a history
of having sustained a slight regression in their mental capacity
insufficient to warrant or to suggest their internment in any
hospital for the insane. It is, perhaps, a little difficult for the
layman and even for some of the old-time physicians to think
of cases of schizophrenia (dementia praecox) as "not insane."
Until the concept of mental disease tJiat is not (medico-legal)
insanity becomes deeply imbedded in the lay mind, as well as
in the minds of medical men and social workers, we shall not
come through with a proper program of community mental
hygiene.

Dana Scott, an unmarried man of thirty-seven, was brought
to the Psychopathic Hospital for observation. The woman
with whom he boarded told of violent fits of temper on Scott's
part, during which clothing was torn and furniture knocked
to pieces. As a matter of fact, the landlady greatly overdrew
the story about Scott, as investigation failed to substantiate
any destructive tendencies, nor was the landlady herself a good
sort of person to live with. Nevertheless, with all the smoke

284

THE KINGDOM OF EVILS 285

there was some fire. It was generally agreed that Scott lacked
ambition and initiative and might perhaps be the victim of some
sort of mental defect. Had it not been for the landlady's char-
acter (an angel from heaven, it was said, could not live peace-
ably with her), Scott might have remained in the community
even to this day without being noted by any expert to be psycho-
pathic. He had been a rather queer child. It was told of
him that he took books to the attic and stayed all day with them,
omitting meals. The country neighbors who saw him daily did
not consider him at all harmful. A nurse who brought him
to the hospital said that he was one of the most willing and
obedient patients she had ever had.

Here then was a man who was plainly in some sense a psycho-
path. Perhaps by straining a point he could have been com-
mitted to an institution. He was in charge of a guardian and
had some little property, so that board could be paid for him.
A place in the country was found in the family of a widow
and her daughter. Here Scott could help with chores and
might perhaps obtain some work in the neighborhood. Shortly
letters were received from Scott telling how much he liked his
new home. The family were well satisfied with him and
pleased at having a permanent boarder who was so helpful.

It may be permissible to point out that with the old system,
under which the public or private charitable institution "bor-
rowed no trouble," the hospital work might have ceased with
the diagnosis. In point of fact the social service was at first
merely requested to secure a history. Yet, when such history
was secured, perfectly obvious and valuable social-service meas-
ures stood revealed as the proper procedure. In institutions
where psychiatric social work is carried out effectually this is
no infrequent event, namely, that the social worker, sent out
to secure a few facts, comes back with a series of rational
measures.

Victims of the so-called simplex form of schizophrenia are.
often looked upon, even by physicians, as feeble-minded, nor
is it at all possible in routine examinations always to determine
medically with which condition one is dealing. The psycho-
metric tests, executed by a properly grounded mental examiner,
are sometimes of service ; for instance, in the case of Scott, the
Binet record stood at 12 1/5 years, and he was set down as
beyond question not feeble-minded. His deterioration was

286 THE KINGDOM OF EVILS

not intellectual. The mental impairment was, as it characteris-
tically is in all cases of schizophrenia, in the field of the emo-
tions. There was a marked dulling of them. He was, from
some points of view, not at all unintellectual ; was. for example,
a great reader of books on science and art, and conversed very
fairly on current topics. Although psychopathic in this par-
ticular way, he had no savor of feeble-mindedness and would
have been quite above the level of the majority of the teach-
ings, which are so skillfully carried out for the feeble-mmded
in the schools appropriate for that group of defectives. There
can be no doubt that his life with the widow and her daughter
upon a farm was exactly the right fate for him. As with the
psychological examination, so the physical and mental exami-
nation by psychiatrists at the hospital failed to show any strik-
ing deviations from normal, and the psychiatric impression
of the case, based upon the medical and social history, was
accordingly left at the diagnosis schizophrenia (dementia prae-
cox) of the simplex form.

Of course many cases of schizophrenia, particularly of the
catatonic group above mentioned, are not unlikely to become
suddenly excited or violent; nor can it be absolutely excluded
from the range of possibility that Scott may turn catatonic
through some sudden access of the structural or functional dis-
ease which underlies his symptoms.

The layman, as well as the physician, must have forced upon
his attention a certain sexuality in the symptoms of the ma-
jority of cases of schizophrenia (dementia praecox) ; but it
would be an injustice to many examples of the disease to think
of the sexuality as socially dangerous. Whatever bad habits
in the sexual field and whatever bad table manners and other
impolitenesses Scott might have been guilty of, probably all of
these matters may never fall within the social danger zone.
No doubt many of these psychopathically bad manners and cus-
toms can be, to a great degree, trained out of patients of this
order by proper methods. Just as it is possible to train or tame
certain animals without the employment of the methods open
to a Socrates or a Plato, so it is possible to get sundry effects
sometimes termed recducative in cases of the schizophrenic
group. Whether the training is in all cases a genuine rationali-
zation with the Socratic or Platonic echo may be doubted.
However this may be, the well-managed hospital for the chronic

THE KINGDOM OF EVILS 287

insane, harboring as it does so many victims of this disease,
shortly becomes a very effective school for schisophrenics. In
some governmental units, colonies for such schizophrenics have
been developed, whose star patients are not those who, like
Scott, are very easy to deal with from the outset, but patients
who have passed through most violent and dangerous phases
or phases of extreme apathy and utter economic worthless-
ness, only in the end to be schooled into a very fair efficiency.
With respect to Dana Scott, then, we may perhaps regard
the non-angelic landlady as really something of an angel in
disguise.

Hours spent by Medical record, 38 pages

Social record, 4 pages
Physician, 4^^ Social work:

Visits, 2
Psychologist, i Interviews at hospital, I

Telephone calls, 9
Social worker, 5 Letters, 2

DEMENTIA PRAECOX
IN A MACHINIST

January, ipi6 January, igiy

Industrial Disability Good Health

Unemployment Regular Work

Debts Out of Debt

Suicidal Attempts Cheerful

Vagrant: irregular worker: alcoholic: attempted suicide.
Men's Club. Peculiarities indulged at home. Steady, reliable
zvorkman: a compensated schisophrenic. Economy of social
care.

Case 71. Ralph Johnson left home at thirty-one and was
not heard of for the next seven years. In point of fact he was
roaming over the country on foot, jumping freights and work-
ing ofif and on in railroad gangs. Wanderlust over, Ralph got
back to Boston and worked as an automobile repairer for the
next nine years in six different places. He then ceased to work
altogether for a number of months. It seems that he had had
an infection in his hand for some three months. He felt "run
down and weak," one night grew suddenly talkative, said he
saw dead people, friends of his, and cut an artery in his wrist
with a razor. He had been drinking, and a diagnosis of alco-
holic mental disease was made. There were no sexual contents
or ideas of jealousy in Johnson, but he did show delusions of
persecution (people were going to kill him) and ideas of refer-
ence (the people that he saw outside of his house seemed to
him to be "laying for him"). There were no genuine halluci-
nations (false perceptions) in any sensory field.

Johnson was now referred to the out-patient department and
when jogged by letter reported from time to time. He ceased
to take any alcohol and for the most part felt "fine, though
somewhat unsettled in my mind with thoughts constantly
changing." After a few months he came in one day agitated
and weeping, maintaining that "his left side was dead" and
that he had "done terrible wrongs to several people" — could
he not be chloroformed or have his head cut off? Nobody
would hire such a man as he was and consequently he would
not ask for a job.

However in the course of a few weeks he came in again much
more clear-headed and alert, laughing about the death of his
left side, etc. Again he complained of "lack of concentration
of his thoughts" and talked somewhat ramblingly. He was
fading away, having lost he said, fifty pounds. From time to

291

292 THE KINGDOM OF EVILS

time he reported rather regularly for the Men's Club and after
a time became one of the most regular attendants at this Club
which he found his only recreation. However, finally he
stopped coming and, upon being visited, assumed a hostile
attitude and feigned indifference to the hospital, its staff and
its attendants. He said he had other things to do than to
attend a men's club.

The entire history, since his first appearance at the hospital,
has occupied five years. There was, however, a second appear-
ance in the wards of the Psychopathic Hospital some eleven
months after the first admission. Some days before entrance
to the hospital he had begun to cry out aloud at night. He
said his mother was calling him. For several days he cried out,
talking rather desperately at times yet laughing at other times,
and told of a feeling of electric currents over him. He was a
readily committable case, telling the committing physician that
he had heard God's voice and could hear it in the hospital as
well as at home.

The diagnosis upon his discharge from this second admis-
sion stood at a question of dementia praecox, where the diag-
nosis should, perhaps, still stand. There is no longer any ques-
tion of alcoholic mental disease, despite the rather certain view
of the psychiatrist at his first admission that he was a case of
alcoholic paranoia. Concerning the very existence of any such
disease as alcoholic paranoia psychiatrists have registered
doubts, and it can readily be seen that a commixture of schizo-
phrenic symptoms and alcoholic traits can easily confuse the
issue; many psychiatrists hold that the only true form of men-
tal disease of delusional nature produced by alcohol is the so-
called jealousy-psychosis, an example of which, from the social
point of view, is given in this book under the case of Michael
Piso (case 62).

Johnson remained in the hospital four months after this
second admission. On his discharge he went to work once
again in an automobile repair shop. They said he was a good,
handy man at this work, although he worked somewhat slowly
and if at all hurried got nervous and tired. He had to be laid
off once when work was slack. He readily got another position
at eighteen dollars. They said he was a very steady and reli-
able workman. Once he had a petty argument with his fore-
man and lost his job. Immediately he secured another job, this

THE KINGDOM OF EVILS 293

time at twenty-five dollars a week. Johnson's home was on
a fairly high economic level. He lived with his sister. She
had to be instructed concerning the indulgence of eccentricities
on Johnson's part. She learned not to irritate him overmuch
and was got to manage him with exceeding intelligence.

Is this a case of schizophrenia (dementia praecox) ? It is,
at all events, a case with definite psychopathic phases and prob-
ably belongs somewhere in the general group of the schizo-
phrenics. Yet we may think of Johnson as in some sense a
compensated schizophrenic. Perhaps no one would regard
him as entirely normal, though it would certainly stump the
ordinary observer to pick anything psychopathic out of his
behavior for days and weeks at a time. There seems to be no
question whatever that the social service here aided and abetted
the process of character compensation. Again, we may not
unduly insist that the ordinary method of letting such cases
go adrift in the community without supervision and follow-up
is, in the long run, a much more expensive process to the com-
munity than the cost of proper medical and social care and
supervision (to say nothing of the effects of a non-compen-
sated schizophrenic in the matter of possible violence, and
disturbance of the peace). There was also to consider the alco-
holism, to which this wanderer had fallen victim when he first
came to observation at the age of forty-eight. How many
of the wanderers on the countryside and persons found jump-
ing freights may really be schizophrenic is a statistical ques-
tion whose answer might vary in different communities and
countries. Whether the tally reaches fifty per cent may be
questioned. A good many epileptics, manic-depressive psy-
chotics, and psychoneurotics may also be found amongst the
hoboes to say nothing of queer characters whose abnormalities
are of a milder and not easily classified form. (There is even
a group of so-called victims of poriomania that seem to repre-
sent a specially developed instinct of wandering.)

Hours spent by Medical record, 11 pages

Social record, 18 pages
Physician, 7^ Social work:

Visits, 7
Psychologist, o Interviews at hospital, 12

Telephone calls, 7
Social worker, 27 Letters, 5

294 THE KINGDOM OF EVILS

Litigious vagrant: counterfeiter. Case of paraphrenia sys-
tematica.

Case 72. Manual Rizzo is, no doubt, a victim of so-called
paraphrenia systematica, a new name now rather frequently
used for the so-called delire chronique a evolution systematiqiie
of the French psychiatrist Magnan. Although the task of the
social service here was more contributory to diagnosis than
to treatment or care, the Rizzo case is presented because the
social worker ought to have in mind some general picture of
this condition.

Born in the Azores, Rizzo had come to this country at seven-
teen and was now sixty years of age. For some seven years
he had been a vagrant. He was of a rather villainous appear-
ance on account of a turning out of his reddened eyelids. He
was in general docile and affable but would now and then flare
up. In the admission ofifice he said he thought the officer who
arrested him had it in for him. In fact that same officer had
arrested him seven years before. He was very circumstantial
in his talk and gave the impression that he felt he was a rather
important personage. He said he was quite able to supp9rt
himself. He told circumstantially about his trip from the
Azores and the various jobs which he had held. According
to his own story his trouble had begun in his forty-eighth year
over some trade dollars which he exchanged for legal dollars.
He said that ever since he had had a lawsuit over these dollars
with the United States Government. He had studied law and
was now able to handle his cases perfectly well. He said he
was a strong temperance man and gave a long harangue on
temperance. He explained his not working for seven years
on the ground that he had been too busy looking after his affairs
in court. He said he did a little work now and then and lived
on it. However, he did not live very well for he was alive with
vermin. Upon inquiry at the courthouse it was found that
there were actually docket entries of nine cases. He had lost
all of these cases except one. It appeared that he came to
court daily when not in jail and went to file a suit against some-
one every time he had the necessary three hundred dollars.
As for the jail, it was found that he had been sent to jail at
least twelve times for vagrancy. Apparently he had once had a
small tailor shop and a man was found who had known him

THE KINGDOM OF EVILS 295

for some twenty-five years and knew him as "queer but harm-
less." It appears that in those early days he had been very
religious. He had gone to church daily, sometimes had gone
up to the altar and followed the priest about imitating every-
thing he did toward the celebration of the mass. He bored
holes in silver coins and plugged the holes with other material.
Of recent years he had been seen getting food from garbage
pails. He was also much of a collector, keeping pieces of
paper and other objects that he happened to find in ash cans.
He had served three prison sentences for counterfeiting.

The emotions and the will in the paraphrenic are theoretically
supposed to be normal or to suit the nature of the ideas enter-
tained. Rizzo would grow irritable at times, particularly when
telling of his troubles, but this irritability was a very super-
ficial one and soon disappeared. He assumed rather an ora-
torical attitude when speech-making but here again the action
suited the idea and there could be no question of a primary
disorder of the will. The imitation of the priest at mass may
very possibly be so regarded ; yet on the whole, we are better
entitled to regard this old habit as a sign of his belief, even
at that time, in his being a good deal of a personage.

Hours spent by Medical record, 14 pages

Social record, 3 pages
Physician, 5^ Social work:

Visits, 3
Psychologist, 0 Interviews at hospital, o

Telephone calls, i
Social worker, 4 Letters, o

Diagnosis between schizophrenia and cyclothymia. Skilled
salesman who lost his position through peculiar behavior. Re-
covered: remained steady: works regularly.

Case 73. It is an open secret that it is not an easy psy-
chiatric distinction to draw in every case between schizophrenia
(dementia praecox) and cyclothymia (manic-depressive psy-
chosis). The two diseases are paired in the psychiatrist's mind
as sister diseases, the former rather more frequent than the
latter, both in the number of first cases developing and in the
number remaining in state hospitals under observation. When

296 THE KINGDOM OF EVILS

the diagnosis lies between schizophrenia and cyclothymia, ap-
parently the psychiatrist is statistically somewhat more likely
to be right if he decides upon schizophrenia. It should be in-
sisted that psychiatrists chiefly familiar with chronic institu-
tional material are somewhat more likely to take a pessimistic
view of the prognosis of mental disease in general than are the
consulting neurologists of out-patient departments or of special
practice or the specialists in charge of sanatoriums. In the ten-
day period of observation which the law tends to procure for
the majority of cases at the Psychopathic Hospital in Boston,
there will, perhaps, be an error in diagnosis between these two
diseases of something like fifteen or twenty per cent ; sometimes
the error will be upon one side, sometimes upon the other.

The present case of Paul Ernst is not the first in this book
in which doubt has reigned concerning the diagnosis schizo-
phrenia as against some other form of mental disease. At
least three diagnoses, psychiatrically speaking, have been offered
for Paul Ernst : namely, alcoholic hallucinosis, dementia prae-
cox, and manic-depressive psychosis.

Ernst has been a patient twice at the Psychopathic Hospital,
once in 191 3 and again in 1914-15. At the first admission there
seemed no doubt at all of the diagnosis of dementia praecox.
He had run about his house nude, broken up furniture, and
attacked members of the household. He refused to talk and
became very sullen and obstinate. Just before this he had
begun to worry over business matters and had grown morbidly
depressed when an advance in salary was refused. One Satur-
day night he had been quite broken up and discouraged and
unable to sleep. Sunday he had been normal, but Monday
grew wildly excited. His excitement had lasted twenty-four
hours.

In the hospital he became very violent, at times requiring
seven or eight attendants to put him in the wet pack. He
shouted, screamed, swore, and cried out, talking either sarcas-
tically or very angrily about his treatment. During inactive
periods he assumed a disagreeably sullen manner. He remained
for the most part quiet, inaccessible to the examiners, but
evincing some flight of ideas in his talk.

He was committed to the Boston State Hospital where he
remained a month but was discharged with the diagnosis manic-
depressive psychosis. He became entirely clear in his mind

THE KINGDOM OF EVILS 297

before discharge. He now went back to his work as a sales-
man of a special kind of goods. He had never been alcoholic,
so that the initial suggestion of alcoholic hallucinosis was
unfounded.

After a time he began again to worry about finances. One
day at the department store where he worked, he began to act
peculiarly and left for home. There he smashed windows and
brought down a chandelier. He was again brought to the
Psychopathic Hospital and was there acutely maniacal for
some three days, but after this interval a physical examination
became possible, and he was found to be practically negative
in all respects. Mentally he was suspicious, rather facetious,
and non-cooperative upon admission but obviously perfectly
oriented for time and place. He tore blankets and night shirt,
was profane, obscene, and noisy and was treated by the pro-
longed baths and by packs. He either was not, or assumed not
to be, interested in his surroundings, kept his eyes staring
wide open, and winked constantly. He lay in bed in a rather
strained position. For a while on the first day he stood in
front of a window, talking, but there was a large question
whether the behavior was in response to hallucinations. The
psychiatric reader will note how difficult a diagnosis must be
with such phenomena between schizophrenia and cyclothymia.

On about the seventh day there was a change of phase : he
now appeared confused, was quiet but restive, and threw him-
self from the bed a number of times. He would burst into
noises now and then, but was at other times apparently quite
rational. Things going on about him he took in quickly and
was rather mischievous in his remarks and actions. He began
to speak of his wife and family and talked about wanting to
go home. At the end of three weeks from his admission, it
was possible to send him home in a clear state of mind. He
thought that he really had heard false voices just after admis-
sion, but conceived that they might possibly be the talking of
the attendants misinterpreted by him. He had however once
thought that his brother was there talking. He tried to read
The Three Guardsmen, but could not keep his mind on the
book. He was discharged with the diagnosis dementia praecox,
unimproved, despite the fact that his general status was for
the moment markedly improved.

The social service now took charge of him, and for a period

298 THE KINGDOM OF EVILS

of some two years there is a running record which gives no
sign of deterioration whatever. To be sure his former em-
ployers refused to take him back, though he had been formerly
six years employed by the firm in a rather difficult job. He
now had to take temporary jobs as salesman, acting from time
to time as an extra. Amongst the measures of the social serv-
ice were help to the family in the matter of clothes, more or
less continuous reassurance of the wife as to the nature of her
husband's situation and prognosis, advice concerning work on
his part and the securing of vacations for the children.

Then came the death of the wife, upon learning which it
was thought best to reopen the case from the social service
point of view. However, despite the strain of the situation
the family succeeded in adjusting itself, with the oldest daugh-
ter, a capable girl of seventeen, keeping the house. Meantime
Ernst had remained steady, was working regularly, did not
drink and showed no sign of deterioration. The success of
the family adjustment is the more remarkable when it is con-
sidered that there are nine children (one of whom is choreic).

Is or is not this a case of schizophrenia? Perhaps the shrewd
psychiatrist might say that time only would tell. Others might
say that it was a case of dementia praecox that had gotten well
or had made a compensation practically equivalent to recovery.
Others might insist that the case was one of cyclothymia. For
our part we may content ourselves with insisting that, which-
ever of these diagnoses is rendered, there is a certain statistical
likelihood of error in diagnosis with our present knowledge
(especially perhaps in the war group of cases). There may
be noticed many instances of cases looking even more like
schizophrenia than the present case of Ernst and yet turning
out to be curable or capable of decided remission. Also it is
worth while stressing the fact that the term "dementia" in the
phrase dementia praecox should not be allowed to dominate
anybody's conception of the disease schizophrenia. The so-
called "dementia" is from the standpoint of all clear-cut cases
a matter of deterioration of the emotions and not at all neces-
sarily or characteristically of the intellect. The layman, social
worker, or psychiatrist makes a grave error who carries over
any ideas that he may possess concerning dementia and dements
of the old age group into the so-called dementia of dementia
praecox. Perhaps no more unfortunate term than dementia

THE KINGDOM OF EVILS 299

praecox has yet been devised for an important group of psycho-
pathic patients.

Hours spent by Medical record, 9 pages

Social record, 4 pages
Physician, 7^ Social work:

Visits, 2
Psychologist, o Interviews at hospital, 3

Telephone calls, o
Social worker, 2 Letters, i

Spoiled child. Suicidal attempts: state hospital: dementia
praecox? Marriage to soldier after birth of child: deserted.

Case 74. Nora McCarthy was rather a spoiled child
coming from a not too intelligent, quarrelsome, and alcoholic
family. She could not finish high school because she got "tired
out" and "nervous." It seems that she got depressed rather
often and several times tried suicide, once being taken to a
state hospital for a month after a suicidal attempt and therein
receiving the diagnosis of psychopathic personality from which,
perhaps, there should be no dissent.

For some two years she had been at home doing nothing
whatever. Then she became engaged to a very excellent young
man whom she had known a year and who was about to enlist.
They wanted to marry. Nora's mother refused, whereat Nora
cried continually for a month, refused to eat with the family,
was sent to the Psychopathic Hospital for observation and was
there thought to have schizophrenia (dementia praecox).

It was now discovered that she was pregnant. The fiance
was unable to get a furlough for marriage. There were even
preparations for an eleventh-hour marriage as he was en route
for overseas. In point of fact the detachment had been hur-
ried from train to ship and there was not even time to wire.
An attempt at a proxy marriage was made but there was
some doubt of its legality. Her fiance wrote regularly and
sent her money.

At the hospital she was given mental tests and was
found to grade at I4j^ years on the Stanford-Binet Scale.
Her failure lay not so much in intellectuality but in im-
pulsive and hasty answers. She was physically quite normal,

300 THE KINGDOM OF EVILS

psychiatrically some of her talk about her family might give
ground to the suspicion of her being paranoidal, but on the
whole her statements seemed to be accurate or merely exag-
gerated. Emotionally she was somewhat depressed and at
times gave the appearance of apathy. It was, no doubt, upon
this latter ground that the idea of dementia praecox obtained.
In retrospect it would seem that a good deal of this abnormal
emotional appearance was really due to her feelings about her
pregnancy.

She remained for a time as a voluntary patient under ob-
servation and then went home, where she at first did nothing.
Gradually she became interested (in part under the visitor's
stimulation) in making baby clothes. The baby was born be-
fore its father returned from overseas. She worried about the
supposed nervousness of "the poor little thing." She gradually
became interested in housework and grew interested m taking
care of the baby even to the point of absorption. A proper
marriage had been celebrated.

At this point the social service closed the case. It appears
from the record that this decision was influenced by Mrs. Mc-
Carthy's statement that Nora was "very happy and well and
not at all depressed, taking an interest in her baby and in the
household." The closing note reads : "Case closed since pa-
tient is doing well and further visits would simply antagonize
her and her mother. Her mother is keen enough to recognize
new mental symptoms quickly and to insist upon patient's re-
porting to the doctor." Perhaps the fact that the McCarthys
lived at some distance from the hospital and on top of a steep
hill may have influenced the decision to close the case. Pos-
sibly the fact that several times the visitor climbed the hill only
to be told that Nora was out had also played its part. At any
rate, it was judged that her husband could not take care of
Nora; and it was left to Mrs. McCarthy to explain her con-
dition to him. The young couple were to live with the
McCarthys.

Five months later the social worker received a letter from
Nora saying that her mother would not allow her to talk with
the social worker in the past but that she must see someone
now as she was in great trouble. Her husband had gone to
make a visit to his father several months before and had not

THE KINGDOM OF EVILS 3OI

returned. He had communicated with her several times, but
without letting her know his address. The explanation of this
unexpected conduct in a man of excellent reputation has not
yet been found. She was advised to take legal action to trace
him. Meanwhile she is working as cashier in a department
store, and living at home. She still complains of her family
but manages to get on with them.

Hours spent by Medical record, 36 pages

Social record, 28 pages
Physician, 5^ Social work:

Visits, 53
Psychologist, i Interviews at hospital, 3

Telephone calls, 10
Social worker, 81 Letters, 18

Girl committed after three years' observation. Intensive so-
cial treatment. Diagnosis altered from psychoneurosis to
schizophrenia.

Case 75. We cannot regret the kind or the degree of social
work carried out in the case of Clara Goldberg; yet in the
sequel it might be thought that a good deal of someone's time
was, for Clara Goldberg at least, wasted.

We choose the Goldberg case as one of dementia praecox.
In the end, over three years after our original observation, the
girl was duly committed to a state hospital, with the usual
prognosis of cases of dementia praecox, that is, with the great
likelihood of a persistent deterioration.

We noted above in the case of Alfred Stevens (case 25) an
instance wherein the change of medical diagnosis proved of
the utmost importance. The alteration of the diagnosis from
psychasthenia to cyclothymia (manic-depressive psychosis) in
the case of Stevens worked out tremendously to his benefit;
for his stay in the state institution led to the smoothing out
of his depression and his rehabilitation. Clara Goldberg is an
instance of alteration of diagnosis from the psychoneurotic
group to the schizophrenic (dementia praecox) group. The
commitment of Clara Goldberg to an institution for chronic
cases no doubt makes it somewhat easier for the girl herself
and straightens out many family problems. In the present

302 THE KINGDOM OF EVILS

phase of medical science this will no doubt be the issue in the
majority of cases of schizophrenia (dementia praecox).

Let us first consider her appearance and behavior at the
time of her final commitment as a case of dementia praecox.
She was then twenty-two years of age and had just entered the
hospital with a record of not having eaten anything for several
days. She volunteered the statement that she was a bad girl
and a flirt and did not deserve to eat. Direct questions she
answered correctly, but often wore a silly expression, hiding
her face. For the most part she refused to talk. When asked
a question she sometimes appeared as if about to say some-
thing but her words failed to come; she was "blocked." She
was constantly seen sitting in a chair with her head inclined
forward and the saliva running from her mouth. Now and
then her hands and arms would shake violently. Her pupils
were dilated. For the rest the physical examination was not
remarkable.

A psychological examination would have been at this time
impossible. Clara had, however, been under out-patient de-
partment observation for three years and had twice had a
psychological examination. The second time, about a year
before her appearance in the above described characteristically
schizophrenic state, she made by the Point Scale a level of 13.5
years, grading, in fact, somewhat higher than she had graded
on the previous examination a year before. She did, however,
show on the second examination much poorer planning ability
than she had at first shown.

Looking back upon her history, it is now easy to see schizo-
phrenic traits. She is described as having had many manner-
isms from the early teens, such as touching her face and teeth
constantly and continually moving the muscles of her face.
Efforts to curb these mannerisms — she felt that her expression
was silly and even made definite efforts to change her expres-
sion— resulted in movements worse than ever.

In the later teens it appears that she became untidy in her
person. It was wasteful, she thought, to have money spent
on clothes. She would eat dry bread between meals so that
the bread might not be wasted. A habit of masturbation had
begun at thirteen. It is not even impossible that her deteriora-
tion had begun at school days (for instance, she spent three
years in the seventh grade).

THE KINGDOM OF EVILS 303

Clara's mother had had two attacks of manic-depressive psy-
chosis, and Clara had a sister known to be excitable.

A year before the conditions described above, Clara Gold-
berg was the object of considerable attention. The social
workers described themselves as at the end of their particular
rope. They wanted to know what to do. The impression of
this earlier phase was different. Notes, for example, ran at
a staff meeting : The patient came in shrinking, with eyes red-
dened from weeping. She sat herself down and kept twisting
in her chair with her head downcast. She was apparently
laboring under great emotion. She answered haltingly and
in a low voice. In response to questions she said that her
conscience did not work, that she was not the right sort of
person, that she had caused a certain social worker to leave
the hospital, and finally she burst out weeping loudly.

After the interview and a presentation of all available facts,
there was a remarkable split in the opinions of the staff, some
of the more mature and experienced physicians lining them-
selves on both sides of the question, psychoneurosis versus
schizophrenia. The purposefulness and emotionality of her
reactions suggested psychoneurosis to several competent
workers. Still it was noteworthy that when the "pragmatic
rule" was applied and the question was asked zvhether the pa-
tient was committable or not, eight persons out of eleven felt
that she was at that time committable and but three felt that
she was not committable. Now, inasmuch as on the whole
psychoneuroses are probably best treated outside of state in-
stitutions, whereas on the whole schizophrenics are best treated
in state institutions, this opinion on the part of the staff is
noteworthy. Observers who saw a large psychoneurotic ele-
ment in Clara Goldberg were nevertheless inclined to think
she would do best in a state institution.

It sometimes appears that the application of this "pragmatic
rule," What would you do for the case? is technically superior
to asking the question. What particular disease is this patient
suffering from? To be sure, great authorities agree that one
cannot make the generic diagnosis of mental disease safely
without specifying the particular kind of mental disease that
the patient is assumed to have. No general statement that a
patient is "insane," "unbalanced," "deranged," is quite safe to
accept. When the particular type of mental disease cannot

304 THE KINGDOM OF EVILS

be agreed upon by a large and active medical staff, it appears
to be good technique to ask the pragmatic question as indicated
above.

With respect to social treatment, some recommendations
early made were as follows :

1. Mother's attitude should be changed to one of encourage-
ment instead of fussy concern over Clara.

2. Occupation should be secured for the patient, an occupa-
tion interesting to her; if possible, with small remuneration.

3. The girl should be educated by being placed, if possible,
in a domestic-science class.

4. She was to be influenced to mix more with girls of her
own age.

5. She was to report regularly to the out-patient depart-
ment for medical observation and treatment, and she was to
attend a gymnasium for her physical development.

The results of treatment cannot be very briefly stated. While
(a) living at home she failed to show improvement. She went
from one relative's home to (b) another, thence to (c) a con-
valescent home and thence to (d) a working girls' home.
Finally money was raised to send her to (c) a small summer
camp for girls, whence she went back to (/) the home.
Arrangements were made for (g) medical treatment through
payments by her sister. She was engaged (//) to tell stories to
children at a settlement playground and she was even somewhat
successful in this. She was got to go to (/) a cooking class and
then to (/) a pottery class. She was taught (k) to knit and
kept persistently at the task of knitting a muffler, though the
winter was over before the muffler was finished. She learned
(/) to do simple office work in a fortnight at a public stenog-
rapher's office and then did (m) voluntary work for some
weeks in the office of a civic organization. Then she served
(n) as an errand girl in a dressmaking shop. All these em-
ployers reported that she was useful and willing. She received
no pay for this work -which was regarded as educational. At
the summer camp she entered into all sports and games such as
basketball, archery, and swimming. Physically she was greatly
improved by her stay at the camp, (o) Her teeth were filled.

Whereas at home she had made no physical improvement,
she improved steadily after her first stay at the convalescent
home. The mannerisms that she had had since the early teens

THE KINGDOM OF EVILS 305

became less noticeable. She became able to meet and talk with
other persons without much embarrassment. She looked rather
pretty and appealing and dressed attractively. She spontane-
ously bought Christmas presents for social workers.

About ten months before she fell into the utter dilapidation
described at the outset of this description, Clara began to fall
off in her working capacity. She obtained work in a biscuit
company but had no confidence in her ability to do the work
and shortly gave it up. She became slower in all her processes.
She began to accuse herself and said she was not earning her
board. Her employers in the biscuit factory liked her well
enough but found her in the end "impossible." Her statements
and phrases became peculiar. She said, "I have burned my
sister inside of me." She told the forewoman to discharge
her, saying that she (Clara) was silly-looking and no good and
that she had turned the hair of two of the doctors gray. She
was reticent, seclusive, and very forgetful at the mill. At lunch
time she would disappear with her package very mysteriously
and return in time for work. H addressed by the forewoman
she would tremble and shake and be unable to work.

Here then was a fairly promising case, as cases go, of de-
mentia praecox. Here was a case with a good deal of emotion-
ality and apparent insight with considerable ambition. It was
always possible up to the last to exert the kind of influence
upon her which occupational therapeutists desire to use. Her
mannerisms had developed very early and appeared to have
but a superficial relation to the main currents of her emotions
and will. Was or was not the progress of the schizophrenic
process in Clara Goldberg postponed or slowed down by the
social work, rest, treatment, and occupational therapy ?

Aside from the obvious physical improvements above noted,
can we safely allege that her psychosis was slowed up? The
only concrete point we can make is based upon the two special
psychological examinations at a year's interval, the second about
a year before her commitment (at which time a psychometric
estimate would have been impossible). These two psychologi-
cal examinations, so far as they go, give the impression that,
up until about a year before the final slump, Clara Goldberg's
deterioration was not actively in process. This conclusion is
in accord with the maintenance of her general social status and
working capacity up to and beyond the time of the second

306 THE KINGDOM OF EVILS

psychometric examination. Clara, it is worth noting, found
her own jobs for the most part during the years of our treat-
ment. The last one in which she failed was no doubt too hard
for her.

Can it be that with superior light and power over what we
have at command, a simpler job without the disturbing ele-
ments of exact and monotonous mill work and without the
presence of great numbers of fellow workmen would have
saved her from immediate deterioration? The question, some
might say, is of little importance, since in the long run a patient
like Clara Goldberg is bound to decline. This, some would
say, is the almost universal history in true cases of schizo-
phrenia (dementia praecox). Even concede this unhappy trend
to be the rule, it is nevertheless of the utmost importance to
pursue more intensive studies of just this sort, punctuated by
occasional psychometric examinations, so that we may get
some further light upon the interior of the schizophrenia
problem.

No doubt, under the conditions favoring occupational ther-
apy of modern state institutions, the Goldberg girl will become
a sufficiently effective hospital worker, though of no great
industrial value. Accordingly, although we probably should
not have carried out quite such extensive therapeutic measures
in Clara Goldberg unless she had shown many psychoneurotic
features over and above schizophrenic traits in the early period
of her medical observation, we cannot be sorry that so much
work was done.

Hours spent by Medical record, 44 pages

Social record, 42 pages
Physician, 20^4 Social work:

Visits, 45
Psychologist, 2 Interviews at hospital, 33

Telephone calls, 32
Social worker, 90 Letters, 116

Negro soldier cited for bravery. Dangerous paranoid con-
dition after discharge.

Case 76. George Stone, a negro soldier, who enlisted early
in 1918, made an honorable record overseas. His discharge
papers stated that he was in several battles, received a citation

THE KINGDOM OF EVILS 3P7

for bravery in escorting an officer through shell-fire, and was
cited for the croix de guerre. He was gassed and in conse-
quence was declared eligible for compensation on the ground
of "pain in the region of the heart and lung defects." He was
first sent in as a voluntary patient by the Red Cross, four
months after his discharge from the army.

He had married immediately upon his discharge a widow
about his own age (he was thirty-seven), who had shortly
after joined a religious sect that absorbed a good deal of her
time. Stone began coming to the Red Cross office nearly every
day complaining that his wife stayed out all night and read
the Bible all day in bed, would not cook for him, and did not
care for him "since she got that religion." He talked inces-
santly and laughed a good deal in a silly manner. As he thought
the pains around his heart were being made worse by his
troubles, it was easy to get him to go to the hospital. He was
very jealous of his wife and thought she was trying to injure
him. He told her if she bowed to a man on the street he
would kill him.

The case was diagnosed as a "paranoid condition" and com-
mitment was advised. But as Stone was not considered dan-
gerous he was allowed to go home. Within a month he was
brought back by the police, to whom his wife had turned for
protection. Meanwhile he had gone to Washington for a
physical examination, in order, he said, to prove to his wife
that he was not well, as she said he was. Now he accused his
wife of infidelity and believed she was trying to get rid of him
in order to obtain his pension money. He wrote letters to
prominent officials complaining and asking protection from his
wife. He believed that he had two hundred thousand dollars
invested. He said he felt wonderfully healthy and was happy
because God was in his soul. This time he v*^as committed but
escaped from the hospital and started to his old home in the
South. Through Red Cross channels he was steered into a
hospital in Washington and returned here.

Hours spent by Medical record, 37 pages

Social record, 2 pages
Physician, 7^ Social work:

Visits, o
Psychologist, i Interviews at hospital, 2

Telephone calls, 0
Social worker, 2^ Letters, 6

308 THE KINGDOM OF EVILS

Left a state hospital and enlisted.

Case 77. George Mullen was a single man of twenty-five,
who was born in Canada but had spent most of his life in a
New England state where his family live. In 191 5 he was in
this hospital suffering from dementia praecox. He was com-
mitted to a state hospital for mental diseases and discharged
after five months. He immediately sailed for England and
enlisted in the British Army. He fought in France, was
wounded, and returned home. He seemed indifferent to his
family, was excitable, talked continually about money. After
a week at home he attempted to cash a check that he had signed
with the name of a prominent financier, whose partner he
claimed to be. After observation at this hospital he was again
committed to a state insane hospital with the diagnosis of
dementia praecox confirmed.

Hours spent by Medical record, 13 pages

Social record, i page
Physician, 3^ Social work :

Visits, o
Psychologist, 0 Interviews at hospital, I

Telephone calls, o
Social worker, i Letters, 2

Discharged from the National Guard as a case of dementia
praecox. Drafted: again discharged. Claimed to be faking
mental disease.

Case 78. Paul Dawson was first admitted to the Psycho-
pathic Hospital two years ago. At that time he was twenty-
three and had recently married a girl of seventeen. He had
always been a great liar, had never worked long at a time, and
had loafed a good deal between jobs. A year before he had
joined the National Guard and been sent to the border. He
claimed that he had "faked mental disorder" while there with
his regiment and that he knew the symptoms since he had
worked at times as attendant in state hospitals. He was dis-
charged from the service with the diagnosis dementia praecox
(the diagnosis of the Psychopathic Hospital physicians also).

He was sent home from the border to his father under guard.
He and his wife then went to live with her family, but Dawson

THE KINGDOM OF EVILS 309

got into a quarrel with the in-laws and they were put out.
They were taken in by his family, but when Dawson made no
attempt to get work, his father refused to keep his wife, now
pregnant. She returned alone to her own home, where she
received a somewhat cold welcome. Dawson continued to loaf
and drink, insisting that his wife return to him, but making
no attempt to support her. Although several positions were
suggested to him, he failed to go to work. His wife insisted
that she would not "give him up," but finally she settled down
to the necessity of making her home indefinitely with her fam-
ily. When later her husband was drafted, she received an
allotment. After the birth of a fine boy, her attitude was that
she would return to him if he would "make a man of himself."

When war was declared Dawson at first decided to enlist,
saying it would be better to do that than be drafted, but then
he came to the conclusion that he would wait for the draft. He
was taken into the army in the spring of 1918 and four months
later was sent to the Psychopathic Hospital from camp with
the following statement on the admission blank :

"Insomnia, weakness, pains, and poor appetite. Feared
return of old mental trouble. Hears voices and sees people
about his bed; has delusions that he has put electric wires
about his bed to keep enemies away; believes wife trying to
poison him and wants to do his own cooking. Will not speak
to any patient or be spoken to."

He claimed again that his mental disorder was "faked." He
had written his family from camp that he meant "to put up a
game," because he did not want "to go across" and that he
would "give the doctors a run for their money." The physi-
cians believed that he had delusions, which he denied and tried
to conceal, and made the diagnosis of unclassified paranoid
psychosis. He worked for four months at a state institution
and then joined the merchant marine where he became chief
petty officer on a ship sailing for China.

Hours spent by Medical record, 23 pages

Social record, 17 pages
Physician, 6^ Social work:

Visits, 22
Psychologist, i Interviews at hospital, 5

Telephone calls, 35
Social worker, 41 J4 Letters, 4

310 THE KINGDOM OF EVILS

Corporal who developed dementia praecox in camp.

Case 79. Howard Lancaster when drafted was doing ex-
ceptionally well in a bonding house. He worked hard and
efficiently and spent his leisure time studying law. He had
always been inclined to be seclusive and a little suspicious, and
he had times of being depressed, when he thought he was not
doing his work well and that his associates were talking about
his falling-off. He tried to enlist and was rejected because of
a defective eye; but later he was drafted. After two or three
weeks in camp, he was promoted to corporal. After two
months he became ill, acting and talking in a silly manner, say-
ing that he heard voices forbidding him to perform his duties.
The diagnosis was dementia praecox. He was committed to a
hospital, but in a month had improved enough to be discharged
"on visit" to his family.

Hours spent by Medical record, 34 pages

Social record, 2 pages
Physician, 4V2 Social work:

Visits, I
Psychologist, i Interviews at hospital, i

Telephone calls, 0
Social worker, 2 Letters, 2

Army captain zvith dual personality. Arrest for forgery.

Case 80. Major Dobson (who proved to be Captain
James Hill) was sent for examination by federal authorities
after arrest on the charge of having forged a check for one
thousand dollars under the name of Major Mark S. Dobson.
He claimed a dual personality but could not explain it. He
said that he used two names, because he had two fathers, one
of whom was dead, the name of the living one being Hill. He
believed that he had the rank of major and that the check he
tried to cash was his pay check. He thought that Captain
Hill had been discharged but that Major Dobson was still in
the service. Although he had lived all his life in Florida, he
claimed that part of him had been educated in Europe. His
conduct had been peculiar for several months, — in France he
had wandered about for a month (he said he knew what he
was doing but could not control it). He had been hearing

THE KINGDOM OF EVILS 3II

people say such things as, "Kill him." He was worried about
himself and anxious for help in solving his problem. The
newspapers had his story under the headline, "Afflicted by
Shell-Shock."

Captain Hill had seen several terms of army life. He enlisted
in 1912 and purchased release in 1913; reenlisted in 1914 and
again purchased release in 191 5. In 1916 he went to an offi-
cers' training camp and was commissioned. He served eighteen
months in France and was once wounded. While overseas he
cabled a proposal of marriage to a girl he had known for two
years, a dancer in a comic opera company. They were married
on his return and the week that Hill was taken into custody, his
wife went on tour. The court charge of forgery was dropped
when the hospital physicians submitted the diagnosis dementia
praecox and the captain was sent to his family for hospital care.

Hours spent by Medical record, 19 pages

Social record, 8 pages
Physician, 4^4 Social work :

Visits, I
Psychologist, o Interviews at hospital, 3

Telephone calls, 11
Social worker, 5^2 Letters, 4

SECTION IX

CYCLOTHYMOSES ( MANIC-DEPRESSIVE PSYCHOSES)

Young woman with spells of wandering and eroticism.
Three diagnoses rendered — psychoneurosis, dementia praecox,
manic-depressive psychosis. Importance of diagnosis in
treatment.

Case 8i. We find stretched on the records in the case of
Winifred Reed three different psychiatric diagnoses; namely,
psychoneurosis, dementia praecox, and manic-depressive psy-
chosis.

Of all the diagnoses in the whole of psychiatry no doubt
these three offer the maximum of difficulty. To be sure, 'we
place in an eleventh or miscellaneous group of psychoses sundry
conditions of still greater obscurity, both as to their nature
and frequently as to their diagnosis. Yet these eleventh group
cases of psychopathia are indeed so obscure that they prac-
tically defy analysis, but the three diagnoses that come in ques-
tion with Winifred Reed fall into groups which in our Psycho-
pathic Hospital experience we place just ahead of the eleventh
group. The schizophrenic group (dementia praecox) we have
placed eighth in our list; the cyclothymic (manic-depressive)
stands ninth ; and the psychoneurotic group stands tenth. In
short, after we have swept aside the major diagnostic groups
of a more definite character, we find ourselves confronting
groups of cases of great diagnostic difficulty and very doubtful
genesis. It will be the task of the psychiatry of the future to
unravel the cause or causes of the schizophrenic, cyclothymic,
and psychoneurotic disorders. Nor can we undertake in this
book to expound at any length the psychiatric nature of these
or any other conditions. Let us insist that whatever doubt
may at bottom prevail concerning the nature and causes of
these types of disease, nevertheless their treatment, once a par-
ticular diagnosis is rendered, is almost always specifically indi-
cated. Let us insist with all emphasis that it makes every dif-

^12

THE KINGDOM OF EVILS 3I3

ference to the medical and social treatment of a case of mental
disease whether it receives the diagnosis schizophrenia (demen-
tia praecox), cyclothymia (manic-depressive psychosis) , or
psychoneiirosis. Moreover, let us insist that it makes a differ-
ence to the patient even when the diagnosis is incorrect. We
have above considered the interesting case of Alfred Stevens
(case 25) to whose fate the matter of a psychiatric diagnosis
was of extreme importance. It will be remembered that Alfred
Stevens was erroneously classified as a psychoneurotic, was
amply treated therefor, failed to make progress, and was
promptly put on the right road again when the correct diagnosis
(manic-depressive) was rendered. It will be recalled that as
soon as Stevens was called a manic-depressive he was forthwith
prevailed upon to enter a state hospital, wherein all his troubles
quite smoothed out.

Winifred Reed was not very long seriously considered a
psychoneurotic; nor was psychotherapy of the sort indicated in
psychoneurosis used upon her. (In this instance, as every-
where when we speak of psychotherapy and its applicability or
non-applicability to a case, we are obviously not talking about
such advice and counsel as are properly given to every normal
person ; we are talking about psychotherapy deliberately chosen
and planned to affect the particular rationalization of a particu-
lar difficulty.) The vital issue lay between the diagnoses of
dementia praecox and manic-depressive psychosis. In the end,
Winifred Reed proved, we believe, to be a victim of manic-
depressive psychosis, but still she was for a long time regarded
as a victim of dementia praecox. Omitting consideration of the
medical data for and against these diagnoses, what are the
prognostic features that bear upon social treatment? The
psychiatric social worker must, of course, rely upon the medi-
cal diagnosis (erroneous though it may be in fifteen or twenty
per cent of cases amongst these dubious groups) and must pro-
ceed on the hypotheses that underly these respective diagnoses.

We ordinarily think of dementia praecox as a progressive
mental disease without characteristic tendency to recovery.
Per contra we ordinarily think of manic-depressive psychosis
as a disease with a strong tendency to recovery and to recur-
rence. If these ideas are taken boldly at their face value, then
the logician might conclude that this victim of dementia prae-
cox tending to an incurable dementia might as well forthwith

314 THE KINGDOM OF EVILS

proceed to his finish in some receptacle for the chronic insane.
Per contra the logician might conceive that this victim of manic-
depressive psychosis being likely to get well at least of this
particular attack, might well be tided over his attack at home.
But these conclusions of the logician taking the classical prog-
noses on their face value would land us in many a quagmire.
The fact is that the schizophrenic, flattened out and leveled
down as he may to a greater or less extent become, can often
find a suitable nidus in his own home or somewhere in the
community outside hospital walls. Contrariwise, the manic-
depressive can be tided over his attack at a home only with
extremes of difficulty which are quite unwarranted. You may
perhaps at any time set up an institutional equivalent in a
private home, with day nurses and night nurses and constant
medical care, but ten to one you have not helped the patient's
own attitude to his disorder in the slightest and there has been
a very trifling gain in the avoidance of whatever stigma now
remains for the mental case in the modern community. Far
better is it that the tiding over shall be more effective and safely
accomplished within the walls of a hospital. Moreover, if we
attach to the benefits of the hospital stay the value of precise
records for comparison with the data of future attacks and the
potential virtues of social work in family adjustment, then we
feel that there can be no doubt medically or socially of the
propriety of sending these particular curables to hospitals. We
again arrive at an apparent absurdity; namely, that curables
should he forthwith hospitalized and that incurables shall he
kept in the cotnrminity. Obvious though this conclusion is, it
nevertheless proves difficult to make the world understand it.

Winifred Reed was first admitted to the Psychopathic Hos-
pital when twenty-four years of age. The physician who sug-
gested that she ought to be observed said that she had been
much depressed and thought she was "crazy." There was a
history of her having wandered for two days and a night in
the late autumn, hoping to die from starvation and exposure.
Again, in the dead of winter, she had walked off knee-deep in
snow, to the point of freezing her feet, again with the idea of
dying from exposure. Upon examination there was little
psychiatrically to find; she had a considerable insight into her
situation. Aside from depression and over-active reflexes,
she seemed mentally and physically normal enough. After

THE KINGDOM OF EVILS 315

elaborate discussion at staff meeting, the staff felt inclined to
make the diagnosis dementia praecox, though psychoneurosis
was also considered.

She was then dismissed to the social service, who fell into
sundry difficulties with her. Her father was alcoholic. Her
mother was a Christian Scientist. It seems that the father had
become intemperate when Winifred was about ten years old,
and had steadily become more and more of a drunkard (ap-
pearing at one time in a state hospital). The girl had been a
stenographer without special responsibilities. It is not quite
certain what the first mental symptoms were and when they
occurred. It appears that she lost her job through an odd bit
of behavior which has never been explained (she charged a
fellow employee with stealing another's hat). She then lost
another job after some three weeks and then tried to act as a
salesman for her father. It appears that Winifred talked
rather boldly about being "sporty." Some employers thought
that she was "man crazy." It was difficult to decipher the
course of her conduct because of the unreasonable character
of the father. At one time the girl was kept in the back part
of her father's shop, and customers were assured that the
girl was kept there because she was going crazy. Just before
coming to the hospital, Winifred had become careless and
indifferent, though previously energetic and bright. In fact,
Winifred had obtained unusually good grades at the high school
from which she had graduated.

It is difficult or impossible to unravel some of the features
of her history. There is no doubt that she was, in the stock
phrase of the employers, "man crazy" from time to time. She
herself dated her excess of erotic passion from the age of
twenty-one, when, according to her story, she had sex inter-
course for the first time. According to the girl, she had tried
to fight against her intensity of passion but was not able to
control it. In the same (twenty-first) year, there was also a
period of depression which lasted about three months. Nothing
connects this depression directly with the initial sex intercourse.
These periods of depression have come on from time to time
every year since, and in fact have increased in frequency as
well as in duration.

If one read the history as we have just reviewed it there
might seem to be little doubt of the patient's being a victim

3l6 THE KINGDOM OF EVILS

of manic-depressive psychosis. Her general excitability of
temper, her attacks of depression, and her erotic episodes and
trend would be entirely consistent with the diagnosis. If we
look back, however, at the picture which she presented upon her
first admission to the hospital after her fugue-like wanderings
into the woods and snow, and if we bear in mind her change
of character and indifference, to say nothing of the oddities of
her behavior, then we shall readily see how the diagnosis of a
mild dementia praecox could have been set up.

At all events, such is the general opinion of Winifred Reed.
The best line appeared to be to manage her in the community
with such moral support of the girl herself and of the family
as might keep her on a fair level of social efificiency. Despite
the fact that the prognosis of dementia praecox would run to a
certain impairment of personal and social efficiency, yet from
our social endeavors with the girl and with her associates much
might be hoped. An endeavor was made to separate her from
her alcoholic father and socially inadequate mother and to put
her at suitable employment. The first step consisted in sending
her to a convalescent home. From this house she forthwith
escaped and repaired to her own home. Twice afterward she
was also placed in convalescent homes, but whether from a con-
valescent home or from good conditions in some job that was
got for her, Winifred Reed never failed to leave; she would
repair to her home and there keep in hiding for a time, eventu-
ally telephoning to the hospital for help. Her eroticism and
her odd behavior did not abolish the fidelity of a patient ad-
mirer who stood by her throughout, and though practically
engaged to the girl, never married her.

Eventually, after some seventeen months, the overt act
which so often supervenes with psychopaths occurred. Ap-
parently she had a fresh outburst of eroticism (which is medi-
cally to be regarded as a form of attack in her disease). She
was arrested for cohabitation and again brought to the hospital.
The diagnosis seemed now to be much plainer than in the be-
ginning. Instead of community care, with the securing of
jobs for which she was not ready, and difficult supervision,
she was accorded hospital treatment. In two months she could
be discharged to probation. Her attack of slight mania had
subsided. The further steps in this case, in which similar
attacks are only to be expected, are part of a rather clear

THE KINGDOM OF EVILS 31/

program. With this diagnosis in hand, it seems as if Winifred
Reed could in future be managed with considerable if not with
absolute success.

Hours spent by Medical record, 64 pages

Social record, 50 pages
Physician, 13 Social work:

Visits, 23
Psychologist, 2 Interviews at hospital, 13

Telephone calls, 122
Social worker, 81 Letters, 16

Cyclothymic waiter came to the out-patient department
because he lacked initiative.

Case 82. William Donahue, thirty-six, came of his own
volition to the Psychopathic Hospital, out-patient department,
saying he had had depressed spells from a boy up. He said he
was confident enough of his ability to work, but "lacked initia-
tive." He said too that he had considerable trouble in getting
on with other people, being regarded as a "grouch." It ap-
peared upon conversation that he had had short periods of
exhilaration. The diagnosis of manic-depressive psychosis
was soon made by the psychiatrist, and Donahue was referred
to the social service for employment. This was procured at
a department store. He worked there for a number of months,
but reported from time to time that he had not quite got back
to his best form.

Donahue was never referred to the wards of the hospital,
but was handled from the out-patient department and the social
service. It seems he had worked always rather irregularly, usu-
ally as a waiter. His head had been split open when he was
knocked down by a runaway horse at the age of eight. Dona-
hue had never been very strong, had never taken much part in
games with other boys, and had been out of school a great deal
owing to sickness. His father was a heavy drinker. No spe-
cial mental tests were made upon Donahue. He often left his
jobs, which rarely lasted over a few months, for no reason
whatever. He always wanted to work on his own responsibility.
He wanted to be let alone and, if he was not let alone, he did
not want to stay. He was self-supporting except between jobs,

3l8 THE KINGDOM OF EVILS

when he was dependent upon relatives. He was now in debt
to relatives and to the dentist.

Amongst the measures of treatment given the patient, it was
suggested that he attend the Men's Club. He became a most
regular attendant thereat. One important measure was the
explanation to his employers of his exact condition and reports
to them of his improvement as it grew. Social treatment in-
cluded such items as follows : —

Interview to discuss possibility of advancement at his depart-
ment store ;

To persuade patient of the necessity of more aggressiveness
on his part for the purpose of getting promoted ;

To increase his self-confidence and to widen his interests and
increase his acquaintance.

A letter would occasionally be sent to express the visitors'
regret at not seeing him at the Men's Club.

The situation was explained to the secretary of a voluntary
association in which he took out membership.

As a result Donahue did greatly improve although he re-
mained supersensitive and somewhat lacking in confidence and
aggressiveness. He became more interested in reading and cur-
rent events. His aggressiveness w^ore off. He felt he was now
doing a man's work and was filled with the idea of getting ahead
in the world.

This is an example of the handling of what may be termed a
cyclothymic constitution (mild manic-depressive psychosis).
The more we look the more examples of such mild or severe
cyclothymic constitutions are found in all corners of the world.
Precisely these patients make rather good workmen, indeed
sometimes extraordinarily good workmen if their psychopathic
sides are understood and proper adjustments made. Of course
neither the psychiatrist nor the social worker should attach too
much significance to improvement in cyclothymic cases, at least
from the point of view of claiming such improvement as the
result of treatment.

As demonstrated elsewhere in this book, there have been
numerous cases where such patients have improved over periods
of months and years under influences beyond our knowledge.
Still there can be no doubt that direct effects are obtained upon

THE KINGDOM OF EVILS 319

the under and over activities of some of these cyclothymic
patients by counsel, encouragement, and direction of interests.

Hours spent by Medical record, i page

Social record, 19 pages
Physician, iy'2 Social work:

Visits, 6
Psychologist, o Interviews at hospital, 14

Telephone calls, 18
Social worker, 32 Letters, 19

Governess with attacks of excitement and depression, requir-
ing hospital care.

Case 83. Marie Dubois, forty, was a bookkeeper, very
competent and well educated, of French-Canadian origin. She
had a spell of depression at about thirty years of age, where-
upon she came across the line and worked variously as a gov-
erness and a bookkeeper, holding her positions for long periods
except during the year preceding her arrival at the hospital.
We surmise that her succession of jobs during her fortieth
year was due to the gradual appearance of the second depres-
sive phase. Yet there was a more striking occasion for the
eventual necessity of hospital care, — her mother died and two
days later her cousin. This cousin she had been living with as
his wife but without legal sanction, since her religion frowned
upon a cousin marriage. She then fell into a depression. She
was profoundly in love with this cousin. She wrote in her
diary of how he died of a Sunday and how every Sunday fol-
lowing she grew sad.

It was some six months after the paramour's death that she
got into a rather small difficulty which brought her to the
hospital. She appeared at a place where she had formerly
worked and was well liked and wanted to sell some tickets for
a charity. She was allowed to set up her booth. She set this
booth up rather inconveniently to the shop but claimed that
God told her just how to do so and that the Cardinal had
blessed her sales. She got very angry when requested to move
the booth. During her depression she had been rather religious.
She tells in her diary of having gone eighteen times to see,
understand, and enjoy Billy Sunday's pantomime remarking

320 THE KINGDOM OF EVILS

that "it was a splendid derivatif from my recent sorrow" and
that she "admired his perfect subtlety and his complete under-
standing of the masses of people."

While in hospital she narrates in her diary how "in my soul
then I did see at first a beautiful grave of white marble, the
top stone covering herself slowly with a small quantity of
tulle (material for both dresses and veils) . It was a young lady
in the grave. I was helping the lover. It was growing and
growing in my very presence until it was a beauty. Then ap-
peared under this soft mass some wonderful stems of white
lilies. I have never seen anything so beautiful in a funeral
marble yet. This stayed with me all night, but in the meantime
something was going on to prepare a wonderful Caliban that
the committee has never heard of. (Too bad it is only in my
imagination.)"

The first attack, as noted, had been one of depression and
her mood after the death of her mother and her lover had
been chiefly a depressive one. The episode of the ticket-selling
was a sample, however, of excitement and the diagnosis ren-
dered at the hospital was that of manic-depressive psychosis-
manic phase. Miss Dubois was very restless and irritated at
the time she was examined. She could not concentrate her
attention. She grew restless and required packs and baths.
She would sing and play about the room dramatically. She
remained nude a part of the time but seemed not so much
erotic as to have lost for the time being her delicacy. (In point
of fact her diary records a considerable delicacy with respect
to her early handling by the nurses.) Now and again she
would seem to react to hallucinations of vision and hearing
and above has been given an example of the sort of visual hal-
lucination, if it be one, which she had. The imagery was more
of that fixed and solid sort which psychologists have recently
discussed, than of the fleeting, cinema-like sort which we are
accustomed to find in the psychoses. She assumed no fixed
attitudes at any time, took her nourishment willingly, and ap-
parently had a rather good insight into her abnormality of
mind. Physically she was almost normal, though her eyes were
a bit prominent.

Upon discharge she reported from time to time to the out-
patient department and the notes indicate that she remained

THE KINGDOM OF EVILS 321

exhilarated for some six months further. After a year it
seemed to the out-patient medical staff that she need report no
longer as a patient. To be sure she was a little overemphatic in
her speech but perhaps not more so than a French-Canadian
woman should be.

Hours spent by Medical record, 22 pages

Social record, 15 pages
Physician, 9^ Social work :

Visits, 20
Psychologist, o Interviews at hospital, 2

Telephone calls, 8
Social worker, 35 Letters, 6

Hyponmnic hoy on probation: ran away. A "had actor" in
school.

Case 84. Joe Marino, fifteen years old when he was
first referred to the hospital from a juvenile court, is a kind of
adolescent delinquent that psychiatrists feel belongs pretty cer-
tainly in one of the more definite groups of mental diseases,
namely the so-called manic-depressive or cyclothymic group.
He yielded the impression of the so-called "hypomanic" man-
ner of mild overexcitement when he first came to the hospital
and his entire history seems consistent with his being funda-
mentally a cyclothymic.

He was a short, stocky Italian boy with rather an old-looking
face. He was very talkative and noisy, easy enough to control
but apt to get into mischief when not under immediate super-
vision. It seems that he had had an idea, perhaps an obsession,
about going to California. He was opposed in this idea at
home and became abusive and rather violent there. He boarded
a train and got as far as Providence, when he was picked up by
the police. He was brought back to the juvenile court where
he had twice before been and from which he was even at that
time on probation. Employers had always found him way-
ward and impertinent, and he had never stuck to a job longer
than five weeks, for the most part leaving a job after only a
few days. He had been arrested for breaking and entering,
had ripped off plastering in unoccupied houses, and was re-

322 THE KINGDOM OF EVILS

garded as a "bad actor" in school, where he had shouted and
broken windows.

He was one of seven American-born children in an Italian
family that lived in cramped and rather squalid quarters. His
father got rather irregular employment but was somewhat in-
telligent and well disposed. The mother was an ignorant and
excitable woman suspicious of interference and unreliable.
The other six children were lively, jolly children and not espe-
cially troublesome. The family regarded Joe's visits to the hos-
pital as rather a joke. They regarded his activity and pug-
naciousness as due to his being "a kid and full of fun." Joe
was under hospital observation in all for about seven weeks at
two different times. His associations and his replies to ques-
tions were very rapid. He showed very well the symptom
called distractability. picking up all the features of his immedi-
ate environment and weaving them into the conversation.
Upon staff rounds, for example, he talked as if he were in a
courtroom, affixing comments to the bystanders, calling one a
lawyer, another a witness, another a stool pigeon, and the like.
He was at times so active that the treatment of prolonged
baths was executed ; and the hypomania so verged upon a true
mania that the committing physicians felt themselves entitled
to take the extreme step of actually committing him to hospital
by procedures of the probate court.

After his discharge from the hospital he remained "on visit" ;
that is, on the books subject to recall for a year. He got his
picture in the newspapers at one time by desiring to enlist in
the marines as a water boy who had had plenty of experience.
He said that as his name was Marino he ought easily to get
into the marines. (Of course the name Marino is fictitious
and the very characteristic maniacal pun which the boy made
was actually a good deal more complex than the form we offer.)

The case was closed by the social service some eight months
after his first appearance at the hospital although, as above
stated, his name was carried on the books of the hospital for a
year. At the expiration of the eight months it would seem that
the great wave of overexcitement which had been punctuated
by the various adventures mentioned was now, for the time
at least, well over. Perhaps Joe will appear again in another
phase of mania or possibly even of depression if our diagnosis
of cyclothymia is a correct one. No doubt previous experi-

THE KINGDOM OF EVILS 323

ence with Joe will allow for rapid and accurate decisions con-
cerning him should he become once more a "bad actor."

Hours spent by Medical record. 14 pages

Social record, 17 pages
Physician, 8j^ Social work :

Visits, 13
Psychologist, 0 Interviews at hospital, I

Telephone calls, 8
Social worker, 25 Letters, 5

Sailor who became overactive. Had been given to ''excited
actions."

Case 85. The following is Robert MacPherson's story as
recorded by the social worker, when she interviewed him on
the wards : —

"The patient is a nice-looking boy with a very pleasant
manner, which, however, seems to become rather suspicious at
times. He is twenty-three years old. He was born in Phila-
delphia. The family came to Boston when he was a baby.
When he was three years old, his mother was taken to a state
hospital, and he and his younger sister were placed in some
sort of institution at that time. His sister developed pneumonia
and died. Patient's father took him at that time, and patient
has lived with him since then until a year ago. Patient says
his father has never worked very steadily, that he is a drinking
man and so was his father before him. His father is now
about sixty years of age. He is not a man of much education
and patient thinks maybe he was jealous of him because he
got so far ahead of him. He thinks his mother was quite
educated. He does not know how old she is, as she will
never tell him. She is now in a state hospital where he goes
to see her. She seems all right but at times if she becomes
discontented or something happens to upset her, she is liable
to create quite a disturbance.

"Patient went to grammar school, then to a high school of
commerce where he graduated, and also graduated from an
evening high school. Then he went to a commercial college
for two or three years but he did not finish, as he did not
like the course. While he was still going to school he worked
with Weston Brothers as a clerk (his father works there as a
packer). He also worked at the Plymouth Publishing Com-

324 THE KINGDOM OF EVILS

pany and ushered at the Lexington Theater. At clerking he
would make about three dollars a week a^d at ushering he
earned fifty cents a performance; however, he thinks the latter
is 'a poor way to earn money.' When patient started work
regularly, he started in at the National Sugar Company where
he earned nine dollars a week. Then he worked at the
American Electrical Company, earning fourteen dollars a week ;
later he worked for the Standard Insurance Company 'at
eighteen dollars a week. He was two years there and he says
he knows enough about insurance not to want to take it out.

"When war was declared he enlisted in the naval reserve; he
was never called and so secured his discharge August 21, 191 7>
but reenlisted in the United States coast guards. He was on a
revenue-cutter. About July, 19 18, he was sent to a naval hos-
pital where he stayed a month. He was circumcised there.
He was discharged in August, 1918. It was about this time
that his mental trouble began. He became more ambitious,
attempted things he had never done before and led 'sort of a
wild life.' He had saved up about seven hundred and fifty
dollars and he purchased a Big Six Buick. He says that is
enough to show he was 'out of his mind.' He would invite
everybody to ride and would 'kick them out' just as quickly.
He sold the magazine, The Puritan, and because he was in uni-
form he made quite a lot of money and he spent it just as
quickly. His father 'kicked him out.' After his discharge he
became a four-minute man and it was while he was speaking
in dififerent theaters that he was advised to go to the Fenway
School of Oratory. There he met a Mrs. Reed. They oflfered
to give him lessons and after a time Mrs. Green (who was
also connected with the school), Mrs. Reed, and Mr. Reed
(who was a tea salesman) all 'vamped' him, so that he went to
live with them. He says he will do anything that they tell him
to do. Patient later went to work with the United Importa-
tion Company. At first he was a checker. Later he started the
follow-up system and soon established a department of adver-
tising. When he started he was the only one in the department,
but now there are six and he is the head of the department.
His salary is only twenty dollars a week ; but he made more
on the side in business deals in connection with the firm. He
says he has made as much as ten thousand dollars at one time,
but he does not often make these sales. Patient wants to get
into the foreign department and wants to get down to South
America. He speaks some Spanish which he studied in high
school and has made arrangements to study Portuguese with
the son of a former ambassador.

THE KINGDOM OF EVILS 325

"Patient says that he has recently become interested in pur-
chasing automobiles again, and he thinks that maybe it is
because he has been doing these things that they got him into
the hospital, but he intends to sue whoever was responsible for
having him 'shanghaied' here. Patient already has four motor
cycles, a motor boat, a sail boat, a deer skin, and a bear skin,
which he purchased through the company and which he intends
to have made into gloves and a coat. He doesn't know how
much he has in the bank. He has been looking up Buick
roadsters and on Saturday he repeated 'the same sort of stunt'
that he had done before, just after he was discharged from
the navy.

"At that time he took two girls out riding in his car, drove
them out a mile and then stopped his car in front of a garage
and made them all walk home. On Saturday he asked the
same girl to go out with him in the roadster, which he was
trying out; he drove her over to the garage, where he made
a deposit on the car; he left the car there and took her home
in a jitney, Saturday night Mrs. Reed asked him to lend her
four hundred dollars. He thought this was very queer as she
had never made such a request before. The more he thought
the matter over the queerer it seemed, so he took a suitcase and
decided to go back to his father to stay with him for a while.
He promised to let them know when he got to his father's, so
he telephoned them and they asked him to come out. He and
his father went. He says that while they were there, he noticed
that they kept a pretty close watch on him. A Dr. and Mrs.
Foster arrived, who were evidently friends of the Reeds. Dr.
Foster started talking to him and seemed to draw him out, but
he was perfectly willing, so he talked ahead. The doctor said
that he had a car to sell, and invited him to come riding with
him, so they went and he was brought here to the Psychopathic
Hospital. Patient says that 'the same stunt was pulled' on his
mother twenty years ago and it is no wonder that she is still
in a state hospital. He knows that there is something wrong
with her now, but his father has never told him what happened
twenty years ago. He would like to know about it as he thinks
there may have been 'some crooked work.' "

This somewhat highly colored story if taken with a grain of
salt gives a fairly accurate account of Robert's experiences
between the time of his discharge from the navy, in the sum-
mer of 1 91 8, and his stay in this hospital, in the fall of 19 19.
He was very talkative and active, getting into difficulty with the
other patients. He had no marked outbursts of excitement but

326 THE KINGDOM OF EVILS

was continually restless. His hypomanic condition made in-
definite hospital care necessary and he was transferred to the
same state hospital where his mother was a patient.

Before enlistment Robert had worked in an insurance office
and lived with his father, who helped out with his expenses,
so that he had been able to save about seven hundred dollars.
He had shown average ability in school but had been more
interested in athletics than in studies. At one time he was
engaged to a girl who broke the engagement on account of
Robert's "excited actions." He did not show any great or
deep regret over the affair. He was always full of energy; in
the habit of having his own way and rather self -centered. He
was neat in his personal habits and did not show peculiarities of
conduct up to the time he left the navy. His attack of excite-
ment began about a month before his discharge.

Hours spent by Medical record, 14 pages

Social record, 5 pages
Physician, 3^ Social work:

Visits, o
Psychologist, o Interviews at hospital, 2

Telephone calls, 5
Social worker, 41/2 Letters, 5

Enlisted; gassed; discharged. Became restless, talkative,
moralistic. Voluntary patient.

Case 86. Clarence Adams was gassed fourteen months
after his enlistment and, after passing through several hospitals
in France, was discharged four months later in the neighbor-
hood of Boston. He took a few months' vacation and then
during the hot weather of early summer held a clerical position
in a large mill. One day he fainted on the job and gave it up.
He held several other positions for short periods but was over-
active and could not concentrate. His family then sent him to
the woods, by a doctor's advice, in company with a man com-
panion. After some weeks his companion felt that he was
not improving and brought him back to Boston. When he was
admitted to the Psychopathic Hospital he was restless and talk-
ative. He took pleasure in reading the Bible and instructing
the patients from it.

THE KINGDOM OF EVILS 327

Adams was now twenty-six years old. He had had several
attacks previously, the first four years before, when he became
absorbed in the stock market and speculated recklessly. At this
time he became "moralistic," according to his brother, and made
efforts to bring together his parents who had been separated.
After he had been in this condition a year the family sent him
to a private hospital for mental diseases, where after five
months he recovered. Once or twice after this he resorted to
the same hospital for short periods. Adams had made a
rather brilliant record in school and after entering college he
had done well for a year. During the second year he became
"dissipated," contracting gonorrhea. He was in the second
month of the senior year when he went into the army ; and he
returned to college and got his degree. During his term of
army service he did very well, so far as can be learned.

From the Psychopathic Hospital (where he was a voluntary
patient) he went of his own accord to a near-by hospital, as a
further period of hospital care was advised.

Hours spent by Medical record. 14 pages

Social record, 6 pages
Physician, 3^ Social work:

Visits, o
Psychologist, o Interviews at hospital, I

Telephone calls, 3
Social worker, 334 Letters, 10

SECTION X

PSYCHONEUROSES

Cigar-maker with psychonetirosis. Financial worries: dis-
like for his trade. Family adjustments. Different forms of
psychotherapy. Individualization.

Case 87. In one of the great Atlantic seaboard hospitals
(which shall be nameless) there used to be an out-patient de-
partment diagnosis Judaism, although the diagnosis Judaism
was probably a sly Caucasian hit at the frequenters of the clinic.
There is some basis for the idea of a preponderance of psycho-
neurotics amongst Jews. But, inasmuch as the Jews have the
excellent habit (from the mental hygiene point of view) of
very speedily resorting to physicians for their ills, the statistical
preponderance of Jews in many Atlantic seaboard clinics is
perhaps deceptive. There may be as many Caucasians of dif-
ferent varieties that fall victim to psychoneurosis as there are
Jews. It would be difficult to point out anything really differ-
ential in the psychology of the Jew.

Maurice Eastman was a Russian Jewish immigrant, forty
years of age. He came on his own initiative to the Psycho-
pathic Hospital complaining of indigestion, stomach trouble,
constipation, frequent urination for months at a time, year-
long headaches, and what he summed up as nervousness. In
point of fact various doctors told him he was a victim of
nervous instability, nervous prostration. He had evidently
been coached by physicians to know that "it was all foolish-
ness." He said he was always worrying, always afraid (that
the children would be killed, that there would be accidents while
he was asleep). He was unable to control his thoughts.
He had what would almost amount to a symptom in itself;
namely, an intense and analytic interest in his case. He slept
well, in fact he always felt sleepy and tired, but even more tired
on rising. He knew that he ought to "cheer up as there was
nothing the matter," but he could not. He had read an ac-

328

THE KINGDOM OF EVILS 329

count of the Psychopathic Hospital work in the Sunday news-
paper. Later interviews showed that he was worried over his
physical condition, over family finances, over increase in the
number of children (there were now five ranging from twelve
to two years), over his domestic relations and over practice of
self -abuse which he thought had affected his health.

Here is a sufficiently characteristic picture of a psychoneu-
rotic with many features suggestive of the obsessive or psy-
chasthenic. We omit further medical details, insisting merely,
by the way, that the above picture, although characteristic, can
be found in a variety of other mental diseases than the psycho-
neurotic group. (Particular cases of that sort may actually
prove to be syphilitic and greatly improve by antisyphilitic
treatment. )

Eastman was forthwith placed for some time under the care
of a student in psychology who had made a special study of the
methods of psychotherapeutic suggestion. (This sort of tech-
nique can still well be studied in Bernheim's excellent old work,
Suggestive Therapeutics, as well as in sundry newer works of
Bernheim that carry out the early ideas of Liebault. The
patient acknowledged great improvement by the suggestions
offered, in periods of one-half to three-quarter hours, and ap-
parently was genuinely much improved for a time. Besides the
"talking cure," he was made to read popular works on psycho-
therapy. The patient thought he was better because he had
learned to check his thoughts. He got to reading many books
on psychology and on suggestion. He practiced abstinence
from sex intercourse for eight months at one time so that the
family should not increase too rapidly.

However, he continued to have troublesome symptoms and
feared he would become insane. He had obsessions of several
sorts (when he saw a knife he wanted to stab somebody with
it; upon looking from a window he wanted to jump out).
While these psychotherapeutic efforts at persuasion were going
on, occasional hospital visits (at the same time patient was tak-
ing hydrotherapeutic treatments there), the domestic adjust-
ment had to be made. The mother was an unusually intelligent,
thrifty woman, adept at cooking and sewing. Eastman him-
self, although he had gone to work at the age of eleven in
Russia, had picked up a fairly good education, knew several
languages, and read some philosophy. He hated his cigar-

7^0 THE KINGDOM OF EVILS

making trade although he earned good wages thereat. The
family income was just enough to meet current expenses, left
no margin for clothes, and allowed only tenement-house life on
a shabby street, overcrowded with very poor neighbors. It is
clear that several of these domestic, economic, and social fea-
tures cannot easily be met by psychotherapy, either of the sim-
ple "Cheer up" or "Forget it" kind or the more elaborate and
subtle practice by the student of psychology in Eastman's case.
There was a social (family) problem as well as the individual
one. Possibly it is the social problem both superadded to and
lying deeply underneath the individual problem that has caused
physicians to fail in the past to effect cures in many psycho-
neuroses, despite the fact that a very perfect individual psycho-
therapeutic technique was being thoroughly carried out. It is
an error of the psychiatrist and the psychologist to rest pro-
found faith in arm-chair methods of psychotherapy. It is
great merit of the medical social worker in general and the psy-
chiatric social worker in particular to have shown the faults
of this arm-chair method taken by itself. Meantime the social
worker must not fail to acknowledge the extraordinary results
of some therapy in camera, such as the amazing results of
hypnotism in selected cases and the equally amazing results by
psychoanalytic treatment of patients reporting from time to
time in the consulting room of the psychiatrist. Our tiresome
old formula. Circumstances alter cases, is the only true formula
to apply to the whole field of psychiatric social work.

If there is anything which this book stands for it is plainly
the individualization of the diagnosis and treatment of psychiat-
ric cases. The adherents to one or other method of psycho-
therapy (such as hypnotism, psychoanalysis) are rather apt to
overdraw their statistical values in any psychiatry. The social
worker has to steer her way very carefully betwixt these vari-
ous statistical prejudices of the enthusiastic adherent of some
method that is a perfect success in some cases. It is as requi-
site for the psychiatric social worker not to cry up the wares of
a particular kind of psychotherapeutist, as it is for the psychiat-
rist himself to bear in mind that there is more than one way
to "kill a cat." Of course, when one is in Rome, one must do
as the Romans do. In a large part of France during the war,
hypnotism was officially forbidden as a method of treatment for
those psychoneuroses familiarly termed "shell-shock." Never-

THE KINGDOM OF EVILS 33 1

theless, elsewhere in France and in other belligerent countries,
hypnotism was being employed in some selected cases with
positive and even startling results. The modern formulations
of psychotherapy are not so many decades old that they will not
be greatly molded and revamped before the last word is said.
When all is said on the matter, however, the doctrine of the
treatment of the individual as such remains the common pos-
session of all forms of psychotherapy.

After all the psychiatric social worker does not by virtue of
contacts with psychopathy become a psychiatrist. The fact that
she may know more about individual details and technique of
family adjustment than the psychiatrist, does not cause her to
have sound ideas concerning the central psychopathic figure in
the family under adjustment. In the same sense the student in
psychology employed in the case of Maurice Eastman might
have been wasting his own and everybody's time by perfectly
correct technical endeavors in treating a man with many of
the same symptoms which Eastman possessed who should
happen to be not psychoneurotic at all. One of our Psycho-
pathic Hospital patients who had been regarded for five years
as psychoneurotic is described in Neurosyphilis; he was actually
syphilitic and the patient plaintively inquired why it had taken
so long to establish a diagnosis. Neither the social worker nor
the psychologist can be expected to avoid pitfalls such as that
case presented. On the other hand, it is just as certain that
the psychiatrist has neither training nor time to execute the
family adjustments undertaken by the psychiatric social
worker. Nor has a psychiatrist often the time and perhaps the
temperament to execute persuasive therapy in its best form.
Indeed, we are sometimes tempted to think that different types
of psychotherapeutist will eventually prove necessary for differ-
ent types of psychopathy, just as different sorts of automobiles
suit different temperaments. All of which is another example
of our constant insistence ; that is, that psychiatrists as psychiat-
rists are not social workers or psychologists, and that neither
of these other types of workers is likely by training or tem-
perament to be able to swap places with the other or make
more than snap diagnoses in the psychiatric field.

The medical measures adopted in Eastman's case (persua-
sive psychotherapy) ceased after a time, as all the internal ad-
justment that could be made in this way had apparently been

332 THE KINGDOM OF EVILS

accomplished. The man was apt to be irritable and unreason-
able at home. He would complain of the children's noise which
prevented him from reading; he complained that his lot was
harder than that of other men in like circumstances, as he was
more intelligent (this was true) than the average man. He
had the advantage of having no bad habits to interfere with
his being a good steady workman. The treatment carried out
for a period of some six years now finds him much better
adjusted to his lot in life. No other form of work could be
found for Eastman that would bring him as high wages as
cigar-making. As the family was after all not destitute it
proved impossible to get supplementary relief by means of
loans, such as might have been put into effect for certain
indigent families. The wife and children were getting an
annual vacation through the settlement house and a vacation
was now arranged for Eastman himself. He had not had a
vacation in all of his adult life. He helped with the work of
the Men's Club, and from time to time pieces of work were
secured for the wife who was a clever needle woman to sup-
plement the family income. Eastman still hates his work.

Hours spent by Medical record, 2 pages

Social record, 35 pages
Physician, 4 Social work :

Visits, 20
Psychologist, 6 Interviews at hospital,

Telephone calls, 19
Social worker, 70 Letters, 18

GIRL OF 15 YEARS

SOCIAL CONDITION

Hard Work
No Recreation
No Training
Insufficient Income
Feeble-minded and Inebriate

Father
Family Discord

19^5

SOCIAL CONDITION

Light Work
Recreation
Trade Training
Adequate Income
Home with Sister

Separation from Family

MENTAL CONDITION

Hysterical Convulsions
(2 in one month)

MENTAL CONDITION

Hysterical Convulsions
(3 in past year)

Girl with hysterical convulsions. Father feeble-minded and
alcoholic. Psychoanalysis. Social investigation. Prolonged
social treatment. Cure or alleviation.

Case 88. Sadie Strauss was a seventeen-year-old Russian
Jewish girl, a case of hysteria whose cure or alleviation could
be variously claimed at different times by psychiatrists or social
workers. Perhaps neither the psychiatrist nor the social worker
should claim too much, since the hysterical trend may be
ingrained and persist for years. For some years, however,
there have been no clear or striking hysterical outbursts, and
only traces of that excessive fear reaction which some of her
human sisters often seem a little proud of — that is, fright at a
mouse. As it takes more than one swallow to make a summer,
so it takes more than one case to break the general medical
conception or prejudice: once a hysteric always a hysteric. In
passing we make remark that it would seem that the war experi-
ences with shell-shock will probably serve to break down this
old conception.

There is still another older conception of hysteria as an
''aristocrat" amongst the functional diseases, that is as markedly
hereditary. Concerning heredity in Sadie Strauss, we can find
only that the father is perhaps somewhat feeble-minded; pos-
sibly his low mental level is really acquired, i.e., alcoholic.
Sadie herself was determined by the psychological examiner
to be normal. She was deft with her fingers, but did not prove
very resourceful in the tests for planning and analysis. She
was very "suggestible," but got easily discouraged and seemed
more than normally fatigable. Her measurement by the Binet
Scale was ii 4/5 and by the Point Scale 11 7/10.

Menstruation began at twelve. Sadie went to work as soon
as the fourteen-year law allowed and was working on piece
work in a mill earning from six to seven dollars a week for
fifty-four hours' work. After a painful menstruation she one
day collapsed, feeling a lump or stone in the stomach. She
was taken to the hospital, then home again and back to the
hospital, where there was a seizure of pain, screams, laughter,

335

33^ THE KINGDOM OF EVILS

and unconsciousness. She was then brought to the Psycho-
pathic Hospital. It appeared that she had fainted two or three
times in the last few years.

The psychiatrists could find no abnormal sign upon physical
examination either on the motor or the sensory side. In an
attack she rolled from side to side on the couch, held an arm
or leg in the air, was sometimes stiff, sometimes quite relaxed,
but always apparently somewhat conscious, occasionally assum-
ing a silly expression, sometimes attitudinizing, sometimes
pointing as if hallucinated and quite mute. She did not bite
her tongue or void urine. This particular attack was slight
and took place during an interview for the purpose of psycho-
analysis.

Psychoanalytic conversations finally turned up news of an
early childhood episode. The child had been terribly frightened
by having to undress, one night when alone, her drunken father.
This episode may have developed sex-consciousness prematurely
or it may have provided "buried" memories that could operate
after the manner of the Freudian mechanisms. In conversa-
tion it developed that the girl dreamed of a dark man in a white
garment who chased her. The man's hands were her father's,
but his face was like the face of a man who was the first dead
person she had even seen. This psychoanalytic discovery
might have been supposed to work, as such discoveries some-
times work, by the so-called method of psychical "catharsis"
to effect an immediate cure. That is to say, if there was a
"buried memory" of this infantile sex experience, then (ac-
cording to the theory) talking it out will relieve the effects of
the repression. It is not entirely sure that the memory in
question was buried in Sadie's mind. At all events she had
some eight attacks of pronounced hysterical nature after the
supposed catharsis.

Perhaps it will not do to quarrel with the psychoanalyst con-
cerning his therapeutic results, and no doubt a large share of
the effect in Sadie Strauss' case is to be awarded to the psycho-
analyst. Nevertheless it is to be pointed out that a routine
social investigation would bring out very promptly informa-
tion concerning the Saturday night debauches of the father.
A good deal more was found out by such investigation than
the psychiatrist or psychologist could discover from the arm-
chair. The father was in point of fact brought to the clinic and

THE KINGDOM OF EVILS 337

proved to be feeble-minded. Supervision of his life yielded
definite improvement in the family condition, although he
fell from grace and once got into the house of correction.
There were many more than merely the medical and tempera-
mental problems in the Strauss situation. Clothes were pro-
vided for Sadie, so that she could go to the trade school for a
year. The family needed Sadie's wages and could not clothe
her. They were too proud at first to accept such help but were
eventually persuaded. The patient then made her home with
her sister ; vacations and recreation were arranged for ; more
or less regular reporting to the out-patient department was
made a habit, and medical encouragement was there doled out
to her.

Two and one-half years after her initial appearance at the
hospital Sadie was married. She had matured visibly and was
now capable of much better self-control. Attacks had long
since stopped. Her husband was a man of a very good sort,
and the case could appropriately be closed. Her husband said
that he gave his wife pretty things and let her have her own
way in household matters. Outside of hospital time, some of
the social workers attended the wedding.

Hours spent by Medical record, i8 pages

Social record, 40 pages
Physician, 17^ Social work :

Visits, 44
Psychologist, i Interviews at hospital, 24

Telephone calls, 37
Social worker, 107 Letters, 11

Voluntary patient in state hospitals from time to time.
Cyclothymia: sex obsession. Industrial adaptation.

Case 89. Joseph Fangillo, forty, has been three times a
voluntary patient at the Psychopathic Hospital and has also
spent some time at the hospital's suggestion at one of the state
hospitals also as a voluntary patient. His history shows that
he had also, at the age of thirty-four, been a patient at one of
the state hospitals.

He has received a number of diagnoses but he is probably
best classified as a psychasthenic. He had recently gone into

338 THE KINGDOM OF EVILS

the liquor business and rightly or wrongly felt that his affairs
had been going downhill ever since. Besides there had been
the Billy Sunday campaign and there was the national pro-
hibition movement. In addition to ideas touching money, he
had some obsessions about sex. He thought that he had an
uncontrollable sexual desire and interest and felt that he would
be tremendously excited if he saw the pictures of women or if
he came at all in contact with them. He complained, too, of his
eyes although there was no objective evidence of eye disorder.

If we regard the diagnosis of psychasthenia as correct then
it is plain that the medical and social contacts with Joseph
Fangillo will mean much. His five different hospital experi-
ences have all been as a voluntary patient. In fact, the last
four hospital stays have been part and parcel of a single psy-
chasthenic phase out of which he appears now to have passed,
aided by the direct influence of counsel and family adjustment
between himself and his wife effected by the social service.
The wife is intelligent and devoted but needed a great deal of
encouragement since she was living upon the family savings.

If our present diagnosis is incorrect and he is actually in
some sense a cyclothymic patient, then so far as we are now
aware the thing which will bring him out of a given phase is
rather the curative power of nature than any medical or social
efforts of any description. However, it is clear that if Fan-
gillo is a cyclothymic and the course of his disease is, as the
phrase is "self-limited," nevertheless the social service contact
with the wife and the counsel to her with respect to her adjust-
ment to her husband's psychopathy would mean a great deal.

This case has not been intensively handled by physicians
at any time upon any specific line of psychotherapy such as
psychoanalysis. The sexual obsessions above mentioned may
date from a specific occurrence which conversation might at
last unfold. The psychoanalyst and, for that matter, all kinds
of therapeutists, would hope from all cases of psychoneurosis
for a fundamental cure by the process of so-called reeducation
or rationalization. Without entering the debatable confines of
the psychoanalytic question, it is plain that where the diagnosis
is so in doubt as in this instance, proceeding to elaborate
reeducation upon sex lines or upon other lines of character
development would be very time-consuming from the stand-
point of the patient himself. If the patient is a cyclothymic,

THE KINGDOM OF EVILS 339

then he is likely to emerge with absolute normality after a time
in any event. If he is a psychasthenic, at all events he has the
record of having emerged with perfect normality from the
previous attack and his psychasthenia may itself be of periodic
or cyclic nature. (It is well for the lay as well as the medical
observer to bear constantly in mind that cyclothymia is not the
only mental disease which is cyclic.) Accordingly, for better
or worse, no special psychotherapy has been undertaken other
than that involved in the routine social service contacts by com-
petent and intelligent social workers, familiar with psychopaths
of various sorts.

Fifteen months after we first knew him Fangillo was able
to take a position in the stock room of a large firm with which
he is offered a good prospect of advancement. He made the
choice of this position rather than a better paying position of-
fered by a former employer because he felt that the larger firm
promised a more stable future. Now, a year later, he is still
working for this firm and beginning to realize his expectations.

As a detail of social service technique, it may be remarked
that Fangillo was gotten a temporary job with a certain firm
through the efforts of a worker who was doing special work
on the industrial problem of the psychopathic employee. The
employer said that he liked to get workers from social agencies
because a good deal more was known about such workers than
about the ordinary run of applicants for employment.

(See also Appendix A for the social record of this case.)

Hours spent by ]\Iedical record, 26 pages

Social record, 21 pages
Physician, 7J/2 Social work :

Visits, II
Psychologist, i Interviews at hospital, 13

Telephone calls, 13
Social worker, 23J/2 Letters, 6

Industrial accident. Traumatic hysteria. Compensation
qiiestions.

Case 90. Dennis O'Donnell was sent to the hospital by
the Industrial Accident Board. He had gotten a number of
fractures, especially of the arms. X-ray examination failed
to show that he had any fracture of the skull. After his fall

340 THE KINGDOM OF EVILS

he was treated for a time in the company hospital, went home
at his own request, and in the space of three months began to
do some work again, though he was not very successful at any
kind of job. He left for a distant state but did not work
there for some eighteen months. His left hand was weak.
Heat and noise disturbed him greatly in various factories
where he tried to work. The family had accumulated many
debts and he was much worried about these. His memory had
been very poor since the accident. He was a very quiet and
contemplative sort of man. He said that his hand felt weak
and this was verified by test, but besides this it was found that
he had a complete anesthesia of the left side of the body with
deafness in the left ear and even some visual disturbance in the
left eye. Yet at the same time the reflexes were not different
upon the anesthetic side from their condition on the right side
of the body. The arm muscles were not atrophic. On the
whole there seemed to be no evidence of any organic lesion to
account for the weakness or the anesthesia.

The diagnosis was one of tramnatic hysteria which, to quote
from the hospital report, is "a very real disease and so far as
we can see would justify compensation."

O'Donnell had been paid after his accident nine dollars a
week for four months and later for six months at the rate of
ten dollars a week. This compensation was discontinued by
the Accident Board which felt that the man's condition was
due more to alcohol and syphiHs than to the accident. After
seven months' delay O'Donnell was admitted to the Psycho-
pathic Hospital upon the representation of liis lawyer. The
lawyer was unaware tliat the patient was working all this time.
Four months later O'Donnell was offered a sum of five hundred
dollars as a lump settlement to cover unemployment. This sum
O'Donnell is not willing to take but says he has not the funds
to contest the case. In war times he earned about thirty-four
dollars a week but after being a patient at the Psychopathic
Hospital he could not get this thirty- four-dollar-a-week job and
is now working at fifteen and eighteen dollars a week in a
factory.

Perhaps this case will serve as well as any to indicate the
very doubtful question of social-service technique that arises
in industrial accidents. Probably the question of syphilis
raised by the board is to be answered in the negative; at all

THE KINGDOM OF EVILS 34I

events there seems to be no evidence of syphilis of the nervous
system as a cause for the symptoms shown. Nor had there been
any history of alcohoHsm for a period of some fifteen years,
ahhough before that time O'Donnell had been alcohohc. It
would seem wise for O'Donnell to report from time to time
to the out-patient department. There is always a question
whether the advantage of counsel afforded by the hospital is
countervailed by the loss of self-reliance which some men might
feel through having to resort to a hospital.

Hours spent by Medical record, 21 pages

Social record, 15 pages
Physician, 5 Social work:

Visits, I
Psychologist, I Interviews at hospital, 7

Telephone calls, 15
Social worker, g^ Letters, 18

Machinist in aviation suffers from traumatic hysteria after
blow on the head.

Case 91. Walter Nelson enlisted at twenty in the naval
reserve, during the spring of 191 7, and in the fall was as-
signed as a first-class machinist in aviation. While he was
vvorking on a plane in a tent hangar during a windstorm, the
tent blew down and he was hit by a pole across the back and
head. He was unconscious for half an hour and in the hos-
pital three days with weakness and backache. There were no
other symptoms at that time. Two weeks later he was among
volunteers accepted for foreign service, but the party was not
sent at the expected time and Nelson was very much disap-
pointed. After this he became shaky and excited and was sent
back to hospital. He went home for a Christmas furlough
and was not well enough to return to duty at the end of his
time. He seemed to his family to be "far-off, hazy, in a
trance" and "had to be cared for like a child." He worried
for fear people would call him "a slacker."

After a month in the naval hospital, he went back to duty
but was still somewhat dazed and confused. He wrote his
family that he was afraid of being court-martialed for having
done some of his work wrong and asked them to send him
poison to take. In the spring he was discharged for physical
disability. On his return home he was advised to come to our

342 THE KINGDOM OF EVILS

out-patient department. He said that he felt "dopey" and
changed since the accident, that he had very Httle interest in
anything. Reluctantly he told of having a fear after the acci-
dent that he had been cursed by a young woman with whom he
had had sex relations for a short time, (he had a friend who
had been cursed by a young woman), and said he dwelt on
this thought constantly. His condition was diagnosed as
traumatic hysteria.

In a month he had improved slightly and in another month
was much better. In six months under the influence of treat-
ment, including massage, hydrotherapy, suggestion, tonic, and
light work, he was much more cheerful and animated and able
to work three-quarters time. He had given up the obsessive
idea of the young woman's curse and was showing steady
improvement.

Hours spent by Medical record, 5 pages

Social record, i page
Physician, 4^4 Social work :

Visits, o
Psychologist, o Interviews at hospital, 3

Telephone calls, 0
Social worker, 1J/2 Letters, 0

Feeble-minded soldier discharged for hysteria. Marfied a
prostitute to refonii her.

Case 92. Martin O'Hara was sent to the hospital by the
court charged with indecent assault upon a six-year-old boy
in the hotel where he was working as janitor. He denied the
charge, the child admitted previous knowledge of perverted sex
practices, and it was never determined whether O'Hara was
guilty.

He was twenty-nine years old and his mental rating by the
Point Scale was 11.8. At the age of twelve he had run away
to sea and spent a few weeks on a fishing boat. His father
would not let him go again to sea so he started to work and
held countless odd jobs in theaters, amusement parks, and
circuses. He never liked to loaf and when work was not to
be found he would go up to the Maine woods. After war was
declared he tried to enlist and was rejected because of bad teeth.
A year later he was drafted and became sick in camp during
the trial gas attacks. He was sent home for a rest and soon

THE KINGDOM OF EVILS 343

after discharged from the service with the diagnosis hysteria.
He was suffering then with gastric pain and vomiting and a
sHght tremor of the head. These symptoms disappeared after
a while.

He went to work and in a few weeks married a girl whom
he had known for several years. He said that he had known
she was sexually promiscuous, but that he had always treated
her with the greatest respect and loved her devotedly. They
were married in a pool-room where he worked, by a justice
of the peace. That same night he returned to work and con-
tinued to work until midnight so that he might get double
pay. The girl went to stay with her parents that night. The
following day he discovered she had a six-months-old baby,
and after inquiry he was forced to the conclusion that the
father of the child was actually unknown. He forgave the
girl for the deception and wished to live with her, "to reform
her," but she left him and continued to live as a prostitute.
Both she and the baby were syphilitic. He had never lived
with his wife since the marriage.

Under the excitement of these events the tremor had re-
turned. When he left the hospital after nine days he still had
it, although at times it disappeared entirely, especially when
he was interested and intent upon what he was doing. Later
when he came to the out-patient department he would some-
times tremble violently but at other times would appear quite
composed. He went to live with his parents and made up
his mind to secure a divorce from his wife. After some months
he felt able to work and got a job.

He is beginning to feel strong and cheerful again and the
tremor is less marked and comes less frequently. He says that
although he knew a good deal about his wife, before he married
her, he did not know "half of it" and he is no longer in love
with her. He has worried a good deal over being dependent
upon his parents, who have no surplus income, but now he
feels fit to maintain himself.

Hours spent by Medical record, 25 pages

Social record, 12 pages
Physician, 4^ Social work:

Visits, 2
Psychologist, i Interviews at hospital, 3

Telephone calls, 23
Social worker, 51^ Letters, 0

344 THE KINGDOM OF EVILS

Drafted soldier discharged for physical incapacity. Psy-
chasthenia. Improvement.

Case 93. Joseph Levenson was drafted in the fall of 191 7
(twenty-five years old) and discharged in three months for
physical incapacity. When he came to the out-patient depart-
ment six months later he was complaining of insomnia, lack
of appetite, and pains in his head and back. He claimed that
discipline and the rigorous winter had caused him a physical
collapse.

On the theory of a possible developing of acromegalia, an
X-ray picture of his head was taken; but it showed nothing
abnormal. The diagnosis was psychasthenia. In four months
he had made definite improvement and was planning part time
work.

At first a marked increase of symptoms occurred when he
was told that he ought to get to work. He was living with a
devoted family in a good home. He undertook a course in
salesmanship, and at first he was unable to sit through the
classes on account of his pains. He would stand it as long
as he could (for about two hours) and then stretch out on a
table or chairs until he felt able to go on again. After a time
he could sit through the seven hours of the school day by
relaxing for a few minutes now and then. At this time, even
after three months of treatment, he could not walk much. He
said once he thought he could never "bear it and live" but now
he knew he "had it in him" and could "look forward happily
to the future." Later on he had a plan for starting a provision
store of his own if the Red Cross would make him a loan; but
this was decided to be an insecure investment. Levenson then
got a position as salesman in a meat market. He works full
time and is improving, though he still suffers from pain and
weakness.

Hours spent by Medical record, 5 pages

Social record, 5 pages
Physician, 4 Social work :

Visits, 3
Psychologist, o Interviews at hospital, 3

Telephone calls, 12
Social worker, 3J/2 Letters, o

PSYCHOPATHIC PERSONALITY

IN A WOMAN TYPESETTER, 28

1915
Inebriety

Insufficient Income
Non-support of Mother
Family Discord
Friendlessness
Lying
Fabrication
Suicidal Attempt

ic)i6
No Alcohol
Adequate Wages
Contributions to Mother
Away from Home
Companionship
No Lying
Slight Fabrication
Cheerfulness

SECTION XI

PSYCHOPATHOSES (DUBIOUS AND SPECIAL PSYCHOPAtHlAS)

Psychopathic personality. Typesetter, sickly, unhappy, un^
popular, discouraged, attempted suicide. Trained to be self-
sustaining. Psychiatric social work. Many workers on the
case.

Case 94. There is much discussion as to the meaning of
the term "psychopathic personaHty." Whereas in one sense
every victim of mental disease shows effects in his personality,
the effects by the same token require psychiatric social atten-
tion even if the victim have brain tumor. The term has come
to be used for many forms of usually rather slighter mental dis-
eases than those which receive more definite designations as
belonging to well-defined disease entities. Possibly the term
being briefer and smoother is theoretically better than the term
"constitutional psychopathic inferiority." But the latter term
has been worked into sundry official documents, and it is to
be feared we shall have it with us for some decades and until
a greater definition of the whole topic of psychopathic per-
sonalities shall occur. According to one group of thinkers
every psychopath, and especially every victim of psychopathic
personality, is practically sui generis; that is to say, has a most
highly individualized and specialized make-up of soil and taint.
Nor does it do any harm to insist upon this ultra-individualism
in diagnosis and treatment, as it practically comes up in the
clinic. According to other authors there threaten to break out in
the group of the psychopathic personalities sundry subgroups.
One of these formulations was made a special study of by the
former Chief of Staff, Dr. H. M. Adler, at the Psychopathic
Hospital. It is mentioned in greater detail in the summary.
Perhaps as valuable a statement as any general statement can
now be concerning these personalities runs to the effect that
the victims are to some extent infantilistic. Some of the per-

347

348 THE KINGDOM OF EVILS

sonalities are a little infantile along the line of their emotions.
These are likely to belong to a group with hysterical trend.
Others show more or less childlike obstinacy and episodic over-
reactions to ordinary stimuli, recalling effects in certain chil-
dren. Some cases seem to represent enormous exaggerations
of particular instincts and are given to wandering, to special
types of sex activity and the like. Possibly some alcoholics
may be regarded as weak of will in the direction of psycho-
pathic personality, so that alcoholic mental diseases cannot
be set down as directly and proportionately due to their
alcoholism.

Harriet Farmer was not at all feeble-minded ; in fact tests
at intervals of two years showed that she was making a proper
improvement to test. Let us take occasion to insist, however,
that not seldom the selfsame psychopathic traits do occur in
morons or other subnormal persons. We did not have to face
in the Farmer case the lack of judgment characteristic of a
moron.

Harriet was certainly an average scholar and indeed read
much good classical literature. Twenty-eight upon her first
contact with the hospital, she had been for two years very alco-
holic, not infrequently drinking alone. She had also been un-
truthful and unreliable; she told scandals about a priest; told
of mistreatment by her family; and made up stories about the
attentions of men to her. Harriet was rather talkative and
aggressive with people with whom she came in contact. Church
club members did not want to see her at the club. At home
she was lazy, slovenly, and thoughtless. She lay in bed late and
expected her mother and sister to sew and wash for her.

It was discovered that her father died of general paresis ;
her mother was also treated for many years for syphilis which
she had contracted from Flarriet's father. The girl herself was
short, slight, pale — the so-called wiry type, rather unattractive,
possibly anemic, and with bad teeth. She came to the hospital
after an attempt at suicide, which attempt was made a day
when nothing at all unusual had been noticed in her behavior.
She had been at times depressed at menstrual periods, but there
had at this time been no depression. She had lunched with
her mother, who a few hours later was notified that paris green
had been taken by Harriet. Harriet said she had originally
bought the paris green for plant insects. She had taken it

THE KINGDOM OF EVILS 349

feeling discouraged with her Hfe and with the poor physical
condition of her mother.

The psychiatrists found her practically negative in every
respect. Even anemia was found to be not present. Psychiat-
rically nothing abnormal could be found beyond the provisional
diagnosis "manic depressive" suggested by some observations.
She clearly was not committable. As for a motive for suicide,
a somewhat curious history transpired. She had put her name
and address in a candy box and had gotten up a correspond-
ence— "object matrimony" — with a man who turned out to
be sixty-five years of age and otherwise ineligible. This episode
appears to have helped her to think that there was nothing left
for her in life. There had, of course, been considerable
pecuniary trouble in the family. The two brothers had mar-
ried and were no longer able to help the family. The parents
had been separated when Harriet was eight years of age.

After a month's observation the determined diagnosis was
"not insane, not feeble-minded — psychopathic personality."
Harriet has now for some years been under pretty continuous
observation by the social service. After a period of some two
and one-half years she was so compensated or adapted to life
as to require little aid. During this period of two and one-
half years a rather intensive type of social work, supported by
medical consultations, was carried out. The psychiatrist's
general recommendation was that a good deal more variety in
life was necessary. It was the task of the social worker to
secure such variety and to make changes in her living and
working arrangements before she should get stale. It was ar-
ranged that she should live away from home, and in the house
where she lived she now began to make girl friends after a
fashion which had been quite unknown to her before. The
other girls liked her. Exercise, diet, and bathing became sys-
tematic. Menstrual difficulties were discussed with women
physicians at the hospital. She stopped drinking and ceased
to mention suicide. She no longer told out-and-out lies and
the tendency was represented for the most part by exaggera-
tions or slight perversions of the facts.

From time to time she became discouraged and made vari-
ous complaints, apparently fearing she was "to be put away."
But these spells of bitterness were transient and left her with,
her usual friendliness. She began to have a number of dif-

350 THE KINGDOM OF EVILS

ferent suitors and went walking with them and took meals at
hotels and dairy lunches with them. Harriet very gladly ap-
peared at the clinic for social workers and told her story in an
approximately correct and engaging fashion. The experienced
social worker is apt to say, "Why this sort of thing is just what
every social worker has to deal with !" We are far from deny-
ing that such is the case. We hold that statistics of medical
social workers will probably show that practically one case in
two of all intensively studied medical social cases will turn out
to be in some important way psychiatric. If such commentary
means to argue that psychiatric social work is unnecessary as a
specialty, just because psychiatric social cases are so frequent
that every social worker has met them, then we should be com-
pelled to decline to follow the argument. One of two conclu-
sions, and we hold that both conclusions, can be drawn from
this state of afifairs, namely : First, that instruction in social
psychiatry should be given to every medical social worker;
second, that there should be specialized training to develop
specialized psychiatric social workers.

It seems to us that the amount of personality study required
for the diagnosis of Harriet Farmer and the amount of per-
sonal adjustment required would mean that there must be in
the world a gro.up of specializing psychiatric social workers.
Many medical social workers are by temperament unfit for
psychiatric social work, or at all events not as well fitted as
are others. It is also, we believe, going to be held that all social
workers whether medical or non-medical ought to be given
psychiatric training of some sort. It would be hard to show
convincingly the extraordinary change in Harriet Farmer from
the unsociable, pallid, unattractive girl, with rather a bitter out-
look on life, to the competent, self-supporting, physically much
improved, rather pleasing cooperative girl with a normal set
of outlets along all of the main social lines.

Too much and too little can be made of the so-called per-
sonal relation between some one individual therapeutist and
the patient. The slogan "individualization" is often taken to
mean that there should be in the ideal a one-to-one correspond-
ence between the social agent and the social patient. It is true
that many effects, especially in the field of alcoholism, are
gained in this manner. But individualized treatment is not
necessarily, or as a rule even possibly, the treatment of one in-

THE KINGDOM OF EVILS 35 1

dividual by one individual. We do not need to paraphrase Lin-
coln by saying social treatment is treatment of an individual,
by an individual, and for an individual. Treatment is as often,
and perhaps always should be, the treatment of all the indi-
viduals in a given family — each individual taken as such. The
individualization of treatment does not refer to carrying all
of the measures up to one head. There is a certain democracy
in social treatment, the advantages of which have not been
sufficiently preached. In the case of Harriet Farmer, for in-
stance, although two social workers not trained in psychiatry
had failed to make proper contacts with her personality, yet
after the Psychopathic Hospital contact was made the social
treatment of Harriet was carried out by not less than six social
•workers of various temperaments, who nevertheless all suc-
ceeded in aiding the development of Harriet's character with
its consequent stoppage of drinking and bitterness. There
were also four physicians more or less intimately concerned
with the case.

Of course what Harriet did was in some sense to personify
the entire Psychopathic Hospital and to consider herself under
its auspices. This relation is by no means uncommon, nay,
perhaps, is the usual one. The hospital with its medical and
social officers becomes a sort of religion with the patient. No
hospital run under what we are sometimes tempted to term
"regular-army" regulations can become a religion with such
patients. H the social workers were suddenly removed from
the institutions, the chances are that a patient of this type
would not return to the hospital more than once.

There is a certain uniqueness about this psychopathic hos-
pital relation with its patients which stands out in sharp relief
against the "borrow-no-trouble" attitude of the old-style in-
stitutions for the committable insane.

(See also Appendix A for the social record of this case.)

Hours spent by Medical record, 41 pages

Social record, 55 pages
Physician, 5^ Social work :

Visits, 76
Psychologist, 2 Interviews at hospital, 16

Telephone calls, 50
Social worker, 150 Letters, 14

35^ THE KINGDOM OF EVILS

Son of an educated Belgian family. Wanderer and irregular
worker.

Case 95. Louis Sand, the son of a Belgian professional
man, was twenty-eight "^years of age, an immigrant, upon a
rather irregular allowance from his father. He had spent time
in twelve different states during five years, working here and
there for a few weeks or months at factory or farm work. In
fact he had made eighteen changes from one place to another
and had borrowed small sums of money here and there. He
spent much of his time looking for work and reading. He
had the ambition to take courses in engineering and had had
some college work in Belgium. There was no language diffi-
culty since he spoke and wrote English fluently. It was thought
he was a victim of Meniere's disease — one ear was growing
deaf and he was dizzy.

Sand never became a house case at the Psychopathic Hos-
pital but was immediately left to the social service after his
coming on his own initiative to the out-patient department.
Some loans were made to him which he came back from time
to time to pay. Nine months after the first observation he was
found a position with an engineering firm which he held for
some four months and was taking a correspondence course
in the general topic. The case was accordingly closed. How-
ever, Sand began to feel restless, wrote appealing letters to
the social service telling about lack of will power — his desire
to get back to Belgium. The case was accordingly reopened
by the social service and work was secured for him in new
places. He gave the visitor a sum of money which was put
in the bank for him, a nasal operation was performed, and
new lenses for his glasses were gotten for him. He then left
for a distant state.

Sand, although he desired to return to Belgium, was ashamed
to go until he had made good in America. He had no friends
or associates with persons of his own educational level. He
talked a good deal of his interest in books and in music, but
these interests proved to be superficial. He had not rationalized
his relations with women, affecting refinement and chivalry on
the one hand, on the other hand resorting to masturbation.
He had a shell of ambition with apparently little power behind
it. Perhaps he is to be classed as a sort of constitutional in-

THE KINGDOM OF EVILS 353

ferior, inasmuch as the disorder or defect is particularly one
of will. If we were asked for a single phrase for him, it would
be hypobulic. Hypobulics no doubt require the social worker
and the physician to act more as mental splints than in any
other definable way.

Our Belgian correspondence concerning Sand shows that he
had been as unsuccessful there and weak of will as he was here.
What is to be the outcome of his Meniere's disease, if that be
the correct diagnosis? No one can say, but Sand is going
to keep in touch with the Life Extension Institute, whose
examiners will no doubt trace the further effects if any of the
aural condition.

Hours spent by Medical record, 13 pages

Social record, 25 pages
Physician, s% Social work :

Visits, II
Psychologist, o Interviews at hospital, 27

Telephone calls, 30
Social worker, 43^ Letters, 30

Child of a thief and a prostitute; brought up by charity.
Psychopathia sexualis.

Case 96. An interest was taken in Theresa Beauvais by a
lady who had lived in the town where Theresa was born.
Theresa's father was a professional thief and her mother had
been a prostitute. Theresa herself had already entered upon
this life and was in the poor house when her townswoman
found her. When Theresa at fourteen had learned the dangers
of pregnancy, she had stopped promiscuous intercourse and
begun mxasturbation. Theresa never tried to conceal her life
or habits and a psychoanalyst who saw her said that as there
was nothing repressed, psychoanalysis was superficial. Be-
sides, she was rather unintelligent or at all events looked so.
(She later tested at I5>4 years by Stanford-Binet and by Point
Scale as 17.5, accordingly probably not at all feeble-minded.)
Although unintelligent-looking she made a very good general
impression and was well liked. She had studied in an academy
for some years but had not finished her work.

She was observed at the Psychopathic Hospital and finally

354 THE KINGDOM OF EVILS

regarded as a case of psychopathic personaHty, though a ques-
tion of psychoneurosis and a question of dementia praecox
had also been raised. She was found to be abnormally senti-
mental and somewhat dramatic in her attitude toward her
delinquency. She seemed rather to enjoy making an impres-
sion upon the maids and nurses with details of how bad she
had been and the things she had undergone. She was, how-
ever, on the whole, fairly truthful. She said that she could
not control herself with respect to sex relations. (There was
a history of absolute promiscuity for a period of some three
months before admission to the hospital.) Amongst the psycho-
pathic personalities there are, no doubt, a number of cases of
psychopathia sexualis and amongst these a form called satyriasis
to which Theresa may belong, but of course that designation
does not afford much information as to prognosis or treatment.

She had, ten months before admission, started learning to
be a nurse and after her discharge from the hospital she was
placed as a ward maid in a hospital where she stayed three
months. She there had sex relations with an employee who
talked of marrying her but had trachoma and was in general
unreliable. The marriage was accordingly discouraged. She
then got work in mills for short periods, refusing to room in
a girls' boarding house, disappeared from view for a fort-
night, and then telephoned that she had become a maid in a
questionable lodging house. Then she was brought by the
police to the hospital again. This was six and a half months
after her discharge from the hospital. It transpired that she
had been living with a sailor who had forsaken her. She had
shown odd conduct, going out two days in succession with her
hair down, moccasins on her feet, and a coat over her shoulder,
returning exhausted and (by her own story) confused. There
was also a spell of screaming and she was picked up by the
police sitting on a doorstep. The diagnosis of psychopathic
personality was again made.

After discharge she was put to work in a mill and made to
live in a very good boarding house for working girls. She
talked about taking a fresh start, yet within two months she
was found to be pregnant and was sent to a maternity home
where there was a miscarriage. She now went to work. in a
professional man's family near by and actually took full re-
sponsibility for his house during his wife's illness. She stayed

THE KINGDOM OF EVILS 355

there eight months. She had been found to have a positive
Wassermann test with the serum and was receiving treatments
weekly. After a trip to the hospital for such treatment she
failed to return to her working place. About six weeks later
an officer of her maternity home met her on the street. She
said that she had been living as a street-walker and resorting
to masturbation constantly. Sent to another hospital for
syphilitic treatment she ran away six weeks later, was found
again and returned in a few days and again discharged. After
further hospital treatment in another hospital she, two months
later, took another job in a mill and a pleasant room in a good
lodging house was arranged for her. She was interested in
her work but was slow in learning the trade. She was easily
discouraged. She kept in close touch with the social worker
but had spells of being inaccessible and almost antagonistic.
She grew tired of her factory work and a position was found
for her as nursemaid to care for a semi-paralyzed woman.
She was pleased with her new position and was very hopeful
about her future.

Very soon she entered into sexual relations with a man living
in the same apartment house, whom she had met in the hall-
way. She left her position in a few months and made plans
to go to New York with another patient, Bertha Greenwood
(case lo). Bertha, however, weakened and telephoned anony-
mously to the social worker about the proposed trip; so that
Theresa was intercepted and persuaded not to go. She was
found to be in need of hospital treatment for gonorrhea. In
the end an operation was necessary. While she was in a con-
valescent home, she expressed gratitude and afifection toward
the social workers for the care she had received from them',,
but insisted that she wanted "complete independence.."' Iiii
spite of her desire to work in a factory and live i-n a lodgings
house, she was persuaded to take a more sheltered position in^
housework.

Such hypersexuals as Theresa are pathetic figures. Aside
from the hypersexuality, a girl like Theresa may make an
excellent impression and we have letters about her ambitious
although not brilliant school work, her interest in church affairs
and the general esteem in which she would be held for months
at a time. We must remember in particular the skill and
fidelity which she showed in the professional man's family as.

356 THE KINGDOM OF EVILS

above noted. The sex instinct must be thought of as some-
how standing out in relief against a pretty normal background
of the other instincts. It is, perhaps, a considerable achieve-
ment that these cases are now considered examples of Morbi
rather than of Vitia. The entire attitude of the world to
morbid hypersexuals must be naturally different from the atti-
tude toward the sexually immoral. Sometimes it seems that
these frequent social diagnoses, "immorality/' ought to be re-
placed with some other diagnosis, since from time to time im-
morality is made to cover some psychopathic hypersexuals like
Theresa. Yet the psychiatrist would feel a great deal more
comforted could he advocate a special treatment of hyper-
sexualis. An artificial menopause by X-ray often seems a bit
over vehement, at least as routine treatment.

Hours spent by Medical record, 47 pages

Social record, 51 pages
Physician, 9 Social work :

Visits, 46
Psychologist, 2 Interviews at hospital, 13

Telephone calls, 86
Social worker, 84 Letters, 24

Family known to thirteen social agencies. Mixed marriage:
marital discord. Oittljursts of temper: assault: arrest: proba-
tion. Border-line psyclwpatJi.

Case 97. The showing of social "symptoms" (factors and
phenomena) in Leon Blumer was by the card-catalogue . as

follows : —

Social syrnptoms:
Outbursts of temper
Assault

Marital discord
Arrest
Probation
Insufficient income

Social diagnosis:
Family dissension

THE KINGDOM OF EVILS 357

Analyzing by forms of evil shown we find provisionally:

Medical — nothing; possibly family discord, outbursts of
temper, and assault on wife mean something psychopathic.

Educational — nothing; insufficient income possibly due to
language difficulty?

Moral — family discord, outbursts of temper and assault (if
not fundamentally psychopathic).

Legal — arrest ; probation.

Economic — insufficient income (language difficulty?).

We can easily dispose of the language question. Blumer
speaks English, rates 14 years psychometrically, and gives the
impression of being fairly intelligent. Blumer had married at
twenty a Nova Scotian Protestant girl. This marriage may
have been due to bad judgment, but there are perhaps no
eugenic principles well established enough to speak against a
Caucasian-Semitic crossing.

A Malthusian argument is possible. There were nine preg-
nancies in ten years. Blumer was a salesman earning from
twenty to thirty dollars a week. The family income was in-
sufficient. Advocates of birth-control might use such a situa-
tion to point a Malthusian moral. But insufficient income
would never by itself have led to assault and arrest, nor would
Blumer on the basis of insufficient income alone ever have
appeared at the Psychopathic Hospital.

Yet, mirabile dicfu, the family was known to thirteen chari-
table agencies. Quarrels began soon after marriage. Children
had been placed out for years. The wife broke up the home
repeatedly. As a rule the different agencies were consulted
on account of the marital difficulties (sometimes for children's
health, once for financial relief).

There the situation stood. Even our own social service let
the social diagnosis stand at family dissension. Our orderly
analysis by forms of evil clarifies the issue, if it does not solve
it. The issue is moral versus medical at bottom. Racial mis-
cegenation is not yet to be conceded an error. The legal diffi-
culties are plainly secondary to whatever underlies the out-
bursts of temper. The economic straits of the family might
have been material for dissension, not its adequate cause.

Let us examine the medical situation. To the offhand ob^
server Blumer had himself well under control. He readily
admitted his quarreling, but said he did not know whether

358 THE KINGDOM OF EVILS

his wife or the general situation at home irritated him most.
He was rather emaciated and proved to have a pulmonary
tubercle on one side (he now was thirty years of age).

It was further found that he had had gonorrhea at seventeen
and had at some time acquired syphilis (positive serum test first
at twenty-eight).

The wife appeared normal and enlisted general sympathy
amongst the agencies. Her husband was sent to the Psycho-
pathic Hospital by one of these agencies in the fourth year
of the marriage to see whether there was a psychopathic basis
for the marital discord. But neither feeble-mindedness nor
frank mental disease nor a milder psychopathy could at that
time be determined.

It is the same today : tests and observations fail to prove
mental disease or defect, though they do give a definite medical,
though non-psychiatric, background for the increasing temper-
amental difficulty. Discounting early sex irregularity, mixed
marriage, and a possibly fundamental overirritableness as not
proving psychopathia either alone or together, we can still see
the value to the court of thinking about Blumer as a medical
case. If his difficulty is essentially moral, nevertheless there
will inevitably be something medical to do.

But what is a moral case? By classifying a major group of
evils as Vifia, we do not explain the nature of Vitia. The
medical urge is to make Morbi of all Vitia forthwith. That
decision would lead to nothing practical. There is a certain
proportionality between Blumer's bad conduct and the compli-
cation and duration of his domestic difficulties. Disease does
not so nicely proportion causes and results. There is no doubt
a strong moral element in Blumer's plight, whence we may
probably infer an improvement by training and by guidance
in the future.

Thus we must leave Blumer himself scientifically unresolved.
But it is plain that much of value to his family has been brought
out. The family syphilis question must be answered. The
tuberculosis yields some indications. Next time Blumer ap-
pears in the Psychopathic Hospital, further progress may be
made in the deep-lying temperament matter. We cannot rid
ourselves of the suspicion that we deal with a border-line
psychopath.

THE KINGDOM OF EVILS 359

Hours spent by Medical record, 35 pages

Social record, 2 pages
Physician, 4I/2 Social work:

Visits, I
Psychologist, i Interviews at hospital, I

Telephone calls, 2
Social worker, 3^ Letters, 7

Psychopathic boy enlisted in the navy: discharged after
pneumonia. Sick and ''nervous."

Case 98. Word came from a neighbor in Francis Cor-
coran's home town : "The less said about him the better. If
he would go to work as the other boys in town have done, he
might be a help to his mother." The mother is a neurotic,
hard-working woman, who is taking boarders to support the
family through the father's illness. The severity of our corre-
spondent's judgment of this nineteen-year-old lad might be
moderated if she knew that the physicians at the Psychopathic
Hospital found him to be a person of constitutional psycho-
pathic inferiority suffering from nephritis and possibly from
pulm,onary tuberculosis.

He was sent from a public health hospital, where he had
been under treatment for his physical condition, because he was
"nervous." had "attacks of depression," and "could not keep
from telling lies." He told many yarns about himself, among
them the story that he was a student at the Harvard Medical
School. He explained that he wanted to get in to see the
operations at the hospital and thought he would be admitted
if he were a medical student. After telling the doctor in the
public health hospital a number of contradictory fanciful tales,
he later came to him to admit the falsehoods, saying that he
had just "realized" what he had been doing. He said that he
felt a force that compelled him to tell extravagant stories and
to do things that he did not mean to do, such as walking the
streets until one o'clock in the morning.

Corcoran was disabled, nine months after his enlistment in
the navy, through exposure on transport duty and sent to a
hospital with lobar pneumonia. He was discharged after
fifteen months in the service. He went home for a while, and

360 THE KINGDOM OF EVILS

then came to Boston to enter a business school. He had done
rather poorly in school. He had entered high school at fifteen
but had left almost immediately. After a few weeks' study in
Boston, he got nervous and discouraged and resorted to the
pubHc health hospital. He was advised to return there for
further physical building-up.

Hours spent by Medical record, 14 pages

Social record, i page
Physician, 3^4 Social work :

Visits, o
Psychologist, i Interviews at hospital, 3

Telephone calls, 3
Social worker, 3 Letters, 0

Orchestra-player drafted. Sergeant in the band. Gave out
in camp.

Case 99. From flute-player in a symphony orchestra to
band sergeant in a military camp proved a change too severe
for the endurance of Manuel Giordani. As a boy in Italy he
had been allowed to stay at home instead of being apprenticed
to a tailor, doing odd jobs and studying the flute. When
he was seventeen he came to America, and by playing at sum-
mer resorts earned enough to study music during the winter,
until he had attained a position in a first-rate orchestra. He
was drafted when he was thirty and was quickly made sergeant.
The life was rather hard o him because he was not used to
active physical exercise, but he liked it.

Sometimes he would have to play almost continuously from
morning to night. One day after the band had been away from
camp playing nearly all day, the sergeant remembers that he
was tired and had a feeling of uneasiness and timidity. He
went past his station and started to walk back along the high-
road until an officer in a motor picked him up. He did not
sleep well that night and the next day after a cross-country
race felt exhausted in the evening. He could not sleep and in
the morning got up and went to his old barracks where he
thought it would be quieter, so that he might get some sleep.
He was found in a confused state lying on a bed spring, and
sent by a physician to the base hospital. He was afraid some-

THE KINGDOM OF EVILS 361

thing was going to happen to him, and was excited and very
talkative.

In this hospital he was normal in behavior, but very worried
because he feared he would lose his standing if it were known
that he was discharged from the army because he was "crazy."
It was the opinion of the medical staff that his mental disturb-
ance was not of the nature of a psychosis, though they were
not able to determine exactly what type of disorder he had
suffered from. Four months later Giordani was playing in a
summer hotel, and wrote that he was quite well.

Hours spent by Medical record, 27 pages

Social record, i page
Physician, 4^/^ Social work :

Visits, 0
Psychologist, I Interviews at hospital, 3

Telephone calls, o
Social worker, ij4 Letters, 2

Draftsman who thought people laughed at him. Given work
alone, his earnings doubled.

Case 100, Henry Allen made a very high mental test,
being especially good in construction puzzles. He had come
to the hospital as a voluntary patient in a depressed frame of
mind, feeling unable to do his work. He had been sleeping
poorly. He was fifty years of age and was physically quite
negative except for tremors of the tongue and fingers. He
complained of headache, aches in the bones, shortness of
breath, and general weakness, but there was no physical basis
determined for these particular complaints. He said that peo-
ple laughed at him and said things about him in the office where
he worked and that they had been doing this for years. In fact,
he had really for years been worrying about this attitude of his
fellow workers but had kept on in the ofifice up to a fortnight
since.

We found Allen a most instructive case from a certain in-
dustrial, vocational aspect. He despised the constructional de-
tails in his work and rather wanted to do designing. Of course
the details in designing would, no doubt, have been as elaborate
as the details of the constructive work; apparently it was the

362 THE KINGDOM OF EVILS

matter of an attitude adopted by Allen to the general nature
of his work rather than to his mechanical capacity in it. It
was as if he wanted to be more of a figure in the whole office
by doing designing rather than constructive detail. As the
other workmen so constantly talked about him (as he thought)
he did not want to work in a large office with many looking on.
He felt he had worked only up to about twenty-five per cent
of his efficiency because he had not been rightly placed in the
office.

The hospital diagnosis remains at psychopathic personality
but very possibly we should regard this patient as tending
towards the cyclothymic (manic-depressive) constitution where
he belongs in the depressive group. According to his own
story he has been somewhat blue all his life. The self -accusa-
tory trend is a characteristic of such cyclothymics. Very pos-
sibly his idea that he was being persecuted by fellow workers
would transform itself upon analysis into a form of self-
accusation nor does the story of the whole case suggest any-
thing paranoid, that is, looking in the direction of the persecu-
tory delusions of a schizophrenic.

Allen's case came up for particular consideration at a meet-
ing of employment managers at the Psychopathic Hospital.
It was at that time suggested that he ought to work for a firm
large enough to employ a number of designers so that he might
be given the work he liked, rather" than merely constructive
detail. It was also suggested that he should work alone in an
office. These suggestions have, in a measure, been met by ar-
rangement with an employer who has given him greater and
greater responsibility in his work. Short notices and pressure
upon him for rapid work are avoided. He is earning now
twice as much as before. One of Allen's letters to the social
worker will tell the story.

"My Dear Miss Hall:

"Your inquiry with enclosure from my sister has only just
reached me, owing to an error made in forwarding at the post
office.

"My conscience has reproached me many times of late for
my apparent discourtesy in neither reporting or calling at the
Psychopathic and letting you know what had become of me.
Owing to the exigencies of Mr. Anderson's work, in part, and
more perhaps because I knew you were on your vacation, I

THE KINGDOM OF EVILS 363

waited at first to get myself adjusted, and lately have had so
much given me to do it has taken all my time and energy to
accomplish what was expected of me. I am working very
smoothly and getting a good deal done, but only by close appli-
cation. I am not just ready yet to form an opinion as to how
it will work out for me. Expect to get together with Mr.
Anderson on his return from the South in a few days and see
if I cannot get things adjusted more satisfactorily.

"The conditions the work demands are speed, efifectiveness,
and thought. The two latter I can supply but not the former,
so my problem with myself and with him is to reach a compro-
mise which I hope in fact must work out. One cannot work
for Mr. Anderson without being put on their mettle, even
when, as is certainly true, he is one of the kindest and in inten-
tion considerate of employees, and always interesting.

"For reasons best known to himself he has established me in
my own office or work room at considerable present expense
to himself. His work would be considered by a designer or
landscape man as of a very choice and charming character.
It is, or should be, all beautiful. Just how I shall measure up
to the opportunity we will have to wait and see.

"Personally I feel that I have benefited by my stay at the
Psychopathic and the difficulty of concentration which I once
mentioned to you seems no longer to exist in my work. Will
you please remember me very kindly to Dr. Reed, Dr. Patter-
son, Miss Dean, and the others?

"In closing I can only say that I am not sure yet for reasons
more readily said than written, whether or not the work, as it
is coming to me, will prove the work that I should wisely en-
deavor to hold. I am trying it out in the most matter-of-fact
and sensible way I can and am reserving my final opinion.

"When it has developed a little farther, I may want, if I may
do so without imposing unduly on your time, to talk over condi-
tions as they develop. For no matter how ideal the nature of
the work may be I am by no means sure that ultimately to be
pinned down as closely to a drawing board as I have been will
become impossible — physically I am waiting to see.

"I trust that your vacation has been very beneficial to you
and that you have returned to your profession refreshed for
the work which I am sure is as exacting and trying on the social
workers in some ways as it is helpful and beneficial to the
people you help.

"Trusting you will pardon the length of my letter and my
delay in writing, I am "Very sincerely,

"Henry Allen."

364 THE KINGDOM OF EVILS

"p.s. It has occurred to me that what I have written of
my work may suggest to you that I am being unduly confined.
It is true for the time being, but I think I shall remedy it
without difficulty ; and add this lest you should think it wise to
write Mr. Anderson on the subject, for I know it is part of
your profession to look after the patients when they need it.
In this case there is nothing but will adjust itself. And it is
all incidental to getting started, so while I have written to you
frankly I shall be quite as frank with Mr. Anderson and can
instantly make it right, and I do not know how he would take
a suggestion from the stafif while I am certain he will from me.
Probably you wouldn't think of it in any case. But I have such
a warm regard for the intelligent work you are doing at the
. Psychopathic I am sure you would do it unless you knew there
was no need !

"If there is any further information I can send you at any
time, I shall be only too happy to do so.

"H. A."

It is a question whether it would not have been wiser to have
Allen overcome his fear of working in a large office. Possibly
if we had regarded his condition as cyclothymic or an obses-
sional cme, it might have been wiser to try to break up the
obsession by counsel and the initiation of new habits. Where
we are dealing, however, not with besetting ideas so much as
w^ith a habitual and self -accusatory gloom, it is not likely that
"rationalizing," or idea upsetting, psychotherapy would be
much in point. Here again, as in the case of Arthur Morton,
the differential diagnosis between the depression of psycho-
neurosis and the depression of a constitutional cyclothymia be-
comes a matter of extremest importance to the victim of the
depression which is aided by rationalization on the one hand,
and no doubt by abstention from psychotherapy of the argu-
mentative or persuasive sort on the other.

Hours spent by Medical record, 18 pages

Social record, 38 pages
Physician, 4^ Social work :

Visits, 2
Psychologist, I Interviews at hospital, 20

Telephone calls, 10
Social worker. Letters, 19

BOOK IV

What is man, that Thou shouldest magnify him,
And that Thou shoiddest set Thy mind upon him,
And that Thou shoiddest visit him every morning,
And try him every moment?

Job, Chapter 7, Verses 17, 18.

EPICRISIS

The descriptive task of this volume is complete. The body
of the text presents a set of social cases chosen from psy-
chiatric material to illustrate the theory and practice of
social work. The first three books present the practice of
social work inductively, to the end that the student may almost
unconsciously gain an insight into the underlying principles of
diagnosis and treatment in social cases. To be sure the reader
will find scattered amongst the case-descriptions in all three
of these books numerous theoretical remarks. But in Book
IV these scattered remarks concerning theory are to be united
into a body of principles. At the outset of Book IV we shall
offer statements of an exceedingly general nature, designed to
align this work with others bearing on the various arts and
sciences that have come to be termed sociological.

RELATIONS OF SOCIAL WORK TO SOCIOLOGY AND PSYCHIATRY

There is not much in books on sociology, ancient or modern,
that touches even the theory of social work. Works on so-
ciology since the establishment of the theory of evolution
have treated mainly the relation of the family taken as a
group to the community also taken as a group. That both
the family group and the community group are sets of individ-
uals, no sociologist ever denies. Indeed some sociologists pro-
claim that the unit of sociology is and must be the human
individual. But we believe it is fair to say that modern soci-
ology is in the main a theory of the relation of human groups
to one another rather than of the relation of the individual
"soul" to its fellow or fellows in daily life.

Certain it is that the sociology books rarely present any case
material after the manner of the present work. Yet there is
much to be said for building up a new sociology from the bot-
tom. If we are to build thus from the bottom, we must cer-
tainly begin with the relations of man to man, woman to
woman, and man to woman, whether those relations are by

367

368 . THE KINGDOM OF EVILS

blood, by marriage, or otherwise. What has been done by
jurists upon domestic and personal relations is not only meager
but in part doubtless quite false, being founded on the very
partial insights obtainable by Bench and Bar. Many of the sit-
uations that we have described above will suggest dire need of
logical analysis of personal relations with a deeper insight and
a less general point of view than the juristic one. This new
point of view and insight we can only in this work faintly
indicate. We conceive that social work will some day pass, in
the form of more or less definite principles, into a great body
of sociological theory. The new sociology will in our opinion
be, not merely a theory of human "groupism," but a theory of
the relation of individuals to each other. Though the student
of social work can today find little or nothing to his purpose
in sociology books, he should not despair. He is himself
recording facts that will go to make up new sociological text-
books of the future and give the theory of human group rela-
tions its proper fundament in a theory of human individual
relations.

In one sense this volume is a collection of cases of social
maladjustment. The whole of life, according to Herbert
Spencer, is an adjustment — a continuous adjustment of
inner to outer relations. Roughly speaking, we look to the
psychologists for a study of the innermost of life's inner rela-
tions. Perhaps it is not astonishing that we should find the
sociologists beginning with the outermost of life's relations,
namely the group relations of the family to the community.
But the history of the mental sciences in recent years shows
that the psychologists are beginning to study man's inner rela-
tions as they touch society (witness books like McDougall's
Social Psychology) and that the sociologists are beginning to
write books that endeavor to carry society back to certain
springs of action in the individual mind. In short we can see
signs that the mental sciences are beginning to study not merely
life's inner relations as such and life's outer relations as such,
but also the adjustments of interrelations of the two. Now
the social worker stands in the practical center of these adjust-
ments, so far as they concern the relations of man to man.
The contributions of the psychologists and of the sociologists
are still as separately visible to the readers of books on so-called
social psychology as the separate flows of the Missouri and

THE KINGDOM OF EVILS 369

the Mississippi for a long time after their junction. We are
now inductively building up the facts for a true social psy-
chology (or shall we say psycho-sociology f) , which is to be
something new in which the contributions of psychologists and
of sociologists will no longer be separately recognizable as such.
Adaptation is the key word of much of the psychology,
sociology, economics, and political science of the nineteenth
century. Adaptation and maladaptation are the key words of
our own branch of practical or applied sociology called social
work. The hurnan mind is no doubt the most exquisite of the
adjustments of which the nineteenth century talked so much.
But the supreme organization of man's mind has its penalty.
That penalty is the ease of its maladjustment and maladapta-
tion. Man builds up outer relations quite as complex as his
own inner ones. There are frequent flaws both in the psychic
interior of man and in his environment. These flaws, whether
in the shape of initial lacks, or of acquired losses, or of mere
twists without lack or loss of constituent elements, can hardly
be made good without extraordinary effort, conscious and un-
conscious, on the part of man. These efforts we term efforts
at reform, reconstruction, rehabilitation, readjustment, readap-
tation.

The fitness of the environment to life has been affirmed
with great strength and skill by the modern sciences of chem-
istry and physics (witness such works as those of L. J. Hen-
derson on the Fitness of the Enznromnent and the Order of
Nature). Yet the fitness of man in his environment, or the
fitness of the environment to man, is a very general and loose
adaptation rather than a special and precise one. Whether it
is the generality of the laws of environmental fitness or whether
there is some other reason, we have no point to bring in this
work ; but it is obvious enough that human maladjustments do
occur precisely on the plane in which life's inner relations meet
the outer ones. Man perhaps shows the defect of his virtue.
He has high sensibility and a delicate responsiveness to his
environment. He finds most ingenious ways of shunning ob-
stacles. But he finds equally ingenious ways of contriving
new obstacles, along with the devising of new ideas, practical
and theoretical. To use a homely figure, man is often in the
plight of an adventurous cat, which has climbed a tall tree
with admirable audacity, but finds herself quite unable or

370 THE KINGDOM OF EVILS

unwilling to climb down. The order of events is (a) the
existence of a perfectly good general adjustment of life's rela-
tions, (b) the development of specific maladjustments between
those relations, and (c) the social necessity of readjustment
amongst the relations. The social worker cannot be respon-
sible, as social worker, for the integrity or the interior perfec-
tion of the minds of the human beings dealt with. Again the
social worker cannot be responsible for the status of all the
outer relations which are indispensable to life.

The duty of the social worker lies in the plane of adjust-
ment and of readjustment between the human mind and
society. Modern social work undertakes consciously to effect
readjustment, so far as possible, in all concrete human cases
in which the vital relations, inner and outer, have become mu-
tually disorganized. Society has come to regard itself as more
and more responsible for the cure and the prevention of all
human maladjustments. The man who takes a serious view
of human life and human society on the one hand may seek
to promote man's "welfare" or on the other hand he may pre-
fer to think in terms of man's increased "efficiency." In either
event the serious student of social adjustments is looking
towards concrete betterment. In a practical age, and with the
inevitable memories of the Great War, the student of sociology
grows weary of abstractions, generalizations, and universal
formulae, such as dogged the world's footsteps before and up
to the year 1914. Modern social work finds the prevailing
after-war spirit identical with its own familiar spirit of recon-
struction. For decades, doubtless, the world will be in a frame
of mind to repair and restore rather than to build uncertain
novelties upon shifting foundations. Social work has in fine
come into a perfectly congenial atmosphere. Social work can
be at the same time as charitable as it likes and as efficient as
it likes.

Just as man is more complex and less stable than other
forms of life, so inside man himself is man's mind more com-
plex and less stable than all else he possesses. Man's mind
is at the center and crossing of all those inner relations which
Spencer defined as requiring adjustment to the outer world.
If modern social work demands readjustment of man to his
environment, not to say of the environment to man, then it is
clear that the specialist in social adjustment must find his chief

THE KINGDOM OF EVILS 37I

aid and mainstay, but also the greatest bugbear and stumbling-
block, in this selfsame highly sensitive, highly unstable mind.
Inside the developing specialty of social work there is now
unfolding with great speed and surprising precision a new
type of social work called psychiatric.

Psychopathology and psychiatry are respectively the
science of the mind diseased and the art of mental healing.
Psychiatric facts and observations are what constitute that
practical specialty of medicine known as psychiatry. Psychia-
try is a practical branch of medicine. Sometimes its theoretical
side is given the name psychopathology. Psychopathologists
are theorists that describe and explain what we scientifically
know or think we know concerning mental diseases. For
example, William James, besides being a psychologist (that is
a theorist dealing with the normal and general aspects of the
mind) was a psychopathologist (that is a theorist dealing with
morbid aspects of mind) ; and the interested reader will still
find in James's larger Psychology, published in 1890, a ma-
jority of the important facts concerning the general theory of
mind and concerning its morbid aspects. Indeed, the general
reader is perhaps safer in the reading of that older work than
in the somewhat precarious plunges he might readily make in
the current magazine literature. But, although James was a
psychologist of the first rank and a psychopathologist amongst
the most competent, he would not have claimed to be a psychia-
trist. To be sure James bore the M.D. degree; but he was
not a practitioner of medicine and therefore not in the fullest
sense a psychiatrist. The interested layman must never con-
found theory with practice, chemistry with dietetics, physics
with bridge-building, psychopathology with psychiatry, the
theory of mental disorder with the practice of the cure and
prevention of mental disease.

The layman is drawn by a mysterious yet perfectly legiti-
mate attraction into the field of what used to be called in-
sanity, but which we now like to spread out into the field of
mental diseases and defects. Time was when insanity was
somehow in the same breath attractive and repellent. On the
whole the mind diseased was a forbidding topic. Nowadays
the situation is altered. To be sure, there are in various recep-
tacles contrived by the philanthropic and self -insuring state
governments a certain number of legally insane persons, a

372 THE KINGDOM OF EVILS

great many more in the urbanized states of Massachusetts and
New York than in rural and unorganized states. Of course
what the civihzed state is here doing for the chronic insane is
in itself a kind of social work which makes for betterment in
the state. But the benefits for the state at large are rather
negative than positive, and only in states of an advanced civ-
ilization is there much coordinated effort, by special treatment,
by medical and social teaching, and by well-conceived re-
searches, to the end of directly helping the victims inside asy-
lums and their families at home. Which means to say that
the highest type of social work, both general and psychiatric,
is seldom found upon the planet. Still, in the most urban por-
tions both of our Atlantic seaboard and in parts of the interior,
where the need is most urgent, successful social work, both
general and psychiatric, is being carried on. The phrase "ex-
perimental stage" can no longer be properly hurled at this work.
The blue-prints of it have, so to speak, been manifolded. Com-
mittees like the National Committee for Mental Hygiene are
forwarding the work throughout this country. But for years
to come the work of such committees in many states and com-
munities must be limited perforce to that perfectly crystallized
form of social work frequently known as "state care of the
insane."

In the first part of this work we have called attention to
the distinction between public endeavor and social endeavor,
contrasting the public and social spheres of influence with
the more personal and individual sphere. Practically we no
longer term social work that special portion of the community's
task which has been taken over by organized government and
reduced more or less to thumb rules, which are perfectly good
rules unless interfered with by the exigencies of the public
treasury, real or imaginary. There is a good deal in the public
(that is organized governmental) service which the social
worker, operating from voluntary agencies, cannot touch or
modify. The social worker then has to operate, as the military
men say, "through channels." Nevertheless, the voluntary
agency is often able to flick the wheel of officialdom. The fit
of government and law is, we are almost inclined to thank
Heaven, not a close fit. The legal order and the administrative
order are general rather than individual in their application,.

THE KINGDOM OF EVILS 373

There is a wavy line separating the pubhc from the private
(where we mean by "private" either social or personal consid-
erations, not yet reduced to rigid rules and regulations).
There is also a wavy line between social considerations on the
one hand and personal ones on the other.

The successes of public health and preventive medicine
it is no part of the present work to restate. Public service is
one of the most successful things, so far as it goes, that man
has accomplished. The theory of sanitation passed smoothly
and efficiently from a set of considerations bearing on such
matters as sewage and other sanitary concerns to another far
more delicate set of considerations bearing on infection and
bacteriology. The public health movement is now passing into
a phase in which personal hygiene is coming into sharp focus.
The mental hygiene movement is about to fuse with the rest
of the doctrines of public health. An important part of mental
hygiene is a public affair. In the same state governments that
were developing departments of health, another movement was
quietly going forward for the so-called "state care of the
insane." This program is well-nigh complete, so far as the
legally insane are concerned. The models for state care have
been laid down. In several parts of the world public service
has done practically all that our knowledge now allows for
the group of unfortunates known as the chronic insane.

But the chronic insane form a comparatively small group
of unfortunates. Psychiatry, as almiost any case in this book
will prove, is luckily no longer limited to the classification, care,
and treatment of the legally insane. For every insane person
now confined in a state receptacle, it may be suspected that there
is another almost or quite equally insane person outside brick
walls who might very appropriately be interned at once for his
own sake and for the state's sake. Laws for the temporary
reception and care of such suspects have been placed on the
statute books of a few of the most civilized states. In some
of these states special psychopathic hospitals have been built
and equipped for their care and specialized treatment, study
and investigation. The data of this book intend to bring to the
layman and to the social worker special information concern-
ing mild, incipient, and dubious cases of mental disease, which
we shall come to know either as mild instances of various well-

3/4 THE KINGDOM OF EVILS

known mental diseases or else merely as psychopaths (i.e., not
subject to diseases of a well-known and definite character —
as it were unspecified cases).

But the aim of modern mental hygiene is much more ambi-
tious. How can the tasks of modern mental hygiene be de-
fined? It is plain that, if our analysis of "spheres of influence"
in Book I is correct, mental hygiene might well deal with (a)
the establishment, maintenance, and improvement of various
public, legal, and administrative institutions and relations, (b)
the encouragement and improvement of various voluntary and
private agencies for the betterment of social relations and the
molding of society's opinion on these matters, and (c) the es-
tablishment of new facts and devices for improving man's in-
dividual relations, particularly the very interior relations of the
man to himself.

The mental hygienist of the present day, whether he be a
psychological theorist, a specialist in mental tests, a psycho-
pathologist with theoretical interest paramount, a practical psy-
chiatrist, or an educationalist specially concerned with high or
exceptional talents or with the "ungraded," wants to spread a
gospel about mind much wider than the crystallized doctrines
of medico-legal insanity, the newer knowledge about the "tem-
porary care" (psychopathic hospital) group and the out-patient
group of mental diseases and effects of a more or less mild
nature. The ambition of modern mental hygiene is to spread
its point of view over the entire field of the mental sciences
and arts, wherein sociology and economics look especially ac-
cessible. Not only the insane, not only the psychopaths, but
also the eccentrics and the very slightly subnormal are topics
for modern mental hygiene. Nor, as above hinted, would
mental hygiene object to considering the supernormal person
and the person with specialized capacities as within the range
of its point of view. We may mention again the work of
William James, this time pointing out how in his Varieties of
Religious Experience, published in 1903, he utilized his vast
psychological and psychopathological equipment in the study
of what he sometimes termed the religious "geniuses." It is
worth while insisting that the psychiatric approach does not
mean calling everybody crazy or even a little bit crazy ! James
himself went to extraordinary lengths in his chapter on "Re-
ligion and Neurology" to refute this idea. James's acid test

THE KINGDOM OF EVILS 375

of psychopathology did not destroy the golden geniuses of
religion. When, therefore, we say we want to apply the psy-
chiatric insight to practically the entire human world, we are
not at all asserting or suspecting that the majority of human
beings are in any sense psychopathic. We believe that more of
the psychiatric point of view will be of great service to the
world, as well in domestic as in political life. Just as James
gave new viewpoints concerning the religious ecstasy, and just
as Hippocrates and Galen before him were physicians who
made the most extraordinary contribution to our knowledge of
temperament, so we hope by the spread of the mental-hygienic
point of view and the point of view of psychiatric social work
to aid the common man and woman to deeper, practical insights
into everyday questions.

METHOD OF APPROACH

We shall now try to describe in a few sentences and in the
most general way the somewhat novel method of approach
adopted in this book.

There has heretofore been no special treatise upon psychiat-
ric social work. There is in fact no comprehensive treatise
upon social work in general. Accordingly this book has per-
force to include much that may seem entirely non-psychiatric.
We do not seek to describe comprehensively the technique of
social diagnosis or the technique of social treatment. The gen-
eral features of the technique of social diagnosis have been
ably catalogued by Miss Mary E. Richmond in her work on
Social Diagnosis. Comprehensive studies upon Social Treat-
ment are rumored to be in preparation, and the experiences of
decades, from the first philanthropic endeavors up to the more
scientific procedures of present-day social treatment, may then
become available for the growing group of general social
workers. It is not our design to anticipate future formulation
of the methods of social treatment or to repeat the systematic
chapters of Richmond, so far as they deal with mental hygiene
and psychiatry. We have carefully reviewed Richmond's
work and found to our surprise that fully half of the social
cases presented by her are cases with a strong mental hygienic
or psychiatric flavor. What this signifies can be discerned if
we remember that Richmond's selection of cases was a purely

376 THE KINGDOM OF EVILS

random selection, made for the purpose of illustrating differ-
ent forms of technique of social diagnosis. The collection was
in no sense designed to display the importance of psychiatry
in social work. Reading between the lines we can reasonably
conclude that a much higher proportion of the Richmond case
collection would turn out upon closer study to be cases involv-
ing mental hygiene in its broadest sense — cases, that is to say,
that illustrate the importance of considering mild character
defects and perversions, mild feut important temperamental
distinctions, and the like. Rising from this sort of analysis
(and any case collection of social work, so far seen by us, will
point the same moral), we are tempted to inquire whether after
all psychiatric social work is not merely social work in general
with special emphasis upon its mental hygienic features.

We conclude that the present case collection is perhaps com-
prehensive enough to amount to a case collection demonstrating
in the rough the main principles of all medical social work.
We bear in mind that the great medical inspirer of the develop-
ment of medical social work, Dr. Richard C. Cabot, has for
years insisted that the supreme values of medical social work
lodge in the diagnosis of human character and the care and
treatment of social patients in the light of our knowledge of
their character. A chief aim of medical social work must
always have been recognized, more or less vaguely, as a sort
of character-building, a labor with "sick souls" as well as with
sick bodies, a labor inevitably interrupted by all sorts of tem-
peramental handicaps. Even where no such handicaps stood
out in silhouette form upon the history of the patient, still even
the more positive forms of character-building would need to
take account of fundamental, temperamental, and character
traits. This insistence by Dr. Cabot upon the centrality of
character-building in social work took the right line. But in
those days the modern psychiatric point of view had not ar-
rived to deal with the subtle differences amongst men as to their
temperamental deviations and slight eccentricities of character.
The tendency of eighteenth-century individualism had been to
the thought of general ethical principles common to all men.
When the eighteenth-century individualism died away to be
replaced by the statistical average man of Ouetelet, and when
Quetelet's Physique Sociale was supplanted or made over by
the evolutionary ideas of man as a species, there was outstand-

THE KINGDOM OF EVILS 377

Ing a certain overgenerality of view, a certain opinion as to
desirable conformities of human beings, old and young, male
and female, married and unmarried, white and black, to some
norm or model.

Nowadays we are beginning to look more at differences than
at resemblances of human beings. Individualization is the war
cry. But the warp and woof of the argument for individual-
ization depends on actual case material. This case material
can, we think, be supplied nowhere so well as in the wards and
out-patient departments of psychopathic hospitals. To the end
of making character ultimately better, we now proximately look
at the mild psychopaths, eccentrics, and "deviates" of psychi-
atric clinics. We are often eloquently reminded to become
"masters of our fate" by the utilization of our very handicaps
themselves. Grail-hunters, according to available legends, had
sundry dragons to slay by the way. The strength of Sir
Galahad was as the strength of ten, not merely because his
heart was pure, but because of his righteous exercise of soul
and body in the leaping of obstacles and the destruction of
evils. In point of fact, social work did not lose in moral fer-
vor by taking on the more scientific form of seeking social
justice rather than a more or less refined alms-giving. But
whether with the philanthropist you are giving gifts, or
whether with the social worker you are paying society's debts,
— in either event you are a dealer in morals. Even the bare
aim of efficiency, which causes our legislatures year by year
to appropriate more and more money from the tax levy, has a
moral motive. The watchdogs of the state treasury, with
whom we are so familiar, have their ears to the ground of
morality, of social justice, and of such altruism as the com-
munity may afford. Yet withal, it must be insisted that the
ideas of character-building, of masterhood of fate, of the
utilization of one's handicaps, of old-time philanthropy, and
of modern social justice are moral ideas derived from the gen-
eral stock of such ideas to be found in everyone. Up to recent
years the leaders in. social work, like their predecessors who
called themselves philanthropists, took their ideas of morals
and of moral development from the general stock rather
than from any special studies of the moral status and out-
look of their patients, taken as "persons," "individuals,"
or separate and distinct "souls."

378 THE KINGDOM OF EVILS

We are entitled to claim for psycniatric social work that it
employs not only the general stock of human ideas about char-
acter, but seeks with some success to employ the new point of
view of mental hygiene. Possibly that point of view can best
be intimated in a single word by the term individualization.
It was the reproach of older medicine, as it was of the educa-
tional, legal, and economic orders of our own day, that the
human unit was not treated as a whole.

The late Professor James Jackson Putnam was one of the
earliest physicians to point out the necessity of treating the
whole man rather than parts of man, such as heart, liver, or
kidneys taken as separately subject to disorder. Man seemed to
the analytical pathologist of the last century a heap of viscera,
in which systems such as digestive, muscular, nervous, respira-
tory, and excretory were to be found. Especially in the last
decade of the nineteenth century, the "skin and its contents"
(as the slang medical phrase runs) began to be tied together
once more through the central nervous system, composed, as
was discovered, of countless enormously long interconnecting
strands, the so-called "neurones." Then followed in the first
decade of the twentieth century another process of tying organs
together. These new ties were chemical ties ; that is, the so-
called ''chemical messengers" or "hormones," which flowed
through blood and tissues from the glands which made them to
the organs they were designed to stimulate and control. Thus,
by the second decade of the twentieth century, even the analyt-
ical pathologists were ready to see in disease and health com-
binations where they formerly had seen separations, syntheses
where they had formerly seen sundering, and all sorts of remote
effects which had formerly lain quite unsuspected.

It was as if a traveler had suddenly by the break of day
become aware of great numbers of telegraph lines, great quan-
tities of railway trackage, in a landscape which had in semi-
darkness seemed to him quite barren and wild, and had become
aware of a vast transportation system of highly artificial prod-
ucts capable of entirely altering the scene. The men of science
had in short by their own endeavors come to see new unities of
body and mind and were once more able to work conscien-
tiously with their colleagues in social tasks. Analytical men
of science are thus now able to work again with the rest of the
world on the platform of individualization. What may be

THE KINGDOM OF EVILS 379

called the neurone set-up of man, that is, his nervous frame-
work in the finest sense, is clearly a very individual affair, and
the hormone set-up, that is, the special and intimate construc-
tion of man in certain vital chemical ways, must needs be also
a very individual matter. The individualization of man, as
we now look at him in the second decade of the twentieth cen-
tury, is individualization to the second power, or to the cube,
of what it could possibly seem in the third decade preceding
ours, the decade in which so many extraordinary discoveries
in bacteriology were made. If it were worth while to drag
the argument out 'at greater length, we could point out the
obvious increase in individualization in the processes of educa-
tion and even somewhat in those of law and economics. That
ihe time is ripe for individualization of morals can hardly be
doubted. That the technique by which the world shall achieve
this individualization of morals is mental hygienic technique,
we that write this book are persuaded. The resulting distinc-
tions are not medical distinctions, but purely and simply moral
ones. In the field of education it is a matter of familiar his-
tory that Madame Montessori derived her special ideas for the
education of normal persons from the study of the methods
used for the feeble-minded. So it is with the new insight into
morality which the study of the mild mental disorders is begin-
ning to afford. The resulting ethics will be ethics for the
normal individual. The dynamite of disease may serve to
split out building stones. The acid tests of medical study may
display the true moral structure of normal human beings.
Psychiatric social work can establish and is now estab-
lishing new principles for social work in general.

The time may come when medicine can be forgotten and
hygiene alone maintained. Then would be the golden age of
keeping well rather than of getting well. Likewise psychiatric
social work may (theoretically) disappear and leave the every-
day problems of financial relief, of legal aid, of standardized
moral training and of perfectly systematic education. But,
even if such a golden age without disease is ever to develop,
the chances are good that the study of medicine in its broadest
sense would be an indispensable factor in the gilding process.
Individualization is very properly the war cry of today. Path-
ological method will have much to do- in establishing the prin-
ciples of that individualization upon a sound basis. That por-

380 THE KINGDOM OF EVILS

. tion of pathological method which deals with the diseases and
defects of the mind, especially the mildest psychopathies and
the faintest eccentricities, will carry the banner of individu-
alization to the farthest point now visible ; namely, the con-
fines of the mind of man. We have already begun to study
with delight and profit the nature of geniuses and of excep-
tional persons with special abilities. The varieties of moral
and religious experience are being levied upon in the literature.

Even the legal order, which has been so terribly general
in its plan for securing the interests of man, has begun to raise
the cry of individualization ; witness not only various theoreti-
cal assertions of this trend, but witness the jurists themselves
and also the pleasing vogue of a book like that of Dr. William
Healy upon the Individual Delinquent — a book founded upon
case descriptions.

Lastly, even in the field of economics, a book like that of
Taussig on Inventors and Money Makers serves to show how
far the idea of individualization may penetrate a field devoted
for decades, or practically since its initial survey, to the "aver-
age man." Social work, as plainly shown in the case descrip-
tions of this book, touches all these fields of education, morals,
law, and economics, and must naturally share the effects of
that increase in individualization which all of these great de-
partments of knowledge and practice are showing.

If we concentrate attention upon the medical division of
the field of social work we cannot fail to see that the individu-
alizing trend must be greatly strengthened by modern develop-
ments in medicine, upon which the analyses of medical social
workers must depend. If we further concentrate our attention
upon the psychiatric division of the field of social work, we
cannot escape the conclusion that here at last we find the very
pitch and apex of individualization. Landscapes and habitats
extraordinarily differ. Races and people differ still more
extraordinarily. Human bodies show differences obvious to
the casual eye, and their contents such as livers, kidneys, and
other glands, must show even greater differences than the
environments of their owners. When we take into account
the interconnecting filaments of the nervous system and the
special qualities of the various chemical messengers uniting
the different parts in the body with one another, we perceive
that the resulting unities are capable of still greater differentia-

THE KINGDOM OF EVILS 381

tion. Leibnitz pointed out that no two grass blades were alike.
He called his discovery by the extraordinarily obscure name of
the law of the identity of indiscernibles. Well! if two grass
blades must perforce be different, two brains interpenetrated
by the highly specialized bloods and juices must be capable of
still greater differences than mere grass blades could display.
From this line of argument our main claim will stand out;
namely, that progress in the psychiatric division of social
work will inevitably bring progress in medical social work
las a whole. This progress in medical social work as a
whole must react upon the more general non-medical
parts of social work.

What are the relations between psychiatric social work and
other fields of social case work? Logically, all portions of
the field of social case work are intimately connected. Prac-
tically, there are at least three divisions of social case work, if by
"practical" we mean divisions defined by the existence of a
corps of special workers limited by training, experience, and
interest to each special division. On this practical ground we
may thus distinguish (a) a field of general social case work,
(&) a field of medical social case work, and (c) a field of psy-
chiatric social work. We here limit consideration to social
case work as distinguished from the broader fields of com-
munity work. We speak merely of that total field of social
work that deals in one way or other with the individual, either
in his public or social or personal relations.

The point of view of (a) the general social case worker
derives historically from the older philanthropic point of view
and is still largely founded upon the necessity and desirability
of the so-called "poor relief" and the economic establishment or
reestablishment of the family. (We must insist that every
social case worker, whether general, medical, or psychiatric,
has the family point of view ingrained in her training and im-
bedded in her practice; the point in the text refers to the pre-
dominance of the economic point of view in general social
work, pivoting, as it so often must, upon the total wage intake
of the family and its proper distribution or supplementing.)

The point of view of (&) the medical social worker derives,
not so much from the older philanthropic point of view as from
modern developments in medicine. The medical social worker
has her economic interests indispensably, for she also pivots

382 THE KINGDOM OF EVILS

her work upon the family. But essentially the medical social
worker has in mind the restoration of the health of the family
and of its individual components. Some of the pioneers in
medical social work have been general social workers who had
become convinced that medicine must be their particular target.
But other leading medical social workers, even at the outset of
its development (see Ida M. Cannon, Social Work in Hos~
pitals), were persons theretofore quite untrained in the eco-
nomic aspects of social work, who became medical social
workers de novo. There was, to be sure, a fortunate union
and mutual adaptation of economic and social interests from
the beginning of the development of medical social work ; and
there are signs of an equally happy reaction running both ways
between general and medical social work.

The point of view of (c) the psychiatric social worker de-
rives from the modern developments in mental hygiene. Else-
where in this book we have sufficiently insisted that psychiatry
(that is, the art of mental healing) is in one very definite sense
a branch of the practice of medicine but we have pointed out
with equal emphasis that psychiatry has far broader contacts
with the world than with medicine alone. We have pointed
out that mental hygiene is in some ways a much broader topic
than medicine, touching education, ethics, the legal order, and
economics, to say nothing of science, art, political science, re-
ligion, and philosophy. Practically, moreover, the field of
psychiatric social work would never have been developed in its
present form, had it not been for the labors of the mental
hygienists, amongst whom we must count not psychiatrists
only but also psychologists. Psychiatric social work is accord-
ingly not alone a logically separate division of social work but
also practically a separate division, as defined by the existence
of a type of specially trained worker and as defined by the
history of the movement itself.

It is plain that the field of (a) general social case work
stands logically somewhat farther apart from (&) medical
social work and (c) psychiatric social work than {h) and (c)
stand apart from each other. Indeed, it might be claimed that
psychiatric social work is nothing but an important subdivision
of medical social work akin to such subdivisions as the tuber-
culous, orthopedic, lieart, syphilis, and pediatric subdivisions.
In fact, this claim has been made by some workers, though

THE KINGDOM OF EVILS 383

nowhere supported by a thorough logical and historical argu-
ment. The observer must bear in mind, however, that, if we
are talking logic alone, the public-health movement ought to
carry in its front lines the banner of mental hygiene. Public
health officers and specialists in preventive medicine ought to
have developed mental hygiene divisions as logically and as
practically as they have developed their work in sanitation,
bacteriology, and in later days personal hygiene. But the pub-
lic health movement has never taken the "person" on so broad
a basis as the individual "person" of mental hygiene. What-
ever the public health movement ought to have been or ought
to have become in relation to mental hygiene, the facts are
against anyone who should claim that mental hygiene is his-
torically an outgrowth of public health. So it is with the move-
ment for psychiatric social work. The movement is derived
from psychiatric clinics, psychopathic hospitals, out-patient
clinics for mental and nervous diseases, mental hygiene so-
cieties, and kindred mental hygiene units of the community.
Perhaps it has been better so. The man interested in sanita-
tion, bacteriology, and the simpler devices of so-called personal
hygiene is not apt to be a person profoundly interested in social
relationships and their adjustment and readjustment. The per-
son interested in economic relief and primarily in the solution
of the comparatively simple problems of the tuberculous, the
orthopedic, the "heart cripple," and even of the sick child, is
not a person who is apt to give due weight to educational, ethi-
cal, and legal sides of her problem, having in mind adjustments
which transcend the wage intake and the bodily health and
comfort of the sick person.

Now it is perfectly true that to solve the problems of the
lame, the halt, and the blind, or of the tuberculous, or of the
child sick-of-body, the bigger and more complex social adjust-
ments are more and more coming to be regarded as indispen-
sable. In the terms of the future history of social case work,
we may safely predict that the psychiatric point of view will
react upon the general medical point of view in case work.
The very same thing is happening in the field of medicine re-
garded from the standpoint of the physician. The general
practitioner of medicine in every parish is inevitably busy with
psychiatric problems, though he may not think of them as such.
Psychiatry is a branch of medicine every whit as general in

384 THE KINGDOM OF EVILS

one sense as is the general practice of medicine itself. The
nervous system penetrates every part of the body and the mind
influences every diagnosis, every prognosis, and every thera-
peutic procedure in medicine. Nevertheless, it will be a num-
ber of years before the general practitioners become equipped
with the psychiatry they need. So it is with psychiatric social
work. Psychiatric social work is bound to influence medical
social work, and, in fact, all forms of social case work. Just
as the general practitioner of medicine would greatly benefit
by getting into his head the main facts about psychiatry, so
the medical social worker will equally benefit by absorbing the
new principles of psychiatric social work. Logically the two
fields of medical social work and psychiatric social work pre-
sent aspects of resemblance and aspects of difference. His-
torically the two fields present separate lines of development.
Practically, even at the present day we must insist that psychi-
atric social work is by no means a specialty coordinated with
pediatric or orthopedic social work, but presents a body of
principles applicable alike to all the subdivisions of medical
social work.

The new theories of social work or practice must soon effect
changes even in sociolog}^ as a whole. Sociology as a whole
has run perhaps too much to a schematic and general account
of supposed evolutionary laws of the nature, structure, and
development of society. In this general account of society's
evolution commonly called sociology, the individual is very
likely to get named on page one but not to figure extensively
in the table of contents. We claim then that, by beginning
with a study of the individual in his finest and most delicate
deviations from the normal, we are starting an inductive study
which if carried through sedulously will react upon sociology
itself and therefore upon political science, economics, ethics,
and the rest of human interest. Let no reader say that this is
an elaboration of the obvious. The inductive method has been
on the cards since the Novum Organon of Francis Bacon, but
inductive progress toward a completer sociology has not begun
with the individual and especially not with the individual as
delicately dissected out in mental disease.

We have arranged the case studies of this work in a certain
formal way. For the most part, however, we have presented
them so that each stands upon its own feet. Nor do we think

THE KINGDOM OF EVILS 385

that the data have been essentially modified by the process of
analysis to which they have been subjected. The narratives
are chiefly drawn from "intensive" cases in our hospital files
rather than from cases of so-called "slight service." The data
presented are condensed to even far less than one-tenth of their
original extent, with the omission, however, of no important
link in the narrative, taken as a narrative. The book might
thus be read purely at random and each case regarded as a
source of texts. We have constructed the index to the book
in such manner that many of these texts or special maxims can
be studied in particular cases, even where no attempt has been
made in the summary to unite the cases to demonstrate par-
ticular precepts.

The object of dividing the case descriptions of the book
into three main parts was a purely practical one. In Book I
we sought to show the main spheres of influence which are
brought to bear upon social cases in civilized communities
where (a) government and (b) systematic voluntary social
agencies and (c) special methods of handling the individual
are highly organized. Book II is devoted to a much more
individual analysis of the social cases from the standpoint of
the various troubles, difficulties, maladjustments, or evils that
they present. The analysis of Book III is a medical analysis
and gives some slight idea of the varieties of social diagnosis
and treatment of cases falling in the more generally recog-
nized groups of mental disease and defect.

THE METHOD OF BOOK I : SPHERES OF INFLUENCE

The principle upon which the seven cases of Book I are pre-
sented may seem a novelty in social work. The triple division
of the spheres of influence under which social cases fall, viz.,
public, social, and individual, corresponds with categories of
the legal order as developed by Dean Roscoe Pound. Dean
Roscoe Pound's forthcoming work on Sociological Jurispru-
dence will soon unfold a logical view of the bases of this triple
division. We may be pardoned for remarking more super-
ficially upon the division in these pages. The usual distinction
between "public" and "private" is still of practical value, de-
spite the unclear line which may separate public from private
duties and responsibilities. The term "public," as we under-

386 THE KINGDOM OF EVILS

stand Dean Pound, might well be restricted to the operations
of organized government, which is, of course, a part of society-
taken in its broadest sense ; but the operations of society taken
as a whole are essentially non-governmental, not yet organized
into state affairs. In short, there are a great many of the
most important concerns of society w^hich are not acknowledged
to be public in the sense of governmental affairs. They re-
main "private," although they affect social groups. In default
of a better term for the non-governmental operations of social
groups. Dean Pound, as we understand him, proposes to use
the term "social." Social operations in their widest sense
would then include governmental operations as well as numer-
ous others. Whenever we are talking about governmental op-
erations, however, we shall almost inevitably want to dis-
tinguish them as such, and we may appropriately use the term
"public" for these more fixed, solid, and rigid products (fos-
sils) of the social development of bygone days. Dean Pound
developed these distinctions in a discussion of the interests of
personality derived from a reinvestigation of the so-called
"natural rights" of man. Into that deep discussion we do not
care to penetrate. We simply adopt this suggested nomencla-
ture for the agencies and other spheres of influence that come
in contact with our cases. From a practical point of view the
social worker must soon concede the influence of public agencies
in this special sense of organized governmental agencies. The
fixity, solidity, and rigidity of the public service may be a
virtue or a fault as the case may be, but in any event nobody
is more clearly aware than the social worker of the ex-
istence of these obstacles or leverage points of the public
service.

But we also distinguish between the "individual" and the
"group." We have come to see that individualization is a
leading trend, not only of modern social work, but of most
departments of human knowledge. The old distinction be-
tween "public" and "private" is accordingly no longer able to
serve our best purposes. We need to build up the idea of the
private into the idea of privacy as opposed to public or gov-
ernmental responsibility — privacy in the sense of what James
called "the warmth and intimacy" of the individual man.

Thus an ancient distinction was : public 7's. private. Another
very plain distinction is : group z's. individual. We now have

THE KINGDOM OF EVILS 387

to combine logically these two distinctions and the results are
as follows :

^ /Public

G^o"P {social 1 p^.^^^^^
Individual/

For practical purposes we can then distinguish the interests of
our cases as public, social, and individual. We shall never
forget that in the present state of advanced civilization in the
communities where social work flourishes, no individual and
no social agency can fail to be affected by the public service in
some fashion. But public servants can and do forget that
their responsibilities, although strictly limited by law, organi-
zation, and regulation, are surrounded by conditions in which
the responsibilities of social groups are numerous and also in
some respects paramount. Neither the public officer nor the
social worker should forget his duties to the individual as such.

The social worker, standing as she does midway between
public service on the one hand and the ideal of individual
service on the other, must not remain aloof from both. She
can often imagine a procedure far superior to any now afforded
by the public service for the forcible handling of a given case,
yet she finds the public sphere of influence paramount.
She must bow to the public service. Her recourse is so to
stimulate social opinion that it shall become public regulation.

Looking in the other direction, the social worker may often
find a situation in which she feels that some family group or
neighborhood group would be greatly benefited by a particular
invasion of individual rights and a particular interpretation of
the interests of this individual running counter to his desires.
Persuasion rather than compulsion must here be her aim. This
persuasion may not be hers to attempt or to carry through ;
that persuasion may be the duty of some physician or other
adviser. The middle ground occupied by the social worker
between public service and individual desires and rights is a
position of danger. She stands in that middle ground, untram-
meled by the laws and regulations of the public service and
beyond the control in essential ways of the physician. So far
as law and medicine are concerned, she is on rather neutral
ground. In critical and limited phases of her work she is, to
be sure, governed and guided by judge and physician, but she
has every chance to push on to crises and limits that may not

388 THE KINGDOM OF EVILS

be necessary and may not represent the "one best way." She
is, as has been remarked, a sort of professional or intensive
layman. It may be that a judge or physician would do no
better in her place amongst these non-legal and non-medical
problems; but, if she pushes her non-legal and non-medical
problems into the legal or medical zone, she is likely to be
charged with causing difficulties when she has merely shaped
their course toward the only available beacons. Can there be
any doubt of the importance of securing men and women of
the highest grade for social work? Is it not clear that they
must understand the main principles of the interrelation be-
tween medicine, education, morals, law, and economics ? There
used to be much discussion as to what might be given if we
could turn the problem around. Define what constitutes a
psychiatric social worker — the "points" of such a worker
would then correspond with those of the so-called "educated"
man. Elsewhere we give a summary of such "points" as prac-
tical experience seems to agree upon.

So much then for the raisoii d'etre of Book I. It will be
noted that there are seven cases in Book I. When three terms,
such as public, social, and individual, are combined in eight
ways, the eighth combination (logically speaking) is that situ-
ation in which all three are absent. Accordingly we find that
to illustrate all existent combinations, public, social, and indi-
vidual, we need but seven cases. Book I also serves as a sort
of general introduction to the whole topic, and we have placed
in the discussions of the seven cases of Book I a few general
remarks that apply to the remainder of the volume as well.
But what we especially hope to drive in by the contentions of
Book I is a wholesome respect on the part of the social worker
for the problems of the individual as such and for the problems
of public service as such. If she does not like all aspects of the
public service of the present day and if she is dissatisfied with
the medical and other knowledge of the psychic interiors of
her patients, she must not kick against the prick of judge and
administrator in public matters or act as a substitute for the
physician or other adviser upon matters depending upon medi-
cal diagnosis. There are certain interests of personality to be
secured by the legal order and by the public administrator.
There are certain aspects of personality which are to be han-
dled, so far as they can be handled, by the best expert advisers

THE KINGDOM OF EVILS 389

obtainable. The task of the social worker, and especially of
the psychiatric social worker, remains a morally heavy task —
the task of utilizing the fixities and fulcra of public service and
at the same time the delicate and elastic values of the expert
in personality. Couched in these terms one might think the
psychiatric social worker or any social worker must be some-
thing celestial. We can only point to the relative successes and
instructive failures of the cases presented in this book to show
that there is no celestial claim but only a purely practical and
human claim made for these workers. If all expert work in
the adjustment of personality seems to be rather atmospheric
and if the public service seems to some of us at times to have
become a solid immovable mass then we must thank the social
worker. She remains liquid. She is the ideal being, a uni-
versal solvent. She proves herself to be a useful intermediary
in whatever field her path finally arrives.

Whereas the considerations of Book I seem more novel than
they actually are, the arrangement of data in Book II is actu-
ally the most novel feature of our work. How far the divi-
sion of the troubles, difficulties, maladjustments, and evils of
society into five groups is a sound, enduring division, it is hard
to say. This is not a textbook of sociology. We claim a
purely practical applicability for our subdivisions. The data
of these cases were not secured under the headings so presented.
Since the collection of these data and the completion of this
work the divisions of the so-called Kingdom of Evils have begun
to be practically used in social work by many workers connected
with the state institutions for mental diseases in the Common-
wealth of Massachusetts. Practical lectures upon these classi-
fications have been given, and the active workers have brought
their data to the conferences for discussion. The divisions
seem to work out in practice. Surely some division of data
is better than no division.

Heretofore social case records have often proved to be
nothing more than ill-digested narratives, with vast accretions
of facts hardly analyzable by any person save the original col-
lector of the data. The case worker familiar with her case
might in the end be able to give a fairly competent account in
narrative form of her case. Of course the self-consistent nar-
rative may actually miss the point. We have frequently seen
maladjustments set down to the score of ignorance which were

390 THE KINGDOM OF EVILS

actually due to f eeble-mindedness ; sometimes (though seldom)
feeble-mindedness has been erroneously suspected. To call a
purely moral defect psychopathic is a slant which psychiatric
social workers early in their practical work may fall into. To
call clearly psychopathic phenomena immorality is a prevalent
fault amongst laymen, many physicians, and very many public
servants. To charge any or all of these difficulties up to the
account of poverty is perhaps the commonest flaw in social
analysis in the world at large. Just as the "economic factor
in history" was so greatly the rage some decades since, so the
economic factor in personal life has been greatly overdone. To
be sure it does not take the data of mental hygiene to demon-
strate that poverty is not the main cause of social trouble.
Social work, before it had attained the psychiatric range, had
long ago proved to its own satisfaction that much more was
wrong than mere economics. In fact progress from philan-
thropy to social work was no doubt largely due to the growing
appreciation of the fact that giving alms or financial relief did
not go far to solve social problems.

THE METHOD OF BOOK II : KINGDOM OF EVILS

The method of Book II is no less practical than that of Book
I. Book I treating spheres of influence over social cases pre-
sented the cases in their social matrix, as confronted by the
social worker looking for practical results in a workaday world
full of necessary and unnecessary obstacles. The compulsions
of government, the suggestions of the voluntary social agencies,
and the intimate lines of attack upon personality were reviewed
in the seven possible forms of their combination. Book I thus
endeavored to teach the social worker that no layman can set
himself up against the power of government and law with any
hope of success in the concrete instance. On the other hand,
we perceived that it was the social worker's duty, if she found
her patient's trouble intimate, individual, and personal in its
nature, to swing the whole policy of treatment at once to the
physician, to the teacher, to the spiritual guide, or (often the
best plan of all) to the man himself. But how is the social
worker to pull apart all the concrete particular and special
facts and surmises about the patient, to the end of judging
whether the patient is best given over to physician, teacher,

THE KINGDOM OF EVILS 39I

moralist, or back to himself? It is the province of Book II to
try in a somewhat novel manner to give the social worker a
practical method of analyzing the facts available.

It has been found possible to present this method of analysis
in Book II in the form of thirty-one cases. We pointed out
that the three spheres of influence discussed in Book I could
mathematically be combined in eight ways, or practically in
but seven ways, since the eighth was the null class in which
all three elements were absent. The five great groups of what
we term the Kingdom of Evils must likewise mathematically
combine in a limited number of ways, namely in thirty-two;
but again the thirty-second combination would be that com-
bination in which all five groups of evil would be absent. Thus,
after we had sufficiently described thirty-one instances of evil,
(that is, in the combination in their various ways of five forms
of evil), we might reserve the thirty-second compartment for
some absolutely normal person, if there be such, who had never
undergone any form of evil whatever ! It is very convenient
to work with five forms of social difficulty rather than with
four, with six, or with seven. Had we been dealing with four
major groups of social trouble, we should have been able to
get on with but fifteen combinations, that is, with the mathe-
matically possible sixteen combinations minus one. If we had
practically found in our social case analyses six forms of evil
we should have been compelled to describe in Book II no less
than sixty-three cases, for the purpose of illustrating all pos-
sible combinations (sixty- four minus one). And if the world
had been still more complex and had yielded up seven kinds of
trouble, our exposition in Book II would have had to contain
no less than one hundred and twenty-seven cases (the one
hundred and twenty-eight mathematically possible combina-
tions minus the null case in which all seven kinds of trouble
were by hypothesis non-existent!).

We must eternally insist that such analyses as we make in
this volume, and particularly the analyses of Book II, must be
made after all the facts are in hand. By no means do we
lay down any principle to the effect that the practical social
worker shall practically collect the case data in the order in
which these data are later to be analyzed. It might be signally
unwise to fly at the situation with questions concerning health,
educational status, moral trends, legal entanglements, before

392 THE KINGDOM OF EVILS

the worker had got in hand the main facts about the economic
level of the case or of the family. There must be a proper
technique of approach for every case as to the collection of the
data. Some points and categories in this connection are of-
fered in Richmond's Social Diagnosis. We offer in this book
no especially new points as to the technique of the collection
of social data. Especially with psychopathic cases the appli-
cation of any rigidly set method for the collection of the facts
might prove injurious, not necessarily to the patient himself,
but to the accuracy and speed with which the data are collected.
There are some facts which only the extraordinary authority
of the courtroom is likely to extract. There are other facts
which a judge, however learned, can never hope to unearth by
the tools at his disposal. Again it is most obvious that there
are many facts that only physician or pastor in consulting room
or vestry can obtain. Experience also abundantly proves that
there are many facts that physicians and pastors, or even both
together, cannot by any means secure. Some of these facts
the social worker, especially the woman worker, can elicit by
methods which cannot, or at least in this place cannot, be de-
scribed. And we are quite ready to admit that some facts can-
not be dragged out of some patients by wild horses. That
experience with mental cases, stretching over a period of sev-
eral months or years, gives the professional social worker far
more insight into the technique of quickly securing the intimate
facts most useful for the patient's successful treatment, cannot
be denied. It is on this account that we elsewhere in this sum-
mary insist on the importance of placing in the practical por-
tion of every social worker's training a certain amount of ex-
perience with mental cases. We shall also point out that to give
the proper basis and background for the interpretation of such
experience with mental cases, the ideal curriculum of every
social worker {zvhether or not the worker is going practically
into the field of psychiatric social work) ought to contain a
strong didactic part dealing with mental diseases and defects
and including the mild psychopathies, eccentricities, and devia-
tions from the normal. Dr. G. L. Walton some years ago en-
deavored with more or less success to get the term degenerate
replaced with the term deviate. Not only was Walton's new
standpoint theoretically well based, but there was nmch prac-
tical wisdom in these suggestions by the genial author of Why

THE KINGDOM OF EVILS 393

Worry. For it is much easier to persuade or convince an
everyday person that he is perhaps a Httle deviate than to show
him that he is a httle degenerate ! In short not only v^ould the
mental hygiene of the social worker be improved by a study
of mental cases as they practically occur in everyday life, but
so also would benefit accrue to the mental hygiene of every-
body else.

Let us picture the social worker returning from the day's
work in a reflective state of mind. Let us suppose that the
social worker is thinking over all that is now known as the
result of, say, twenty-five hours of contact first and last with
the case and its surroundings. In describing the method of
Book II in a practical way to elementary workers at the outset
of their training, we have sometimes recommended to them
the following simple device. Let the worker count off upon
the fingers of the left hand (the hand conveniently for our
present purpose called sinister) the facts as conceived. Upon
the thumb let there hang the diseases and defects of the patient
and of related members of the family, in fact all more or less
non-hygienic features of the situation, including very particu-
larly even the slightest mental disorder or defect. Secondly,
Tipon the index finger let there be suspended all the forms of
ignorance which the patient and the persons around him ex-
hibit, so far as these afifect the situation; and let these data
include, not merely lack of education, language difficulties and
the like, but also all positive misinformations and errors of
point of view, so far as these are of intellectual origin. Upon
the longest or middle finger let there be strung whatever there
is of moral defect (of course not psychopathic and not merely
a matter of ignofance), including all sorts of vices and bad
habits and many of the so-called sins of theology and common
sense. Upon the ring finger there may be placed all sorts of
legal entanglements, whether in the nature of crimes and de-
linquencies on the part of the patient or on the part of his
associates, whether actually subject to court review or poten-
tially so subject. There remains the little finger upon which
to dispose all such matters as pauperism, poverty, and other
forms of resourcelessness. It is the province of Book II to
show cases combining all these forms of social trouble in vari-
ous ways. If it were quite certain where the trouble of each
concrete case should be classified, the task would be relatively

394 THE KINGDOM OF EVILS

simple. For example in practice many social workers are in-
clined to ascribe to ignorance much that ought to be called
feeble-mindedness. Elsewhere we have given other instances
of the improper placement of concrete facts in these groupings.
Practical experience goes a good way towards abolishing these
errors of the social worker. The didactic part of any curricu-
lum can never be counted on to prevent such errors. Frequent
conferences are necessary to keep the workers on the right track
during their practical experience.

Book II shows the advantage of considering social facts in
a definite order. Everybody will concede that some order is
better than no order, and everybody knows that a brief list can
be borne in mind better than a long list of categories. We do
not want to dogmatize about our plan. The future may well
yield up a better order for the consideration of social facts;
but we are inclined to prophesy that social work, so far as it
remains a systematic and scientific affair, will surely cling to
some order rather than no order in its analysis of the facts
in hand. Again the social work of the future may provide
a quite different list of categories than the fivefold list of evils
discussed in Book II; but we are inclined to predict that the
final list chosen by the perfected art of social work will not be
a long list of categories, and probably not much longer than
our own fivefold grouping. The very fact, which was pointed
out above, that six items would require sixty-four separate set-
ups of social fact to illustrate the possible combinations of the
six items, means that the social worker would find her sixfold
load too great to bear.

Be it remembered, as developed a little further on in this
summary, that oftentimes the difficulties are not merely sepa-
rate items added to one another to form a mere heap of sep-
arate facts, but that in numberless instances the evils multiply
themselves into each other in a bewildering way. Let the social
worker think for a moment of the extraordinary complications
which may ensue when poor moral training is combined with
psychopathic trends. In the body of the book we have abun-
dantly demonstrated the production of social difficulty of this
higher order. A patient combining in himself the effects of
poor moral training and the effects of psychopathic tendencies
may fall into such a status that neither measures of moral
reform nor the procedures of medical treatment will serve to

THE KINGDOM OF EVILS 395

remove any important fraction of the trouble. For such in-
timate comphcations of combined moral and psychopathic
trouble, the experts of the future will be required to find com-
binations of moral and medical training and treatment not yet
dreamed of.

We must acknowledge, too, that the perfect art of social
work might well in the future shorten the list of categories.
There is a widespread tendency amongst social thinkers to re-
gard immorality and crime as forms of disease. We believe
that no serious philosopher of the social life is today willing
to concede that either vice or crime is in the bulk ready to go
over to the group of diseases. The Vitia and the Litigia are
not soon, if ever, as a whole to go over to the Morbi. (We
do not deny that many instances of so-called Vitia really be-
long in the group of Morbi. But that is a matter of erron-
eous diagnosis in the given instance, and not a matter of scien-
tific reclassification of Vitia as Morbi. And a like argument
holds for various Litigia. It is worth incidentally consider-
ing that the jurists ought increasingly to admit that many of
their Litigia or conditions of being "at-law," would be thor-
oughly resolved if the medical and mental aspects of one or
more parties in the case were to be recognized. Nor are signs
lacking that, with the tremendous increase of the idea of in-
dividualization in at least the criminal part of the law, the
jurists will come to see the point of psychiatry.) But we must
theoretically allow the possibility of the telescoping of our list.
If the list could be telescoped by so much as the subtraction
of one item — for example, the item of poverty and the like
(what we here call Penuriae), there would be but sixteen
major combinations of the four remaining great items rather
than the thirty-two which form the basis of our studies in
Book II of this volume. With the unlocking of great and
increasing amounts of energy from the universe by modern
research, there can be no doubt that pauperism, poverty, and
other forms of resourcelessness, here termed Penuriae, are
undergoing a decline slower than we might wish but faster
than some congenital pessimists readily acknowledge. Some-
one, the other day, claimed that the science of the last few
hundred years, and especially of the last century, had blessed
the human being on the average with an amount of energy
equal to that of, say, some thirty body slaves (the analysis

396 THE KINGDOM OF EVILS

presumably took into account the great reservoirs of electric,
chemical, and thermic energy which we see displayed about
us so profusely, though perhaps irregularly, in the great cities).
Every social worker, like every other good citizen, should
support with all that is in him the cause of scientific research,
to the end that more and more energy be unlocked from the
infinite quantities available to man. A doubling of the amount
of energy unlocked in the last few hundred years ought to
diminish the tale of the Penuriae to a very visible degree.
Available slave power in non-human forms would bring back
at least the memory of the Golden Age.

For the moment, no social worker can hope to put the
Penuriae out of mind or to lose contact with any other of
our five categories of social evil. To be sure, in large sections
of the American community there is less and less evidence of
the effect of raw ignorance or of the result of any other forms
of the group that we have called Errores. Literacy rules
in many communities and illiteracy is a problem that can be
far more readily surrounded, it would seem, than the problem
of the vices and bad habits (Vitia) or of many forms of dis-
ease ; for example, cancer and mental disease. It has been a
matter of curious observation with the authors how relatively
few instances of the pure and uncomplicated effect of igno-
rance could be found in the Psychopathic Hospital material
which lies at the basis of this book. Language difficulties
were of course frequently in evidence. The misdeeds of quack
doctors and their advertisements turned up now and again in
the shape of misinformation distinctly hurtful to our patients.
Some instances of the evil effect upon the intellect (as well,
of course, as upon the morals) of the movies were discovered
in certain patients. Sundry housewives had plainly not been
taught the rudiments of good housekeeping by their parents
or guardians, and extraordinary success in their social treat-
ment was found to follow the education of these patients in
very simple procedures. Education serves to remove the bodily
filth characterizing sundry immigrants, so that the members
of the filial generation look with genuine horror on habits of
the parental generation. We are willing to acknowledge cer-
tain prejudices born doubtless of our special experience, and one
of these prejudices runs in the direction of assigning not quite
so much weight to the virtues and importance of education as

THE KINGDOM OF EVILS 397

its worthy devotees are likely to assign. We here allude to edu-
cation in its narrower, intellectual sense, rather than in the
broader usage of education to cover moral as well as mental
factors. Our prejudice runs to the claim of far greater value
for moral training than for intellectual teaching. It has be-
come a commonplace with many modern observers that the
senses are easier to educate than the emotions are to train.
The senses are after all a somewhat simpler affair than the
emotions; for the latter dig very deep into the "skin and its
contents." Those, however, who observe the wonderful re-
sults of animal training whether by the technique of terrorism
or by the technique of tact, can only be optimistic as to the
powers of man to form character. Man can no doubt form
character more easily than he can reform character. Man
can build and turn his temperament in a variety of ways far
more easily than he can reform and divert his temperament
after its dilapidation or distortion.

Up to this point we have argued that some arrangement
of social facts was better than no arrangement, that a short
list was superior to a long list, and that a further abbreviation
of our present list was devoutly to be hoped for but hardly
to be expected. Let us now ask the further question, Is there
a warrant for terming the present list of five forms of evil
a sequence rather than a list? If some order is better than
no order, why do the forms of evil listed as we list them fall
into this particular sequence? The particular sequence we
have adopted is a much more doubtful affair than the prin-
ciple of the sequence itself. The social thinker might well
accept the principle of the sequence of evils in this book with-
out wanting to adopt the order chosen. Why should the social
worker, it might be questioned, always begin with the topic
of disease? Why not begin with the topic of morals, or the
topic of poverty, as being the prime logical factor in the par-
ticular case in hand? Of course nobody will doubt for a
moment that psychopathic hospital material by and large de-
mands and must demand prime consideration for disease.
Indeed it is plain that medical social work as a whole demands
prime consideration for disease, if only because the patients
that come up for social treatment are sick patients. But, the
general social worker may inquire, why, in the non-medical
and non-psychiatric field, should the consideration of disease

398 THE KINGDOM OF EVILS

SO inevitably come up; and why in particular should we think
of disease in the beginning rather than in some subordinate
place? There are a number of good reasons that we might
adduce for our choice. For example, we might claim that
the social worker who fixes her mind on the illiteracy in the
social situation so frequently forgets the feeble-mindedness
or slight subnormality of her patient (or even of several mem-
bers of the family) that all sorts of effects get erroneously laid
at the door of ignorance rather than of mental defect. If a
social worker gets firmly fixed in mind at the outset of her
work some apparent instances of the effect of ignorance, she
may never during the rest of her social work be able to forget
that initial concrete instance. She gets dazzlingly in mind the
idea of education for all, thinking that education will solve
every problem of apparent ignorance as well as every problem
of real ignorance. But if this selfsame social worker raises
the question of feeble-mindedness or subnormality in the situa-
tion she faces, she will time and again be rewarded with a
point of view entirely new to her; that is, with a medical and
mental point of view, which as a child and in her youth she
had no means of grasping.

Again, there are still social workers who have their minds
fixed on pauperism, poverty, and other forms of resourceless-
ness (in this book summed up under the term Penuriae) and
leap to the explanation by defect of wages or compensation
of all the difficulties in the case. We hinted above, this idea
was no doubt the idea in the minds of the earlier philan-
thropists. Although no doubt the early workers in the field of
social science in our country recognized that not all history
could be given an "economic interpretation," yet the supporters
of philanthropy were perhaps more informed with the idea
of helping out the resourcelessness of their less fortunate
brethren than penetrated with the. ideal of consciously altering
the entire hygienic, educational, moral, and legal orders.
Financial relief is today so much more obvious than legal aid,
moral training, intellectual teaching, and medical care, that
not a few workers virtually stop in their minds with the idea
of monetary aid for their problems. At least we can help out
with money, is their feeling. With money we can get for our
sick ones proper medical care. As for education, that is now
largely a matter of public service. How barren and abstract

THE KINGDOAI OF EVILS 399

seem the suggestions for moral training and legal counsel that
we have to offer! There is no doubt a certain truth at the
bottom of this idea of primacy of so-called "poor relief" in
social work. We are all aware that even in the advanced
community where a charity organization approaches perfec-
tion, there are very many instances in which pauperism or
severe degrees of poverty fail to get duly met. Such situa-
tions in rural communities can almost be left to the unin-
structed neighbor. In the urban community, the organization
of charity is, so far as poor relief is concerned, undeniably a
statistical success in places. (We do not here refer to any
questions of the general raising of the wage level or of other
methods than wage-control for establishing the entire com-
munity on a higher terrace of wealth and resourcefulness. We
can only hope that in the end the slumless condition of cer-
tain of our middle western towns and cities can be made to
extend the world over, perhaps by the process of scientific in-
vestigation, for which the National Research Council, de-
veloped in our country during the war and paralleled by simi-
lar organizations in several belligerent countries, so boldly and
efficiently stands.) But we are entirely sure that the social
worker who leaps to the idea of poor relief is rather apt to
get breathlessly impaled thereon. She is apt to remain quite
incapable of giving due emphasis to the possibility of these
other factors, of disease, of ignorance, of immorality, and of
legal entanglement, as vv^hole or partial causes for the out-
standing poverty. We felt compelled practically to place the
Penuriae at the bottom of our sequence of evils.

Assuming that the Penuriae, that is, poverty and other
forms of resourcelessness, may well be placed at the bottom
of our sequence, is it not possible to argue that some other
group than the Morbi (diseases) ought to be placed first?
Certainly not ignorance, as was above argued but — and here
we approach the crux of many faulty points of view, to our
thinking — would it not be wiser to consider any given par-
ticular bad social situation as probably the effect of immoral-
ity or of bad habits, rather than of, say, disease? Should
not the Vitia head the list? Everybody who has passed
through childhood at all recently or has the childhood experi-
ence vividly in mind, knows and feels the immense and almost
universal values of moral training, and almost everybody finds

400 THE KINGDOM OF EVILS

in his life a smaller or larger trace of some great moral mis-
take touching some portion of his life. Most of us, as the
years travel on, get a bit of cynicism or a slice of fatigue about
our own possible reformation of character. But we see vari-
ous persons about us whose characters are undergoing a trans-
formation and we are irresistibly led to think how these neigh-
bors of ours might rather cleverly be reformed by simple
devices, and how many of them might have their characters
built and molded anew with the proper models for imitation
and the proper tools of training in hand. If our neighbor
gets drunk we think of him as probably addicted to a vice —
the vice of inebriety. We do not at the very first inquire
whether he has not some character defect or is not the victim
of some early misapprehension as to the values of a little wine.
If the neighbors' children write impossible legends on our
backyard fences, we are apt to regard the children as vicious,
and we do not charitably trace out the ignorance of their
parents or even the feeble-mindedness of parents or children.
We feel that the perpetrators of these vices, these ''sinners,"
ought to be morally trained or reformed. We know instances
of the successful training or reformation of just such persons.
We run to the hypothesis of immorality, vice, or bad habits
forthwith, and practically on a basis of our own experience.
We see in these "sinners" precisely ourselves, and — charitably
or maliciously, according to our natures — we would like to
have these persons given what in our American slang is some-
times termed a "course of sprouts." Now "sprouts" is a most
optimistic term for the plight of our neighbors, who may be
in no condition to allow the new growth of moral ideas by
reason of mental twist or lack, by reason of mere ignorance
of the socially good. Now it is plainly most uncharitable and
itself well-nigh a form of immorality to charge up vice and
sin to a mentally defective or merely ignorant person. It is
the charitable and right thing to raise the hypothesis in every
serious case of social maladjustment whether the center of the
situation may not be medical (and often actually psychopathic)
or mental (in the sense of misinformation on the part of the
supposedly sinful or immoral person). It is assuredly not
more "insulting" to charge an alleged sinner with disease,
bodily or mental, than to charge him with vice or sin. To
be sure, the layman when he thinks of disease is rather apt

THE KINGDOM OF EVILS 4OI

to think of severe disease, and when he thinks of moral defect,
he is apt to think of mild defect. This is no doubt because he
bears in mind only his own severe diseases and only his own
mild moral difficulties. In short, the average citizen thinks
of disease with a feeling of terror, and of vice with a leaning
towards exculpation. He thinks of himself as just a little
sinful and of his neighbors as equally excusable.

But whether this ethical account of the average citizen's
attitude on these matters be a correct one or not, there is to
our minds no doubt in the world that the serviceable formula
for the social worker to bear in mind is to think of each social
situation as possibly bearing within it a kernel of disease, espe-
cially of mental disease, and particularly of the mildest forms
of mental disease known as temperamental deviations and
mere eccentricities. If the social worker analyzes her situation
from the standpoint of these contained kernels of mild mental
deviation and eccentricity, she will gradually lose the terrors
associated with the idea of insanity, and will more and more
adopt the attitude of William James, which we discussed at
length at the beginning of this summary. She will get the
psychopathological point of view which the keen spirit of the
late Carleton Parker, himself not at all medical in training, got
from his practical contacts in living amongst laborers and
miners. Carleton Parker, though an economist, got the point
of what might be termed the "psychopathic interpretation of
history" as opposed to the long famous "economic interpreta-
tion of history." Nor will the reader of this book mistake
our meaning when we use the phrase "psychopathic interpreta-
tion of history." We do not mean an interpretation of history
as a product of psychopaths. We mean that history (at all
events, the history of our individual instances of maladjust-
ment) can best be interpreted by the technique which starts
from the outset to observe the minor deviations and
variations, the differences and the contrasts, rather than
the similarities and the analogies that so fill the mind of
the observer of "averages."

There will, we think, be far less objection to our ordering
of other factors than the ones just discussed ; namely, the or-
dering of Penuriae, the Morbi, and the Vitia. If a man is
not in full possession of his bodily and mental health, it is
just a little idle to discuss at length the quantity of his knowl-

402 THE KINGDOM OF EVILS

edge and the quality of his wisdom. But if a person is not
mentally healthy and reasonably well informed, no doubt in-
quiries as to his moral turpitude are a bit futile. Again, if
we do not know a man's health, education, and morals, how
can we adjudge the nature, cause, effect, and manner of
extrication of his legal entanglements? Finally, if we do
not know the medical data, the educational status, the^moral
tendencies, and the civil standing of the man, how can we
sensibly talk about his economic level?

We assume that the reader is now thoroughly convinced
that some order in social case analysis is better than no
order; that a short list of categories is better than a long
list ; and that our sequence has a good deal to recommend
it, both from the practical standpoint of psychiatric and med-
ical work, and from sundry more general standpoints. But a
more general question may be raised. Why do we advocate
the analysis of evils at all? Why discuss liabilities instead
of assets? Why discuss negatives instead of positives? We
might answer and remain content with the answer, that it all
amounts to the same thing, and that what looks like a re-
mainder is as a matter of fact a sum. Or again, we might an-
swer that much depends upon the point of view. That is, we
might say that some persons like to analyze from the side of
evil, and others like to analyze from the side of good, and
that we are writing for those who prefer in the first instance
to slay dragons rather than to seek the Grail. No doubt we
should be on very safe ground if we claimed the existence of
these two temperaments ; the temperament of the dragon-
slayers and the temperament of the Grail-hunters. Moreover,
we might point out that the dragon-slayers have perhaps in
the past secured as many Grails as those who started Grail-
hunting from the first.

COMPARISON OF THE KINGDOM OF EVILS WITH OTHER SCHEMES
OF SOCIOLOGICAL ANALYSIS

Our attention has been called to a formula of Malthus, re-
sembling in its categorization our own grouping of the evils.
Malthus, like his father (a friend and executor of Rousseau)
was in a sense a perfectibilian. He thought that societies tend

THE KINGDOM OF EVILS 4O3

to happiness but have been checked by miseries due to an in-
crease of population. He showed that the positive checks to
the increase of population were war, vice, crime, disease, and
poverty. Four of these five Malthusian checks upon the in-
crease of population roughly correspond with four of our own
categories. It will be easy to show, we think, that war is in
itself by no means a category quite so simple as any of the
other four. No doubt also Malthus would have been happy
to acknowledge that ignorance was a great cause of an over-
increase of population. Indeed Malthus or any other theorist,
following Socrates, might well feel that ignorance lay at the
bottom of several of our own categories. Population some-
times increases, sometimes decreases. It would be equally
easy to show, we think, that either the Malthusian five cate-
gories or our own might be as capable of decreasing popula-
tion as of increasing it. To claim that the increase of popula-
tion or the decrease of population is in itself an evil is some-
thing like the claim that superficial thinkers might make that
war is an evil. It is indeed unwise to assert that any condi-
tion is or is not intrinsically an evil. It is far better to weigh
observed conditions or factors in the light of a set of categories
like the ones suggested.

Malthus, it will be recalled, used the phrase "struggle for
existence" in relation to social competition. Here again
is a phrase that suggests that a given condition can be set
down as essentially an evil or as essentially a good. The idea
that the struggle for existence was not all happy was repug-
nant to sundry theologists, when Darwin gave reflected luster
to Malthus in his new contentions concerning evils. On the
other hand it would seem that German thinkers, say of the
Ernst Haeckel stripe, might w^ell find the struggle for exist-
ence in no sense an evil, but think it rather a good.

It seems to us that this concept of the struggle for exist-
ence also will greatly benefit from an analysis of what
might be called its evil constituents. We might find that
the pathology of the individual was a negligible factor in that
development. We might fi.nd the struggle for existence a
function of intellectual development in different species and
describe it in plain terms in an attractively simple fashion. We
might note the moral values of the struggle for existence or
again the vicious effects of centering one's life upon rnere

404 THE KINGDOM OF EVILS

existence. We might study law and order in its lowest terms
(insect life) or work upon the human level, and again find
components of a constructive and beneficent nature and com-
ponents of a destructive, maleficent nature. The field of eco-
nomics would also blossom under this double analysis. Dar-
win believed that the struggle for existence greatly aided man
and that his rapid multiplication was largely responsible for
his success in the world. He fully conceded the values of
these moral influences that in the end supersede the simpler
factors. Still, even upon the moral level, Darwin was inclined
to depreciate measures which would reduce the natural ratio of
increase for man. On the whole, he took an anti-Malthusian
view of man's multiplication in the world. A blanket view
of the evils or of the excellence in to to of increase or decrease
of population within prescribed limits is, no doubt, apt to be
an erroneous view. The analyst will benefit himself and the
world if he clearly conceives in his own mind whether he is
analyzing for forms of evil or for forms of goodness in the
heap of factors that he sees before him. Having made his
major decision as to whether he is studying the negative,
privative, and destructive factors or the positive, additive, and
constructive factors in his world, the analyst will further bene-
fit by an orderly approach in his study of particular situations.
The five checks of Malthus upon the increase of population
which we found so nearly to correspond with our own five
categories were, no doubt, not original with Malthus. Many
of his arguments were derived from thinkers like David Hume,
Adam Smith, and Montesquieu. The same set of categories
with various additions will be found amongst modern
writers. Thus Small classifies the interests of man un-'^er six
headings ; namely, health, wealth, sociability, knowledge,
beauty. Tightness. It will be observed that these six cate-
gories fairly well correspond, though in a different order, with
our own five categories.

We have omitted any craving for beauty and its lack of
satisfaction from amongst our categories, not because it is
non-existent, but because to the practical adult ugliness seems
not to be a primary or highly important evil in the world of
social difficulty. Small himself can find hardly more than a
paragraph of ideas concerning the beauty interest of man ; he
quotes from Schiller and is virtually clone. There seems to

THE KINGDOM OP EVILS 4O5

be no completed esthetic theory amongst philosophical doc-
trines even at the present day. The majority of the esthetic
dissatisfactions which we have found in our social case work
can rather readily be placed amongst the Errores as matters
of misinterpretation or misinformation: in fact that Platonic
theory of beauty which reduces it to a kind of harmony is a
theory very consistent with the practical placement of the
ugliness evil in our group of Errores, but in any event the
esthetic dissatisfaction is at the present day wholly upon a
practical level of investigation. Small quotes from Emerson's
essay on Resources an interesting passage which we give be-
low, a passage which also omits from its categories the
esthetic. This is the more remarkable as Emerson was doubt-
less more a litterateur than a philosopher or at all events was a
I'itterateur of first magnitude.

Ross has quarreled with Small's groupings on a variety
of grounds. He sees the main interests in man, hunger and
love, as specific demands of man, not at all to be covered in
under the designation, "desire for health," and points out that
health is more of a sine qua non than an object of desire as an
end. Concerning the latter point we would commend the
placement of health first in Small's series of desires — a place-
ment analogous to our own placing of the Morb'i at the head
of our own list. Furthermore we would take advantage of
Ross's critique of Small to point out that, when the morbid
side of nutrition and of reproduction comes into view, Ross's
objection to Small's grouping to a great extent falls away.
We may not regard hunger and love as items in our health
program, but when there is disease affecting nutrition and
reproduction, certainly these particular categories do impera-
tively cry for attention.

The desire for wealth (Ross again asserts) is not a pri-
mary desire but depends upon a still more fundamental opera-
tion of the ego (so-called egotic desires of Stuckenberg) ; but,
if we approach the wealth or economic question from its nega-
tive and privative side {i.e., from the standpoint of what we
had termed the Penuriae or resourcelessnesses) we shall find
that by changing our point of view we have escaped this par-
ticular critique. The desire for wealth may not "dififer in
principle," as Ross says, "from the lust of lordship over per-
sons (power), or lordship over man's admiration (glory),

406 THE KINGDOM OF EVILS

or lordship over man's judgment (influence)" ; but where there
is absolute resourcelessness, the very ego itself is hindered in
its progress. Resourcelessness hurts life, as one may say,
more than increasing resourcefulness helps life. This is at
least true on any particular level of attainment. By setting
the mind on the sort of Grail that some men take wealth to be,
we may miss various dragons of resourcelessness that could be
readily slain.

Ross objects to Small's category of sociability on the
ground that the craving for companionship is one sort of thing
and an eagerness for appreciation quite another sort of thing.
But again consider this phenomenon of sociability in its nega-
tive form (as one might say, dissociability). The craving for
no companionship amounts to an almost psychopathic trend of
seclusiveness,^ or is at all events a vicious attitude or bad habit
which helps neither the race nor the individual. Again an
absence, like an excess, of desire for appreciation would form
an important attitude of viciousness or a bad habit sometimes
developed in degree or kind almost to the point of mental
disease.

Concerning Small's categories of knowledge and rightness,
Ross makes no particular objection. We can see, then, that,
in general, Ross's strictures concerning Small's categories can
be readily avoided by change of point of view from the analysis
of those interests as positive to an analysis of them in their
negative or privative form. Had Small taken the pathological
view he would, we think, have uncovered rich leads in the
analysis of society.

The passage from Emerson mentioned above is at the end
of his essay on Resources and runs as follows : —

"But the one fact that shines through all this plenitude of
powers is, that, as is the receiver, so is the gift; that all these
acquisitions are victories of the good lirain and ])rave heart ;
that the world belongs to the energetic, belongs to the wise. It
is vain to make a paradise for good men. The tropics are one
vast garden ; yet man is more miserably fed and conditioned
there than in the cold and stingy zones. The healthy, the

CIVIL, THE INDUSTRIOUS, THE LEARNED, THE MORAL RACE

Nature herself only yields her secret to these. And
the resources of America and its future will be immense only
to wise and virtuous men."

' The name of a familiar symptom in psychiatry.

THE KINGDOM OF EVILS 407

There are thus five kinds of thing that are essential in the
Emersonian search for Nature's secret. But it is interesting
to note the order in which Emerson has put the assets of the
favorites of Nature. He gives the honorable first and last
places to health and morality, but as he sums up the whole
situation concerning the resources of America in the future
he considers that wisdom and morality are, after all, the great-
est aids to the unlocking of the immensest resources of his
country. Health he too would regard as indispensable and
may on this account put it first amongst the qualities of the
race to which Nature will yield her secret. That a race shall
be civil, that is a race under government and law — here also
is an indispensable rather than an essential from Emerson's
standpoint. To be industrious was doubtless also to the New
England mind of Emerson a mere indispensable rather than
an essential. Upon the basis of three indispensables,
health, civic order, and industry, Emerson builds the more
essential science and morals.

The Emersonian ordering of these five categories is as well
thought out as it is sublime in implications. The Emersonian
order is, no doubt, the important order leading from the in-
dispensables to the essentials in human endeavor. But, from
the standpoint of the analysis of a world run down or of a
bad social situation, it may w^ell be that this order is not the
best one. Lack of health remains a primary consideration, but
ignorance, misinformation, and misinterpretation have far
wider scope than the operations of organized law and indeed
are found at work in the innermost sanctums of private life,
where they destroy morality, render legal advice useless or
harmful, and are a prolific source of resourcelessness in
themselves.

To be healthy, wealthy, and wise is the desire expressed in
an ancient adage. To be healthy is as always indispensable ;
but hardly any reflective person would rather be wealthy than
wise. For our part we are inclined to place education next
in order upon the indispensable lower layer of health, not be-
cause virtue has really been proved to be knowledge, but
because without a healthy and trained intelligence it is im-
possible to meet successfully the complex moral problems that
compose so large a part of the field of social work, not to say
of the world's work so far as it concerns the individual.

40S THE KINGDOM OF EVILS

DEFINITIONS OF THE FIVE GROUPS OF EVILS

We have thought it worth while to set down in a special
part of this general discussion some approximate definitions
of evil and its major groups. Elsev/here we refer briefly
to certain philosophical viewpoints about the nature of evil in
general. Here our statement must confine itself to a few
phrases.

The term evil itself seems to be related in root to the words
up and over. Ev and ov of evil and over respectively stand
very close from the standpoint of those who investigate the
origin of words. Apparently evil carries within itself more
the idea of excess than of defect. This would be the nat-
ural view of the early thinkers and word-makers since they
would naturally people evil situations with something super-
added in the nature of spirits or demons. In fact, in the field
of disease itself in relatively recent times there has been a ten-
dency to ascribe disease to an Archeus or an Incubus, that is
to something thrown in, as it were, on top of the situation.

By far the greater number of terms which we use for
evil are used for positive qualities although there are a good
many privative ones. Thus to be evil (following the Century
Dictionary) is to be merely "depraved, bad, wicked, vicious";
or again, to be "harmful, hurtful, mischievous, prejudicial, mis-
leading, boding ill"; or again, "causing discomfort, pain, or
trouble" ; or again, "unfortunate, miserable, wretched" ; or
again, "as in reference to misfortune, sorrowful, bad luck, dis-
aster." Several of these terms are positive from one aspect and
negative (or privative) from another, but apparently the ma-
jority of the words are used in the positive sense. We do not
need to take a philosophical attitude towards the existence of
evil as such in the world. Even if there were philosophically
no evil, still these named conditions would exist to be met in
some way or other.

There are also a variety of privative meanings, such as the
meaning of being insane, that is of having an "evil head" or
again, "unwholesome, of inferior quality, poor, unsatisfactory,
defective, unskillful." Evil, in general, is censurable, mischiev-
ous, undesirable, painful, disastrous, and the like. It is in-
teresting to note that the term "ill" is the same as the word
evil by a natural omission of the consonant "v." We would

THE KINGDOM OF EVILS 409

especially insist that we should not like to have the term evil
used for specific evils where it is possible to give it a more
exact and specific term such as are to be found under the major
subgroups that we describe. The theologians say that the term
"evil" is likely to become obsolete. Yet it is used in a number
of important places in the Bible. For example, in Genesis we
hear of the tree of knowledge of good and evil. In the second
book of Esdras the evil is broken in pieces and the good
created.

It will be, as a rule, a confession of relative ignorance con-
cerning the fact if all we can say of a situation is that it is a
bad one, that it is a maladjusted situation, that it, so to speak,
belongs somewhere in the Regnmn Malorum. We must
specify further. Our point in speaking of definitions is to
insist that the majority of evil's meanings in a practical
workaday sense of the term refer to positive rather than
to privative badness of situation.

(a) Morhi: Diseases and Defects of Body and Mind

As to disease, this term upon its face looks like a priva-
tive term for lack or absence of ease, and such terms as
uneasiness, pain, distress, trouble, and discomfort are synony-
mous of the term as used outside of pathology. Huxley terms
disease as "perversions of normal activities of a living body";
but a question might here turn upon what is normal activity
of a living body. Sometimes we try to define disease quanti-
tatively. We seek to show that it means an excess of some-
thing or a defect of something. We gather valuable data
about disease from the weights and measures of the organs
and tissues and the plotting of curves and their reactions. But
those same weights and measures and to some extent the curves
of reactions may be found in the dead as well as in the living
organism of constituent part of the organism.

Another way in which it has been attempted to define dis-
ease is, first to describe some norm, pattern or model or struc-
ture and function, to which a body and its organs are supposed
to conform. Here it is not so much a question of weights and
measures of the body and its organs as of the conformity of
these weights and measures to some standard set. The stand-
ard body and the standard organs that constitute it are de-

4IO THE KINGDOM OF EVILS

veloped perhaps by some evolutionary process. The hypoth-
esis would be that that body or organ survived which was
of greatest use in the struggle for existence of the species own-
ing such a body and such constituent organs or tissues.

On the whole perhaps it is best to define disease as an inter-
ference with the life of the body or of any part thereof or
with the persistence of any activity or function of the body
and its constituents. Thus disease interferes with life of the
body as a whole, which lives or dies. But again disease may
affect entire organs and, though it destroy them, may not de-
stroy life unless these organs are (as we say) capital organs.
But the organs are made up of tissues, great portions of which
may die and be either partially or not at all replaced by re-
generative processes. Herein would be an example of disease
and recovery with defect. There are constituent factors of
safety in the make-up of the total organism, so that many
elements of it may die without death of the whole. Disease
may doubtless affect even the smallest cell of the body, though
the study of such minute processes of health and disease is a
difficult one. But the lay student must not get too much in
mind the idea of an organism, an organ, a tissue, a cell in
the structural aspects of all things. He must likewise think
of disease as affecting function, of the curves of response to
certain stimuli as damagingly in excess or in defect. The
holding fast to this idea of the functional in disease is particu-
larly necessary in the field of mental disease, where so many
of the entities have not been proved to be due to loss of
structure.

The difference between a structural and a functional disease
is hard to define. We have spoken of disease as an interfer-
ence with the life of vital units (like the cell tissues or organ)
and as interference with the persistence of a given function
such as breathing, the heart beat, or the food exchange in
tissues. Professor Royce once remarked that almost, if not
quite, the total meaning he could extract from the term func-
tional was the idea of reversibility. A functional disease is,
on this definition, a disease whose phenomena are reversible
to the state antecedent to the perturbing factor. To ask,
then. Is the present situation a reversible one? is often of
practical value.

Disease, then, consists of an interference with the life of

THE KINGDOM OF EVILS 4II

living Structure or interference with the persistence of func-
tions of those living structures. In the former event there is
apt to be something discoverable by the microscope, by the
more or less elaborate methods of the pathological laboratory.
In the latter event, that is, in the case of the interference with
the persistence of vital functions, there may be nothing micro-
scopically to be found ; perhaps even theoretically nothing need
be found by the microscope in pure perturbations of function.

(b) Err ores: Educational Deficiencies and Misinformation

Let us turn to a definition of the Err ores. Probably we
have often spoken of our group of Err ores under the English
term "ignorance." The Err ores do indeed contain a large
fraction of pure ignorance whether in the shape of mere lack
of education or in the shape of an immigrant's not knowing
the language of the country of his adoption. But the Errores
contain positive as well as negative terms. A man may be
not merely uneducated but actually maleducated in that he has
been given actual misinformation. So far as the maleducated
man is concerned, we may say, it is no fault of his (that is,
we do not lay it up against any vice or bad habit of his or
charge it up to disease). To be sure, his teacher may'have been
mentally deficient or twisted, or may have been the victim of
some vice or bad habit of thought, or may have harbored a
vicious design in teaching him certain things. But from the
standpoint of the maleducated man himself, he belongs in the
group of Errores in an analysis of the total situation. His
psychopathic or vicious teacher would have to fall in other
categories than those of Errores. But a still more important
sub-group of Errores exists. A man may be not merely un-
educated or maleducated, but he may be a victim of misappre-
hension or given to misinterpretation. To be 3ure, any pro-
longed trend toward misapprehension or misinterpretation
would doubtless throw one into some psychopathic group.
Practically there would be hardly any difficulty in determining
that degree or kind of error which falls within the adage "To
err is human." We do find the inexperienced social worker
charging up to ignorance, misinformation, and misinterpreta-
tion much that belongs in the field of feeble-mindedness. With
a little more experience, the social worker, as elsewhere inti-

412 THE KINGDOM OF EVILS

mated, may swing too far in the other direction and find
feeble-mindedness where there has been nothing but lack of
education or maleducation. Common blunders and mistakes,
as well as logical fallacies of reasoning, belong in this group
of the Err ores, where they do not argue mental disease itself.

When Sir Benjamin Brodie says that much of the evil which
exists in the world may be traced to mere ignorance, he is,
no doubt, functioning as an optimist. As social workers we
must see to it that we hew to the line in both directions. Let
us never be content with ascribing the situation for long as a
mixture of feeble-mindedness and ignorance. Let us analyze
these constituents of maladjustment and try to cure or com-
pensate the one and educate or reeducate the other.

In the dictionaries we can find a number of phrases that
indicate the sort of thing that should be included under the
Err ores, such as experience, lack of information, misappre-
hension, misinformation, malinstruction, no schooling, poor
schooling, deception, sophistry, unsoundness of argument, mis-
taken notions, false belief, delusion (sane), inaccuracy, am-
biguity, illiteracy, blunder, misinterpretation. Sometimes the
term error is used in a moral sense to indicate a wrong doing
or transgression, but to ascribe a sin to a mere wandering from
the path is to take away from the sin most, if not all, of its
responsibility; it is an over-charitable way of viewing a sin
or vice in the eye of the ordinary man.

We now come to that which we shall, no doubt, fail to de-
fine thoroughly, namely the group of the J'^itia. One advan-
tage of the Latin names here adopted is that they are rather
more comprehensive than any single English equivalent. Thus
the Morbi we use to include not only disease in the narrower
sense but also defect and anomaly. Again we are using
Err ores not only in the negative sense of ignorance, but in the
more positive sense of misinformation and misinterpretation.
Again Vitia is a term which we intend to use more compre-
hensively to cover not merely vices but also bad habits. Thus
we can see that not merely the most opprobrious vices but also
such a bad habit as laziness about brushing one's teeth are to
be included under the Vitia. There is an extremely long list

THE KINGDOM OF EVILS 413

of synonyms and variants upon the ideas of vice and sin which
we do not here reproduce. It will repay the reader to consult
a good dictionary and trace down a large number of these con-
ceptions to their final ramifications in meaning. We have not
used the term sin to any extent in this book, because we have
regarded this term as a theological term and have not cared
to venture into the debatable questions of the kinds and de-
grees of theological sin. Still, in a practical view, we regard
most of the sins as falling, socially speaking, into our group
of the Vitia. Some of them, no doubt, in old times and in
certain theological systems of the present day would fall into
a field of ecclesiastical jurisprudence (penance questions and
the like) and therefore belong in our group of the Litigia, but
these considerations have nothing to do with the main thread
of our argument, which is quite innocent of theology.

A practical question to lodge when one wants to decide
whether a thing is a disease, a matter of error (in our special
sense), or belongs amongst the Vitia, is the following: Is this
factor something I should like to cure in a medical sense
of the term cure? or is it something I am fain to meet by a
process of reeducation? or again is it a factor subject to some
process of reformation? We try to prevent disease or to
cure it. We try to .avoid ignorance and misinterpretation by
teaching or by so-called reeducation. We try to train for the
moral life or to reform the immoral. The pragmatic question
what ought to be done at this point is often the successful step
in analysis. If you can't help wanting to reform Tom's char-
acter, whereas you want to reeducate Dick's intellect and are
fain to cure Harry's mental deficiency, you may find that you
are unconsciously on the right track when elaborate final
analysis will fail you.

(d) Litigia: Legal Entanglements

As for the Litigia, here is a knotty question which presum-
ably none but jurists should strive to answer. It is a nice ques-
tion whether being-at-law actually or potentially is always an
evil. The legal order seeks to secure a variety of interests,
many of which are of positive significance to the man or the
community. But nevertheless we conceive that being-at-law,
whether in or out of court and whether in esse or in posse is

414 THE KINGDOM OF EVILS

in some sense a maladjustment. Somehow the whole connec-
tion of the law is that of a process for securing order where
there was disorder. There may be a legal order which is of
purely positive and constructive value to the world. If so we
should exclude its processes from our group of the Litigia.
Litigia is a term which is much broader than most terms for
legal situations. Its usage accordingly allows the inclusion of
arbitration and other processes of law outside of the judiciary.
Apparently it is the best term available for the situations we
are here attempting to designate. A delinquent falls into this
group, but delinquency on the part of somebody else than the
patient makes also a situation of litighim. There need be no
moral attributes (although there may be such) in a contro-
versy against the law. Ignorance is, as we say, no excuse in
the eyes of the law, so that one may still be involved in Litigia
even though one has been ignorant of automobile ordinances.
One may inherit legal difficulties as in the celebrated case in
Dickens of Jarndyce vs. Jarndycc.

Enough has been said to indicate the breadth of this con-
cept of Litigia, which runs altogether beyond the considera-
tions even of law books on personal relations and domestic
relations. General social work and much of ordinary medical
social work may fail to show much sign, of the Litigia, but
the moment one gets into any serious family situation or into
any complication of mental disease, there is apt to appear a
smaller or larger trace of legal entanglement. The whole con-
cept should be subject to a proper definition. No doubt this
proper definition will obtain when sociological jurisprudence
has been further developed.

Let us review instances of Litigia that appear in this vol-
ume. In thirty-five of our one hundred cases legal entangle-
ment of some sort is a major factor of the social difficulty.
Minor considerations of legal interest enter into another four-
teen cases, — questions of legal commitment (cases 47, 75, 76,
yy, 79, 85) ; also matters potentially legal that never developed
to the point of legal action, such as instances of illegitimacy
(cases 36, 48, 52, 66), non-support (case 78), desertion (cases
32, 74), pilfering (case 25). There are then in this book
forty-nine cases of possible interest to jurists. We list below
the forms of Litigia presented in these cases : — adoption, case
12 ; adultery, case 8 ; alcohol and drugs, cases 58, 61, 63 ; arson,

THE KINGDOM Ol^ EVILS 4I5

case 9; assault, case 97; cohabitation, case 81; commitment,
cases 47, 75, y6, yy, 79, 85; damage suit, case 7; deportation,
cases I, 5; desertion, cases 32, 74; sex disguise, case 23;
divorce, cases 13, 17; forgery, cases 2, 80; guardianship, case
70; illegitimacy, cases 36, 48, 52, 66; juvenile delinquents, cases
20, 31, 65, 84; murder, case 54; neglected child, case 22; non-
support, cases 4, 2)7 y 7^; pilfering, case 25; sexual assault,
cases 15, 92; stealing, case 3; technical deserter, case 29; va-
grancy, cases 51, y2; "work or fight," case 26; workmen's com-
pensation, cases II, 19, 90.

{e) Penuriae: Poverty and Other Forms of Resourcelessness

We have insisted throughout upon the fact that our group
bi Penuriae includes not merely poverty in the everyday sense
of that term but also all other forms of resourcelessness, which
can be defined as belonging to any one of the other categories.
A man might be wealthy in the technical sense of a bank ac-
count, but be placed in a desert or on an inaccessible island.
He would be then resourceless. In the wake of wars such non-
pecuniary resourcelessnesses are to be found.

ERRORES

Trust in Inadequate Authority
Force of Custom
Opinion of Inexperienced Crowd
Parading of Superficial Wisdom

CAUSES OF ERROR

It was Roger Bacon (c. 1214-c. 1294) who dealt systemat-
ically with the causes of error ; namely, the four Offendicula.
These causes of error were: (i) trust in inadequate authority,
(2) force of custom, (3) opinion of the inexperienced crowd,
(4) concealment of real ignorance by a parading of superficial
wisdom. Of these four errors the fourth was to Roger
Bacon's mind the most dangerous. The concealment of down-
right ignorance by a pretense of knowledge was perhaps the
cause of all the others. Apparently Bacon had no doubt that
some kind of knowledge would be available to everyone. What
he feared far more was the foisting upon the world misin-
formation; he apparently felt that the fourth of the Offen-
dicula, the parading of superficial wisdom, would not in itself
produce error had not the thinker been somewhat deceived.
Why should one (i) trust in inadequate authority, (2) be
overawed by the force of custom, (3) follow the opinion of
the unskilled many, (4) be cheated by a pretense of knowl-
edge, if there were not a certain weakness of mind in the
recipient of the false ideas. Put another way, the stumbling-
blocks to knowledge that Roger Bacon tried to chart reduce
largely to a false or weak-willed attitude in the thinker. Over-
weening authority, the cake of custom, the herd instinct, in-
tellectual fraud, would probably not be effective were it not
for a certain frailty of will. In short, to modern analysis the
stumbling-blocks of Roger Bacon are at least in a large meas-
ure inside the stumbler's mind. The victims of what we might
term "raw ignorance" will be fewer and fewer to the close in-
vestigator of the causes of error. The Errores of our own.
classification tend to flow over into the Morhi in the, form; oft-
greater or lesser degrees of pathological weak-willednesSi
(aboulia, hypoboulia) or over into the Vitici: in- the form of^
over-compliances with authority, easy-going habits of thought,
following the crowd, facile deception by those who, in modern
phrase, are "putting it over." Possibly this tendency of mod-
ejn, science to classify the obstacles to knowledge under the

419

420 THE KINGDOM OF EVILS

heading of mental or moral disorder rather than as plain errors
due to ignorance, misinformation, or misinterpretation will
explain why we find in our social patients so little that unre-
servedly flows into the group of Errores. We quote Sir Ben-
jamin Brodie to the effect that the world's evil might largely
be traced to mere ignorance — this we might grant as also the
truth of the formula "virtue is knowledge." But ignorance
and other obstacles to knowledge turned out so frequently to
be inborn or acquired mental disorder or character defect
or ingrained moral defect that Sir Benjamin's formula sounds
to the modern ear a bit hollow.

Francis Bacon (c. 1561-c. 1626) has yet another fourfold
classification of the general causes of error in the human mind.
He laid them down so as to clear the path for the introduction
of the new method pf science which he was to advance. The
doctrine of fallacies appears in final form in the Novum
Organon as the four Idola. The first of the Idola bears some
resemblance to his namesake's stumbling-blocks, — the opinion
of the unskilled many; these are the Idola Trihus, idols of the
tribe, fallacies to which the human race is one and all subject.
But for that matter it would seem that all of the Offendicula
of Roger Bacon might well be put under the tribal fallacies
of Francis Bacon. When we looked at the second kind of
Idola of Francis Bacon we saw how much more modern is the
point of view of Baron Verulam. The Idola Speciis, the idols
of the cave (probably here is meant the hollow of the skull),
are fallacies that depend upon the individuality of the particu-
lar man. Apparently, for his namesake and predecessor,
everybody in general is more or less subject to identical stum-
bling-blocks. For Francis Bacon the individualities of men
stood out. Under this head the Baconian practical rule for
avoiding individual tendencies to error runs as follows : "Let
every student of nature in general take this as a rule, that
whatever his mind seizes, dwells upon with particular satis-
faction, is to be held in suspicion." Whereas Roger Bacon
sees ignorant men, trust in inadequate authority exerted from
without, Francis Bacon sees clearly the error of trusting over-
much one's own internal authority based upon his mental or
bodily construction. The psychopathic personalities that ap-
pear so frequently in this volume are pronounced instances of
subjection to the Idola Speciis, or idols of the cave, of Francis

THE KINGDOM OF EVILS 421

Bacon. Of course we suspect that these "Idols of the Hollow
of the Skull" are somewhere dependent upon peculiarities of
the brains contained within the skull or upon peculiar influ-
ences streaming in upon those brains from the rest of the
body. It is clear that the classification formulated for the
Idols of one's brain pan must be our familiar war cry in all
forms of mental hygiene — "individualization." If we are to
adjust inner relations to outer relations, as Spencer contends,
for a perfect life, we shall be compelled to hold sharply to it
when the inner relations themselves are defective. What a
rigid aspect the notion of "cure" takes on when by "cure"
we compromise all the individualizing processes of adjustment
entailed by the individual peculiarity of man !

The third class of Idola were the Idola Fori, or Idols of
the Market Place. These errors or fallacies Francis Bacon
contended arose from the influence exerted upon the mind by
mere words. This class of Idola corresponds somewhat to
Roger Bacon's stumbling-blocks of the parading of superficial
wisdom. How many empty formulae exist in social work,
not to say also in the work of physicians and of public serv-
ants, that ought to be classed in the Baconian Idola Fori !
Book II presented at length cases that illustrate a variety of
formulae of social difficulties in a series of cases. The cases
run, for example, all the way from that of Rose Talbot (case
8), in which all five forms of social difficulty were presented
to the five instances (cases 34 to 38) in which one class only
of social difficulty were found. Now in point of actual prac-
tice the social worker is altogether too much inclined to classify
a given case as one of disease alone, or of ignorance alone (or
other form of error), of legal entanglement, or of poverty
alone. This tendency may simplify the keeping of social
record books but it does not comport with the actual situation
in point of social fact. It is a tendency that belongs with the
Idola Fori, or Idols of the Market Place, in the Baconian sense,
to fall under the spell of this particular error, — to classify
under but one head. How simple social work would be if
cases all fell smoothly into place as cases to cure merely, merely
to reeducate, or again merely to reform, to supply with legal
aid, or to compensate in any monetary sense !

Let us call especial attention at this point also to that group
of cases in Book II which exhibits simple binary combinations

422 THE KINGDOM OF EVILS

of two forms of social difficulty. If we should consider the
simplest case of medical social work — namely, a case which
showed but two factors say, (i) need of orthopedic splint,
(2) need of money — possibly these two needs could be sepa-
rately met. Possibly the granting of financial relief would
forthwith settle the question of getting a splint. In such an
instance the primary social difficulty might well turn out to be
poverty. Whilst the orthopedic need might be a very remote
and secondary phenomenon. But suppose we have a combina-
tion of poverty with such a weak will disorder as lack of ambi-
tion. Let us suppose this lack of ambition is not psychopathic.
Then it is obvious with half an eye that the dole-giving is not
going to settle the problem. Yet to quote Richmond's "Social
Diagnosis," there was in charity organization work "at first
no accepted program of treatment other than the giving or
withholding of relief." Here and there advanced agencies
formed more thorough programs of what could be done; but
in the earlier days these were carried out with difficulty against
the main current of charity activity which ran strongly toward
dole-giving. These two instances may suffice to raise the im-
portant point that we shall learn more and more about social
work if we study merely binary combinations of social diffi-
culty. That is the combinations of Morbus with Error or
Morbus with Vitiuin, or Morbus with Litigium, or Morbus
with Penuria, or Error with Pcmiria, or Vitium with Litigium,
Vitium with Penuria, Litigium with Penuria-. The cases of
binary combination (cases 24 to 33 inclusive) in Book II of
course present only a simple indication of the possibilities of
each of the five main groups. A vast deal of work must be
done when we get into the main outlines of social work en-
tailed by a study of binary combinations. When two social
difficulties are loosely associated with one another, so that each
may be simply and separately treated, social work will be rela-
tively easy. But when two difficulties are multiplied into one
another social work will be relatively hard.

To continue with our remarks upon the four classes of
Idola, according to Francis Bacon we find the fourth and last
class to be the Idola Tlieatri, or so-called Idols of the Theater.
(The theater here means the speculative or "theorizing" mind
and does not refer to theater in the ordinary sense.) The
victims of this class of Idola are those who force nature into

THE KINGDOM OF EVILS 423

empty, abstract schemes and want to explain existing condi-
tions by mere definition. Again there are those that leap to
general conclusions by too few experiments, or again those that
work in an imaginative way by the overuse of analogies. This
particular type of error is one which the theorists of social
work must take to heart. The existence of these Idola of the
speculative mind is the best reason for our having chosen to
place the case material of this volume at the outset rather than
as merely illustrative material. We have tried to analyze some
of the cases available to us, with the richest display of facts
and most intensive social treatment, and to deduce from these
data certain general principles. If the reader dissents from
the principles he has the recourse of going back to the facts.
Moreover, as the cases are for the most part still alive and
both capable of investigation and willing to tell their stories,
we shall in the long run be able to test the validity of our own
conclusions by the test of time.

THE PROBLEM OF EVIL

Although we have drawn the analysis of this volume upon
a classification of the social evils taken in their broadest sense,
we cannot pretend to be competent in the theory of morals or
to write a textbook of ethics. No doubt the historical de-
velopment of the idea of medical social work (and naturally
of its related branch psychiatric social work) are, in the New
England community in which we write, greatly influenced by
the philosophical work of Professor Josiah Royce upon the
problem of evil. Professor Royce's work upon evil as well
as upon social consciousness and later upon the logical theories
of order have unquestionably prescribed some of the most im-
portant lines in Dr. Richard C. Cabot's development of medical
social work and in our own additions to the concept from the
field of mental hygiene. We have been compelled to choose
mottoes for the four books from Job. The initial paper in
Professor Royce's Studies of Good and Evil deals with the
problem of Job. The problem of Job, according to Royce, is
the problem of unearned ill fortune. Whatever evil is, Royce
is most cordially of the opinion that it is a "distinctly real fact,
a fact just as real as the most helpless and hopeless sufferer
finds it to be when he is in pain." Elsewhere he speaks of

.424 THE KINGDOM OF EVILS

another view, "that essentially pernicious view nowadays some-
what current amongst a certain class of gentle but inconsequent
people — the view that all evil is merely an illusion and that
there is no such thing in God's world." Good and evil, ac-
cording to Royce, do not exist as opponents but merely as ex-
clusive agents side by side in experience. A longer account
of this view runs as follows : —

"Taking a wider view, one may observe that the greater part
of the freest products of the activity of civilization in cere-
monies, in formalities, in the long social drama of flight, of
pursuit, of repartee, of contest and of courtesy, involve an
elaborate and systematic delaying and hindering of elemental
human desires, which we continually outwit, postpone, and
thwart, even while we nourish them. When students of human
nature assert that hunger and love rule the social world, they
recognize that the elemental in human nature is trained by
civilization into the service of the highest demands of the
Spirit."

A briefer formula is as follows : —

"It is impossible for one to know a higher good than comes
from the subordination of evil to good in a total experience.
Love of moral good is the thwarting of lower loves for the
sake of higher organization."

It will be seen that, according to Royce, "the eternal world
contains Gethsemane."

This point of view ot Royce's is the point of view of the
so-called philosophical idealism ("your sufferings are God's
sufferings"). It is obvious that the considerations of the pres-
ent volume do not depend in the slightest upon any philosoph-
ical view whatever. Even if we should run with the "essen-
tially pernicious view" which regards all evil as an illusion, we
should nevertheless have to grant the existence of the illusion
as a distinctly real fact. The illusions and delusions of the
sane we should be inclined to place in our group of Errores.
We should regard those who identify diseases, sins, crimes, re-
sourcelessness with the delusions as unwise persons who have
made singularly poor use of some of the formulae of philo-
sophical idealism.

In the course of writing this volume we have met sundry
persons who have denied the existence of evil under that name,
maintaining that evil is an illusion or an error. We have

THE KINGDOM OF EVILS 425

wondered whether they were not all unconsciously identifying
the genus with the species and abolishing the regmini malorum
with its subgroup Err ores. We are the more inclined to draw
this conclusion from our observation that these verbal de-
stroyers of evil are ordinarily turned to the hypothesis that
the illusions and errors, or surrogates of evil, are to be de-
stroyed by "taking thought," by adopting certain beliefs and
sometimes by the plain anodyne of forgetting. Even the so-
called Christian Science may fall back upon establishing sana-
toria, thereby conceding that there is a special form of error
needing hospital treatment. Christian Scientists also would
be righteously incensed if their opponents should charge them
with not encouraging morality or the legal order. If the repre-
sentatives of sundry movements for faith cure have been
charged with a loss of interest in the problems of poor relief
and charity in certain communities, in any event the believers
in these cults are for the most part kindly persons as interested
in the economic successes of the community as their fellow
beings. Accordingly, we repeat, the point of view of the pres-
ent work does not, strictly speaking, need to take account of
any philosophical view of evil, even such a view as that of
Christian Science, which turns even disease into a form of
error. Perhaps, we should concede that the point of view of
the ingrained pessimist cannot be the point of view of social
work. The point of view of Voltaire or Nietzsche is not the
point of view of the social worker, although be it remembered
to the credit of Voltaire that he leaves his wretched heroes and
heroines at the end of Candide working in a garden, and even
Nietzsche insisted that the strong were strengthened by evil.

There can be no doubt that the practical social worker needs
to have some philosophical and religious views of the nature
of good and evil, not alone for the social worker's own per-
sonal guidance but for the sake of grasping ingenious argu-
ments which sundry depressed, deluded patients are prone to
offer. According to Royce, the first hypothesis concerning
evil is that it is nothing but natural phenomena — "dirt of the
natural order, whose value is, that when you wash it off you
learn the charm of the bath of evolution." The second hy-
pothesis is that evil has a medicinal and disciplinary value.
The third hypothesis runs to the effect that all real evils are the
results of free finite moral agents. And finally, according to.

426 THE KINGDOM OF EVILS

Royce, the fourth hypothesis of philosophical idealism runs
to the effect that the entire world is built on a basis of "inner
tension of manifold impulses and interests," which, as he re-
marks, are not "mere accidents of rather imperfect human
nature but must be a type of the organization of every rational
life."

Our own study has dealt not so much with the definition of
evil as with the classification of the evils as they have presented
themselves in the Psychopathic Hospital, a clearing-house for
the evils of individual man. Our study has been an inductive
one from the concrete facts to a classification of these facts in
certain groups. These groups, it appeared to us, might effec-
tively be united in a greater group of evils taken in a more
general way. We have thus come upon an idea of the social
worker as a person professionally at work amongst all types
of evil. The social worker, as we remarked above, must re-
main a layman with regard to the great special fields of medi-
cine, education, morals, jurisprudence, and economics. But
the social worker is a very intensive sort of layman with, some
might say, an exaggerated amount of common sense — that
kind of comprehensive insight which utilizes the professional
specialist without supplanting him.

The Roycean formula of the inner tension of manifold im-
pulses and interests within our natures goes a step further
than the Spencerian formula of the adjustment of inner to
outer relations. In the first place Royce calls attention to the
existence of tensions within our own make-ups, and in the
second place he seems to define ethics in terms of the relations
of the interior tensions. We have had abundant cause to ob-
serve a practical truth in our patients of this hypothesis of
interior tensions. But the world's evil, even according to
Royce, is not confined to the inner life of a man but has spread
through the universe. Certainly in that part of the universe
with which we are dealing ; namely, society, some sort of ten-
sions have been found to prevail. But can we conceive that
the analyses of the present work do not hang upon the com-
parative richness of the Spencerian or the Roycean formulae
concerning relations in the universe ? The cases here presented
are presented on a practical level and the workers who worked
with them have as a rule paid no heed to philosophical
questions.

THE KINGDOM OF EVILS 427

But the social worker must not think that because she is
practical she is inevitably just like everybody else in her point
of view toward the world. It would seem that the social
worker possesses a special temperament. At least the medical
and psychiatric social workers have a greater interest pri-
marily in the destruction of evil than in the construction of
good. When such workers rationalize their attitudes they say
to themselves that by destroying evils they are helping to
create, or allowing to be distributed, goods, but the tempera-
ment which sees evil as the proximate task of destruction and
good as the ultimate goal is nevertheless a temperament. And
it is a temperament that not everybody possesses. It would
seem that there are dragon-slayers and Grail-hunters. There
are those who prefer to be St. George and others who would
rather be Sir Galahad.

It is doubtful whether the decision to be one or the other is
always a conscious or rational one. Those of us who are
informed of the spirit of medicine or medical and psychiatric
social work, or of nursing, or of the probation officer and the
like, are wakened up in astonishment to the fact that there are
perfectly good citizens in the world who prefer to put diseases
and other forms of evil entirely out of mind. Nor can we
set down these persons who are not interested in evil as merely
materialistic. Often they prove perfectly admirable seekers
after a Grail of one kind or other. The devotees of religion,
wizards of scientific invention, and the artists, do not have,
as a rule, any interests that might be termed malecidal: they
are not built for the destruction of evil, nor should we wish
to swerve these zealots of the Grail from their goal. In fact
the Grail-hunting temperament in its highest development is
next to impossible to divert. We had best not waste our time
and theirs by offering wares of social work to the inborn Grail-
seekers. But there remains a great mass of people whose
parental and filial, and especially whose maternal, joys give
them the fundaments of social interest. From amongst the
common people we shall draw many of our best workers if we
can interest them in the social task, and if we can believe that
through evolution habits of destruction are deeply imbedded
in all of us. Let us point these destructive powers in the di-
rection of evil. That is the essence of strategy underlying
this particular kind of social work. In our task of persuading

428 THE KINGDOM OF EVILS

the everyday citizen that his proximate task is to destroy evil
we have a number of points in our favor. If he repHes that
he would rather do good than merely undo evil we can reply
to him "What after all is the good which you would like to
do?" The chances are that his first response would have to
do with getting rid of some near-by evil. We can point out
to him that evil is very easy to perceive about us. Evil is
easier to perceive than good is even to conceive. Percep-
tion was ever easier than conception. We see evil all about
us. We do not need to make elaborate conceptions or inter-
pretations of the evil that is at hand. Again, evil is not only
easier to perceive than good to conceive but evil subdivides
very readily into plurality of evils. The good is rather apt
to remain a unit or to subdivide itself far less readily. The
farmer has sick cattle. It is plain that they must be cured or
for their own comfort be killed. But suppose the farmer tries
a program of construction. Shall he breed for beef or for
milk? The plot thickens at once. If we look into the vocabu-
lary for words descriptive of good and evil respectively, we
are certain to find in most languages a far larger number of
words dealing with evils than with the goods.

Evils can thus be seen about us (and be items for destruc-
tion) far more readily than the goods. It is obvious too that
evil gets more clearly into the mind than does good. For
whatever evolutionary reason this is so we do not delay to dis-
cuss, but there is something insictent, pricking, sensationally
painful about evils. They attract our attention more readily
and are on the whole more definable than goods. Finally, as
above insisted, concerning our relative powers of destruction
and construction, we men are built more for destruction than
for construction, or at all events are more used to the destruc-
tive processes in our daily lives. We should, therefore, take
advantage of this ingrained destructive trend and endeavor in
the first instance to destroy definite concrete, and observable
evils rather than try to construct indefinite, abstract, hardly
conceivable good. Let the proximate task of evil destruction
be accomplished and the ultimate task of constructive good-
ness will shortly follow. The formula might run "Get the
Grail but first slay the dragon." These are perhaps the
main arguments to the hypothesis of evil's primacy in the
realm of social tasks. We are entirely certain that various

THE KINGDOM OF EVILS 429

readers of the Grail-hunting group will persist in misunder-
standing our program. They will not distinguish a technique
that deals with proximates from a program that runs towards
ultimates. We conceive that social work is a kind of human
technique of proximate nature whose lines are laid down in
the interest of ultimate good.

We have been bold enough to borrow mottoes from the book
of Job. We have taken care to take them from the words of
Job himself rather than from the words of his friends. These
friends, however, skillful in rhetoric, would perhaps not prove
the most successful of social adjusters. Without undertaking
elaborate analysis of the endeavors of Job's friends, for which
we are entirely incompetent, we are nevertheless inclined to
assert that the world has made a considerable advance upon
the ethical situation depicted in Job. Job said that his error
remained with himself, that when he cried out of wrong he
was not heard, that there was no justice, and that the hand of
God had touched him. He thus made an almost complete
analysis of his plight, finding concrete evils in most of the
departments we have discussed. Is it too much to say that
the spirit of civilization, the spirit of Christianity if you will,
has shifted the universe of evil at least by a few units? That
the land of the shadow of death could contain any sort of
order hardly entered Job's mind. It was to him the highest
of rhetorical flights to think of the weighing of his calamities.
In all these respects the modern world has gained a plan of
attack which Job's world certainly possessed not.

Finally as to the motto with which we have introduced
Book IV, the nineteenth century by its researches has served
to magnify the interest of man, if not yet to offer a perfect
technique for preserving him. Remarks like these are petty
enough beside the terror of the facts. We do not find the
social worker irreligious; but if the social worker were at the
outset irreligious, she speedily comes to a sufficient solemnity
— the solemnity of the interrelations of the deeper things in
mind and morals.

Thus we conclude certain generalities about the evils. By
the very order of presentation of the material in this work we
have intended to show that our work ran from observed de-
tails upward to more or less tentative general statements, and
not at all from any preconceived principles downward to the

430

THE KINGDOM OF EVILS

facts. Our study, as we have repeatedly maintained, is induc-
tive and not deductive. In point of fact the observations made
were made in the first instance without any grouping of the
evils and the maladjustments whatever. It was only when we
came to put our work together that we found our material
grouping itself in the way most elaborately presented in Book
II of this work. We think some such classification presented
in some order on the principles of this work will maintain
itself in future social work; but whether it does or not, the
materials for this particular analysis were not collected with
these categories in mind, but were collected with the general
principles of psychiatric social investigation in mind.

APPLICATIONS OF THE FIVEFOLD CLASSIFICATION OF EVILS
OUTSIDE THE FIELD OF SOCIAL WORK

Our fivefold classification of evils, to which Book II is
largely devoted, is a classification that might be applied with
great generality to vast areas of phenomena outside the field
of social case work. It is beyond the province of this volume
to discuss these wider applications, though the entire social
problem would plainly profit thereby. We shall confine our-
selves to two instances of the possible application of our
method of orderly approach to the classification of difficulties
of whatever sort. Let these two instances be the Great War
and bolshevism.

Is war in itself an evil? The Crusaders and the American
Revolutionists might well resent the charge so far as it con-
cerned their own aims and duties. Yet they would be com-
pelled to grant the unfolding of numerous evils in the train of
crusades or revolutions. To our minds the assertion that war
is an ez'il is logically far less accurate a statement than that
war entails ez'ils. War entails a plurality of evils. What,
now, are these evils ? We think they can readily be distributed
amongst our five groups, though some might desire that we
add a sixth miscellaneous group for troubles not specifically
listed as disease, error, vice, legal difficulty, and poverty. In
the wake of war comes disease and pestilence. Educational
systems crumble in war time, vicious attitudes abound. The
legal order is assailed. Poverty reigns.

If every analyst of reconstruction were to catalogue the

THE KINGDOM OF EVILS 43I

evils of war even in this rough manner, he would greatly
assist in the definition of every post bellum task. Re-
formers with but a single nostrum would have no preferred
standing in political councils, whether amongst government
officials or amongst the voluntary associations of the com-
munity. An eventual combined development of health pro-
grams with educational programs would be assured. The
representatives of the church, the lecture platform, and the
theater, as shapers for better or worse of community morals,
would find themselves shoulder to shoulder with the representa-
tives of government and law. In particular, nobody with an
economic panacea would be allowed to run wild without com-
petition amongst theories of reconstruction. To split evil into
such great rough groups as our chosen five of evils would
represent an advance in social reconstruction hardly to be hoped
for in an era of single-track minds. Yet there would be a
place in the sun, a true locus for the single-track minds in the
pragmatic attack upon each of the evils taken separately and
distributively by some single specialist — a specialist, as you
might say, in the slaying of a particular variety of dragon. The
higher speed and the greater safety can no doubt be attained
upon the single, switchless track, and the straighter the better.
In short, the trouble is the ancient trouble of the many and
the one, that is, the determining, amongst a plurality of things
to do, the pragmatic unit, the thing that "makes a difference."

We may again insist, as particularly pertinent to these gen-
eralized applications of our method of orderly approach, that
the items in the list and the order to be adopted in their
consideration. are of lesser consequence than the adoption
of some order in the consideration of chosen categories.
Suppose now, that we were to analyze'phenomena of the Great
War, no longer from the standpoint of the immediate task of
reconstruction but rather from the standpoint of historical
analysis to the end of the prevention of future wars. We
should be looking into causes. Here again the method of
orderly approach in the analysis of data has value.

Was there a morbid factor at the bottom of the Great
War or, more moderately speaking, were morbid factors at
all seriously in evidence? Of course some German propa-
gandists went so far as to describe the French attitude at the
outset of the Great War, and at various times when the French

432 THE KINGDOM OF EVILS

refused to treat for peace, as an example of Psycho pathia
Gallica. This Psychopathia Gallica was a national revenge-
psychosis! One German disputant objected. He noted a re-
sponsibihty on the part of the Germans to France if France
was a national victim of mental disease: France would then
have to be pitied ! But, seriously speaking, was there, or was
there not, a morbid and especially a psychopathic factor in the
Great War? Was the Kaiser a psychopath? The lay reader
must take note that psychopath means, as elsewhere in this
book, not necessarily an insane person in the medico-legal sense
of that term. The Kaiser might be a psychopath and, as
French writers have for years insisted, have still a degree of
responsibility.

But we are not here inquiring about the degree of personal
responsibility which might be laid at the door of a psycho-
pathic or non-psychopathic Kaiser. We are inquiring into
the causes of the Great War. It would be a nice question to
determine whether the Hohenzollerns are in so far eccentric
or "off-center" or "deviate" that they have had an essential
share in shaping European destinies. There are two views
about all such matters which frequently blanket or forestall
concrete investigations. There are those who believe in some
variant of the Great-Man theory of history. There are others
who are equally certain that all big social movements are mass
movements, reminding one of the prodigies of the social life
of ants, bees, and wasps. It is a question whether the real
facts concerning the Hohenzollerns and in particular concern-
ing the now living representatives of this group will ever be
examined by psychiatric experts. Great educators, wise philos-
ophers, exalted preachers, profound moralists, learned judges,
ingenious advocates, formulating political economists and
sociologists, to say nothing of estimable laymen, will claim
the right to make this momentous decision. Many decades will
go by, possibly a century or more, before we can replace the
current interpretations of history with a psychiatric interpreta-
tion. Yet until that psychiatric interpretation comes we shall
not have tried out one of the likeliest measures of prevention.
Who now knows whether both the origin of tyranny and
tyranny's fate were not matters of psychopathic interest?

But now let us suppose either that there were no morbid
factors or only partially effective morbid factors in the Great

THE KINGDOM OF EVILS 433

War, shall we not assign the Great War's origin to our
group of Errores? Was not Darwinism misinterpreted by
German expounders? Was not the German populace misin-
formed concerning political causes and effects? Did the Ger-
mans not proceed upon an erroneous theory of morals incul-
cated under the influence of the Hohenzollerns, Bismarck,
Treitschke, and Nietzsche? Here is a very pretty inquiry,
localized in the field of popular education and the general opin-
ion of German society. Did not Willisen and Clausewitz mis-
interpret the Napoleonic successes and method and supply the
German community with nationalistic ideas basically wrong?
In this part of our inquiry we should need to abstain absolutely
from any considerations of mental disease or of false morals.
Should it be inquired whether perhaps Nietzsche was not a
psychopath and his Will to Power the reflection of a psycho-
pathic pessimism, then our inquiry would run back to the group
of Morbi. Should we determine that Nietzsche, like his
predecessor Schopenhauer, was importantly a psychopath, then
our ideas concerning the origin of the war would change and
some of our measures for prevention would take into account
the necessity of analyzing the claims of a Schopenhauer or of a
Nietzsche long before political economists usually think phi-
losophy needs attention. Yet the ideas of a Schopenhauer and
of a Nietzsche, let them be as vitriolic and destructive by
nature as they list, would perhaps not be dangerous to society
if they were not spread by an educational process, either by
chance or by design.

If it should be discovered that leaders of German thought
for national political purpose deliberately encouraged the
spread of the psychopathic ideas of a Nietzsche or a
Schopenhauer, then the inquiry might throw back once more
to the question whether the leaders of German thought were
themselves psychopathic or whether they were merely mis-
taught by predecessors who were possibly psychopathic, or
whether they were persons with a vicious streak. In short,
this inquiry concerning the spread of ideas ultimately trace-
able to a psychopathic origin might lead us at the outset to
moral attitudes falling in our group of the V'itia; but, at one
degree removed and in the second generation of educators, we
might find that the total immediate cause of the German atti-
tude towards world domination lay in our second group of

434 ' THE KINGDOM OF EVILS

Errores. That is to say, ideas might arise in the group Morbi
or they might not, but these ideas might be promulgated as
misinterpretation, or misinformation by the mistaken leaders
of a given generation (belonging in group E), themselves not
at all psychopathic (i.e. not in group M) and even not at all
vicious ( not in group V ) . They would secure our forgiveness
"for they know not what they do." But again there might be
certain vicious leaders of thought (group V) who would in-
fluence a circle of less powerful thinkers (group E), who
would spread ideas derived from the vicious politicians, who,-
however, might have obtained their ideas from psychopaths
(group M). The analysis might run in a variety of ways;
but our general thesis ought, we think, to be accepted, namely,
that analysis under some such groups or categories as we have
here chosen would be of the greatest advantage to the world.

It is even possible that the exponents of a peculiar form
of legal order might have greatly influenced the origins of
the Great War. Men firmly convinced of the values of the
German legal code might well regard such code and under-
lying principles as the real skeleton and support of world
civilization. Jurists of this kidney would not be psychopaths.
Their ideas would not fall into the field of education, as com-
monly accepted, nor could we charge their system with being
in any obvious way a result of misinformation or of misinter-
pretation. There is no doubt that the representatives of medi-
cine, natural science, morals, religion, economics, and politics
take too little account of juristic developments. And the jurists
too are doubtless guilty of groping about in the same way
in their own water-tight compartment. Only the sociologists
appear to try to encompass all these points of view; yet, even
where the sociologists have a wide range and a sure touch,
they seem to us to fail to take account in an even and repre-
sentative way of all these divisions of human interest. This is
particularly true of the neglect by sociologists, up to very re-
cent days, of any right view of the importance of the psycho-
path in history.

Lastly we may consider that an economic interpretation of
history might prove that the basis of the Great War was
economic. Of course this dictum means very little if we are
listening to economists who regard virtually everything in the

THE KINGDOM OF EVILS 435

world as essentially economic in its basis. But surely that
proof has never been brought.

Enough has been said to intimate the sure advantage which
would follow analyzing the Great War in an orderly way con-
cerning both its origins and its effects. Advantage would
accrue if the phenomena of the Great War were analyzed under
the podtive categories of health, education, morals, law and
order, and economics. But we contend that the negative and
corresponding categories of our five groups would possess a
still greater advantage for the analyst.

Let us now turn to bolshevism. It would be of funda-
mental importance and value, could we discover and disen-
tangle any psychopathic elements in bolshevism. Marx
was, no doubt, not at all a psychopath. Bakunin on the other
hand was no doubt a psychopath. Socialism and anarchism
need not be set down as non-psychopathic and psychopathic in
origin on account of the nature of the lives of their founders,
Marx and Bakunin. Modern anarchists are a little impatient
of any attribution of great movements like socialism and
bolshevism to great men like Marx and Bakunin. They are
prone to leap into another category when the argument waxes
hot concerning individual founders and to begin to talk about
general, economic, legal, and moral or educational tendencies,
of mass movements and the like. There is a time for the con-
sideration of these other categories, but we can see that there
is a time for rounding up all the psychopathic elements that
there may be. Let psychiatric specialists deal to the best of
their special knowledge and training with these facts, and let
dll the facts be considered that might have a bearing on the
morbid sides of certain bolshevistic, socialistic, governmental,
or capitalist trends. (For in this skeleton of an argument con-
cerning bolshevism we must not be understood to say that the
various proponents of law and order and of capitalistic ven-
tures are not also sometimes in an important way psycho-
pathic.) After decades it may be allowable to think of George
III as a psychopath. How impatient a politician of the present
day would be if an inquiry along this line were made concerning
the Lenin who lives today ! These are very sharp tools, the ob-
jector to our program of the psychiatric analysis of present-
day politics may urge. But the tools we suggest are after all

436 THE KINGDOM OF EVILS

no sharper than the political tools of terrorism used by a
Hohenzollern or a Lenin. Finally the world will learn not to
flinch under the application of expert analysis.

But suppose we decide that Lenin and the rest are not
psychopathic or not importantly so, how much of the situa-
tion of bolshevism is an educational affair? How much is
it due to vicious or quixotic moral attitudes? How much is
it due to reaction against certain more or less false ideas of
law and order and how much, finally, is it due to the economic
resourcelessness of Russian peasants? We are not com-
petent to offer positive points concerning this analysis, but we
are inclined to think that every dispassionate person will agree
that the present-day type of analysis of such conditions does
not make for clarity. We can see that it is because the analyst
continually changes his categories, leaping from positive to
negative phenomena and leaping from group to group of each,
perhaps making each of his arguments swerve in a particular
and favorite direction.

The contentions in the last few paragraphs concerning the
possible analysis of the Great War and of bolshevism do not
touch the argument concerning the utility of our classification
of evils as applied to the individual psychopath. Our conten-
tions do not rest upon a thorough study of historical and po-
litical phenomena. We shall be entirely satisfied if the reader
regards these contentions as pure hypotheses. The argument
will at least serve to bring out into stronger relief the method
of orderly approach in the classification of social difficulties
as applied in the body of our work.

THE METHOD OF BOOK III : MAIN GROUPS OF MENTAL DISEASES

The cases of Book III are arranged according to their oc-
currence in the Major Groups of Mental Disease. Precisely
the same types of patient are presented in Book III as in Book
I, which dealt with the spheres of influence and in Book II,
which dealt with the various forms of evil. Our volume is
in no sense a treatise on psychiatry. Yet for several reasons
the arrangement of Book HI is a desirable one. In the first
place physicians, both psychiatrists and others, may want to
learn what kinds of social work are likely to be most applicable
in the major groups of mental disease; and, whereas the m

THE KINGDOM OF EVILS 437

count here presented is far from complete, we conceive that
the major issues of social treatment of the mental diseases are
clearly indicated. In the second place the social worker must
understand the larger features of mental disease as shown in
the great groups which physicians recognize; even if the social
worker's ideas are limited to very rough ideas concerning the
prognosis in the major groups of mental disease, she will un-
derstand the physician's point of view certainly better than do
many teachers, pastors, lawyers, and business men, with all of
whom the social worker may have to deal. In the third place
the cases of Book III may be used by the reader for the pur-
pose of independent judgment whether Book I's conclusions
on the spheres of influence and Book II's conclusions on the
forms of evil are sound conclusions; for the cases of Book III
are presented in far bolder form and with more reference to
treatment and outcome than to the technique of authority
brought to bear or of diagnostic details.

What are mental diseases? Luckily this is not a textbook
of psychiatry and we are not stringently required to ofifer a
definition. For practical purposes the mental diseases are dis-
eases which common consent leaves in the hands of a special
group of physicians for diagnosis and treatment ; namely, the
group of so-called psychiatrists. Common consent means that
the medical schools, the medical associations, and the medical
textbooks are practically unanimous in conceding the existence
of a field of mental diseases, related somewhat closely with
the so-called nervous diseases but rather less closely with all
other forms of disease. Medical schools have formally recog-
nized, though as a rule very inadequately, in their curricula
departments of mental disease or of psychiatry. National as-
sociations, like the American Medico-Psychological Associa-
tion, now the American Psychiatric Association, exist for
the purpose of promoting the study of mental diseases as op-
posed to all other forms of disease. Until recent years
these associations have been far from "scientific" in the
sense of presenting programs of investigation and research.
Although the American Medico-Psychological Association is
the oldest national medical association in this country, yet its
progress upon lines of research and investigation has up to
recent times been singularly slow. The predominance in its
programs of administrative and other practical features has,

438 THE KINGDOM OF EVILS

however, one point to commend itself in the eyes of the social
worker, — the social worker will find that the practitioner in
mental diseases, i.e., the psychiatrist, is probably by nature and
training a man especially accessible to ideas of social work.
In fact the superintendent of a hospital for the insane and his
subordinate officers have often been engaged in a type of work
not far removed from social work performed as a rule inade-
quately from a central office desk and without due emphasis,
perhaps, upon the educational, moral, legal, and economic sides
of the problem. On the whole, however, the psychiatrists had,
by virtue of the very nature of their material, made much
greater progress toward "socialization" than had practitioners
in other fields of medicine. Many of the underlying concepts
of social work are far more deeply imbedded in the mind of
the psychiatrist than in the minds of other practitioners of
medicine.

Psychiatry is that field of medicine devoted to mental dis-
eases, and psychiatrists are the practitioners in that field.
Many readers are aware that the term "psychiatrist" has only
recently taken hold of this country. The term "alienist" is
still used rather freely by the older generation. There is, to
be sure, not much difference between these terms, yet the slight
distinction is one which is of the greatest importance to the
development of mental hygiene. The situation is somewhat
as follows. Insanity and mental disease 'are not synonymous.
Insanity is a legal concept, mental disease is a medical concept.
A man is sane or insane or as yet indeterminate as to his in-
sanity. Many hold that there are no degrees of sanity or
insanity. A multitude of courts will still be found holding
that there is but one degree and but one kind of sanity or of
insanity.

On the other hand there are all degrees of mental health
and mental disease and there are many kinds of mental disease.
Insanity, we may say, depends upon medico-legal decisions.
Mental disease is an affair of medicine alone. Sanity and
mental health, decided respectively by the law and by medi-
cine, may characterize the same human subjects. But — and
here is the definite point — sanity may characterise many sub-
jects of mental disease. These sane subjects of mental dis-
ease are subject to mental disease, mild or severe, of a kind
or degree that does not concern the courts. It would even be

THE KINGDOM OF EVILS 439

permissible to say that no man is either sane or insane until
properly reviewed and adjudged by the courts. It is perhaps
enough to claim that sanity and insanity are characteristics
such that courts decide them within limits of accuracy of
courts. Accordingly sanity and insanity are legal, govern-
mental, public matters. On the other hand mental health and
disease are matters of individual medicine and individual
psychology, and while of familial, district, group, or com-
munity interest, they do not necessarily even approach govern-
mental regime. Insanity is a public matter, mental disease a
social, family, or personal matter.

We believe that the above statements will be commonplaces
in the minds of many, perhaps of most advanced medical men.
It is probable that many competent jurists hold identical con-
cepts. It was on this basis that the senior author of this work
proposed some years since that the medical specialists, who
are medico-legal aids, be given the familiar and appropriate
designation, alienists, and that the term psychiatrists be re-
served for those specialists who act as physicians only, — in
short that the insanity expert be spoken of as an alienist and
the mental-disease expert be called a psychiatrist. In a some-
what revolutionary way the suggestion was at that time made
that the records on mental cases might run as follows. (The
reader must take note that these suggestions have not to any
extent been applied practically up to this time and are here
offered purely to bring out the existence of border-line cases
of mental disease that are not medic o-le gaily insane.)

Example i. — "As alienist I consider this person insane. As
psychiatrist I consider this patient subject to general paresis."

Example 2.- — -"As alienist I consider this person sane. As
psychiatrist I consider him in complete mental health."

Example 3. — "As alienist I consider this person sane. As
psychiatrist I consider him subject to mental disease; namely,
subject to a psychoneurosis of hysterical form."

Exa'mple 4. — "As alienist I consider this person sane. As
psychiatrist I consider him subject to dementia praecox in a
mild degree."

Example 5. — "As alienist I consider this person sane. As
psychiatrist I consider him subject to paranoia of great severity.
This mental disease (which I find as psychiatrist) I regard, in
this case, as of no public interest (when I review the findings
as alienist)."

ALIENISTS
Field: Insanity, The Insane

Field : Public, Governmental,
Legal

Field : Opinion for Court Use

Decisions Alternative : San-
ity versus Insanity

Insanity Implies Mental Dis-
ease

Sanity : Insanity = i : o

PSYCHIATRISTS

Field: Psychiatry, the Men-
tally Diseased

Field: Social, Private, Medi-
cal

Field : Medical, Psychological,
and Social Diagnosis and
Treatment

Decisions Selective: e.g.,
Syphilitic, Feeble-minded,
Epileptic, Alcoholic, Coarse
Brain Disease, Sympto-
matic, Senescent - senile.
Schizophrenic, Cyclothymic,
Psychoneurotic, etc.

Sanity Consistent with Mental
Disease of Mild Degree or
of Special Type

Mental Disease of All De-
grees of Many Kinds

The hypothetical and indeed Utopian reports (Examples 1-5)
are made, it will be observed, by a physician who announces
himself to be both an aHenist and a psychiatrist. No doubt
every good physician must, in the nature of things, be a good
alienist, since the expert in mental diseases, as a rule, must be
an expert in those mental diseases which are, from the legal
point of view, insanities. No doubt, too, every alienist (in the
narrow legal sense here adopted) ought to be a good psychia-
trist. Yet it is still true that many alienists are to be found
who have no interest in mental diseases outside the field of the
medico-legal insanities, and having no interest (especially no
therapeutic interest) therein really never do become psychia-
trists in a deep sense. This unfortunate state of affairs will
persist in most states until the best available technique for
handling border-line cases (namely the psychopathic hospital)
is established. We place upon another page in parallel columns
several of these points.

As we have throughout insisted, psychiatry is an art, a
branch of practical medicine. Yet it cannot be denied that
there are many generalities about psychiatry which go to make
up a respectable body of theory. Some authors distinguish a
special psychiatry from a general psychiatry, the former con-
taining descriptions of separate forms of mental disease and
the latter presenting a variety of general statements. The bet-
ter usage is to apply the term "psychopathology" to the body
of scientific theory which has been built up out of psychiatry
taken in relation to medicine, psychology, and other mental
sciences as a whole. The best usage would define the psycho-
pathologist as a theorist in mental disease and the psychiatrist
as a practitioner therein. To be sure every practitioner needs
a body of theory to go upon and must therefore be trained in
psychopathology. The reverse is, no doubt, not at all the case ;
and non-practitioners, even non-medical men, have made enor-
mous additions to our knowledge of the theory of mental
disease. The lay reader who dips into modern works on the
topic of psychiatry will almost always find long sections deal-

443

444 THE KINGDOM OF EVILS

ing with "general" psychiatry or with psychopathology and
will find therein descriptions of, for example, hallucinations,
delusions, morbid emotions, and will-disorders taken in a gen-
eral way and outside their setting in the special forms of men-
tal disease. The lay reader must be warned against trans-
ferring ideas from these theoretical parts of textbooks directly
to the patients. On the other hand it is rather easy for the
lay reader to gain some notion of the special forms of mental
disease in their larger outlines. Indeed we have known medical
students, social workers, psychologists, and even jurists who
possessed more exact ideas about some forms of mental disease
than do many general practitioners of medicine.

A word concerning clinical neurology. Medical school cur-
ricula, national medical associations, and a variety of textbooks
assure us of the existence of a field of nervous diseases sepa-
rate from that of mental diseases. The relations here are a
little difficult for the lay reader to grasp. The mind has close
relations with the nervous system, and the term neurology
seems to specify a science of everything nervous. Accordingly
the neurologist living up to the Greek roots of his professional
title is apt tp regard himself as ex officio a psychiatrist. On
the other hand the psychiatrist in his practical diagnostic work
has to use many of the coarser methods of the neurologist and
finds himself nolens volens in the end a sort of neurologist.

In the Great War the surgeon general of the army developed
a division of neurology and psychiatry, and practically no dis-
tinction was made between the officers working under this
division. In fact, they were often termed neuro psychiatrists.
Some think that a new art of neuropsychiatry combining the
neurological and psychiatric branches of older medicine is to
be established. This is not the place to discuss or to define
the fields of clinical neurology and psychiatry. After all, both
the clinical neurologist and the psychiatrist are physicians and
have the same fundamental medical training. Many men unite
theoretical and practical knowledge in two fields. The senior
author of this work has elsewhere tried to define the present-
day differences in these two types of professional men by de-
scribing the clinical neurologists as rather more analytical and
the psychiatrists as rather more synthetical in their viewpoints.
This means to say that the clinical neurologist is on the whole
rather more apt to leave his patient a mass of reflexes, and the

THE KINGDOM OF EVILS 445

psychiatrist is rather more apt to talk of his patient in general
terms. It is easy to see that each method readily slips into over-
emphasis of details or generalities. The middle of the road
must be taken.

We pass to a brief summary of the major forms of mental
diseases as they occur in practice. It is customary to say that
textbooks on psychiatry greatly disagree upon their subject
matter. But there is far more disagreement upon terms than
upon facts. And there is naturally far more disagreement
about details than about the major groups of mental disease.
The cases in Book III have been presented in groups which are
found in most textbooks of psychiatry. These groups are pre-
sented in a special order. We do not here need to argue for
the virtues of an orderly approach in diagnosis, since our entire
work must be regarded as perfectly hopeless if the reader has
not been convinced of the value of the orderly approach as
shown in Book I and especially in Book II. The value of
order in the world's work is a truism. The orderly diagnosis
of mental disease is as valuable a method as the orderly diag-
nosis of the social factors which we have grouped in this
book under the title of the Forms of Evil. In fact the impulse
to the classification of evils herein adopted was derived from
the senior author's work on the orderly diagnosis of mental
diseases.

We have thrown our cases into eleven groups, of which the
eleventh is a miscellaneous or rag-bag group of mental dis-
eases either severe or mild (but for the most part mild) that
do not fit the definitions of the other ten major groups of
mental disease. This eleventh miscellaneous group would be
of special abhorrence to the old-time alienist limited in his
view of mental disease to the notion of medico-legal insanity.
The old-time alienist who cannot think of insanity except in
terms of internment in an asylum or of testamentary incapac-
ity, cannot readily be got to deal with the psychopathic per-
sonalities and other disorders of this eleventh group. It is
somewhat as if the general practitioner of medicine should
refuse to consider any case of disease which was not bedridden.
The eleventh group of the psychopathies, psychopathic person-
alities, etc., must comprise, it will be seen, many of the cases
of mild and dubious mental disease which the modern psycho-
pathic hospital has been especially established to class and treat.

446 THE KINGDOM OF EVILS

The eleventh group is placed last, because the attempt should
be made to class every mental suspect more definitely in one of
the preceding groups. Concerning these preceding ten groups,
it is worth while to insist that nothing ultimate is claimed
either for the number or the nature or the special order of the
groups. That some order of disease groups should be adopted
for the purposes of diagnosis is highly desirable. That this
particular order is the best at the present day is perhaps doubt-
ful. Nor will anyone maintain that this particular order will
outlast the decade.

The first four groups in this sequence are of particular social
interest. The first group contains the mental diseases due to
syphilis, a group of diseases of increasing importance in prac-
tical psychiatry and the bridge over which the new associations
between mental hygiene and public health will pass owing to
the fact that the most concrete contributions to the technique
of mental hygiene have been made in this field. Nor can any-
one doubt that feeble-mindedness is a leading social problem.
Epilepsy, particularly in its milder and so-called "equivalent"
forms, is another topic of social interest both because public
institutions must always eventually be built for epileptics of a
given state and because there are always so many "sane" epi-
leptics who are in no sense asylum cases but are very proper sub-
jects for social work and mental hygiene. Fourthly, alcohol-
ism is, or has been in this country up to the passage of the
national prohibition legislation, a most important social factor
of mental hygiene. Inasmuch as the group here defined con-
tains the drug addicts (so far as drugs produce mental dis-
ease and disorder), the group may, no doubt, always remain of
practical social significance.

Though the main reason for arranging these disease groups
in this particular order (first proposed in 191 7) was the
reliability of tests and other diagnostic criteria in the groups,
yet the order was adopted with a weather eye to the social
values of the groups. If the psychiatrist could be made to con-
sider definitely such socially interesting matters as (a) syphilis,
(b) feeble-mindedness, (c) epilepsy, (d) alcohol and drugs,
the battle was almost won for a broad conception of psychiatry.
If the psychiatrist was compelled by routine to learn whether
his mental patient was syphilitic, he was compelled to resort to
laboratory methods of a certain refinement. If he took seri-

THE KINGDOM OF EViLS 447

ously the question of feeble-mindedness, he had perforce to
resort to standardized methods of mental testing. If he was
to make up his mind about either epilepsy or alcoholism he had
to have by him the means of securing a social history. In short,
the psychiatrist who should deal scientifically with the ques-
tions raised in these first four groups would have to have at his
command the services of a proper modern clinical laboratory,
the resources of a psychological service, and the resources of
psychiatric social work.

It will be known, even to the layman who has had contacts
with this field, that the majority of cases in these first four
groups are cases of the so-called "organic" type. That is to
say, these cases will be found upon autopsy to show serious
disorder of the nervous system which can be demonstrated
either by the naked eye or by the microscope. In fact the
whole table of groups is found to have, roughly speaking, the
property of being more "organic" at its upper end and more
"functional" at its lower end. But the sequence was not chosen
upon this particular basis, but rather, as stated above, on the
basis of the reliability of diagnostic tests and criteria. Above
all, the lay reader should not conclude that "organic" means
incurable or permanent as to symptoms.

The fifth group is a group of mental diseases in which the
brain shows demonstrable lesions. It is the "organic" group
par excellence with the syphilitic, feeble-minded, and epileptic
cases removed therefrom. The sixth group is a group of
mental diseases in which the brain is relatively normal and in
which the cause seems to reside outside the brain in some one
or more organs of the body. So far as asylum material goes
this group of somatic cases has seemed up to recent times to
be limited. The seventh group is the group of the senile psy-
choses. The remaining three groups deal with topics of great
difficulty and of doubtful scientific standing even today. The
eighth and ninth groups of the so-called dementia praecox and
of manic-depressive psychosis are groups whose distinction is
a practical matter of difficult diagnosis almost daily in every
hospital for the insane and even more so in psychopathic hos-
pitals. These two disease groups may be regarded as "sister"
groups of mental disease. The tenth group is that of the psy-
choneuroses, Avith which the reader of the first three books has
to become familiar, in striking instances in which mental fac-

448 THE KINGDOM OF EVII^

tors, operating apparently by themselves, have directly pro-
duced mental disorders. So far as we are aware, practically
every psychiatrist of today recognizes the existence of these
major groups or of their most important single representatives
amongst the diseases.

The alert reader may well have inquired long before this
point in our exposition whether a patient may not fall into two
or more of these groups. Let us emphatically say that it is
entirely possible that a patient shall be syphilitic, feeble-minded,
epileptic, alcoholic, a victim of coarse brain injury, a victim of
somatic disorder operating from outside the nervous system
and a senile ; that is, a patient may possess characteristics that
fall in every one of the first seven groups. To be sure it may
be better to describe him chronologically. He inight be de-
scribed as a feeble-minded person whose brain lesion was such
as to have produced epilepsy, who had not only acquired syphilis
of the nervous system but had sundry other destructive in-
juries of his brain and who had, in the vicissitudes of life,
become alcoholic, had developed diseases in the body at large
which had in turn reflected themselves in the patient's mind
and who had at last become senile in such wise that the senile
brain changes were contributing a dementia to the already
complicated picture. To be sure for the present we have no
such case to offer, and such extensive combinations of factors
are, no doubt, rare. But can we continue to catalogue on a
theoretical basis? Is it, for example, possible for a feeble-
minded person to become a victim of dementia praecox? The
answer to this question cannot be given with certainty at this
time; but on the whole there is considerable evidence for an
affirmative answer, and some authors freely assert that de-
mentia praecox may be grafted upon feeble-mindedness. As
for manic-depressive psychosis its phenomena are found in the
majority of mental diseases, which may develop periodical
emotional disturbances ; but it is doubtful whether we should
term all such instances of an apparently cyclothymic nature
cases of manic-depressive psychosis. As for the psychoneu-
roses, no doubt they can develop upon any or all of the bases
above enumerated. But if a case of mental disease exhibits
phenomena that might, at first glance, place him in one of the
lower groups in our sequence, then, in fact, it is the usual rule
to give him the diagnosis of the earliest group to which he can

THE KINGDOM OF EVILS 449

be found related. This is probably on account of the prag-
matic and therapeutic value of so classing the patient.

Let us indicate some of the more important social values of
these groups.

Group I, the syphilitic group of mental disorders, is a very
important one to the social worker. In the first place the
establishment of the diagnosis almost always means the pos-
sible suggestion of treatment, which treatment may be rela-
tively expensive and sometimes hard to persuade the patient to
take. In the next place, the spouse and children of the neuro-
syphilitic need examination to determine whether they are not
likewise infected with syphilis. If so, they can come before
they have developed mental symptoms and in their own interest
be treated in suitable clinics or otherwise. It is the task of
the social worker to see that this family work in neurosyphilis
be carried out. Some of the points in this work have been set
forth in a work by Southard and Solomon entitled Neurosyph-
ilis, Modern Systematic Diagnosis and Treatment (191 7), one
whole section of which is devoted to medico-legal and social
problems. Some of the cases in this book have been presented
again in this work redescribed from the standpoint of social
work. This group is the group of the popularly known dis-
ease, general paresis, sometimes known as "softening of the
brain." Southard and Solomon in 191 7 reported that some-
thing like twenty-five per cent of their cases of general paresis
yielded considerably to treatment. This percentage is higher
than other authenticated percentages. Perhaps the lay reader
will not be too much impressed with a twenty-five per cent
yield of therapeutic successes; but if the layman considers the
results in chronic diseases in general and remembers that this
disease comes as a rule ten years after the initial infection with
syphilis, he will see that such results as twenty-five per cent
recoveries are important.

The social values of Group II, of the feeble-minded, are
too much in the public eye at the present moment to require
exposition here. Not only have the psychologists following
Binet produced mental tests of value but these tests have been
very widely employed by the more or less competent lay work-
ers and the whole topic has absorbed public interest. The
articulation of this problem with the problems of crime and
prostitution is well known, not to say overdrawn, in the public

450 THE KINGDOM OF EVILS

prints. Practically half of the prostitutes examined by the
White Slave Traffic Commission of Massachusetts turned out
to be in some degree feeble-minded.

Concerning Group III, note was made above of the popular
interest in the "sane epileptic." Some authors have empha-
sized the relation of the so-called epileptic personality with its
very pronounced egotism and ill-humor. Doubtless in this field
there will be much scope for mental hygiene in the future.
But the social worker can do the most good by remembering
that epilepsy has a large number of subgroups. The formula
to bear in mind is that it is much truer to speak of "epilepsies"
than of "epilepsy."

Concerning Group IV, the alcoholic group and the drug
group, we have at times referred to the special values of the
Men's Club as employed for some years at the Psychopathic
Hospital in Boston. But the idea is an old one. The Salvation
Army has in the past done much good in the rescue of alco-
holics from their habits. The victim of delirium tremens is
an especially good social risk, as he often cooperates extremely
well upon recovery.

Groups V, VI, and VII are of lesser social importance since
for the most part the problems that arise therein are either
not at all to be settled by social work or else can be settled
with considerable ease.

Groups VIII, IX, X (that is, dementia praecox. manic-de-
pressive psychosis, and psychoneurosis) become once more of
prime interest to the social worker. Dementia praecox and
manic-depressive cases are constantly apt to fall into the dubious
position, whether they require interning in an asylum or do not.
The relations of the friends to this situation then become criti-
cal. Apparently a multitude of adjustments may need to be
made in these groups by the social worker. Mild cases of both
of these diseases, but especially of the manic-depressive group,
often want to go home prematurely and often do go home
against the advice of the physicians. The social worker may
here become of great practical value. Somehow the laity is
rather apt to regard the psychiatrist as a kind of ogre who
wishes to get even the mildest and most doubtful psychop-
athies into his institutional net for safe-keeping or observation.
The social worker can help to dissolve this idea of something
ogreish in the psychiatrist. Patients recovering from depres-

THE KINGDOM OF EVILS 45 1

sion (manic-depressive psychoses) are particularly difficult
cases to handle. During convalescence these patients are ap-
proximately normal; yet at a time when the depression still
persists but the power of the will has steadily increased comes
the zone of danger of suicide. The patient is still dominated
by depressing thoughts but is no longer protected against sui-
cide by the weakness of will which prevailed in the peak of
his illness. The relatives need to be convinced that their patient
should be retained in hospital a few weeks longer to pass
through this zone of will weakness.

Finally nothing in this book has been more convincing than
the need of social work in the field of psychopathic personalties,
here grouped in the last Group XI.

Now and then from a general social worker comes a request
for lists of symptoms by which, supposedly, the different men-
tal diseases may be recognized. Social workers who have
dipped into works upon psychiatry can follow us when we say
it is not at all impossible to match the symptoms of any dis-
ease which we may confront with the symptoms of several dis-
eases as described in the medical books. In fact, the more
thorough and accurate the psychiatric textbook, the more likely
would be the facts in the particular case to match with the facts
in the books as presented under a great variety of headings. It
is not alone the tyro, but also the expert, who is amazed to find
that all the symptoms in his case can be found, let us say,
under the different headings of syphilis, dementia praecox,
manic-depressive psychosis, etc. To use the language of medi-
cal logic, we can- briefly put the situation by saying that in the
field of mental diseases, there are few or no indicator symp-
toms. Any symptom, e.g., mania, depression, persecutory
ideas, grandiosity, hallucinations, and so on through the list,
may be found alone or even in multiple combination with other
symptoms of the list in virtually any one of the great groups
of mental diseases.

A good many persons believe that a disease is composed of
symptoms, but nothing is more erroneous. The symptom indi-
cates the disease. The disease is an infinite mass of processes
and of arrangements. It is a mistake to think that because it
can be shown that general paresis has a certain kind of pupil-
lary disorder and a certain kind of speech disorder, and a cer-
tain mental state characterized by feelings of grandeur, these

452 THE KINGDOM OF EVILS

three things, disorder of pupils, disorder of speech, delusions
of grandeur, in any sense constitute the disease. No symptom
constitutes the disease. No group of symptoms constitutes a
disease. One rather comforting fact about mental disease is
that, after all, there are so few symptoms to a given disease.
The most complicated disease that runs through the entire
make-up of the person, influences every move of his entire
future, goes back to his entire past, will be found to have but
one symptom, or two or three, rarely more than ten or a dozen
symptoms. These must be, in the nature of things, mere indi-
cators of the situation.

In short there are no indicator symptoms, or what are called
in the books pathognomonic symptoms. In medicine there are
certain pathognomonic symptoms; thus in smallpox, the pock
of smallpox is pathognomonic; it does not occur in any other
disease, and you get it when you have that disease. Of course
there are some doubtful cases where you cannot make out
whether you have got a pock or not of this characteristic sort.
The pock of smallpox is so characteristic that we regard it as
pathognomonic. The tubercle bacillus in tuberculosis is pathog-
nomonic,— it does not occur except in tuberculosis. But in
mental disease we have not any such pathognomonic symptoms
that point to any certain disease.

There are a few combinations of symptoms or signs that
indicate certain diseases. However, these combinations are
probably beyond the range of a person not trained in medicine
to use. There may be ope or two small exceptions to this in
the whole of medicine. A nurse, a layman, anyone can learn
to diagnosticate smallpox from the pock just as well and per-
haps better than a physician. Just as a man without knowing
a thing about engineering says about his automobile "the en-
gine is skipping." The man may not know what to do about
it, or he may, without knowing anything about engineering, be
able to fix it ; so that people ca,n make certain diagnoses which
are merely recognitions of things, of data. But when it comes
to mental disease this is not so. There are not any simple
points by which to recognize it, and its complicated ways are
not too easy for the medical mind or for any other mind.

MAIN FORMS OF NEUROSYPHILIS

DIFFUSE NEUROSYPHILIS

(non-vascular forms of "cerebral," "spinal," and "cere-
brospinal syphilis")

VASCULAR NEUROSYPHILIS

("cerebral arteriosclerosis," "cerebral thrombosis")

PARETIC NEUROSYPHILIS
("general paresis")

TABETIC NEUROSYPHILIS
("tabes dorsalis")

GUMMATOUS NEUROSYPHILIS

("gumma of membranes, of brain")

JUVENILE NEUROSYPHILIS
(paretic, tabetic, diffuse)

NEUROSYPHILIS

The problems of neurosyphilis (Group I) are presented in
eight cases (39 to 46) at the beginning of Book III. In the
book of the senior author written in collaboration with Dr. H.
C. Solomon, Neitrosyphilis: Modern Systematic Diagnosis and
Treatment presented in one hundred and thirty-seven case his-
tories, there had already been given sixteen cases of neuro-
syphilis having medico-legal social interests in the foreground.
Numerous other cases in that series also possessed social inter-
est. Case 39 of our present series, Greeley Harrison, was
case 9 of the book Neurosyphilis. Greta Meyer (case 40),
Walter Heinmas (case 41), David Collins (case 42), Archi-
bald Sherry (case 45) were also all cases from the Neuro-
syphilis book, being cases 107, 97, 61, and 38. A whole vol-
ume might be written concerning the social aspects of the prob-
lem of neurosyphilis. The lay reader must bear in mind that
the medical men are apt to term protean the nature of neuro-
syphilis. Practically every form of mental disease can be
imitated by syphilis of the nervous system. Lesions pro-
duced by the spirochsete in the nervous system are of several
kinds and of widely varying degree. In the first place syphilis
may affect the membranes that surround the nervous system
giving rise to the various forms of meningeal syphilis (both the
delicate pia mater that immediately invests the brain and spinal
cord and the thicker dura mater that overlies the pia mater are
affected by lesions that may be either isolated or widespread).
The blood vessels of the brain and spinal cord may be the par-
ticular target of attack by the spirochsetes and the lesions of
these blood vessels may give rise to destruction of the brain
and spinal-cord tissues which they supply with blood. Again,
when neither the investing membranes nor the blood vessels
are severely or at all affected, the tissues themselves may be the
point of attack by the spirochsete.

We present upon page 453 the main forms of neuro-
syphilis as classified for practical purposes in the above men-
tioned book of Southard and Solomon. Of these six main

455

456 THE KINGDOM OF EVILS

forms of neurosyphilis we illustrate in the present volume five
forms. The form omitted from the present volume is the
form known as gummatous neurosyphilis, that is a gumma of
the membranes of the brain. This lesion is sometimes open to
surgical attack and sometimes to treatment by antisyphilitic
drugs, such as salvarsan, mercury, and the like ; but the prob-
lems of the disease would have nothing of special interest from
the social standpoint. Diffuse neurosyphilis is represented in
this volume by Greta Meyer (case 40). This disease may be
a long-standing one. There is no prognosis of comparatively
early death such as attends the diagnosis of general paresis
represented in our series by Greeley Harrison (case 39), Hein-
mas (case 41), Collins (case 42), Spindler (case 43). In
cases of diffuse neurosyphilis, such as that of Greta Meyer, ac-
cordingly the social worker may look for a long history of
gradual development, numerous variations, remissions, and
an outlook of considerable success in medical treatment. With
respect to the paretic form of neurosyphilis, commonly called
general paresis, we have brought out in our discussion of Gree-
ley Harrison (case 40) that the paretic form of neurosyphilis
is not necessarily completely intractable to treatment. We
here point out that this point is a most important conception
not yet well established in the medical mind. Southard and
Solomon felt from their work published in 191 7 that intensive
treatment had proved to be of the greatest value in a number
of cases of general paresis. They felt that they had cured an
excellent salesman of forty-six years of age who had suffered
from most aggravated mental symptoms. He not only recov-
ered symptomatically but all his tests have been rendered nega-
tive and he has remained entirely well and economically effi-
cient for about five years even without further treatment.

Southard and Solomon pointed out also that two or three
months of active treatment will often be carried out before
any signs of improvement whatever are seen. They con-
cluded that it was "unfair" to give an entirely grave prog-
nosis in any case of neurosyphilis until the effect of treat-
ment had been tried. But whatever the outcome of the medi-
cal treatment of neurosyphilis in any of its forms, we can hope
to prove in the present volume that social treatment yields
efficient results and should be carried out even if the medical
prognosis be regarded as grave.

THE KINGDOM OF EVILS 457

The case of Walter Heinmas is a particular one from the
standpoint of the social worker. As we pointed out, the rather
obvious motto should be adopted by social workers, namely, —
the families of paretics are the families of syphilitics. This
motto should be followed by action. This action should con-
sist in having the blood serum of each member of the family
of the paretic (that is, his spouse and children) examined by
blood tests for syphilis. The two children of Walter Heinmas
had fortunately been absolutely healthy. The patient himself
and his wife had no idea that there had ever been syphilis and
could remember no symptoms or suspicions. Mother and
daughter were well endowed in mind and general physical
health, yet blood tests of all three proved positive for syphilis.

The case of David Collins is particularly valuable for the
social worker. The data of this case seemed to show that
neither intense medical care alone nor elaborate social care
alone would ever turn the trick. Neither form of treatment
would have been quite justifiable from a practical point of
view if carried out alone. Whatever is to be the outcome in the
case of David Collins, we must concede that partial or tem-
porary cure by social service methods must be scored for the
Collins family. At the present writing we have a history of
five years since the first appearance of David Collins at the
hospital after his falling into convulsions on the street, and we
have a history of three years since the initiation of a period
of regular treatment.

Archibald Sherry (case 45) is a very unusual case medically,
a case of juvenile tabes, sometimes known as locomotor ataxia.
Rather good therapeutic results were obtained for this twelve-
year-old boy, although social work was difficult by reason of
lack of cooperation on the part of the child's mother.

Harold Gordon (case 46) falls into the group of vascular
neurosyphilis (see table of main forms). These cases may be
completely arrested by medical treatment leaving a certain in-
curable but not necessarily incapacitating impairment. The
point of these results lodges in the fact that the loss of power
on the one side of the body (hemiparaplegia) is due to lesions
of blood vessels in the brain, which lesions may be cured com-
pletely by antisyphilitic treatment, but the destruction of brain
tissue entailed by the temporary or permanent plugging or rup-
ture of the artery cannot be made good. Tissue of the cen-

45^ THE KINGDOM OF EVILS

tral nervous system, once destroyed, cannot be regenerated.
However, the victim of such a disease as syphiUtic hemiparesis
may recover without excessive impairment, as in the case of
Harold Gordon.

Neurosyphihs is then one of the most protean of diseases.
The blood test for syphilis is one of the most reliable, if not
the most reliable, single blood test available to the worker in
mental disease. Inasmuch as syphilis of the nervous system
may through its special ways of affecting brain and spinal cord
imitate practically every other kind of mental disease it becomes
important to eliminate the hypothesis of neurosyphilis from
virtually all cases of long-standing mental disease, particularly
if this disease occurs in the male sex. It is possible for the
nervous system to harbor spirochsetes that cause syphilis with-
out yielding any symptoms whatever, at all events for years
or even decades. We sometimes find elaborate evidence for
syphilis of the nervous system in persons who show absolutely
no sign or symptom of nervous disease. But again spiro-
chsetes may produce extraordinary effects or produce huge
tumor-like masses known as gummata. These gummata are in
their practical effects rather more like tumors than like most
syphilitic lesions.

Again it would seem as though the process is a sort of siege
of the nervous system, the spirochaetes affecting certain nerve
tracts. This is the case in tabes dorsalis (locomotor ataxia)
where the destructive process is largely limited to the posterior
tracts of the spinal cord. The form of attack in diffuse neuro-
syphilis is quite different, as if the nervous system were not
so much attacked by siege as taken by storm, and the results
are disseminated over a large area. Again neurosyphilis is a
simple secondary effect of blood vessel disease which results in
the scooping out of huge masses of tissue which die and give
rise to so-called secondary degeneration in different parts of
the nervous system. These lesions or spirochsetes may be over-
looked and disappear and the lesions may resemble extin-
guished volcanoes. Yet again the diffuse process may run on
apparently with perfectly fatal results to mortality in a few
years both with and without treatment. However, in other
cases, as we have insisted, treatment appears to accomplish
much. As Southard and Solomon insist, the prognosis of
neurosyphilis is not worse than that of the chronic dis-

THE KINGDOM OF EVILS 459

eases in general. The prognosis of neurosyphilis so far as
length of life goes is certainly not bad. Remissions are always
possible though they are not frequent. We found amongst
three hundred untreated committed cases of paretic neuro-
syphilis five that were capable of self-support and ten more
that seemed normal enough to live at home. The patients were
said to have "remissions." Perhaps the most important thing
for the investigator to bear in mind is this : During a good
part of the early period of the course of neurosyphilis, it is
difficult or impossible to tell the paretic from the non-paretic
forms of diffuse neurosyphilis by any combination or single
observations and tests. In short we should take any diagnosis
either of general paresis (with its outlook that the patient is
going to die in from three to five years) or of diffuse neuro-
syphilis (with its much better prognosis) with a grain of salt.
In either case, however, it is desirable to proceed along the best
lines of social treatment whatever is to be the outcome of the
neurosyphilitic. In each instance also it is important to remem-
ber the other members of the family and to submit them to
blood tests. It would be an important addition to the tech-
nique of preventive medicine if the spouses and children of
all paretics were subjected to blood tests for their own
individual interest and in the interest of the health of the
community.

FEEBLE-MINDEDNESS

FIELDS OF INQUIRY

Physical Examination

Family History

Personal and Developmental History

School Progress

Examination in School Work

Practical Knowledge

Social History and Reactions

Economic Efficiency

Moral Reactions

Mental Examination

Walter E. Fernald, 191;

FEEBLE-MINDEDNESS

We present the topic of social work in connection with
feeble-mindedness (Group II of Book III) in six cases (47-
52) in Book III. But the topic has been extensively covered
also in Books I and II, more particularly in cases 2, 9, 11, 13,
15. 26, 32, 35.

The social worker must become familiar with at least the
generalities concerning the major subgroups of feeble-minded-
ness from the standpoint of the measurement of their mental
levels. American usage counts amongst the feeble-minded
(a) the idiots or feeble-minded of the lowest grade, (b) the
imbeciles or feeble-minded of middle grade, and (c) the morons
or feeble-minded proper. (English usage often employs the
term feeble-minded for the morons only.) Modern work
seems to show that between the feeble-minded proper or so-
called morons and normal persons there is a group of (d)
subnormal persons measuring by mental tests at a higher level
than the morons. If this new definition is established, we shall
then count from below upwards, four groups of the "feeble-
minded" ; namely idiots, with a mental level corresponding to
that of infants; imbeciles with a mental level corresponding to
that of young children ; morons with a mentality corresponding
to that of older children before puberty, and subnormal persons
with a higher mentality but still a mentality falling short of
the normal. It must be granted, however, that the mental
tests at present available do not serve to mark out these higher
subnormals with perfect accuracy. Indeed the term "feeble-
minded" seems to have become much too strong a term to use
of many persons whom we can still put down as clearly sub-
normal. It may be well enough to term imbeciles and idiots
simply more and more pronounced examples of feeble-minded-
ness. It is, however, a shock to the layman's mind to hear
persons of but slightly substandard mentality termed feeble-
minded. Indeed, when we examine the brains of these sub-
normal persons, post mortem, we find that they are in general
appearance but slightly, if at all, removed from normality,

463

464 THE KINGDOM OF EVILS

When we perceive normal-looking brains in subnormal persons
(even in morons we are apt to find brams that are not strik-
ingly abnormal in the gross) we are likely to think that, by a
slight twist of the wheel of fortune, such substandard persons
might possibly be made proper inhabitants of the world, proper
voters, and even proper parents. Perhaps a slight variation
of the glands of internal secretion might serve to turn the scale !
Or the trick might be accomplished, we are apt to think, by a
little more intensive education ! Meantime it is almost or quite
impossible to draw a line between those subaverage subjects
that go to make up the group of normals from these substand-
ard persons that we are willing to term definitely subnormal.
The social worker remains as much at a loss as does the psy-
chologist. Lawyers and even judges flounder in a morass of
doubt when it comes to calling these but slightly substandard
subjects "feeble-minded."

Is there a group of (as it were) superfeehle-minded above
the group of the feeble-minded proper (morons) and far
above the imbeciles and idiots? The senior author of this
work has sometimes argued for a new term to cover all the
forms of feeble-mindedness, including the unnamed slight de-
gree of subnormality that lies above the so-called moronity.
The term chosen was hypo phrenic and the condition of feeble-
mindedness of whatever degree may be known as hypophrenia.
We believe that, if the layman, lawyer, or judge feels quite
smcerely averse to calling certain persons "feeble-minded,"
particularly persons in this subnormal group above the level
of moronity, he ought to be far more willing to have the term
"hypophrenic" used. Moreover in our public discussion of
these cases (particularly in the presence of the patients them-
selves), would it not be highly convenient to be able to use the
term hypophrenic, a term which is of unknown insignificance
to the patient himself. When a patient who is slightly sub-
normal and perhaps (as often) is rather acutely conscious of
his subnormality, hears himself dubbed "feeble-minded," he
has a certain right to feel nettled. We feel that the employ-
ment of the term feeble-minded, even for morons of the upper
grade and certainly for the subnormals that are above the level
of morons, sometimes makes a kind of permanent scar in the
patient's mind. We have also seen persons, who upon dis-
covering themselves to be "feeble-minded," have forthwith

THE KINGDOM OF EVILS 465

denied all responsibility for any acts of theirs and given them-
selves serenely up to behavior which they could very readily
and profitably restrain. It is all very well to be, as Dr. Richard
Cabot has often insisted, belligerent in truth-seeking and in
telling the truth, but if we employ the term feeble-minded in
a very extended sense, not consistent with the lay usage of the
adjective feeble, we are not telling the whole truth about our
patients. It is worth while to insist upon this little point since
so much important psychiatric social work has to be carried
out with persons that are feeble-minded.

Feeble-mindedness is of interest to a great number of work-
ers in the world. For example, (a) educators, responsible for
the laggards, truants, dullards, "exceptionals" ; (b) court au-
thorities to whom the educators' problems in part drift and
figure as psychopathic cases, defective delinquents, prostitutes,
and the like; (c) eugenists and other persons interested in
heredity who are inclined to advocate segregation in institu-
tions or perhaps even sterilization of the feeble-minded on the
basis that the entire problem is a hereditary one; (d) legisla-
tors, to whom of late feeble-mindedness has become the most
interesting of social problems.

Under the case of Florence Warner (case 47) we have
spoken of conditions under which mental tests must be carried
out (absence of fatigue on the part of the examiner and pa-
tient; absence of all clouding of consciousness, such as infec-
tious disease, alcohol, drugs, and the like may produce ; and the
absence of all stupor or dullness of mental faculties incident
to mental diseases like dementia praecox).

Florence Warner illustrates the relations of feeble-minded-
ness to prostitution or at all events to sex irregularity. The
White Slave Traffic Commission of the Commonwealth of
Massachusetts did indeed find that about one-half of the pros-
titutes examined for their mental levels turned out to be in
some degree feeble-minded. But, even if all or almost all
prostitutes were feeble-minded, it does not do for the social
worker to think of all feeble-mindedness in women as fatally
determining irregular sex life. Further investigations of the
lives of feeble-minded persons released from schools for the
feeble-minded, after their schooling has been completed, has
shown that many frankly feeble-minded persons, even of the
female sex, have not fallen into the group of sex delinquents,

466 THE KINGDOM OF EVILS

Even when feeble-mindedness is present in the sex dehnquent
it is not always possible to assign prostitution to feeble-minded-
ness as a cause. The most we can say in this contingency is
that a feeble-minded person whose sex irregularities may be
due to something quite other than feeble-mindedness may still
be tmable to react zvith proper judgment to the measures taken
to stop the sex irregularity and to divert the patient's interest.

We may also refer to the discussions under case 47 of the
differential values of the psychiatrist, the psychologist, and the
social worker in the handling of feeble-mindedness.

The case of Bessie Newman (case 48) will be remembered
as a very striking family case in which it was psychologically
desirable to consider every one of the ten members of the
family from the psychiatric point of view. Amongst all the
cases of this work that of Bessie Newman is the one which
will perhaps most repay study. The Rosenthal family (case
49) has also shown that three out of five of its members are
psychopathic. The case of Bernard Bornstein (case 50)
shows how a moron boy in a protected environment could be
the support of his family; whereas navy life proved to be
beyond his powers.

Beatrice Cellini (case 52) was handled as an out-patient
under the social service without ever being in the wards of the
Psychopathic Hospital. Reference may be made to the remarks
under the discussion of Beatrice Cellini concerning variations
in her moods.

EPILEPTOSES

Syphilitic Symptomatic

Alcoholic Idiopathic

Traumatic Psychic

Encephalopathic Narcoleptic

Jacksonian Borderland

EPILEPSIES

Epilepsy (Group III of Book III) is ordinarily a disease
with at least (a) unconsciousness and (b) convulsions. An
attack of unconsciousness alone does not constitute epilepsy
and does not in itself prove the existence of epilepsy. Neither
would a single convulsion, even though it were very character-
istic in its appearance, prove the existence of epilepsy. If,
however, the diagnosis of epilepsy is once established through
medical observation of several attacks of unconsciousness with
convulsions, then it becomes possible for the physician to iden-
tify certain minor attacks and disorders of consciousness with
little or no evidence of convulsions, as epileptic. Accordingly
when fainting spells, abstraction, blank feelings, and episodes
of loss of memory occur, the physician is very apt to think
of the possibility of epilepsy.

Modern work seems to have shown that there is an epileptic
temperament or personality in which self -consciousness (ego-
centricity) and inharmony and irritability are found. The
epileptic mind seems, on the whole, a little childlike, even when
there- is little proof of feeble-mindedness. Modern study of
epilepsy has shown that it is much more exact to speak of
epilepsies than of epilepsy.

The major or so-called grand mal attack of epilepsy con-
sists in a fall with unconsciousness and spasm. The spasm
is at first a steady tonic spasm, but there shortly appear inter-
rupted or clonic spasms. Automatic movements follow these
clonic spasms. The patient then either wakes up or passes
into a deep sleep. On waking the victim feels lame and weak
in the convulsed muscles, and his head may ache. There is
often absolutely no warning of these attacks though very
striking warnings or so-called aiirae (such as flashes of light,
sounds, or smells) may occur and as a rule always in exactly
the same form. The muscles are apt to be affected, always in
the same order, and the convulsion is then said to "march" in
a characteristic way. Tongue-biting and frothing at the mouth
are observed, and the patient may involuntarily urinate. It can

469

470 THE KINGDOM OF EVILS

readily be seen that the social worker who secures the history
of tongue-biting or urination in an attack of epilepsy may be
contributing most important evidence for medical diagnosis.

It seems to have been proved that the epileptic attack of the
nature above described may sometimes be represented by an
acute mental attack without convulsion and even without evi-
dent loss of consciousness. Such an attack without characteris-
tic features of epilepsy is termed an epileptiform equivalent.
The patient may fall into a state of automatism or into a dream-
state in which violent and destructive or criminal acts get done,
of which the patient will have no remembrance. The crimes of
violence commited by epileptics may be of the greatest brutality
(see our case 54, Patrick Donovan, who killed his mother).
Luigi Silva (case 53) had also been violent and destructive
during a fit. The episode in Silva's case followed a heavy
drinking bout. Alcohol is clinically known to bring out epilep-
tic attacks.

MENTAL DISEASES CAUSED BY ALCOHOL AND DRUGS

In our account of the pharmacopsychoses, that is, the mental
diseases due to alcohol and drugs (Group IV of Book III),
we have presented five cases, four alcoholic and one drug
(Marian Spring, case 63).

The four alcoholic cases are intended to exemplify the four
forms of alcoholic mental disease that come to the attention
of the social worker. John Logan (case 58) is a case of acute
alcoholism. We may remind the lay reader that acute alcohol-
ism is not identical with acute alcoholic psychosis. Of
course it is true in one sense that drunkenness is a temporary
mental disorder, but drunkenness is not a disease in the sense
of an entity with a characteristic onset, course, and duration.
Drunkenness is not commonly accounted a mental disease.
Acute alcoholism is a term frequently used to cover drunken-
ness and other comparatively mild mental effects of alcoholism,
falling short of our conception of mental disease. Chronic
alcoholism is a term used to describe a habit of drinking which,
though it may be the basis of a development of mental dis-
order, is also not in itself a mental disease. Drunkenness and
alcoholism, acute or chronic, are conditions, according to pres-
ent usage, outside the field of mental diseases.

THE KINGDOM OF EVILS 471

Patrick Nolan (case 59) is a case of delirium tremens
which may be compared in its symptoms with the case of John
Sullivan (case 60) an instance of so-called alcoholic hallucin-
osis. Delirium tremens, the better known and somewhat com-
moner of these two affections, is a comparatively brief disease
whose acute symptoms commonly do not run beyond a week
in duration. Alcoholic hallucinosis, on the other hand, is apt
to run two or more weeks. Neither delirium tremens nor alco-
holic hallucinosis depends for its severity upon the amount of
alcohol consumed. Both diseases, as a rule, appear in persons
who have long been victims of alcoholism. (Here again it is
impossible to assert that the severity of a mental disease can
be measured by the duration or extent of the alcoholic habit.)

The distinction between these two diseases is even to the
physician far less easy in practice than in theory. The most
striking mental difference in the two diseases is the presence
of hallucinations of sight in delirium tremens and hallucina-
tions of hearing in alcoholic hallucinosis. Yet even this dis-
tinction may fail us in certain cases. The name delirium tre-
mens in itself points to the extreme severity of the symptoms,
that is to the existence of (a) delirium and of (b) tremors,
and the victim of delirium tremens is, on the whole, a much
sicker-looking man than the victim of alcoholic hallucinosis.
Of the two diseases, alcoholic hallucinosis is ordinarily the
worse one, since the capricious scolding voices readily lead to
suspiciousness and delusions of persecution that may outlast
the pronounced mental symptoms and reach into the convales-
cent life of the patient. In fact some of these latter cases dur-
ing their state of recovery and for long periods after the acute
symptoms are over, very strikingly resemble victims of de-
mentia praecox. Moreover cases of alcoholic hallucinosis are
not apt to get well so frequently or so completely as victims of
delirium tremens.

Michael Piso (case 62) we have used to represent the so-
called alcoholic jealousy-psychosis. The theory here seems
to be that long-continued alcoholism has reduced the sexual
power of its victim, who then becomes jealous of the relations
of the spouse to some supposed paramour. The case in the
text shows a comparatively happy outcome through medical
and social effort.

Our case of morphinism, Marian Spring (case 63) is, no

472 THE KINGDOM OF EVILS

doubt, an example of the so-called psychopathic personality, as
are many victims of morphinism and cocainism. We count the
case as a social-service failure, but the details (note especially
the patient's lying) are of interest. Marian Spring also illus-
trates the tendency of morphinists and other drug addicts to
work in groups.

That the reader may obtain some inkling of the conditions
in certain other major groups of mental disease, we present in
cases 63-68 two instances each of mental disease due to de-
structive disease of the brain, the disease of the eye indirectly
affecting the mind, and to certain complications of old age.

BRAIN DISEASE

It is plain that destructive disease of the brain (Group V of
Book III) will, as a rule, send its victim pretty promptly to
some hospital for nervous or jnental disease, leaving the fam-
ily problem a comparatively simple one, not as a rule troubled
by any special mental feature on the part of the patient him-
self. The group, a fairly small one in this line of practice, is
of no great statistical consequence to social workers.

BODILY DISEASE

As to mental disease due to diseases of the body at large
(Group VI of Book III) such as diseases of the glands of
internal secretion, typhoid fever, pneumonia, influenza, pellagra,
and the like, there are on the whole very few cases, statistically
speaking, and still fewer that come under the social worker's
care. An exception would need to be made for pellagra in the
southern states and no doubt an important piece of social
research could be carried out upon the pellagra situation in the
southern states. Most important data concerning the culinary
and sanitary relations of pellagra could be made by social
workers.

We have chosen to illustrate this group by a case of hyper-
thyroidism, Ethel Murphy (case 66) and one of mental dis-
ease due to influenza, Joseph O'Brien (case 67).

OLD AGE

Problems of great interest are associated with social work
amongst seniles (Group VII of Book III). Of course it is

THE KINGDOM OF EVILS 473

well known that not all old persons pass into anything like a
condition of dementia or evident deterioration. Some authors,
it is true, speak of a physiological dementia ( ?) and seem to
think of old age as capable of producing mental disease or at
least dementia. We must guard ourselves against generalizing
in this way. We have chosen two cases which ordinarily would
seem a bit hopeless from the standpoint of social work but
which proved very amenable to social-service methods. We are
under the impression that the psychiatric point of view, if it
should penetrate to the homes for aged persons and old sol-
diers, might prove of singular value in the handling of con-
crete problems of senescence.

DEMENTIA PRAECOX

The schizophrenic cases — dementia praecox (Group VII of
Book III), form a large and important group in the field of
psychiatry. Beginning most frequently during adolescence or
early adult life and having a very grave prognosis, schizo-
phrenia affords many distressing social situations. This psy-
chosis has two main characteristics : (a) a splitting of the per-
sonality (schizophrenia) and (&) a tendency to deterioration.
"Splitting" means that there is no longer a congruity between
the three psychological elements that form the personality;
namely, the intellect, the affective reactions, and the will. The
result is emotional apathy, loss of interest in one's family, lack
of normal activity, inability to carry out one's purpose. The
majority of persons afflicted with this form of disease develop
ideas of persecution, believe they are being followed, interfered
with, not given a square deal, and the like. Hallucinations
are apt to be prominent. These disorders associated with a
general psychic decrepitude may necessitate commitment in an
institution for the insane. When the disease remains chronic,
the patient may continue in an institution for the remainder
of his life. The social procedures in the chronic committed
cases are relatively simple. It is not, however, correct to as-
sume that no case recovers. Many patients with dementia
praecox make fair recoveries and are able to live in the com-
munity. Often the defect resulting from the disease is mild
in degree. Even so, these patients need guidance and aid, and
most of them require some form of social assistance.

474 THE KINGDOM OF EVILS

The schizophrenic group is brought to the attention of the
social worker chiefly, during the early or incipient period of the
disease. For months and often for years before a patient has
the outstanding symptoms of a psychosis, mental peculiarities,
character anomalies, unusual actions, and maladjustments lead
to observation by social agencies. Unless an astute psychiatrist
sees the patient in this early state, the person is likely to be
considered as stubborn, unreliable, delinquent, obtuse, peculiar,
or lazy, rather than ill and a proper subject for understanding,
sympathy, and help. Many are the difficulties, delinquencies,
and misfortunes due to early symptoms of the disease.

Despite the relative impossibility of affecting cures in the
disease with our present knowledge, it is surprising how much
may often be accomplished to improve the social reactions of
these patients by proper social adjustments. Unfortunately
much useless effort is expended by social workers in attempts
to aid such persons before their disease has been diagnosed.

The symptoms which may be manifested by schizophrenia
patients are numerous and varied. In fact, Kraepelin, in his
latest classifications, considers seven varieties of dementia
praecox and the closely allied paraphrenias. It is obviously not
desirable to present the medical points of this complex disease
except in a medical treatise. It may be noted that the symp-
toms result in peculiarities in the patients that lead to a lack
of "empathy."

Medical science has not solved the major problems of
schizophrenia, i.e., etiolog}^ and pathology. As a corollary no
specific treatment is known. Every case must be carefully
considered, however, from the purely medical side for evi-
dences of endocrine disorder, organic disease, and metabolic
disorder, as well as for psychological factors in the life of the
patient. Life experience and environmental conditions play
an important role in the development of the psychosis. So the
social worker may have a function in prevention and treatment
as well as in social adjustment.

It is important to place schizophrenic patients under care
at the earliest possible moment ; as it is with any person devel-
oping a disease, acute or chronic. Many schizophrenics show
character anomalies from early childhood that are suggestive.
Among these traits may be mentioned "shut in" personality,
inability to make friends and take part in communal activities

'THE "KINGDOM -DF EVILS 475

"with zest, supef sensitiveness, over-conscientiousness, egocen-
tricity, metaphysical ruminations, obstinacy, phantasy- forma-
tion, or day-dreaming. These characteristics cause such per-
sons to be considered peculiar, eccentric, exceptional, or
difficult; whereas they should indicate a careful psychiatric
examination.

Some of the problems of schizophrenia are presented in
twelve cases of Book III, cases 70-81. Dana Scott (case 70)
is a case of the simplex form, a type that is often undiagnosed.
This type of schizophrenia is seldom seen in the institutions
for the chronic insane, the victims usually remaining in the
community, presenting difficulties to society and finding life
a serious problem. Proper environmental treatment met with
relative success in the case of Scott.

Ralph Johnson (case 71) is another patient who presented
numerous problems to society, which arose, presumably, as a
result of his mental state, diagnosed as dementia praecox.
Wanderlust, alcoholism, idleness and poverty, hypochondria,
hallucinations and delusions, punctuated the life history of this
man. Improvement in his attitude and conduct was shown
after the combination of medical and social treatment. Per-
sons with this type of mental disease are familiar to social
agencies as prostitutes, tramps, almshouse habitues, and
dependents.

Paraphrenia is a diagnosis applied to cases akin to dementia
praecox, but showing less dissociation of the personality and a
slower progress toward deterioration. These cases are rela-
tively rare and present problems similar to the dementia prae-
cox cases. In fact, the paraphrenias are described in a sub-
heading under the schizophrenic group. Manual Rizzo (case
72) is presented as an illustration of this type of disease, diag-
nosed paraphrenia systematica. (See also case 58.)

The case of Paul Ernst (case 73) emphasized the difficulty
in the dififerentiation of schizophrenia (dementia praecox) and
cyclothymia (manic-depressive psychosis) and offers a good
lesson in the value of optimism. Hasty conclusions may lead
one to a pessimistic inactivity in cases called dementia praecox.
It is well to suspect the worst but to act on the optimistic as-
sumption that effort will be repaid. It was so in this case.

The "spoiled child" should always make one suspicious of
the possibility of a future psychosis. Nora McCarthy (case

476 THE KINGDOM OF EVILS

74) was considered a spoiled child. Her later reactions led to
a psychiatric diagnosis of dementia praecox. However, with a
comparatively small amount of assistance, she learned to get on
fairly well.

The usual mistake, especially outside of psychiatric clinics,
is not that of making too serious a diagnosis and prognosis,
as might be assumed to have been the case with Nora McCar-
thy (case 74) but, on the other hand, the tendency is to diag-
nose the early stage of a mental disease as psychoneurosis. A
large number of schizophrenias are at first considered psycho-
neuroses. Clara Goldberg (case 75) received much attention
under the diagnosis of psychoneurosis, but after three years
of unsuccessful efforts at social adjustment the diagnosis was
changed to dementia praecox, and she was put under the care
of a state hospital.

George Stone (case 76) calls attention to the difficulty of
deciding whether a paranoid individual should be committed.
At times such patients are able to get on fairly well in the com-
munity under supervision. Stone was unable to get along,
however, and had to be committed. George Mullen (case jy^
on the other hand, was able to serve in the front lines of the
British Army after a five months' stay in a state hospital. His
improvement proved to be but temporary, and he had to be
committed again after his discharge from the army.

Paul Dawson (case 78) had been a problem from early life.
At the Mexican border he "broke" and received a diagnosis
of dementia praecox with his discharge. He then became a
"difficult case" for his family. Drafted into the army, he was
again discharged with the label dementia praecox. He claimed
to have "faked" mental disease to get out of the army. Experi-
ence has taught that most malingerers are psychopaths and
likely to become definitely psychotic. Dawson was considered
a real case of dementia praecox. Nevertheless he made good in
the merchant marine. It is a question how long he will remain
well.

Howard Lancaster (case 79.) seems to show that environ-
ment is an important factor in the development of mental
disease. Under civilian conditions he did well but became ill
in the military service, recovering when again placed under the
conditions of civil life.

The relationship of psychiatry and criminology is depicted

THE KINGDOM OF EVILS 477

by Major Dobson (Captain Hill, case 80), whose dementia
praecox symptoms took, in one instance, the form of forgery.
His marriage may also be considered as having a psychopatho-
logical basis. It may be assumed that many of his past ad-
ventures and his instability were forerunners of more overt
symptoms.

MANIC-DEPRESSIVE PSYCHOSES

In many ways the cyclothymic group — manic-depressive psy-
chosis (Group IX of Book III), offers more of interest to the
psychiatrist and psychiatric social worker than any other group
of cases. The mental disorder called cyclothymia is character-
ized by occasional attacks with remissions, or intervals of good
health. The attacks usually vary from a few days or weeks to
a year or more, while the remissions may last for years or
decades, or the disease may be limited to one attack. The
severity of the symptoms likewise varies from very mild emo-
tional changes to the severest types of mania and depression.
The disease is chiefly an affective one, causing pathological
exaggeration of the emotions. Depression, with feelings of
insufficiency, self-accusatory ideas, difficulty in thinking, and
general slowing up of mental and physical activity are present
fn the depressive stage of the disease. In direct contrast to
this are the symptoms of the maniacal phase, feeling of well-
being, self-appreciation, exaggerated ideas of one's own power,
and mental and physical activity. In the so-called mixed
phases of the disease a combination of the symptoms of depres-
sion and mania exist. Most of the symptoms are easily under-
stood by a second person, because they are exaggerations of the
normal feelings rather than new or "different" or "peculiar"
reactions. Hence it can be said that one's "empathic index"
is usually high toward such patients.

Cyclothymic patients do not deteriorate. No matter how
severe the symptoms, how long the attack lasts, or how fre-
quent the attacks may be, there is no resultant dementia. And
as may be expected if this statement is true there is no patho-
logical destructive brain lesion.

The hospital for mental patients is only a temporary refuge
for the cyclothymic, if such hospital care becomes necessary at
all. Winifred Reed (case 81) spent but a few days in the hos-
pital for purposes of diagnosis during the first seventeen

478 THE KINGDOM OF EVILS

months of her acquaintance with the Psychopathic Hospital,
and WilHam Donahue (case 82) has never been an inmate of
an institution for his mental diseases. Mild attacks of excite-
ment or depression are frequently not diagnosed, and in the
absence of proper diagnosis the patient may be entirely mis-
understood and wrongly handled. When one correctly under-
stands Winifred's eroticism as a symptom of the maniacal
stage of a manic-depressive psychosis of only temporary dura-
tion, sympathy is evoked and proper treatment is available.
Likewise one is ready and able to help Donahue over his
"grouches" and spells of "lost initiative" on the ground of
treating a depressed patient.

Marie Dubois (case 83) is presented as a case of manic-
depressive psychosis, having a first attack at thirty years of
age and a second at forty. The first attack was one of de-
pression, the second beginning with depression went over
into a mild excitement before recovery. Such a sequence is
by no means rare. Her return to the community after a fairly
severe attack of mental disease brings into prominence the
problem of the complete readjustment that is necessitated.
Such a patient must again take her place in a community all
too ready to be suspicious of anyone who has been "insane."
Friends who comprehend the situation and who can aid are
quite essential. The family, even if possessed of sufficient
means, are rarely capable of offering intelligent aid. Here
the psychiatric social worker is invaluable.

Hypomania falls in the group of cyclothymias. It is a very
mild degree of mania. Joe Marino (case 84) developed this
condition when but fifteen years of age. Difficulty after diffi-
culty resulted from his overactivity. His activities were rather
typical of the hypomanic — frequent changes of position and
actions that led to arrest punctuated his useful career. The
hyperactivity in Joe, as is typical in cases of hypomania, lasted
a comparatively short period, and then he settled down. Dur-
ing the period of excitement, however, he was a very difficult
problem, and, as during a large portion of his disease he was
able to live outside of the hospital, one can see the great need
for some oversight in order to steady him.

Robert MacPherson (case 85) is another example of the
hypomanic condition. When the excitement is mild enough,
the overactivity that is characteristic of this state may lead to

THE KINGDOM OF EVILS 479

useful accomplishments. This, of course, is not the rule, but
at times patients are seen who are more successful during this
period because of the lessened inhibitions. They may be more
capable as salesmen. They execute their ideas without further
thought. MacPherson made more money during his hypo-
manic state than he would have made had he been normal.
However, he squandered it with great abandon. Frequently
patients in this condition, as well as patients in the early stage
of general paresis, will squander their possessions and run up
debts, as well as spoiling their reputations by fast and lascivi-
ous living. From this point of view, if from no other, it is
very important that recognition of this condition be made
early, in order that the patient may be prevented from per-
forming foolish and dangerous acts.

Two main characteristics of the manic-depressive psychosis,
namely, repeated attacks and complete recovery, are well illus-
trated by the case of Clarence Adams (case 86). For the
rest his case shows the same type of problem as the two pre-
ceding cases.

A word should perhaps be said about one important social
complication of the depressive phase of the manic-depressive
psychosis. This is the potentiality of suicide. While it is
quite possible to supervise maniacal patients outside of the
hospital, despite their tendencies toward fast living and delin-
quency, it is much more dangerous to handle a depressed pa-
tient outside of the hospital. Although the symptoms may be
mild and the patient quite willing to sit about the house, and
so may be easily cared for, it is an exceedingly risky matter
to leave the depressed patient at home and in the community
because of his great tendency to suicidal attempts. It is for
this reason that one is prone to advise hospitalization for
the depressed case until recovery is quite complete.

METHODS OF PSYCHOTHERAPY

HYPNOSIS

Verbal Suggestion
Fixation
Fascination
Various

SUGGESTION (WAKING)

Verbal

Drug

Apparatus

AUTOSUGGESTION

DISTRACTION

TERRORISM

INFLICTION OF PAIN

PERSUASION

WILL TRAINING

OCCUPATION THERAPY

ISOLATION

PSYCHOANALYSIS

PSYCHONEUROSES

Various classifications have been offered for the cases that
fall under the general heading of psychoneuroses (Group X
of Book III). A fairly generally accepted and workable
classification is that which divides the psychoneuroses into
cases of (a) neurasthenia, (b) psychasthenia, (c) hysteria,
and (d) anxiety neuroses. These various cases were placed
together in a group called psychoneuroses on the assumption
that there was no definite underlying organic pathology to ex-
plain the symptoms. The mental attitude or psychological
condition is supposed to have a prominent place in the de-
velopment of these conditions. The diagnosis is usually diffi-
cult. It must be made only after a careful physical examina-
tion which rules out bodily disease. Neurasthenics are usually
considered by the laity as imagining numerous organic dis-
eases. They feel tired and worn; complain of peculiar sensa-
tions in their heads and inability to concentrate; and are apt
to fear many types of disease. Psychasthenia may be con-
sidered as something of a psychological anomaly. Under this
diagnosis are placed those people who are known as worriers
and doubters, who have many fears and obsessions, who often
have difficulty in thinking clearly and logically, becoming
"mixed up" as they often say. This condition is usually pres-
ent from early life, but is subject to exacerbation of symptoms.
The hysterics are those patients who present numerous symp-
toms, such as paralysis, blindness, deafness, mutism, convul-
sions, sensory disturbances, in fact, almost any symptom with-
out evidence of organic disease. The anxiety neurosis is
characterized by a condition of anxious fear, which may over-
come the patient at any time.

Patients suffering from one form or another of the psycho-
neuroses are very common at all medical clinics, and are
usually the despair of the physicians. Finally they make their
way to the psychiatrist, possibly after months or years of
treatment in the general clinic; possibly after having numer-
ous operations in the attempt to relieve symptoms which it

483

484 THE KINGDOM OF EVILS

is later believed were dependent upon a mental state rather
than upon a visceral pathology. Only in the severe exacerba-
tions of their symptoms do these patients become inmates of
a state hospital for the care of mental cases. During a large
portion of their disease they remain in their homes, frequent-
ing physicians' offices or dispensaries. Occasionally an out-
break of marked symptoms may lead to residence in a state
hospital. As a rule, these attacks last only for a short period,
and they are not at all frequent. It is more usual for those
patients who can afford the expense to go to a sanatorium for
treatment of a "nervous breakdown." A modern psycho-
pathic hospital will treat numerous examples of these cases.

Patients of the psychoneurotic group are patients par excel-
lence for psychotherapy. Under efficient psychotherapy must
be considered all those factors that affect the mind and life of
the patient. Among these should be included the patient's
environment. It is generally conceded that the experiences of
a person and the conditions under which he lives have much
to do with the development of a psychoneurosis. Therefore
it is logical that efforts to improve the general environment,
habits of life, and living conditions, must have a valuable
place in any psychotherapeutic treatment. In conjunction
with whatever form of treatment, psychotherapeutic or or-
ganic, is applied to the patient, the shaping of his living con-
ditions is very important, and this work must fall, in large
part, upon the social worker.

Maurice Eastman (case 87) is presented as a case of neu-
rasthenia, and shows in a degree how much can be accom-
plished by intelligent social work.

Sadie Strauss (case 88) manifests a fairly typical hysterical
condition, and is a good case in point to show the value of
social work in addition to formal psychotherapy. The assist-
ance in ironing out the family difficulties was certainly of
great value to the psychiatrist in aiding him to get results by
his analysis. It is pointed out in the case history that the in-
formation obtained by the social worker of the home conditions
and environment of Sadie was a valuable addition in giving
a rounded view of the case.

Joseph Fangillo (case 89) received the diagnosis of psy-
chasthenia. A hyperconscientious individual, prone to doubt,
finding decisions difficult, he had upon such a background at

THE KINGDOM OF EVILS 485

least five acute exacerbations of symptoms. From all of these he
recovered fairly satisfactorily, but during a large portion of
the period of convalescence he lacked sufficient force to hold
himself in line without outside assistance. He had to have
someone reassure him. The aid in obtaining work was very
important. The family also had to be assisted over the diffi-
cult period of his "nervous breakdown." Maintaining the
family in good condition was an important aid in the recovery
of the patient.

Cases of traumatic hysteria, that is, cases in which the hys-
terical phenomena follow upon an accident, are always open
to the suspicion of malingering on the part of the patient in
order to obtain compensation. It is quite true that in many
of the cases improvement is delayed until the financial settle-
ment is accomplished, and the physician handicapped in his
treatment until this matter is adjusted. Something of this
matter is brought out in the case of Dennis O'Donnell (case
90) and the question is brought forward concerning the value
of social-service assistance in the case.

Another case of traumatic hysteria is that of Walter Nelson
(case 91). This man developing an injury during his service
in the Aviation Corps, fell to the lot of the social workers of
the Red Cross, and presents a similar type of difficulty to that
of Dennis O'Donnell.

Hysteria very frequently develops upon what is considered
as poor soil or constitutional inferiority. The early history of
Martin O'Hara (case 92) certainly showed enough instability
to make one consider him pretty poor material. Under army
conditions he apparently broke down with what was consid-
ered to be hysteria. Upon discharge from the army, he was
better, but after running into a very unsuccessful marital ex-
perience, his symptoms came on again. This case might be
used to show the importance of environment on the appearance
of symptoms of a hysteric nature. Assistance to Martin in
adjusting his life was followed by improvement of symptoms
and an ability to care for himself again.

Another illustration of the effect of environment on the
production of psychoneurotic symptoms is brought forward
in the case of Joseph Levenson (case 93), who developed
while in the army symptoms considered sufficient to make a
diagnosis of psychasthenia. Much social work was expended

486 THE KINGDOM OF EVILS

Upon this patient in attempts to find him satisfactory occupa-
tion, with a more or less satisfactory result.

Most of the cases of the psychoneurotic group must be con-
sidered as potential patients during a large portion of their
lives. Improvement and retrogression alternate. Unfavor-
able conditions of life are likely to lead to renewed difficulties,
so that these patients represent a fertile field for continued
work and are likely to be known to the social agency year
after year. Nowhere is this service more valuable or neces-
sary, and social adjustment is nearly always essential be-
fore the physician can get very far with his treatment.

DUBIOUS AND SPECIAL PSYCHOPATHIAS

The last group" (Group XI of Book III) includes a pot-
pourri of cases that fit in none of the preceding ten groups.
Among the cases that would fall into this group may be men-
tioned prison psychosis, sense deprivation psychosis, folic a
deux, litigation psychosis, paranoia, monomania, psychopathia
sexualis, psychopathic personality, and a number of undiag-
nosed cases. Most of the cases bearing these diagnoses are not
legally committable. They are, rather, individuals with pe-
culiarities, eccentricities, and psychological anomalies. Living
in the community at large, as they usually do, they are likely
to be the victims of one difficulty after another. Their peculiar
mental reactions are rarely compatible with success in life.
Social agencies, courts, and reformatories are frequently con-
fronted with the problems that these persons present. Com-
prehensive understanding of these people necessitates a psy-
chiatric knowledge and insight into their disease conditions.

Possibly the most frequent of all these types is that spoken
as the psychopathic personality or the constitutional psycho-
pathic inferior. Military experience showed how numerous
are individuals of this type. Many of the conscientious ob-
jectors, malingerers, and deserters fell into this group. They
have in common a personality defect, which usually works
against the best advantage of the patient leading him into a
continuous series of difficulties.

Previous to the military experience, the feeling was that the
vast majority of cases of psychopathic personality or consti-
tutional psychopathic inferiority were of the female sex. This

THE KINGDOM OF EVILS .487

was largely due no doubt to the fact that it was sex delinquency
that brought many girls to the attention of social agencies and
public authorities. The characterization of "defective delin-
quent" was usually given to these girls, and every social agency
was familiar with this problem.

A study of defective delinquency was made by Dr. Her-
man M. Adler. Some of his ideas were published in an article
entitled, A Psychiatric Contribution to the Study of Delin-
quency} A brief review of Dr. Adler's paper will illuminate
the subject. He calls attention, first, to the six groups of
psychopathic personalities described by Kraepelin : the excit-
able, the unstable, those with psychopathic trend, the eccentric,
the antisocial individuals, and the contentious individuals. Dr.
Adler states : —

"It is clear that we are dealing with a group of individuals
who are so nearly normal that it is only in the course of years
and by the effect of cumulative evidence that they appear in
any way different from the average.

"There are two main factors to be considered. The one is
the intelligence of the individual, his ability consciously and
logically to direct his conduct. The other is the emotions. . . .
In health the two are well integrated."

As a result of his experience with a group o'f defective de-
linquents. Dr. Adler believes that they can be classified some-
what more simply than Kraepelin has grouped them or at least
that a simpler classification may be offered as a working basis
to understand the reactions of these individuals. He says : —

"I propose to classify the individuals who present mental
or social difficulties in three groups. These groups are under-
stood to be meant as symbols for unknown quantities rather
than as explanation or precise definitions. The three groups
are, in the first place, the group in which the intelligence is
found to be below the lowest normal level. This is called the
group of defectives or the inadequate. Into this group fall the
feeble-minded, the 'Oligophrenias' of Kraepelin, the end states
of dementia praecox, and of other deteriorating psychoses, of
presenile, organic dementia, and so forth.

"The next group, emotionally unstable, includes individuals
who have average intelligence or better, but who show in their

^ Adler, Herman M., M.D. In Journal of the American Institute of Criminal Law
and Criminology, Vol. 8, No. 1, May, 1917, pp. 45-68.

488 THE KINGDOM OF EVILS

conduct and in their careers the predominating influence of the
emotions. They are moody, changeable, impulsive, and in gen-
eral it may be said that their conduct itself does not correspond
to their beliefs, or intentions.

"The third group, the paranoid, includes individuals of aver-
age intelligence or better in whose careers the emotional in-
fluences are of secondary importance, but whose main difficul-
ties are a result of mistakes in logical thought processes. The
well-known characteristics which are exhibited in extreme form
by the paranoid psychoses, these individuals show often to a
degree which falls just short of a delusional state, egocentric
ideas, and prejudices. Everything that occurs about them is
referred to themselves. Their first reaction is to determine
what effect any extraneous circumstance may have upon them-
selves. They are selfish, vain, arrogant. If they feel in
optimistic mood, they are contemptuous of others. If de-
pressed, they are resentful. Though this is a trait of their
intellect, it does not necessarily interfere with their intellectual
abilities, and these people are often very efficient.

"These three groups can be separated only theoretically.
There are many cases that are composite, so that their charac-
teristics fall into two or into all of these groups. Thus, few
paranoid individuals go through life without strong emotional
reactions which often lead to social difficulties. Similarly, the
emotionally unstable will, especially during paroxysms of rage
or depression, often exhiliit paranoid symptoms. The defective
group may show paranoid tendencies and emotional instability.

"The distinction lies rather in the behaviour of the individual
as observed in the course of years than in a definite quantitative
difference to be observed at a single examination. The intro-
spective psychologist will attempt to determine in each indi-
vidual by psychoanalysis or other means what the mechanism
of the disturbance is. He may succeed in doing this, and still
be unable to predict the future course of the individual.

"The behaviourist psychologist will not lay too much weight
on the results of a single examination by whatever method, but
will lay more emphasis upon the history of the case, and the
previous experiences of the individual and. above all. upon the
reaction of the individual to certain test situations during a pe-
riod of observation. This behaviourist method offers the hope
of a short cut in dealing with these individuals."

Dr. Adler then gives some considerations of a practical
nature upon which to base the care and treatment of such
people. We quote : —

THE KINGDOM OF EVILS 489

"In every given case of delinquency or social difficulty it
should be determined whether the difficulty is chiefly due to in-
adequate intelligence, to emotional instability or to paranoid dis-
position. Nothing can be gained by endeavoring to increase the
intelligence of a mental defective. Nothing can be expected
from an attempt to change the personality of the paranoid in-
dividual. A great deal can be accomplished, however, in con-
trolling the emotional instability of those whose chief difficulty
is the result of such instability as well as the emotional diffi-
culties of the paranoid and defective group.

"Classification such as the one suggested in this communica-
tion is, of course, entirely too simple to completely satisfy all
the demands in the individual cases, and it is to be hoped that
this classification may be altered and amplified, or perhaps com-
pletely reconstructed till finally a working method may result,
but even now, without general information of the subject, such a
simple scheme as this one proposed has served not only to keep
the ideas of the examiner grouped in orderly fashion, and this
to prevent disorderly and unclear thinking on his part, but it has
actually appeared to be of benefit when it was applied as a basis
of therapy in these cases."

A variety of character defects was shown by the twenty-
eight-year-old Harriet Farmer (case 94) who, after a history
of unreliability, a long period of fabrication, alcoholism, and
inability to make her own way, came to the attention of the
Psychopathic Hospital as the result of a suicidal attempt. She
clearly fitted into the group of psychopathic personalities. The
outcome of the case showed how much improvement a char-
acter of this type is capable of making when handled by social
workers guided by psychiatric knowledge.

That the type of hypoboulic (weak-willed) individuals who
despite a sufficient modicum of intelligence are fated to be
failures because of their defect is illustrated by Louis Sand
(case 95). A Belgian of considerable education, with the
best intentions in the world, with ambition but without power
of concentrated effort, he had wandered from place to place.
Such might be considered the classical type of constitutional
inferior.

The case of Theresa Beauvais (case 96) should be a liberal
lesson to the moralist and social worker. Sexual immorality
in this girl is explained on the basis of a hypersexuality which
might be characterized as falling into the group of psycho-

490 THE KINGDOM OF EVILS

pathia sexualis or into the larger group of constitutional
psychopathic inferiority. Her promiscuity is to be considered
rather as a symptom of a disease than as a pure moral deflec-
tion. With a background of exceedingly poor heredity ( father
a professional thief, mother a prostitute) and as vicious an
early environment as could be conceived, one is justified in ex-
pecting a rather poor social result. Theresa certainly showed
enough evidence of instability, will defect, and emotional out-
'-breaks to justify a diagnosis of psychopathic inferiority or
ipsychopathic personality. Appearances might have led to the
conclusion that this girl was a moron, but psychological tests
showed her of sufficient intellectual ability. It was rather in
the sphere of affectivity and will that the disorder lay. It is
quite important to keep this idea in mind ; namely, that the
affective life and the will are often more important in deter-
mining the social reactions of an individual than the intellect
alone. One cannot avoid the assumption that it would take
more than the ordinary amount of will-power to overcome the
sexual desires of such a hypersexual individual, and one would
be expecting too much if one hoped for a great deal of steady-
ing of such a person after adult life had been reached and
many pernicious habits had been formed in youth, but one
should have sympathy for this girl as a victim of disease rather
than as merely vicious. One arrives at this conclusion from
a psychiatric study of the whole life of the patient.

The value of the psychiatric attack on a patient not neces-
sarily markedly psychopathic is discussed in the case of Leon
Blumer (case 97). Pseudologia fantastica, or pathological
lying, falls under the general heading of the psychopathic per-
sonality or constitutional psychopathic inferiority. It is
usually associated with other evidence of character defect or
psychopathia. A person afflicted with this type of abnormality
is certain to be considered a "difficult case" and pretty thor-
oughly disliked by those with whom he comes into association.
This was indeed the fact with Francis Corcoran (case 98).

The results of a constitutional inferiority may only be
brought about under the stress of circumstances. Manuel
Giordani (case 99), a flute-player, got along well enough in
civilian life, but under the stress of military training he had
a psychopathic upset which resulted in his discharge from the
army. Back in civilian life, he again succeeded.

THE KINGDOM OF EVILS 49I

Until his fiftieth year Henry Allen (case lOo) had been
considered from the results of his work, merely as a not very
efficient constructional designer. A personality study at the
age of fifty by a psychiatrist brought out the fact that he was
of a melancholy disposition, unhappy in his work because he
believed he was being made fun of by his fellow employees.
He disliked the type of work he was doing and considered him-
self only twenty-five per cent efficient, and felt that he was
physically ill. Considering Allen from this point of view, it
was possible to change his working conditions, encourage him
and give him a type of work that was more to his taste. Where-
upon he developed greater efficiency and was able to earn twice
as much as previously. This type of analysis has great pros-
pects from the vocational-guidance standpoint, and can add to
the efficiency of the individual both to the benefit of himself
and of the firms employing him.

RECENT APPLICATIONS OF MENTAL
HYGIENE

MENTAL DISEASE IN THE GREAT WAR

Military experience in the Great War brought out many
cases of mental disorder, and showed the large part that the
psychology of individuals played in their adjustment to mili-
tary conditions. Twenty-five cases are submitted in this work
to illustrate, in part, some of the problems with which the
military service, the public health service, and the Red Cross
have had to deal.

In any large group of men, it is of course evident that all
varieties of mental disease will be found to occur, and among
the four million men in the American military service, there
were of course all varieties of mental disorder and difficulty.
The term "shell-shock" which grew up at the beginning of the
war from the experience of the English has led to great con-
fusion in terminolog}'. Originally applied by the British to
cases of mental disorder, mostly of the type of psychoneuroses,
under the misapprehension that these conditions were the effect
of high explosives, it has been used variously to include, on
the one hand, only the pure psychoneurotic manifestations,
and, on the other hand, to include all types of mental disorder.
This matter has been treated in full detail in a book recently
published by the senior author under the title, Shell-Shock.

The Great War brouglit out a large number of cases of
psychoneurotic disorder, to which a great deal of attention has
been paid. The American Army treated these cases abroad, in
large measure, at base hospital number 117, known colloqui-
ally as the "Shell-Shock Hospital." A description of these
cases is very adequately presented in a book by Schwab and
Fenton, entitled, The Psychology of Conflict. On the whole
it may be said that there are no new problems rising out of
the psychiatric cases occurring in the military service. Many
of the mental difficulties would have occurred to the same
patients in civilian life. However, the fact that they did occur
in military service has added a very natural sentimental inter-

492

THE KINGDOM OF EVILS 493

est, which would probably not have been accorded these same
patients had their difficulty occurred during ordinary peace
times.

A new interest in mental disease has been awakened and
this is particularly true in Great Britain, where a veritable
renaissance has occurred. This has been one of the subsidiary
benefits of the war. The American Red Cross has established
psychiatric social units throughout the country, and the prob-
lems that confront these psychiatric social units, as will be seen
by a perusal of the war cases herein described, are in no par-
ticular way different from psychiatric social problems of our
civilian population. It is, therefore, proper to employ the same
technique, medical and social, in the handling of the war neu-
roses and psychoses that is applied to the civil cases. As will
be seen, many of the military cases have been turned over to
civilian hospitals.

One feature that is present in the military cases, which is
not often found in the civilian ones, is that of pecuniary com-
pensation. When the mental disorder "did not exist prior to
enlistment" and occurred "in line of duty" it has been generally
held that the patient is entitled to compensation for disability.
The situation in this regard is similar to that which would
hold for tuberculosis or any other chronic disease.

Seven of the eleven psychotic groups that have been de-
scribed are exemplified by the twenty-five patients having rela-
tions with the military service.

Carl Spindler (case 43) and Thomas Scannell (case 44)
were patients suffering with syphilopsychosis. Carl Spindler
was transferred to a civilian hospital with a diagnosis of gen-
eral paresis. Symptoms of this disease had developed while
he was in the service, but the syphilitic infection which led to
the development of paresis was acquired long before entering
the service. Nevertheless, it is often assumed in these cases,
that the government is somewhat liable in the way of com-
pensation, the argument being that the mental symptoms de-
veloped during service, they were not present prior to enlist-
ment, and that possibly these symptoms would not have arisen
had the patient not undergone the hardships of military life.

Thomas Scannell was probably a case of juvenile paresis,
that is, he had the symptoms of general paresis which had
developed from congenital syphilis. He was being cared for

494 THE KINGDOM OF EVILS

by the Red Cross. Here, again, the same question would arise
as to whether or not the government was responsible for his
care on the grounds that his mental enfeeblement had occurred
while he was in the military service.

The problem of feeble-mindedness was much diminished in
the army by the psychological testing and the rejection of
feeble-minded individuals by the neuropsychiatric division.
Despite this, many feeble-minded were in the army, and it
was held by many that for certain work behind the lines the
feeble-minded had a very definite place. However this may
be, there were numerous examples of the feeble-minded in the
army. The navy and the marine corps were not so careful
to eliminate individuals of low mental status.

Thomas Fuller (case 9) had had a bad record in civilian
life. It was felt that this was largely the result of his mental
retardation, his mental age being only 9.2 years. Despite this
fact, he made good in the marines, and even rose to the rank
of corporal. The obvious reason is that under proper super-
vision a person of inferior mentality may be a very valuable
worker.

It does not follow, however, that all feeble-minded indi-
viduals make good under the type of supervision given in the
army or navy. Bernard Bornstein (case 50) did fairly well
in civilian life, earning between fifteen and twenty dollars a
week, but was quite unable to succeed when he joinetl the navy.
His mates plagued him and he was such a misfit that it was
necessary to discharge him. The feeble-minded individual is
likely to be unreliable, and when this is markedly the case, he
cannot be of course fitted into the discipline of military service.

The sort of difficulty that a feeble-minded individual may
get into in the army is well illustrated by the case of Howard
Driscoll (case 51). His army record was sprinkled with
A.W.O.L.'s and after his discharge from the army he was sen-
tenced to a reformatory. He returned to the army during the
war, where he got into difficulty by leaving his post for four
days because he got angry. He did not receive the treatment
that would ordinarily be accorded to a normal individual, but
was given his discharge as a feeble-minded person. Super-
vision will be necessary for this man throughout life and he
would probably be best served if he could be put under the
paternal care of an institution.

THE KINGDOM OF EVILS 495

One of the important pieces of neuropsychiatric informa-
tion that came out of the army experience was the frequency
of epilepsy in the community at large. In our series four cases
of epileptic psychosis are presented in patients who came within
the purview of the military service. John Manaos (case 29)
was arrested for not properly filling out his draft papers. In
prison he developed a clouded mental state, and at the hospital
the diagnosis of epilepsy was made. Upon this finding, of
course, the charges against him were dropped, as it was felt
that he was not a responsible individual.

Charles Lovell (case 55) was given his discharge from the
army because of epileptic attacks. The epileptic phenomena
occurred for the first time while in the army service in the
cases of Frank Wayne (case 56) and John Bristol (case 57).
Wayne had been a weakling throughout his life, was recog-
nized as somewhat simple-minded, and incapable of hard work.
Under the stress of the army, the seizures of epilepsy made
their appearance, and after discharge he was, of course, a sub-
ject for compensation. John Bristol, on the other hand, had
been a very healthy and stalwart individual, serving on the
police force before his enlistment, and being athletic instructor
at camp. For some reason, seizures began after typhoid inocu-
lation, and have continued with great frequency to the present
time. He is, therefore, another subject for compensation, and
has been obtaining assistance from the Red Cross in securing
work that he is capable of performing.

The types of manic-depressive psychosis will have to be
considered. In a general way, it was considered before the
war experience was at hand that the conditions of the military
service would produce a great many cases of manic-depressive
psychosis, and that the individual who had had a psychosis
would be very likely, indeed, to break down.

Robert MacPherson (case 85) developed a hypomanic con-
dition which was probably the cause of his discharge from
military service.

On the other hand, Clarence Adams (case 86) had had
psychotic symptoms from which he recovered before entering
the service. He did very well, being at the front and being
gassed without having any return of his symptoms. After his
discharge, while in civilian life, he again developed psychotic
symptoms which led him to the hospital. It is indeed to be

496 THE KINGDOM OF EVILS

borne in mind that the change from the military back to
civihan Hfe is quite a severe shock at times, and it takes a
considerable amount of ability to make a successful and easy
change.

Dementia praecox cases were frequent enough during the
war, and are still occurring as a problem in men who have
been in the service. If there is one feature that might be con-
sidered as somewhat different in the military cases from those
in civil life, it is that the prognosis of soldiers who were ap-
parently schizophrenic was much better during the war period
than in the usual prognosis of this type of case as seen in civil
life.

Of the war cases described in this book, five had the diag-
nosis of dementia praecox. Kevork Ardinian (case 26) was
never actually in the army, but was picked up under the "Work
or Fight" law after which it was discovered that he was really
a victim of dementia praecox.

George Stone (case 76) had done well in the army, where
he had won the croix de guerre. After his discharge he de-
veloped a psychosis which was diagnosed as dementia praecox,
and while outside of an institution he gave a good deal of
concern to the Red Cross.

Howard Lancaster (case 79), on the contrary, developed
his mental symptoms while in the army and did well when he
returned to civilian life. Whereas George Mullen (case yy)
was much like Clarence Adams (case 86). Mullen was com-
mitted as a case of dementia praecox in 191 5, but was dis-
charged. He joined the English Army, where he did well, and
was given an honorable discharge after being wounded. On
his return to civilian life, he developed a psychosis which
brought him into an institution with the diagnosis of dementia
praecox.

Major Mark Dobson (case 80) would have been in very
serious difficulty for forgery had his condition not been recog-
nized as dementia praecox.

The cases in the psychoneurotic group were very frequent
throughout the war. Abroad they came chiefly under the acute
manifestations of shell-shock. The cases as seen in America,
following the war, or during the war among those patients
who had not been abroad, were very much less dramatic.

James Bailey (case 7) developed neurasthenic symptoms

THE KINGDOM OF EVILS 497

following a street-car accident. These symptoms did not give
him very much difficulty, however, until he was at camp, when
they became quite manifest, and led to his discharge.

A good example of traumatic hysteria is presented by
Walter Nelson (case 91) who developed his symptoms fol-
lowing a blow on the head by a tent-pole which blew over in
the wind. His symptoms were those that one ordinarily sees
from the same type of injury in civilians, but, occurring while
he was in the aviation service, it was distinctly a psychoneu-
rosis occurring in the military service.

Martin O'Hara (case 92) had had evidences of hysteria
before his army experiences. He was discharged from the
army for physical disability, and after getting into an un-
pleasant marital arrangement, developed his hysterical symp-
toms again.

The picture of neurasthenia was not an infrequent one in
the military service. An example is given in the case of Joseph
Levenson (case 93).

The constitutional psychopathic inferiors presented them-
selves to the military surgeons in considerable numbers, and
their vagaries will be before the people who deal with returned
soldiers for many years to come. Francis Corcoran (case 98)
had been a ne'er-do-well all his life. After his military expe-
rience, he became a burden to the public health service, and
will probably remain a "case" for many years. Paul Daw-
son (case 78) had been discharged from the army for mental
disease, both at the time of the Mexican border affair, and
during the Great War. He claims that in both these instances
he malingered. As a rule it is true that individuals malingering
mental disease are really the victims of some form of mental
disease. Whether or not Paul Dawson was a case of dementia
praecox, as some considered, or of psychopathic personality,
it is hard to state. At any rate, he did not fit into the condi-
tions of military life.

From the standpoint of the psychiatric social worker, the
military man may be of interest not as the main actor in the
drama, but as a subsidiary. Thus, Elliot Calderwood (case
22) who was thought to be more sinned against than sinning,
as he had been deserted by his father, a soldier in the Cana-
dian Army. Nora McCarthy (case 74) was the fiancee of a
soldier and was pregnant. Her mental difficulties arose aftey

498 THE KINGDOM OF EVILS

his departure for France, and were to a large degree patched
up by marriage after his return from overseas.

MENTAL HYGIENE OF INDUSTRY

There are at least forty-two cases in this volume that have
interest from the standpoint of the new mental hygiene of
industry, a movement which we conceive may prove of pri-
mary value in the general social situation of the world. But
we also know that it will be difficult to persuade either the
theoretical psychiatrist or the practical industrialist that he
must build his sociology or his practical plan of meeting
the economic unrest, from the very bottom, namely from
the individual. The standpoint of theoretical sociology and
likewise the standpoint of practical industrialism has interested
itself in man's movements rather than in the individual. Mod-
ern sociology feels Herbert Spencer too much of an indi-
vidualist, yet some sociologists note with alarm the generality
of sociologists. Ross says : "How futile is the endeavor to
establish laws of succession based on the parallelism in all
societies of any special development (e.g., domestic or politi-
cal) taken in its entirety. The error here lies in taking too
large a unit of social life." Tarde also is right in saying,
"This attempt to confine social facts within lines of develop-
ment, which would compel them to repeat themselves en masse
with merely insignificant variations, has hitherto been the chief
pitfall of sociology." "Even the keen-eyed Marx," says Ross,
"opposes to a social Past dominated by class struggle a class-
less, strifeless Future under the collectivist regime." But he
does not come down upon the individual as the true bottom
factor. "The individual," says he, "is a true factor," but he
goes on to identify individualism with the "Great-Man" theory
and says, "There is little of value in the Great-Man theory,
which sets up a Hero for each epoch or movement and subjects
multitudes of men through centuries to the spell of his purpose
or ideal." He continues, "We cannot take the individual as our
unit." Groups, relations, institutions, imperatives, uniformi-
ties are five units favorably considered by Ross who says
"They precede the individual and they survive him ; neverthe-
less they have all risen at some time out of the actions and in-
teractions of men. To understand their jrenesis we must

THE KINGDOM OF EVILS

499

ascend to that primordial fact known as the social process/'
From our point of view we rather hold that these social prod-
ucts can best be studied by analyses of interactions of men
starting even in the simplest groups. This point of view is as
true in industrial psychiatry as in other situations.

We found that many of our patients who were started on
an industrial decline were competent and even excellent work-
men, and that with a little assistance in adapting themselves
to their employment and an explanation of their condition to
their employers, they could be refitted into industry. This
led at once to the idea that similar methods of understanding
and assistance might keep other employees from falling into
the condition of hospital patients, and further to the thought
that mental hygiene, necessary for the psychopathic employee,
would be beneficial to all persons in employment to the end of
promoting their efiiciency and personal satisfaction. A com-
mittee was formed in 1914 to carry on a special investiga-
tion of the subject, on which psychiatry was represented by
Dr. Herman Adler and industry by Robert Valentine. A spe-
cial social worker for psychopathic employees was engaged,
and men patients between the ages of twenty-five and fifty-five
were selected for the study. In addition to the cases assisted,
industrial histories over a period of five years have been se-
cured for two hundred and fifty cases. The continuation of
this study until 1920 was made possible by contributions from
the Committee of the Permanent Charity Fund, Incorporated,
Boston Safe Deposit and Trust Company, Trustee.

As an outgrowth of this work, the Engineering Foundation
of New York, in 191 9, undertook an investigation of the pos-
sible applications of psychiatry in industry. The term "mental
hygiene of industry" was devised by the senior author to in-
clude the contributions of three fields — psychiatry, psychology,
and psychiatric social work. Four papers were written as a
result of this inquiry.^

One of our anchor cases, Henry Loyal, steamfitter (case 4),

» Southard, E. E., M.D.: "The Movement for a Mental Hygiene of Industry,"
Mental Hygiene, January, 1920. Also Industrial Management,^ February, 1920.

"The Modern Specialist in Unrest: A Place for the Psychiatrist in Industry,"

The Journal of Industrial Hygiene, May, igzo. Also Mental Hygiene, July, 1920.
Trade Unionism and Temperament: Notes Upon the Psychiatric Point of

View in Industry." Mental Hygiene, April, 1920.

Jarrett, Mary C: "The Mental Hygiene of Industry: Report of Progress on Work

Undertaken under the Engineering Foundation of New York," Mental Hygiene,

October, 1920. Also Proceedings of the National Conference of Social Work, 1920.

500 THE KINGDOM OF EVILS

was a productive, competent, skilled worker and for the most
part fairly steady in employment. The irregularity in his
employment was due to his mental disease, his psychopathic
personality with its periodical waves. He should not figure in
the turnover analyses.

The Portuguese laborer, John Manaos (case 29), epileptic,
was an irregular worker and brings up certain problems of
epilepsy which every employer of labor should bear in mind.
On the one hand epileptics are prone to exhibitions of extreme
irascibility and bad humor from time to time. On the other
hand they are often of a strongly religious cast exceedingly
faithful in work, as shown to the most casual visitor at insti-
tutions for epileptics where even the so-called insane are under
proper conditions made to work ably and willingly.

The nickel-polisher, Luigi Silva (case 53) is another epilep-
tic unable to work in a community but finally successfully put
to work on a farm.

The chemist John Logan (case 58) was a most steady em-
ployee and most valuable to his firm. In fact his firm was
willing to allow occasional absences due to his alcoholic at-
tacks. There can be no doubt that these occasional alcoholics
would be greatly benefited if the plants employing them Avould
call upon consultant psychiatrists for analyses of these often
very valuable men. In fact such alcoholics might be saved
almost completely for the community.

The salesman Paul Ernst (case y2>) ^^as a victim of periodic
disease, manic-depressive psychosis (at first thought to be a
case of dementia praecox).

The waiter William Donahue (case 82) had always been
irregular in employment. His irregularity was no doubt due
to the same cause as that operating in Paul Ernst. Another
type of irregular worker is found in Louis Sand (case 95)
who was a rover and had worked during five years in as many
as twelve states, having originally wandered from Belgium
where he had been well educated and came from a good family.
We, however, likewise were unsuccessful in keeping him at a
job for more than a few months.

There may be more types of irregular employment than here
illustrated. We have seen instances of the periodic disease,
manic-depressive psychosis, and of the permanent disease
epilepsy, both of which may lead to irregularity of employ-

THE KINGDOM OF EVILS 5OI

ment due to the mental disorder. Especially in the case of
manic-depressive psychosis will it be true that mild attacks of
depression hardly visible to the lay observer may lead to the
throwing up of a job and to premature discharge. Some of
these are amongst the cleverest workmen and the fact that
they figure at all in the turnover is probably on the whole a
great loss to industry. We have seen instances of periodic
alcoholism (the laity is familiar with these cases under the
name of dipsomania) and have called attention to the sales
values to industry of some of these men. Indeed employers
are fairly familiar with the necessity of letting these men
have their sprees. We have become familiar with the rover or
victim of wanderlust, a tendency perhaps allied to that shown
in the psychopath Henry Loyal (case 4).

Alfred Mack, the packer (case 6), was one of our industrial
successes. A man, it will be remembered, made better than
he was to start with. His physical disability was removed and
his alcoholism stopped. He has since remained a steady
worker and one of the best employees in his plant. We might
count the case of the woman who lived as a man, the factory
worker Julia Brown (case 23), as another instance of alco-
holism with certain complications of character, who after social
treatment became a competent and trusted worker in her plant.

The real estate sales agent, John Sullivan (case 60), had
a bad attack of alcoholic hallucinosis but was encouraged to
discontinue alcohol and did so. He was advised to return to
gardening and did well at it. Another alcoholic, Patrick
Nolan (case 59), returned to work after D. T.'s that lasted
ten days. He has since discontinued alcohol. National pro-
hibition will tend to solve many of these problems but we
must not be too optimistic concerning the relief of all prob-
lems of alcoholism by prohibition. We do not here refer to
the possibility of getting alcohol illegally. We refer rather
to the fact that alcoholism when it reaches the psychopathic
degree or comes out in a psychopathic way is perhaps per-
mitted to do so by some hereditary taint or acquired soil in
the nervous system. We may look now for the pure illustra-
tion of such hereditary taint or acquired soil in persons who
can punctuate such taint or soil by drinking.

The industrialists must be interested particularly in cases
of disability from a functional neurosis, that is theoretically

502 THE KINGDOM OF EViLS

an always curable disease. The laundry worker, James Bailty
(case 7) was apparently saved from permanent disability due
to hysterical paralysis. The cure was slow.

The roofer's helper Lewis Goldstein (case 11) made a slow
recovery from an industrial accident, but there were economic
complications in the Goldstein case. The shipping clerk Mark
White (case 16) was industrially disabled from a psycho-
pathic condition that dated back to an accident. He was re-
stored to industrial efficiency under social treatment, as was
also Hamilton Green (case 18). John Flynn (case 19) was
one of complete disability following traumatic neurosis. He
was given work of no great difficulty — made slow improve-
ment and after two years was restored to full efficiency. The
machinist Dennis O'Donnell (case 90) had a psychoneurosis
following an industrial accident. There are a number of
problems in the O'Donnell case; owing to the new economic
conditions of the war he is able to get higher wages in his new
job than before.

David Collins (case 42), the paretic machinist, had to have
money raised for his treatment and his wife also had to be
put under treatment. The child, fortunately, when examined
as to its blood serum, proved negative to syphilis.

This is not always the case as the special work of H. C. and
M. H. Solomon, working in the Massachusetts State Psychia-
tric Institute, under the Interdepartmental Social Hyg'iene
Board, has shown :

"Figures for the two years 1917 and 1918 show that the
social worker dealt with 301 families of syphilitics, of whom 70
per cent reported to the hospital for examination. In 40 per
cent of the families every memlier reported. Among these
families 579 individuals were desired for examination. Sixty-
nine per cent were actually examined and an additional 10
per cent came but were not examined for special reasons.

"As a result of this examination of families, much undis-
covered syphilis — both conjugal and congenital — is found. Of
394 individuals examined, 21 per cent showed a positive Was-
sermann reaction. Of those found to need treatment, 51 per
cent were treated at the hospital and 40 per cent were referred
elsewhere for treatment." ^

A very interesting and complicated case of psychoneurosis
was the case of the cigar-maker David Stone (case 24), who

' Maida H. Solomon: "Social Work and Neurosyphilis," Social Hygiene Quarterly,
January, 1920.

THE KINGDOM OF EVILS 503'

Was handicapped by a fear of open spaces. He has now re-
covered from this fear and works regularly at good pay as an
insurance agent. Herman Simonson (case 27) also had his
employment changed. He had a neurosis from which he made
slow improvement. He was originally a clothes-presser and
has now become efficient as a porter. The plumber Daniel
Griffin (case 34), unable to work for six years as a result of
psychoneurosis, was treated for a year and a half and will not
yet go out alone. He has become far more active about his
house and hopes are entertained that he will finally become
able to work again at his trade. The machinist Ralph John-
son (case 71) was another rover and was suicidal. Under
treatment he has become a steady workman.

An especially interesting case was that of the architect Henry
Allen (case 100). Allen imagined unfriendly attitudes on
the part of the employees and did not want to work in a large
room full of fellow employees. He has now found a chance
to work by himself and is doing well. The cigar-maker
Maurice Eastman (case 87) was a neurotic in employment
quite distasteful to him. With encouragement and occasional
vacations he has been kept at work steadily. A man in the
liquor business, Joseph Fangillo (case 89), had a breakdown.
He was gotten into the state hospital under voluntary com-
mitment. It was his second time in a state hospital. He has
now recovered and has gone to work. A typesetter, Harriet
Farmer (case 94), attempted suicide. She was at odds with
her family and friends, was in poor health, and was earning
low wages. Under treatment she became self-sustaining and
has even been advanced in her work.

We have attempted to give in this volume all the manifold
psychiatric suggestions that come from industrial accidents.
We conceive that industrial accident boards all over the coun-
try should make increasing use of psychiatrists, expert medical
men, but especially of the psychiatric social worker. The In-
dustrial Accident Board of Massachusetts has to our knowl-
edge in numerous cases got most important results from such
social investigations.

That the high-grade feeble-minded person, or so-called
moron, may make a good worker is shown in a number of
cases. Take for instance the elevator operator Thomas Fuller
(case 9). Fuller was even promoted to be corporal of the

504 THE KINGDOM OF EVILS

marines in war time. The army authorities are not too sure
that they want to get rid of all their morons, some of whom
may do very good work in menial tasks that the more normal
soldiers balk at. The moron Agnes O'Brien (case 13) whose
trouble was complicated by hysteria was finally made self-sup-
porting in factory work. The laborer Rosenthal (case 49)
was another moron with psychoneurotic complication, and
might in fact have been figured amongst our accident cases
since his symptoms date chiefly from an accident. He is now
a perfectly steady and capable worker.

Whilst writing this volume we have heard of an up-to-date
industrial firm that is adopting the policy of establishing a
school for its morons. Such a policy is to psychiatrists en-
couraging since it follows the lines of Seguin and Madame
Montessori.

No doubt almost every employment manager would hesitate
to employ a known syphilitic. Let us, however,, call attention
to Greta Meyer (case 40), a case of cerebrospinal syphilis ; that
is to say, syphilis affecting several parts of the nervous system
in a more or less diffuse way. Mrs. Meyer, after her improve-
ment under medical treatment with salvarsan, became a social
problem which could actually be closed and referred to the
voluntary division of the service after a period of a year.

Another syphilitic case is that of David Collins (case 42),
a machinist, a victim of general paresis ; that is to say, a dis-
ease whose duration seldom runs beyond three to five years
from the onset of symptoms. Many social workers and per-
haps a majority of employment managers would regard such
a man as hardly worth the expenditure of an extraordinary
amount of time, and no doubt more time might well be placed
upon other members of the family than upon the syphilitic.
Still, an examination of the records of David Collins shows
that he was made industrially competent and was even pro-
moted to a job as foreman. Consider also Harold Gordon
(case 46), a victim of syphilis in that form which is char-
acterized by paralysis on one side of the body due to a de-
structive lesion of the brain. The medical outlook for Gordon
is one of persistent paralysis on the side affected so far as this
fails to be improved by orthopedic means and by the methods
recommended by Dr. S. I. Franz of Washington. Gordon is
now working regularly at his trade, that of steamfitter. We

THE KINGDOM OF EVILS 505

Single out these three cases of Greta Meyer, David ColHns, and
Harold Gordon as illustrative of three of the major groups of
syphilitic diseases of the nervous system, each with a different
outlook as to duration and impairment. Application of the
best methods of social work secured surprisingly good results.

The jail-bird group of psychopaths would doubtless be
scouted as potential employees by many employment managers.
Plain jail-birds might he regarded as bad enough; crazy ones
would be thought impossible. Consider, however, the elevator-
operator, Alfred Stevens (case 25) discharged for pilfering.
After recovery from depression this elevator-operator became
one of the best employees in another plant. We were also able
to secure for Ignatz Simanski (case 33), a forger, something
like a good future. He was a capable workman and was gotten
work by us after his discharge from the house of correction.
It is to be sure doubtful whether Simanski was at all psycho-
pathic. Ordinarily he might have been handled by some agency
for discharged prisoners. However, he got into the Psycho-
pathic Hospital's hands through the suggestion of a layman
and on the basis that he might possibly be a victim of psycho-
pathic personality.

We are also afraid that after approaching the matter from
a psychopathic point of view, most persons would be disposed
to look with suspicion upon such a person as the mill worker
Julia Brown (case 23), who lived for so long as a man.
Nevertheless with proper measures of social work, Julia Brown
has become a competent and trusted factory worker. No doubt
her mental twist is a profound one. "The inner relations" of
such a person are hard to integrate ; or shall we say that there
is integration of grotesque independence in Julia Brown to start
with? At all events it has been found possible to adjust the
"outer relations" of the environment in such a manner that
this particular psychopath is getting on well. Almost equally
hard to deal with is such a matter as the fear of open spaces
exhibited in the cigar-maker David Stone (case 24). Yet Stone
has recovered and is now working regularly at good pay as an
insurance agent.

Perhaps such interior difficulties as those of Michael Piso
(case 62) might be regarded as still more difficult of adjust-
ment. Piso had illusions of jealousy that interfered with his
employment; but as his jealousy was made to subside (or shall

506 THE KINGDOM OF EVILS

we say, as the jealousy subsided of itself?) Piso went back to
work and got his wages raised.

Another apparently disconcerting fact is the long duration
of disability in some cases, which seems to argue that little
enough can ever be done. But consider the case of the plumber
Daniel Griffin (case 34) who is a psychoneurotic and had actu-
ally been unable to work for six years. After a year's treat-
ment he has become more active about his home, although up
to date he is not willing to go out alone.

We now turn to an analysis of the family interests in the in-
dustrial cases which we have just summed up from their stand-
points as individuals. Certainly twenty-three out of forty-two
industrial cases of this volume are cases with the family prob-
lem in sharp focus.

Consider the case of Henry Loyal (case 4). Here was the
family problem of non-support with marital discord. The
wife was sick; one child had chorea; the second tuberculosis;
the third required special feeding; one daughter was a sex
delinquent. Every member of the family was an object of
special attention. Industrial rehabilitation of Henry Loyal
meant happiness to at least six separate persons. We are in-
clined to think that the non-psychiatric social worker would
have taken the Loyal family situation as not particularly psy-
chiatric. The questionnaires concerning deserted families, got-
ten out by various social agencies, do not bring the psychiatric
question into sufficient relief. It would have been easy to dis-
miss Henry Loyal as a "degenerate." Particularly Mrs. Loyal,
his wife, the sex-delinquent daughter, and the choreic child,
that is at least four of the six members of the Loyal family,
should be more or less constantly under psychiatric review.

Alfred Stevens (case 25), the elevator-operator discharged
for pilfering, had his case complicated by the situation reverse
to that of Henry Loyal, since Stevens' wife left him taking
their child, a child to whom Stevens was greatly devoted. Upon
Stevens' recovery from his depression the family was reunited.

Martin O'Hara (case 92), a loafer, presented another story
of family problem. He had been recently married but never
lived with his wife. He found that she had had an illegiti-
mate baby. The medical problem was one of hysteria on the
part of O'Hara. No doubt the hysteria was on the basis of

THE KINGDOM OF EVILS 507

psychopathic personaHty, from which O'Hara will not recover.
The problem of social work will be a chronic one.

More or less continuous financial aid had to be granted in a
number of cases. Lewis Goldstein, a roofer's helper, during
his slow recovery from an industrial accident had to be helped
and the health of his wife and children made the whole situa-
tion difficult, — practically difficult, however theoretically simple
enough.

The case of John Flynn (case 19) resembles that of Lewis
Goldstein; Flynn required two years of care before he could
be restored to full efficiency following his complete disability
from traumatic neurosis. The Flynn family also had a num-
ber of sick children to care for.

David Stone (case 24), the cigar-maker who feared open
spaces, was also another case not of individual disease alone,
since through the process of his becoming industrially com-
petent ran also the problem of supporting Stone's family and
steering his wife through illness.

Paul Ernst (case y^^), the excellent salesman who had been
discharged alter a manic attack, had an income decidedly in-
sufficient for his family. Assistance was given the family in
the form of clothes and vacations for the children. One of the
nine Ernst children also had chorea. The social worker had to
contend with Ernst's rather natural worry about the family
finances.

Hamilton Green was psychopathic with a mother to support
and the Green family had been in receipt of aid from public
funds. The improvement in Green's mental disease permitting
work regularly abolished the problem of public aid.

Ignatz Simanski (case 33) showed in some sense the oppo-
site situation since he was making financial demands upon his
sister who was only able to support herself with difficulty.

The health of the child of the divorcee Agnes O'Brien (case
13) had to be considered and the second (illegitimate) child
had to be provided for in public custody.

Nathan Rosenthal (case 49), a laborer, was a moron with
psychoneurotic symptoms dating from an accident. The
Rosenthal family first came under observation through the
examination of a son — another example of the rather frequent
uncovering of family problems through the resort to a mental

5o8 tHE ktKGDOM OF EVILS

clinic of sottle psychiatric case. The Rosenthal family entirely
was put under social care. Work was procured for the father.
The mother was given suitable encouragement. The son was
placed under supervision. Meantime the family had an insuf-
ficient income.

Another special problem of advice was offered by the case
of Maurice Eastman (case 87), the cigar-maker whose trade
was distasteful to him. The family problem proved a long
one. The fact that the family was inclined to maintain a high
standard of living made the small income seem more than
ordinarily insufficient. Aid with clothes was given. But more
particularly a specialized kind of encouragement and advice had
to be given with relation to the children's education. The East-
man family showed the usual Jewish ambition for the chil-
dren's education. All the children were bright, and there was
even an indication of special talent in one or two thereof. The
problem of the right kind of encouragement for the education
of a psychoneurotic is a psychiatric one. Of course we may
say that not even psychiatrists find always the right way in
such a plight. Yet, perhaps the psychiatrists should have more
to say in the premises than some other person exempt from any
knowledge of psychoneuroses whatever.

That the industrial problem could not be treated in and for
itself successfully and that the ordinary non-psychiatric view
of the family problem would be decidedly insufficient are points
illustrated also in a case like that of Harold Gordon (case 46).
Here there had been cohabitation with a woman probably
psychopathic.

Paul Dawson (case 78) separated from his wife, failed to
support her and was perhaps a case of dementia praecox. He
had always worked irregularly and under our care could not
be got to take a job. However, upon being drafted he made
an allotment to his wife. Upon his discharge he went into the
merchant marine.

Other cases of family interest amongst the industrial group
are those of Herman Simonson (case 2"]^ with a wife and six
children and wife's parents in Russia dependent upon this
clothes-presser ; Nathan Blumberg (case 37), a case of non-
support in financial difficulty, confused about his affairs, sep-
arated from his wife; John Logan (case 58), the expert chem-
ist whose wife was at first afraid to live with him but upon

THE KINGDOM OF EVILS 509

advice and encouragement kept up the home ; Patrick Nolan, a
laborer whose family was dependent upon his wages and who
was gotten to return to work after recovery from delirium
tremens; the jealous teamster Michael Piso (case 62), whose
family required material aid and also the care of health of the
wife and children; the paranoid case of George Stone (case
76), whose delusions were not severe enough to permit his
being committed to a state institution and who wandered about
not working and threatening his wife; Joseph Fangillo (case
89), whose illness ate up his savings so that his wife might
be maintained ; the industrial-accident case of the machinist
Dennis O'Donnell (case 90), where there was an economic
problem of the family and the problem of advice to the wife.

We have added up the more striking problems amongst the
twenty-three family cases in our industrial group of forty-two
and find that no less than eighteen of the twenty-three cases
yielded acute economic problems for the family as well as for
the industrially disabled patient. When the non-psychiatric
family case worker approaches such a case as a purely family
problem she has unquestionably in the past been inclined to
regard the psychopath as an unfortunate additional complica-
tion. We submit that the treatment of these family cases
with the psychopath as the primary target of attack is the ra-
tional strategy of the present day. Nine of the twenty-three
cases show degrees of sickness in the wife or children. The
medical social worker will no doubt give proper attention to
these physical sicknesses ; and perhaps the medical social worker
from her hospital community experience may exhibit an ad-
vance in social attitude upon that of the philanthropic family
case worker of a former generation. But here again we are
inclined to say that the data of this book proved that the stand-
point of physical health, valuable as it is, is very frequently not
the central problem. Let the central problem of the psycho-
neuroses or other mental diseases in the father or mother be
properly treated and the problems of sickness on the part of the
wife and children will get solved upon comparatively small
lines. But if we try to solve the problem of sickness of the
non-psychopathic spouse or children upon a purely health basis
the psychopathic difficulty in the parent will be apt to run on
indefinitely. (See particularly such a case as that of Henry
Loyal, case 4, or Nathan Rosenthal, case 49, or Maurice

5IO THE KINGDOM OF EVILS

Eastman, case 87.) There were nine cases also of marital dis-
cord. Marital discord is perhaps a purely primary and moral
difficulty, though we are not aware that any proper statistics
on this point of marital discord with relation to psychopathy
have ever been collected. The point of this volume largely
turns upon our considering every case of social difficulty as
possibly in the first instance medical, and perhaps psychopathic.
This point, as we repeatedly insist, is not grounded upon sta-
tistical frequency of mental disease amongst cases of social
difficulty ; we do not feel that there are anywhere in the world
proper statistics on this matter. Our point is that every in-
stance of social difficulty should first or last receive considera-
tion as possibly a medical matter. So with these nine cases of
marital discord. In the Loyal (case 4) family the wife was
possibly slightly psychopathic although the big problem of
non-support was unquestionably grounded in the psychopathic
personality of the husband and father. Nathan Blumberg
(case 37) was separated from his wife after a quarrel, but we
do not here find evidence of mental diseases on both sides of
the family. The discord in the case of Michael Piso (case 62)
was unquestionably due to this teamster's delusions rather than
to any attitude on the part of the wife. Likewise with George
Stone (case 76).

There were two cases complicated by illegitimacy of a child.
Agnes O'Brien (case 13) had an illegitimate second child.
Martin O'Hara married a wife with an illegitimate baby.
Agnes O'Brien illustrates one problem of illegitimacy in the
fact that she was a hysterical moron whom we should not
regard as too responsible for the fact of illegitimacy. On the
other hand the wife of Martin O'Hara was as far as we know
not in any sense psychopathic. As with the questionnaires re-
garding non-support, so with the questionnaires regarding
unmarried mothers; we do not find that these questionnaires
take sufficiently into account the possibility of feeble-minded -
ness on the part of the unmarried mother or father. We have
not the slightest doubt that the problem of illegitimacy will
have a flood of light thrown upon it by intensive study from
the psychiatric point of view.

To sum up concerning the family interests in the industrial
group of cases, we must emphasize the fact that first, each in-
dustrial case must be handled upon its merits as a psychopathic

THE KINGDOM OF EVILS 5I I

case ; second, the members of the industrial psychopath's family
must be treated socially like the members of any other family
case group; third, the treatment of such a family case group
containing a psychopath as a central figure, should not be
treated as a family unit (that is, from the ordinary standpoint
of the family case worker dealing with the situation largely
from the economic side) ; fourth, the point of view of the ordi-
nary medical social worker (that is, the point of view which
takes into account the physical health of each member of the
family), is an inadequate approach, good so far as it goes but
missing the psychiatric point. Cases of industrial disability
might well seem, even to the educated layman, primarily cases
for economic handling from the standpoint of the so-called
family case work. Yet the educated layman who should think
that this primarily could be handled by financial aid alone would
fall far short of the ideals of the present day. Let us empha-
size as ever that both the family case worker and the medical
social worker do their best as moral advisers in these situations.
But the kind of moral advice they are equipped by nature and
training to give needs supplementation by psychiatric training
if the best results are to be obtained.

The moral advice given by the worker untrained in the con-
trast of temperament and the peculiarities of the different
major forms of mental diseases and defects is but too apt to
follow some particular slant of the social worker's own nature
and experience. She is but too apt to try to make the family
as a whole and the central psychopathic figure conform to
some set ideal of action. It is these industrial cases that bring
very acutely the combination of diseases, moral defect, and
economic disability. The formula of these cases is rather apt
to be M. V. P., to use our abbreviated terminology. That is,
we find in these cases some examples of the morbi, some ex-
amples of the vitia, and some examples of the penuriae rolled
in one.

Our complaint as to the shortcomings of the present-day
social work is that too great emphasis may readily be laid upon
economic disabilities (penuriae). Furthermore, even if the
hypothesis of disease (morbi) is brought into the foreground
we find that the morbi are taken in a physical sense rather than
in a mental sense ; the medical social worker is not sufficiently a
psychiatric social worker. With respect to the vitia, our chief

512 THE KINGDOM OF EVILS

complaint reduces perhaps to the charge that the non-psychi-
atrically trained person is but too apt to think that all men con-
form to or fall short of certain standards of morality, whereas
the psychiatrically trained person is apt to see many types of
moral shortcoming following the lines of temperament and
the psychiatric worker suspects that there has been too great
emphasis upon the uniting of moral standards in the human
race as a whole.

All moralists admit that the moral situation (that is, the
situation which considers good and evil, right and wrong)
involves voluntary activity — a point handed down from Aris-
totle. "The agent must know," say Dewey and Tufts, "what
he is about; he must have some idea of what he is doing; he
must not be a somnambulist, or an imbecile, or an infant."
They go on to say that such unformed or deformed personali-
ties exhibit voluntary activities and in moral activity they may
show character or herein necessarily be viewed morally. Now
this standpoint may be perfectly well chosen from the stand-
point of voluntary moral life (we are inclined to concede even
this point, to grant it for the sake of argument), but the stand-
point is assuredly not well chosen if we are trying to evaluate
the vitia; that is, tell just how far the acts formed are immoral
acts and how far they are the acts of untrained or immature
persons or how far they are actually psychopathic. In short,
we feel that the study of morals will greatly benefit from psy-
chiatric analyses. But this point takes us far out of the im-
mediate range of industrial interest. The most prominent
difficulties in the handling of family situations of industrial
disability is the tendency on the part of persons without a
psychiatric training or experience to deal with families upon a
purely economic basis or upon a basis of mere physical health.

OUT-PATIENT SERVICE

Some patients resort upon their own initiative to the out-
patient service (for example, Ethel Murphy, case 66, and
Jeanette Burroughs, case 68) and are then, if desirable, readily
persuaded to enter the hospital wards. William Donahue
(case 82) came of his own initiative to the out-patient depart-
ment and never seemed to need treatment in the wards.
Maurice Eastman (case 87) was treated as an out-patient only

THE KINGDOM OF EVILS 513

by psychotherapeutic means. And though Eastman's troubles
seemed to require at least three types of worker and much
individualization, yet ward treatment never came in question.
Louis Sand (case 95), the roving Belgian immigrant, re-
mained also an out-patient case throughout a long and rather
intensive social treatment.

Shall mental treatment be carried out in hospital beds or
in the out-patient department? Many states still possess no
means of treating mental cases in adequate out-patient depart-
ments, such as those provided for example by Massachusetts
and New York. Yet the establishment of such out-patient de-
partments should be easily brought about in forward-looking
states, since it must be apparent to the most fiscally-minded
legislators that out-patient departments are cheaper to run
than hospital wards. It is obvious that many patients can
be got in for out-patient examinations who would not readily
consent to come even as voluntary patients who stay in beds.
The values of out-patient department work are shown in the
majority of our cases, first from analysis of their reports
thereto through the follow-up work after they have been re-
leased from the wards. But a number of cases are particularly
interesting from the standpoint of the values of the out-patient
department mental examination. Consider Bessie Silver-
man (case 21). This Jewess came herself upon her own
recognizance to the out-patient department of the hospital to
find out the degree of her mental capacity. Bessie, it will be
remembered, was that case of disharmony between ambition
and ability who was bent upon somehow going through college.

Emma Marburg (case 30) came to the out-patient depart-
ment through the advice of another patient. She was unable
to hold out any longer on account of her fatigue and worry.

Some cases are treated with success as out-patients only;
compare Beatrice Cellini (case 52), who came of a family
known to at least twenty-four social agencies. The diagnosis
in the Cellini case could be rendered with apparent safety with-
out resorting to the hospital wards.

We may properly use these cases to prove the independent
value of out-patient services and dispensaries for mental cases.
Yet, we must not forget that where an out-patient service is a
departmental service and lodged in an imposing hospital struc-
ture surrounded by evidences of intensive medical, educational,

514 THE KINGDOM OF EVILS

social, psychological, occupational, and nursing work, the
effects gained are not purely those of the out-patient service
per se. The out-patient service in this sense is under the aus-
pices of something big, complex, almost sacred, ever in the
eye of the patient as a vista of resources for help.

We have spoken of imposing structures. The state hospital
structures whether of the Bastile type or of the more modern
scattered cottage description (sometimes, we regret to say,
like a lot of small Bastiles!) will no doubt ever remain forbid-
ding to certain types of mind in difficulty, which will be entirely
willing to visit the out-patient department of a psychopathic
hospital or the consulting room of a mental hygiene society.
These values are very delicate ones to estimate. The consult-
ing office specialist cannot quite see how his type of patient
could willingly resort to any form of out-patient department,
if he could possibly get the money to resort to a private medi-
cal consulting office.

Yet there are certain types of men and women that seem
to abhor private consulting offices and much prefer public con-
tacts. Again there is a certain class of persons who are effec-
tively drawn under observation by the state and local mental
hygiene societies whose rooms are found in office buildings and
may be resorted to without fear of observation at the door or
in the corridors. Another type of patient is drawn to the
modern psychopathic hospital divorced in construction and in its
practical associations from the district state institution. The
Psychopathic Hospital in Boston has without artificial stimulus
an out-patient department that usually runs to the number of
fifteen hundred per annum. It would be entirely impossible,
we venture to say, for any district institution primarily for the
committable insane to show such a record — a record partly
founded in the public recognition of especially trained physi-
cians, psychologists, and social workers to be found therein,
but more effectively still in the good effects advertised from
neighbor to neighbor as shown by returning patients. We
doubt whether any institution not primarily constructed for the
voluntary class of patients and for the so-called temporary care
group of non-committable patients, will ever draw from the
community so important and extensive a group of out-patients.

The scope of this work does not include a special discussion
of methods of psychotherapy. We give upon another page

THE KINGDOM OF EVILS 515

the main methods of psychotherapy mentioned in textbooks (a
list drawn from Shell-Shock and Other Neuropsychiatric
Problems, 1919, by the senior author). The adjustment of
man to himself is not primarily a function of social work
and we are prepared to admit that there are numerous cases
of complete adjustment of man to himself altogether outside
the field of social work. The works of Janet are filled with
instances of such interior adjustment by the psychotherapeu-
tists. We may call attention to several cases in our group.

Daniel Griffin (case 34) was a case in which there were
many psychogenic factors; that is, factors of mental diseases
that took their rise from troubles inside the patient's own mind.
This was the case of the man who did not work and never went
out in the daytime for a period of about six years. A psycho-
therapy by persuasion was adopted. Another instance of this
is that of Louis Sand (case 95). And Maurice Eastman (case
87) should be carefully reread by the reader interested in psy-
chotherapy. This man had been coached by physicians to
know that his disease was "all foolishness" — an instance in
which psychotherapy may defeat itself. He was given a sort
of talking cure by a psychologist in the Psychopathic Hospital
and was made to read popular works of psychotherapy. We
shall not repeat the remarks under this case concerning the fact
that psychiatric social work is not psychotherapeutic in the full
sense of the term (at all events not in the medical sense of the
term), and is decidedly not competent to decide upon the re-
spective values of the different forms of psychotherapy listed
in the chart (page 481), especially upon the values of such
methods of psychotherapy as hypnosis and psychoanalysis.
The spheres of influence of the psychiatric social worker as of
any social worker are decidedly not either the public or the
personal spheres. The social worker cannot take the place of
the judge or public administrator and must not feel irked by
her inability to act as a substitute for the public servants. As
we have repeatedly said, she must use the public service as ful-
crum. But it is even more true, though perhaps less obvious,
that the psychiatric social worker cannot replace the physician
in the most intimate and personal matters of treatment.

The reason why this is not too obvious to every psychiatric
social worker is that everybody is aware that the methods of
psychotherapy grade very gently over into methods of convic-

5l6 THE KINGDOM OF EVILS

tion and persuasion, in short of suggestion, as employed in
everyday life. Every father or mother, brother or sister —
everybody who has served in any dominant way in relation to
some human being — is aware of his or her suggestive powers.
It is very natural therefore for the psychiatric social worker
to fall victim to the belief that she might solve the problems of
suggestion in her psychopathic patients as well as the physician.
She knows that she can in fact exert certain suggestive powers
under certain conditions of time and place that the physician
can exert. She -has in mind certain successes in conviction or
persuasion as exerted upon given cases in her experience. Yet
mutual adaptation of the interior relations of the mind to one
another under psychopathic circumstances is not at all easy.
Suggestion is easy but the right suggestion is difficult ; when we
examine the life histories of certain patients we find them a
succession of layers of suggestions like the layers of paint in
certafn ancient canvases. Universally the human mind is a lit-
tle more like water-color painting than one in oils, so that' it is
often impossible to eradicate the earlier impressions by fresh
ones. Armed with new knowledge about suggestion and plied
with the histories of successful adaptation by psychotherapeu-
tic means, the youthful social worker may be inclined to enter
where the psychotherapeutist would hardly dare to tread.

Is it wiser to let the public service adjust its own environ-
mental services, gradually molded into proper shape by improve-
ment in communal opinion, and to let the specialist in psycho-
therapy pursue his own difficult course of the mutual adjust-
ment of inner relations without undue interference by the
social worker? To be sure communal opinion about improve-
ments in the public service will never acquire greater strength
than when supported by the concrete facts supplied by the ex-
perienced social worker. By the same token the psychothera-
peutist may be unable to make his weighty decisions (whether
he or she act by conviction or persuasion, terrorism or the vel-
vet glove, hypnotism or psychoanalysis) only in virtue of some
little special indication that the social observer has recorded.

PSYCHIATRIC SOCIAL WORK

HISTORY

In the development of a new profession, from time to time
new interests come to the front, dominate the scene for a while,
and gradually become assimilated into the body of experience.
A new branch remains upon the main trunk, and at the same
time the parent stem is strengthened. This process is the cur-
rent history of psychiatric social work. In the multiform ac-
tivities of social work, gradually taking shape in a new pro-
fession, there are found many traces of interest in mind as a
primary factor in social life, — the keynote principle of psychi-
atric social work. St. Vincent de Paul's efforts to relieve the
sick poor, among the earliest attempts at organized social work,
had for their object "to teach the poor to be provident for
themselves," as well as "to point out to them sources of em-
ployment." Cicero considered the mental effect of alms : "We
must take care that our bounty is a real blessing to those we
relieve, that the claims of gratitude and justice are preferred
to mere compassion, and that due regard is given both to the
character and the wants of the recipient."

The aim of all modern social work has been to build up char-
acter. Nevertheless, until recently, there has been no system-
atic attempt to study character by exact methods. Social
work has not heretofore attempted to apply the mental sciences
to understanding of the individual. "Common-sense" methods
have been relied upon in estimating personality, and "trial-and-
error" methods in solving mental problems. While the world
is far from possessing a science of character, there is a certain
amount of .knowledge derived from the mental sciences, psy-
chology and psychopathology, that can be applied to advantage
in dealing with human beings. Even a small amount of sci-
entific knowledge may afford a large amount of practical
value. The benefit to the individual, whose difficulties are
better understood by reason of some bit of science, may be
incalculable.

517

5l8 THE KINGDOM OF EVILS

This new branch of social work known as psychiatric social
work is a new emphasis rather than a new function. It has
grown out of ideas and activities that already existed in scat-
tered forms. A similar situation is found in the development
of medical social work during the last fifteen years. The new
emphasis upon attention to disease and care of health spread
rapidly in general social work, until now the idea of using
scientific methods to maintain health is part of the equipment
of every well-trained social worker. Theory, to be sure, is
ahead of practice, as it must always be, and social work has
far to go before it can be said to be making the best use of
medical science; but the principle of a medical point of view
is established.

At first social work was dominated by the economis point of
view. Economic features of social disorder are most con-
spicuous (food and shelter are the first obvious needs), and
therefore receive first attention. Moreover, the social worker's
special contribution to social problems is knowledge of the
environment (the social worker is a specialist in environment),
and here also the outstanding features are economic. Again,
the origin of systematized social work in "poor relief" put eco-
nomic considerations in the lead. But just as the medical point
of view came to the front and was assimilated, so at the present
time the psychiatric point of view is in the foreground and is
in process of being absorbed into the movement.

The history of psychiatric social work is the focusing of
various recent influences leading to more attention to the
mind in social practice, under pressure from psychiatry
demanding more attention to social needs in medical prac-
tice. In social work, among these trends, one that stands out
prominently is the increasing insistence of the family welfare
group upon better understanding of motives and more exact
methods of arousing interest and purpose. In the children's
agencies, there has been growing a sense of the need of apply-
ing child psychology in the education of young wards. Agencies
caring for the unmarried mother have come to recognize the
primary importance of mental conditions in these cases. Psy-
chiatric clinics established in connection with courts (of which
Dr. Healy's clinic in the Chicago juvenile court was the fore-
runner), and in connection with prisons and reformatories
(such as the clinic started by Dr. Glueck at Sing Sing prison),

THE KINGDOM OF EVILS 519

have given impetus to the psychiatric interest in social work.
From medical social work came another influence in the insist-
ence of Dr. Cabot that social work was essentially the develop-
ment of character under adversity.

In medicine many definite trends may be seen that have
contributed to the present development of psychiatric social
work. A very explicit statement of the need of social work
in the practice of psychiatry w^as made twenty years ago by
Dr. Theodore H. Kellogg, superintendent of a hospital for
mental diseases, in his Textbook on Mental Diseases: "In-
sanity practically is loss of the power of conformity to the
social medium in which the patient lives. This power is re-
gained in convalescence gradually, and it is a part of psycho-
therapy to furnish a normal personal environment to which the
patient is to practice adjustment;" and again: "The physician
who has conducted a case of mental disorder through all the
vicissitudes of an acute attack to perfect recovery has a final
duty to perform. There are to be laid down definite rules of
life, points in physical and mental hygiene, suggestions of the
best way to meet social and business difficulties, and advice as
to domestic relations." It was some fifteen years later that
systematic provision began to be made for seeing that these
"rules of life" laid down by the physician were actually fol-
lowed by the patient. It was thought that the physician could
perform this function of social readjustment and many hospital
superintendents and physicians did so to the best of their abil-
ity. Others were beginning to see the possibility of specially
trained lay workers for this purpose.

Meanwhile psychiatrists were coming into closer association
with social workers. It is of some interest that at the first
meeting of the National Conference of Social Work (then the
Conference of Charities and Correction), in 1874, the first
subject considered was "The Duty of the States toward Their
Insane Poor," in a paper by a state-hospital superintendent:
and the subject of "insanity" figured largely in the programs
of the early years. A section on feeble-mindedness and insan-
ity was created and in 191 7 became the mental-hygiene section.
Another medical influence, which no doubt gave considerable
impetus to the development of psychiatric social work, was the
growing appreciation of physicians in general hospitals of the
value of the social service, and the experience of psychiatrists

520 THE KINGDOM OF EVILS

in mental clinics of these hospitals that the assistance of social
workers became indispensable.

The chronology of psychiatric social work down its main
line of development, social care for cases of mental disease,
begins with the Society for the After-Care of the Insane in
England, which as early as 1880 was engaged in giving friendly
supervision to patients discharged from hospitals. The first
attempt in this country to employ social work in the care of
patients with nervous and mental disorders seems to have been
in the Neurological Clinic of the Massachusetts General Hos-
pital in Boston in 1905, when Dr. James J. Putnam, who was
in charge of the clinic, secured the assistance of a social worker,
Miss Edith N. Burleigh, and personally trained her for the
work. A year later a social worker was placed in the psycho-
pathic wards of Bellevue Hospital, New York. The New York
State Charities Aid Association was a leading influence in de-
veloping this field through its Committee on Mental Hygiene,
which in 1910 appointed an "after-care worker" to supervise pa-
tients discharged from two of the state hospitals of New York.
The first social worker to be placed upon the payroll of a state
hospital for mental diseases was employed through the influ-
ence of this Committee in 1911, by the Manhattan State Hos-
pital, New York, where she had previously been engaged upon
salary paid by the Committee. Two years later, 1913, two
Massachusetts hospitals, Danvers State Hospital and Boston
State Hospital, each added a social worker to the staff.

The same year the Psychopathic Hospital began to organize
its social service. Although the original plans provided for a
social service, the work was not regularly started until a year
after the hospital was opened. The ideas of the Director con-
cerning the introduction of this new agency into the institution
are expressed in some notes written a year or two later : —

"The social service movement seems to be waxing fast, al-
though not fast enough for its problems. Personally I seem to
have been greatly influenced by some of Professor Royce's
earlier ethical papers touching the social 'consciousness' so-
called, by Professor Putnam's contentions, and by the point of
view of Professor James which culminated in his marvelous
address on The Moral Equivalent of War. Then came brief
but uplifting observations of the Social Service Department of
the Massachusetts General Hospital under the leadership of

THE KINGDOM OF EVILS 521

Miss Ida M. Cannon. After the establishment of the Psycho-
pathic Hospital, I began to get light from a group of persons
interested in social service, among whom, besides Miss Cannon,
I should especially count my colleague Dr. W. P. Lucas, Mr.
Michael M. Davis, and Miss Katherine McMahon.

"My own ideas are derived from many sources. The need
of a social service in the new Psychopathic Hospital became
obvious at once when the plans were tentativel}' begun in 1909-
1910 and the obvious need was expressed in so many words in
the State Board of Insanity's report of 1910. So far as I can
remember, space was reserved for social service in the very
first of the plans from which the eventual plan was developed.
To be sure, many physicians who were shown the plans af-
fected astonishment at the large space assigned to the out-
patient work as a whole, and there was almost no general
appreciation of either the whole out-patient work or its social
service constituents. These critics are now easily won over
by the practical results obtained."

We claim no novelty or originality for the social work of
the Psychopathic Hospital, but rather, we would claim to have
created the part that the social worker is to play in the
mental hygiene movement and to have given it a name —
psychiatric social work. The bases of this new division of
social work are the principles common to all forms of social
case work. It is the application of old methods in a new field.
It will, we expect, develop some new methods, which will in
time be applied in the older fields. In the new field there was
need of bringing to a focus existing trends, of defining func-
tions, outlining requirements of special training, and giving
the whole a distinctive name.

The Great War had an important influence upon the spread
of psychiatric social w^ork. It was clear to those who had seen
the importance of social service in civilian hospitals that psy-
chiatric social workers would be needed for army hospitals.
But there w^ere only a handful of social workers with this spe-
cial training in the whole country. Plans to enlarge the capac-
ity of the training course at the Psychopathic Hospital were
proceeding when it was found possible to combine with Smith
College in a course, given in 191 8- 191 9, under the auspices of
a committee of the National Committee for Mental Hygiene.
Similar courses, conceived as emergency measures or as per-
manent developments of the curriculum, were offered by other

522 THE KINGDOM OF EVILS

schools in New York, Philadelphia, and Chicago, In Canada
a similar course was given at Toronto University. Fifty-odd
graduates of the Smith College course went into army hospitals
or Red Cross organizations. The pioneer piece of psychiatric
social work in the army was done in the neuro-psychiatric hos-
pital at Plattsburg, b}' Miss Margherita Ryther, who had
been for some years social worker in the Neurological Clinic
of the Massachusetts General Hospital, Boston. The need for ,
social service in any program for adequate care of neuropsy-
chiatric cases among soldiers was demonstrated. This princi-
ple established in the army hospitals has carried over into the
public health hospitals. The Red Cross in connection with the
public health service and the Veterans' Bureau are now en-
deavoring to develop a complete organization of psychiatric
social work for the care of ex-service men with neuropsychiat-
ric disabilities.

The effect of psychiatric social work upon general social
work came into focus in a surprising way at the National Con-
ference of Social Work in Atlantic City in May, 1919. There
was suddenly a realization in many quarters that psychiatry's
contribution to general social work ought to be made available.
Dr. Cabot spoke of the new force, "new, not in name, but in
efficiency and energy — which has come into social work — the
force represented by psychiatric social work. In thirty years I
have never seen anything so important as the irruption of psy-
chiatric social work into social work." The idea is now widely
accepted that social case work calls for psychiatric knowledge
and the psychiatric point of view. It remains to find ways and
means to enable social workers at large to get what psychiatry
can offer. A number of means are at hand, — the best perhaps
are the summer courses in social psychiatry offered by certain
schools of social work. Evening courses may be arranged.
Brief extension courses as an introduction to the subject are
offered by some schools, with clinics to demonstrate types of
mental disorder. Reading help^, but the literature of social
psychiatry is mostly in the form of detached articles. In Bos-
ton, a group of twenty-five executives of social agencies and
leading social workers formed a class to study with a psychia-
trist, who was familiar with their field, the best means of ap-
plying psychiatry in social work.

To avoid confusion of terms, it may be well to state here

THE KINGDOM OF EVILS 523

that "social psychiatry" is not used as an alternate for "psy-
chiatric social ivork." Psychiatric social work is the special
form of social work in which psychiatric knowledge is particu-
larly required. Social psychiatry is an art now in the course
of development by which the psychiatrist deals with social prob-
lems. Social psychiatry is a branch of psychiatry and a special
kind of medical art. That part of the knowledge of psychiatry
which has a bearing upon social problems is given to social
workers in courses named social psychiatry, — that is, the es-
sentials of psychiatry from the standpoint of social work. The
special preparation of the psychiatric social worker should
consist not only of courses in social psychiatry but also of prac-
tice in social work with psychiatric cases. The inclusive term
mental hygiene is used to cover the activities of psychiatrist,
psychologist, the psychiatric social worker in promoting mental
health wheresoever.

ORGANIZATION AND FUNCTIONS OF THE SOCIAL SERVICE AT
THE BOSTON PSYCHOPATHIC HOSPITAL

Some account of the development and organization of the
social service of the Psychopathic Hospital may be suggestive
to similar departments in process of formation. Any scheme
of organization is a growth determined largely by local condi-
tions, and therefore may not be suitable to transplant. There
are, however, some fundamental principles and practices com-
mon to all similar institutions, in regard to which experiences
may be exchanged with profit. The psychopathic hospital and
the state hospital for mental diseases will differ in the organiza-
tion of their social service as well as of their medical service;
but both types of hospital will have common features in both
medical and social work. This account is by no means intended
to present a model form of organization. The system here
developed, however, works on the whole with reasonable effec-
tiveness, and most of its fundamental principles and chief de-
vices we would recommend with confidence.

The question of the proper organization of the social service
depends fundamentally upon whether a hospital is regarded as
a community institution, in which medical and social depart-
ments cooperate, or as a medical institution controlled and di-
rected by physicians with social assistants. This question of

524 THE KINGDOM OF EVILS

organization arises irrespective of the question of functional
control and direction of social work in a hospital. Besides the
question of immediate direction (or supervision) of the social
worker's activities, there is a question of the right administra-
tive relation between medical work and social work. The
position taken by a particular hospital on this point affects the
development of its social service in both frank and subtle ways.
A confused policy on this point leads to misunderstandings
and retardation of the work of the social service.

At the present time most of our hospitals are acknowledged
medical institutions, primarily for the treatment and study of
disease, and they are administered by medical men. Therefore
the social work should properly be subordinated to the medical
work, the physician employing social assistants and relying
upon their special skill (without attempt to direct a form of
practice in which he is not trained) to promote the medical
work. As the horizons of medicine widen, it is conceivable
that the hospital of the future may be a social institution, ad-
ministered by men of sociological-medical training. The com-
mimity no doubt will more and more demand that the hospital
treat the whole man, that the treatment of disease aim at com-
plete social adjustment, and that the hospital go outside its walls
to prevent disease.

At the Psychopathic Hospital the social service was organ-
ized to assist in the medical work of studying and treating men-
tal disease. Its function of assisting in treatment was con-
strued in the broadest sense to mean (a) restoration of capac-
ity for normal living, or (b) provision for greatest possible
comfort. The out-patient department and the social service
have developed with close interrelations. While many social-
service cases first receive attention on the wards, the greater
part of the work is of course with patients in the community.
The medical and social aspects of out-patient treatment for
nervous and mental disorders are so closely interwoven that
they can hardly be discussed separately. An occasional case
may be free from social complications and call for treatment by
the physician only. Also, in an occasional case the physician
may find that the root of the difficulty is social and may leave
the case in the hands of the social worker. In most cases,
medical treatment is supplemented and reinforced by social
care. The efforts of the social worker in such cases must,

THE KINGDOM OF EVILS 525

of course, be definitely designed to contribute to medical treat-
ment.

For the best results, social work should be immediately under
social direction, but the practice of the social worker in every
case must be strictly in accordance with the doctor's ideas for
the patient; and if in any case a conflict of social and medical
interests arise, the medical decision obviously must prevail;
since the treatment of a mentally sick person is primarily a
medical problem. This relation between medical and social
work is sometimes not understood by observers, who see the
large amount of responsibility borne by the social worker in
certain cases that the physician sees infrequently, and who do
not realize that the physician has delegated responsibility to the
social worker to carry out social treatment in conformity with
the medical plan.

A routine social examination for all admissions was our ulti-
mate aim,^ but was impossible with the number of social
workers available. Therefore the expedient was adopted of
relying upon the physicians to report cases in which social work
was required. About one-fourth of the cases referred by
physicians are likely to be cases where a history is required
for medical diagnosis, but social care is not required. (See cases
54 and 72.) The physician is apt to look upon this function of
the social service as its most important duty, since his primary
responsibility to the patient is to endeavor to make a correct
diagnosis. In a sense it is also the primary responsibility of
the social worker to contribute to this object, which is the
hospital's first duty to the patient. Equally important to the
social worker, in addition, is the welfare of the patient in the
community. Moreover, the benefit of careful diagnosis can be
secured in many cases only by painstaking, thorough social
care. The social worker, engaged in social treatment, is bound
to feel a sense of interruption if histories for medical diagnosis
cause deferred attention to social cases. The success of social
treatment may depend upon timeliness, steadiness, persistence,
or close application; and emergencies continually arise when
least expected. No matter how thoroughly the social worker
recognizes the importance of the medical-social history, she
cannot feel the same enthusiasm that the physician would feel

^ From Annual Report of the Director, Psychopathic Department, Boston State
Hospital, 191 5: "Of course with a properly increased staff, we should like to secure
a social examination for every patient on admission."

526 THE KINGDOM OF EVILS

in devoting a day's work to it, while perhaps neglecting work
that is her own immediate responsibility. This is especially
likely to be true if the significance of the history turns upon
some fine medical point. Therefore it might be more effective
to have certain social workers give their time wholly to getting
medical-social histories.

Individual case work is the nucleus of the department. Since
it was impossible to treat all cases with thoroughness, on ac-
count of an insufficient number of workers, a distinction was
adopted between "intensive"' and "slight service" cases based
upon the degree of responsibility for social care assumed by
the department. In the intensive cases the social service at-
tempts to assume responsibility for making a full inquiry into
the social condition of the patient and his family and endeavors
to secure the largest measure of social well-being possible for
both patient and family. The "slight service" cases are those
in which assistance is given without inquiry beyond the appar-
ent facts or responsibility beyond the immediate service. (For
examples of slight service cases, see cases 39, 41, and 67.)

An attempt was made to estimate the staff of social workers
needed to cover the case work. There is no direct precedent or
definite standard for determining how many cases one social
worker in a psychopathic hospital can carry, but by a compari-
son of the experience of the Committee on Mental Hygiene
of the New York State Charities Aid Association and that of
other agencies doing somewhat similar work, it was estimated
that one social worker could take in a year one hundred and
fifty cases for investigation and miscellaneous services or could
care for about fifty patients a year under supervision (that is,
ten under treatment at one time for an average period of three
months each), so that a social worker engaged in both inves-
tigation and supervision would average one hundred cases a
year.

Not every patient will require the care of the social service.
In a city with well-developed social agencies, about twenty-five
per cent of admissions may be already in the care of other
social workers, and about twenty-five per cent of the patients
appear not to require social care, the majority being patients
committed to hospitals, who have no one dependent upon them
or whose families have already become adjusted to their men-
tal condition. Others have families able and intelligent enough

THE KINGDOM OF EVILS 52/

to do for them all that can be done ; a few are unmarried per-
sons who habitually wander, so that it is impossible to keep in
communication with them. So' it is possible to estimate roughly
that for every two hundred admissions a social worker will be
required for individual case work. The additional functions
of research and teaching will call for additional workers.

The expense of the social service of a psychopathic hospital
considered from the standpoint of efficient hospital administra-
tion (with the object of restoring patients to competency as far
as possible) has yet to be carefully estimated. We have a few
notions on the matter. (See also case 71.) The saving of
expense to the state in the prevention of crimes by psychopathic
individuals through social supervision cannot be calculated ; but
special instances indicate that it may be considerable. Through
the care of social workers many patients who would become a
charge upon the state are kept at home, either self-supporting
or maintained by relatives. During our first two years' work
at the Psychopathic Hospital, twenty patients, who by all indi-
cations would otherwise have required institutional care, were
kept in the community through the activities of the social serv-
ice. Averaged at a saving to the state of one year's main-
tenance each, these cases showed a saving of $5,200 which was
more than the amount paid by the state in salaries to our social
workers during that period. As three of these patients, who
were insane, were returned to relatives in their native countries,
the state was probably saved in their cases many years' support.
So that, in relation to the state treasury, the department was
then more than paying for itself.

In systematizing the case work, the social service borrowed
a number of devices from the organization of the medical serv-
ice, when Dr. Herman M. Adler was -chief of staff. Workers
and students are divided into "groups" (the "head of the
group" being the most experienced worker on that duty), and
cases as referred are assigned in rotation to the groups, record
being made on a "rotation sheet" The head of the group is
responsible for assigning the case within her group in the best
way to get the work done promptly and well. A worker (or
advanced student) is assigned each day to duty as "visitor for
the day" to receive inquiries and deal with emergencies and to
attend to certain routine duties. The whole staff meet every
morning for the first half hour for discussion of cases. On

528 THE KINGDOM OF EVILS

the fourth day after assignment new cases are presented in
summary with an analysis of "social symptoms" so-called (fac-
tors of social maladjustment) indicated so far as it has been
possible to carry the investigation. Results of social treatment
are reported every three months at the "morning discussion."

A method of giving each case worker a "daily reminder" of
her work for the day has been found serviceable. An explana-
tion of this method and a sample of the card that the social
worker receives each day are here given.

August 15,

1916

H. A.

I day case

George Brown

4 « «

Beulah King

14 " "

John Sheehan

I month case

Grace Haskell
Bessie Snow

3 " "

James Johnson
Ada Jones

Records up to

date

Explanation: Cards are to be marked witli a check after the patient's
name if the work has been done, and returned at the end of the day to
the stenographer. If the work has not been done, the name will be carried
forward onto the card of the following day with the number of days over-
due indicated.

I day case, twenty-four hours after assignment. — Preliminary examina-
tion to be made, including interview with examining physician.

4 day case, fourth day after assignment. — To be presented at morning
discussion.

14 day case. — Investigation to be completed. (If an intensive case, sum-
mary to be completed.)

I month case. — Status to be reconsidered (whether case should be closed
or should be continued for advice and supervision).

3 month case. — Summary of results to be made.

15th of each month records to be brought up to date.

30th of each month monthly statistics to be made up.

A procedure for the work upon a new case has been devel-
oped as follows :

a. Case assigned by recommendation slip.

b. Assignment noted on rotation sheet.

c. Memorandum slip filled out (see Appendix B, Form I).

d. Examining physician seen.

THE KINGDOM OF EVILS 529

e. Patient's story obtained by interview.

/. Registration slip made.

g. Entry made on visitor's monthly statistical sheet.

h. Case folder made.

i. Inquiry slip filled out (see Appendix B, Form II).

y. Decision whether to be dealt with as "intensive" or "slight service"

case made within twenty-four hours if possible. Otherwise case

registered as "slight service," and later if desirable changed to

"intensive."
k. Record folder made out on fourth day (for intensive cases; records

of slight service cases kept in form of "Notes" only).
/. Case presented at morning discussion on fourth day.

The memorandum slip is for rough notes taken from the
medical record or obtained from the patient for use in the in-
vestigation. It is taken along on visits and filed on return to
the office in the folder for the case; so that even before the
record is written there will be some identifying information in
the folder. After the information contained on the memoran-
dum slip has been copied into the record, the slip is destroyed.
The inquiry slip is for the purpose of laying out a plan of in-
vestigation. As soon as all clues immediately obtainable are in
hand, the informants to be interviewed by visit or telephone or
to be written to are listed. Others may be added later on, or
the original plan may be altered. The inquiry slip is taken
along on visits and filed in the case-folder on return. It is
destroyed when the investigation has been completed.

The interview with the patient before any steps in investiga-
tion are taken is considered important. In addition to the
information obtained by the doctor, the social worker needs
certain sociological data for the purposes of investigation, such
as (a) exact names and addresses of relatives, employers,
neighbors, teachers, clergymen, friends, who are possible in-
formants; (b) resources among relatives and friends that may
be a help in social readjustment ; (c) details about the home and
neighborhood: (d) exact knowledge of all the members of the
family group and other close associates; (e) the patient's atti-
tude toward his family and his idea of their attitude toward
him; (/) the ratio between income and expenditures, and the
relation between income and standard of living; (g) the pa-
tient's tastes in regard to employment, recreation, occupation
in leisure time; (h) what relatives or friends have most influ-
ence with him; (i) his own plans for the future.

From the beginning of the department it was considered

530 THE KINGDOM OF EVILS

important to differentiate clearly between the various functions
of the social service. Even when different parts of the work
must be performed by the same person, because of an inade-
quate staff, it is desirable to keep different forms of work
clearly separate, so that each may receive its due share of atten-
tion and may be in line for expansion. After individual case
work, the first duty of the social service that stood out was
assistance in the out-patient clinic, and the first assistant se-
cured was the clinic manager, whose duties are : —

Executive:

a. To direct patients to the examiners during the clinic.

b. To keep in order the records.

c. To keep statistics.

d. To see that reports of examinations are sent to social agen-
cies.

Social:

a. To take the social history of new patients.

b. To assist in discovering and dealing with the social prob-
lems of out-patients.

c. To see that patients and friends with them understand
physician's directions and are able to carry them out.

d. To act as a go-between for outside social workers and the
physicians.

Among other divisions of the social service developed as the
opportunity arose is the follow-up service,^ a routine method
of keeping informed by a card system of the failure of patients
to keep their appointments and inducing them by letter, tele-
phone, or visit to report. This work, besides its clerical as-
pects, has been found to require fine judgment and the point of
view of a social worker, and to show good results in so far as
these factors are present in the worker in charge.

The syphilis service " was developed as a routine system for
keeping syphilitic patients under treatment and securing exam-
ination of their relatives. Here skill and judgment are obvi-
ously required in suggesting to relatives apparently healthy in
most instances a blood test for syphilis. Of 579 persons for
whom examination was sought in the years 191 7 and 1918, 69

» Boston State Hospital, Annual Report 1917 — Report of Director, Psychopathic
Department — Follow-up Service by Dorothy Q. Hale, pp. S3-S7-

= The same — Social Work with Syphilitics and Their Families, by Maida H. Solo-
mon, pp. S7-65-

THE KINGDOM OF EVILS 531

per cent were examined; and of these 21 per cent required
treatment (see cases 41 and 45).

The Men's Club, started at the suggestion of Dr. A. Warren
Stearns as a means of therapy for alcohoHc patients (see cases
6, 58, and 71), proved to be an effective aid in social treatment
for men patients with the habit of alcohoHsm.

The aim of research has been kept in view and as far as
possible material (records, statistics) has been gathered
with a view to possible use in the future in medical and social
investigations.

A study of the psychopathic employee in industry, begun in
19 14, was continued until 1920, through a special social worker
to assist men patients with difficulties of industrial adaptation,
and led to an investigation in the mental hygiene of industry
conducted by the Engineering Foundation of New York. (See
also page 499.)

The principle has been maintained that the search for new
truth concerning human beings rests at bottom upon careful
study of the individual in action. Research and assistance to
the individual in social work are two aspects of the same mat-
ter. This seems to be a truism too simple to require statement ;
but research has become associated with laboratory experi-
ments in the minds of some persons, to such a degree that they
are apt to lose sight of the human value to individual patients
of social case work that is done with the ultimate object of
research.

Plans for special research in methods of social case work
were interrupted by the war. Studies of technique of social
investigation and treatment by the most thoughtful and experi-
enced social workers to be found are clearly the next step in the
development of scientific methods in case work. The psychiat-
ric social service affords unusually favorable conditions for
such study, — with psychologist and psychiatrist at hand to give
their aid, which is indispensable. Moreover, traits of human
nature are more conspicuous and therefore more readily studied
in psychopathic patients. Just as principles of education were
discovered through teaching the feeble-minded, so we may
look for principles of social work to be found in case work
with psychopaths.

The department was organized from the start to permit the
traming of stitdents, for we felt a responsibility to prepare new

532 THE KINGDOM OF EVILS

workers for this field. As none of the schools of social work
had yet developed training courses in psychiatric social work,
we offered an apprenticeship course in which the student gave
full time for six months. The term was later increased to
eight months, as six months was found insufficient for acquir-
ing even the rudiments of social work and social psychiatry.
Several attempts were made to take students on part time for a
longer period, but this plan was unsatisfactory, for the inter-
ruptions in the students' work increased the difficulties of
organization to such an extent that part-time students became
more of a burden than a help. From the students' point of
view, it was apparent that they received much less benefit
from part-time work than from an equal number of days' work
on full time. The full-time student is an asset, taking her
share in routine duties and after a few months giving valuable
assistance in the case work. The presence of students in the
daily morning discussion adds greatly to the value of these
conferences. The alert, inquiring attitude of the student is
stimulating, and the necessity for being definite and clear
enough to be understood by the beginner helps to keep the more
experienced workers in perpetual training.

Another function of the social service from the beginning
has been public education — to promote understanding of men-
tal disease and to reduce prejudice against mental hospitals, and
particularly to help social workers acquire the essentials of
psychiatry. Social workers were encouraged to seek from the
physicians an explanation of the patient's condition and needs
in every case brought by them for examination. In order to
make sure that a correct statement of the examination was filed
with the case record in the agency which had responsibility for
the patient's care, this verbal report was supplemented by a
routine written report consisting of brief summaries of the
physical and mental examinations and intelligence tests. Some
social workers came to depend upon this report without con-
sulting the medical or social workers of the hospital, although
the brief summary of medical findings furnished them was
not sufficient in most cases to serve as a guide to social
treatment.

The social worker would like a written report giving a full
exposition of the case, — the character of the difficulty, the
prognosis, and practical measures of treatment. Such a re-

THE KINGDOM OF EVILS 533

port, however, seems to be so complete that there is still more
danger that the social worker will rely upon it entirely without
further consultation. And there is danger that misleading
or superficial conclusions may be drawn from any written re-
port alone. Moreover, the time required for a physician to
write a careful explanation of the case, adapted to the under-
standing of the particular type of social worker to whom it is
to go, is prohibitive in most clinics and hospitals. The time
required for a stenographer to make a transcript from the
medical record is another matter. It is true that in the present
state of education for social work, a report expressed in med-
ical terms will not be understood by all social workers; but
in every case the worker responsible has the opportunity to
find out the meaning of the medical report. On the whole, the
method of furnishing a transcript from the medical record
and requiring a personal consultation has seemed best calcu-
lated to secure the interests of the patients.

Social clinics have been held every year, sometimes for a
particular group (the Boston Conference on Illegitimacy, a
Red Cross Institute, classes taking extension courses in social
psychiatry at the Boston School of Social Work) and some-
times for social workers at large. A series of clinics for em-
ployment managers was also given. The history and the
actual patient are, as a rule, both introduced. Patients suitable
for demonstration are carefully chosen with an eye to seeing
that the patients do not themselves suffer. In the majority
of instances the patients are actually helped by the clinic, in
that they are made to see the nature of the problems which
they present, and yet are not overborne by the legal authority
which a court appearance would assert. Some of the most
instructive cases, from the standpoint of diagnosis and dis-
position, are in fact cases of delinquency or suspected delin-
quency, in which the clinical demonstration is far less of an
ordeal than would be an appearance in court. As a rule, from
forty to sixty social workers have appeared at the social clinics
so far carried on. Amongst these workers will appear, as a
rule, persons greatly sympathetic with the patient, and the
"third degree" aspect of the meetings is reduced to practically
nil. To many patients, instead of being a severe ordeal, the
experience is rather agreeable. In many cases it is really
beneficial to the patient who is forced by the interest of so

534 THE KINGDOM OF EVILS

many persons to confront his own mental difficulties ana »«
put on his mettle to do the best he can to overcome his limita-
tions. At a clinic for employment managers, one patient suffer-
ing from a persistent traumatic neurosis, John Flynn (case
19), was presented and apparently enjoyed the meeting. A
few weeks later he sent several of his themes, part of an eve-
ning course in English that he was taking at the Trade Union
College, for the physician whom he had met on that occasion
to see, confident that he had a new friend in the doctor.

SOCIAL CASE RECORDS

Most existing record forms in social agencies are admitted
by everybody concerned to be unsatisfactory, either because
they do not contain the material they should or because the
material they contain is not readily accessible. Notwithstand-
ing abundant discussion, very little work has been done on
improved methods of social case-recording. The only avail-
able studies of the subject are the work of Miss Georgia G.
Ralph, Elements of Record Keeping for Child-Helping Or-
ganizations and recent books by Mrs. Ada D. Sheffield, The
Social Case History: Its Construction and Contents, and by
Miss Gertrude L. Farmer, A Form of Record for Hospital
Social Work.

The stage at which a life history was recorded by means of
a printed form seems to have passed. Most agencies now have
an outline of facts adapted to the particular needs of their work
to serve as a guide in recording the social examination. Prob-
ably no record system could be devised that would meet fully
the needs of all agencies. Within the same agency it may
appear economical to use a different form of recording for
"slight service" and "intensive" cases. As a rule the record
of a "slight service" case reduces itself to a brief memorandum
on an index card or a record sheet. It is in the cases where
responsibility is assumed for a complete history and thorough
treatment that the record problem arises.

While the same form will not meet the needs of all sorts of
social agencies, it might seem that the main outline of the
facts to be secured would be the same in any case whatsoever
under social care. The records of different agencies would
vary in the details of some of the subheadings of such a gen-
eral outline. The children's agency would be likely to go into

THE KINGDOM OF EVILS 535

more detail concerning the developmental history of a particu-
lar child than the family agency would need to; the society
for protecting neglected children would require details of evi-
dence not essential to the work of other children's agencies;
in a medical social service certain items of bodily condition
not significant for the general agency might be needed ; certain
details of mental states bearing upon the mental diagnosis
would be found only in the records of the psychiatric social
service. In general the social service of a psychopathic hos-
pital requires for its work just such a record as would be
needed by a children's agency, the parole department of a
reformatory, or a family agency (in individual cases). With
certain modifications, a standard history outline for all social
records might prove very serviceable. It must always be borne
in mind, however, that the value of the record depends not
upon the outline but on knowledge of what facts are significant
and on skill in obtaining information. Given, however, a
skillful and intelligent social worker, a good history outline
as a framework for investigation is a helpful support. With
beginners and less reliable workers, it is an essential.

In considering social case-recording we are of course think-
ing of the history of an individual. The so-called "family
record" is another thing, — there is the story of the family life
to be written. But each member of the family has his own
individual history, which has a claim to be separately recorded.
Each member of the family must be studied separately in
order to understand the family group. And for study of the
individuals of the group, individual histories are required. If
information concerning the different members of the family
is not sorted out and recorded separately, the effect of the
record will be very much like a composite photograph. There
will be a hint of this or that individual member of the group,
but no clear picture. To individualize each member of the
family, it would seem to be essential to record his history sepa-
rately. Certain facts that relate to all members of the family
might be referred to by cross reference in order to save space
and time. The family case worker would perhaps object that
in the process of making individual records the story of the
family group life would tend to get lost. It may be that a
summary of the fofivily would meet this need. We have no
claim to offer a solution for any of the perplexities of record-

536 THE KINGDOM OF EVILS

keeping, — we aim here only to emphasize individuahzation in
social case work.

There is hardly a question anywhere today as to whether
social records should be or not be, — the case is proved that
good records help to make good work. Yet the relative value
of a good record system is indistinctly seen; and many agen-
cies question the proportion of time that it pays to give to
record-keeping. This depends first of all upon the purposes
that the record serves — the ways in which it promotes the wel-
fare of the patient or client.

The immediate purposes of the record are to make the his-
tory available for use (by physicians, as well as social workers)
in a hospital; to save reinvestigation if the case is renewed
after being closed ; to enable a new worker who must take up
the case to understand the situation; and to oblige the worker
to think clearly and to make her work definite. Social records
serve also the ultimate purposes of furnishing material in ac-
cessible form for social and medical research ; making it pos-
sible to study the work of the agency and estimate its
performance; furnishing standards for bringing the work of
other agencies to a higher level ; and affording material for
teaching students. »

The necessary documents of the record we have found to be :

a. A brief first sheet giving identifying information and facts
needed for statistics (see Appendix B, Form I).

h. History (record of the investigation or social examination;
for outline see Appendix B, Form II).

c. Treatment (record of the action taken, the current history
of the case under social care).

d. Summary of history.

e. Summaries of treatment and results at regular intervals and
when the case is closed.

/. Address sheet for addresses in current use.

g. Financial sheet for expenditures or special donations.

h. Correspondence arranged chronologically.

Examples of full records of cases 46, 89, 94 are given in
Appendix A; examples of "Summary" will be found in cases
20, 24, 32; and examples of "Results" will be found in cases
31 and 62. The summary of the history is prepared under
the divisions of social, physical, and mental history, and re-
sults are summarized every three months in the same manner.

THE KINGDOM OF EVILS 537

In the discussions of social workers there seems to be an un-
certainty of opinion as to the nature and uses of a summary.
Some look to it for a full presentation of the case, a complete
digest of the history, which is recorded elsewhere in the form
of interviews and letters. We conceive the summary as the
briefest possible statement of the essential facts of the case,
following in form the outline used for collecting the data. The
judgment of the worker in selecting the essential facts neces-
sarily enters into the summary. A thorough consideration of
a case cannot be based upon a summary alone. In our case
conferences the summary is supplemented by comments and
questions. There have been certain attempts to adapt the five-
fold classification of the Kingdom of Evils to the purpose of the
summary by using the positive aspects of the evils there com-
prised as headings for a summary, but this is a mistake; for
the fivefold classification is far from being a scheme for the
collection of data but is proposed as an orderly method of
case analysis. The summary is a synthesis of the case, in-
tended to present a vivid picture of the main outlines of the
individual's history.

One of the chief difficulties in studying methods and results
in social treatment is the lack of information in the record
concerning the plans and purposes of the social worker. It is
usually impossible to form any idea of what the patient owes
to social care and what to "nature." The technique of treat-
ment can rarely be discovered from the record. There may
or may not have been a method in the treatment, as far as the
record shows. One way of supplying this deficiency is to
record at the beginning of the "treatment record" the general
plan that is to be followed and to indicate in the periodical
summaries of results the modifications of the plan later adopted.
Sometimes a social record will go to the opposite extreme and
consist largely of the worker's own plans and opinions to the
exclusion of information concerning the patient. It is easy to
slip into the habit of recording intentions and impressions
rather than to make the effort to secure facts.

In order to make a clear distinction between the current his-
tory of the patient under care and the social worker's plan and
methods in treatment, an effort was made for a time to keep
a "treatment sheet" separate from the main case record. (For
examples, see cases 14, 17, and 36.) This attempt had to be

538 THE KINGDOM OF EVILS

given up under pressure of work after a short trial ; but the
device seems to us to offer promise of better study of method
in social case work. At the same time it has a tendency to
make the treatment more definite and effective, and to stimu-
late ingenuity and resourcefulness in the social worker. It
might be just as well to make the "treatment" entries on the
regular record instead of on a separate "treatment sheet," pro-
vided the statements of aims and methods were arranged in
such a way that they would stand out clearly.

TECHNIQUE OF SOCIAL DIAGNOSIS AND TREATMENT

Concerning the technique of social diagnosis and treatment
we do not claim any approach to complete discussion, even of
the facts which we note in this book. As a preface to such
remarks as we make below upon social technique and diag-
nosis, we wish to speak of what has been called "family case
work" and to make a general remark about it. The unit of
interest in social case work, like the unit of interest in social
reform and even in theoretical sociology, has often been the
family group. "As society is now organized," says Richmond
in Social Diagnosis, "we can neither doctor people nor edu-
cate them, nor launch them into industry, nor rescue them
from dependence in a thoroughly social way without taking
their family into account. Even if our measures were for the
welfare of the individual solely we should find that the good
results of individual treatment crumble away often because
the case worker has been ignorant of his client's family his-
tory." (Richmond used the term client instead of the term
patient, which at least in medical social work seems to us
preferable.) Briefly put individualization in social treatment
unconditionally requires consideration of the family group.
Richmond quotes the Swiss neurologist Dubois and the Ameri-
can neurologists Healy and Putnam in support of these con-
tentions with which we must all perforce agree. The follow-
ing items in the family group relations are discussed by Rich-
mond. The main drift of the family life, what is it on the
whole? The important distinction between the united family
and the unstable family (especially emphasized by Mrs.
Bosanquet in her book The Family). The necessity of "see-
ing the man" as well as the mother of the family and of seeing

THE KINGDOM OF EVILS 539

him at home; the question of the unmarried father; the ques-
tion of the young couple requiring reUef ; problems of de-
sertion and inebriety; the wife and mother; the home situa-
tion; the family housing; children (here we find the blood
relationship and all those undercurrents of antagonism which
it implies) ; the other members of the family group including
undesirable relatives. Volumes should and must be written
upon these questions of the family group. Of particular value
in a study of family cohesions (the united and the unstable
family as distinguished by Le Play) will be the psychiatric
point of view. Families are said to "arrange themselves along
a scale with the degenerate family at one end and the best type
of united family at the other." But what is the degenerate
family in many or most instances except a family with psycho-
pathic trends in one or more members? Then there are in-
stances like that of Henry Loyal (case 4) of Book I in which,
except at times, there was extraordinary close cohesion of a
degenerate family. Even in this instance the family "solidarity"
proved as social workers have always insisted to be the greatest
asset. Another good psychiatric point is the systematic point
of seeing husband and wife separately so that each may get an
individual opportunity to present the personal view. .Where
character deviation enters, this point comes out in strong relief.
With respect to the unmarried father as well as the unmarried
mother, an enormous insistence has to be made according to our
view upon the question of greater or lesser feeble-mindedness
in the erring parent. If a wife and one or two babies of a
young able-bodied man in ordinary times need any service that
involves social work, this is a situation that demands the
closest scrutiny and to our mind the closest psychiatric
scrutiny. Neglectfulness, slackness of such degree as to in-
volve the necessity of dole-giving, certainly need a psychia-
trist's attention. "Laziness" is another phenomenon which
not seldom turns out to be in some way psychological.

Inebriates would nowadays one and all be subject to psy-
chiatric scrutiny. There is one set of statements that can
safely be made about all inebriates. Richmond quotes Neff
favorably to the effect that "the treatment of the inebriate can
best be expressed in the word individualization." The like can
be said of the family deserters, male or female. Perhaps the
relation of psychiatry is not too evident in questions of home-

540 THE KINGDOM OF EVILS

making and family housing and many programs of social re-
form have in the past endeavored to center upon conditions of
housing and home-making, which w^ould in part at least derive
not so much from economical disability as from ignorance,
bad habits, or even mental defect. It is extraordinary what
different reports will be rendered concerning some family sit-
uations by workers who have the economic view uppermost
and by psychiatric workers. As for children, here the work
of Healy, as Richmond rightly claims, is far beyond his chosen
scope of mere delinquency and points the path of psychiatric
social work far beyond the confines of potential crime. The
psychiatric worker tends to look at social situations rather than
at family groups. The psychiatric social worker finds social
situations dominated by psychopaths, by one or more persons
whose mental disease or disorder may be extremely mild and
entirely invisible to members of the social group in question.
Sometimes the remote members of the family group or the
boarders and lodgers, and even the neighbors, may have a
more penetrating view of what is really going on.

We are more and more tending to insist that each social
situation, looked into by the psychiatric social worker, shall be
analyzed in the end according to the number of persons in-
volved. This number of involved persons may be small or
large. But we almost always find that the number of distinct
and separate points of view in each social situation is com-
paratively small. In a quarrel between a husband and wife
there may be two points of view and the social worker may
add the third point of view. Whereas the husband and wife
are agreeing to disagree within four walls, the social worker
may upon analysis advise another policy, that of separating
husband and wife for a longer or shorter period. Of course
the worker cannot execute any such policy without the consent
and approval of all legal, ecclesiastical, and medical authorities
engaged ; the supposition in the textbook is that the decision
of the social \\orker is supported by these authorities. Or
again the husband and wife may have separated and entertain
antagonistic views of what the family ought to do, whereas
the social worker may leap into the situation with the idea of
reunion. The point we here make is that after all the persons
in the social situation have been listed (somewhat after the
manner of the dramatis personae in plays) the really distinct

THE KINGDOM OF EVILS 541

and separate points of view in the social situation are to be
analyzed and listed (just as one might distinguish the prin-
cipals and accessories in a dramatic cast). We have not con-
sciously adopted this method to any extent in the analysis of
the material of this volume, although in effect we have often
got practical results, — consider, for example, Henry Loyal
(case 4) or Alice Nardini (case 31).

But how shall we distinguish the principals and the acces-
sories and the less important units in the social situation ? The
psychiatric social worker learns that the family is not the unit
of interest for psychiatric social work but finds that the unit
of interest is the individual in his group. There will be found
one, two, three, four, or perhaps sometimes five, but rarely
more than five, human units of interest in social situations.
The children may split as to what they want done, some going
with the father and some going with the mother. Relatives
may take a third point of view separate from that of the father
and mother. Sometimes the social worker may enter with
still a fourth point of view and so on. But many of the per-
sons listed as engaged in the social situation turn out to be of
subordinate importance in that situation. They add themselves
in to enforce a little more strongly some particular policy but
they are accessories agreeing with the policies of some prin-
cipal. How shall these principals be defined? They are, we
think, non-interchangeable elements in the social situation.
They are not merely associates like the members of a club
but they are consociates like the officers of a club that have
separate functions not interchangeable with one another. How
many separate, non-compatible, non-interchangeable points of
view are logically to be found in a social situation? This is
the real question which the social case worker must strive to
answer. The family is a consociate group of persons (as
father, mother, children) having separate and non-interchange-
able functions. Their intimacy of relation, or, as we may say,
their consociate relationship may fall apart, particularly under
the influence of something psychopathic in some member of
the group. They become mere associate members of the group
— that is to say, they are no longer intimately united with one
another or even possibly quite antagonistic. Indeed, their an-
tagonisms may be so intimate that they become almost friendly
enemies, suggesting mutual antagonism, like two universities

542 THE KINGDOM OF EVILS

such as Harvard and Yale. These members of the group whose
views simply add themselves into the views of some principals
in the situation are merely associates in the situation. Their
views are interchangeable with one another. They numerically
strengthen a point of view — they do not determine it.

It is upon these lines that we predict the careful social
analyses of the future will run. Upon these lines we shall
study more effectively the relations of man to man, man to
woman, and woman to woman, whether these relations are
dual, triple, quadruple, or still more complex. Throughout all
this study the psychiatric social worker will be apt to see with
great clearness the predominate importance of the psycho-
path. But the psychiatric social worker will study each mem-
ber of the social situation individually, and each from his own
personal point of view, so that there will be no psychiatric
prejudice in the long run. We conceive that this kind of
analysis has a range much greater than yet afforded by avail-
able analyses of the family group. But we also know that it
would take a long time to reach the confines of the vista.

Discrimination between the summation of evils and the
multiplication of evils has been referred to (case 8) as hav-
ing a bearing upon social treatment. In one case the elements
of disorder may be loosely combined, heaped, while in another
case they are tightly combined, coiled. It is important to know
whether we are dealing with siinnnands or factors. Evils
multiply into one another. The effect of hypersexuality and
lack of information about sex lead to more difficulty com-
bined than the sum of the two evils alone. (See also
Book IV.) The case of Rose Talbot, intelligent sex delin-
quent (case 8), gives an elaborate example of tightly coiled
troubles. A contrast of our first case, Agnes Jackson, with
this case brings out clearly the sum of troubles versus the
product. The Jackson case is a simple additive case,
M-|-E-|-V+L+P, while Rose Talbot is a complex multiplica-
tive case, MXEXVXLXP. In a multiplicative,
interpretative case, if you remove poverty you change the whole
situation; but in the simpler additive case you may send the
patient for various sorts of help to various sources, dealing
with his difficulties one by one. The case of Elliot Calderwood,
misrepresented "little fiend" who proved quite amenable (case
22), as an example of educational, legal, and economic diffi-

THE KINGDOM OF EVILS 543

cultles, is a case in which the factors of difficulty were not in-
terwoven in any practical sense and could be disposed of in
turn, — the misunderstanding with the court set right (L), a
home provided (P), education started (E).

Will the difficulty of social treatment vary with the tightness
of the coil, or on the other hand will the whole coil unravel
quickly when the secret is found? There may be cases for
quick treatment, where a single line of action will solve the
problem. Cases that are sums of social trouble mean increase
of steps to be taken in treatment, — they are logically simple
but time-consuming. We cannot hope to do more in this book
than suggest the idea of the social sum versus the social
product as a method of approach in social treatment.

Psychiatric social work employs the technique of general
social work in so far as systematic methods have been de-
veloped in social case work. There exists a certain amount of
technique of social examination (usually called "the investiga-
tion") that is now generally agreed upon and made available
in the literature of social work, and a smaller amount of tech-
nique of social treatment, which is fairly definite, although
still somewhat tentative. Scientific methods of examination
will naturally precede scientific methods of treatment, for al-
though in the development of its practice social work first
learned to treat and later learned to examine (or "investi-
gate"), in the development of scientific method examination
must necessarily come before treatment. So that the newly
created psychiatric social worker finds already at hand a con-
siderable body of systematized experience in examination and
a small amount in treatment. Obviously it is the part of wis-
dom to acquire this technique, which is the accumulated experi-
ence of twenty-five years or so of tentative effort toward scien-
tific method. The new psychiatric social worker impatient
with the disregard of mental science in the general technique
may have an impulse to discount the experience of social
workers in the past and begin all over again. Sometimes under
the influence of physicians whose acquaintance with social work
in the past has been slight, and perhaps on that account unsat-
isfactory, the psychiatric social worker is inclined to discard
the incomplete technique of social work altogether, and to feel
a naive responsibility to create a new profession. But the ex-
isting technique is not so much incorrect as it is incomplete.

544 Tf"HE KINGDOM OF EVILS

The ambition of psychiatric social work should be to modify
and add to the general technique of social work new methods
developed by special experience with psychiatric cases.

Some of the more conspicuous points at which psychiatric
social work may be expected to influence the technique of case
work are: (a) individualization in both examination and
treatment; (b) objective accurate observation; and (c) train-
ing of character through use of the emotions. The subject of
individualization has been discussed elsewhere. (See cases 48
and 87, also pages 378 and 379.)

Focusing upon the individual soon leads to the recognition
of the fact that human beings are infinitely varied and cannot
be rated for practical purposes at certain levels of merit.
Within the same personality are to be found faults and virtues,
abilities and disabilities. This point of view often gains re-
spect for even the most unsuccessful individual. In cases
where failure is due to natural causes too strong for the in-
dividual's control, the knowledge of this fact will eliminate
the attitude of blame that we instinctively feel for misconduct.
The question of praise and blame is important for social
workers. Undoubtedly much harm is done by the discourage-
ment and loss of energy that blame produces; and praise is
obviously an effective therapeutic agent. One of the primary
aims of the social worker is to deepen the sense of moral re-
sponsibility ; a process which is apt to involve frequent expres-
sion of disapproval. But it is doubtful whether reproof and
blame promote this object. The truth of the matter probably
is that reproof or blame as ordinarily administered is com-
pounded of our knowledge of the error and our impatience
with it. It is perhaps the tinge of personal impatience that
gives blame its unpleasant quality. Many unfortunate psycho-
paths who have been censured and despised by acquaintances,
and often by social workers, when they meet the psychiatric
point of view, feel a sense of relief and renewed self-respect
and are stimulated to fresh effort. (See cases 2, 4, 6, 12, 13,

52' 98-)

Another product of the psychiatric point of view is the habit
of objective observation — the study of an individual as he
really is, not as we feel that we should be in his place, or as
he himself tells us that he is. In social case work we need to
know accurately the nature of our patient or client. We do

THE KINGDOM OF EVILS 545

him an injustice if we form a conception of him in terms of
our own experience. His own account, though honestly
meant, may not be accurate. Through observation of his be-
havior and reports of other observers upon his conduct, the
best account of his character is to be obtained. When we come
to the point of trying to understand him, we must necessarily
think in terms of our own experience, but the objective study
should precede the interpretation. We first find out what an
individual is like, and then think how we should feel and act
if we were like that. This process of objective study, preced-
ing subjective understanding, simplifies many problems in
social work and promotes sympathy. Personalities quite un-
like our own when studied objectively become comprehensible.
Training through use of the emotions rather than through
appeal to reason is a familiar technique of everyday life in
dealing with children and in getting our own way. Everyone
is familiar with the practice of asking a favor when the pros-
pective donor is in a good humor, and upon the strength of the
resulting good feeling after a suitable interval asking another
favor, thereby helping to develop habits of generosity in the
donor. Such technique seems to be the most hopeful method
of training individuals in whom misconduct is the result of
emotional instability. In discussing this point we cannot do
better than to quote somewhat at length from A Psychiatric
Contribution to the Stu/^y of Delinquency, by Dr. Herman
M. Adler (see also page 487), who as chief of stafif at the Psy-
chopathic Hospital guided the first efforts of the social service
in cases of delinquency: —

"It would seem that by careful training based upon an analy-
sis of each individual — especially from the behaviorist's point
of view, considering the past life and career rather than self-
explanatory, subjective statements — it would be possible to
influence the future conduct of these individuals {i.e., the
emotionally unstable). While their fundamental equipment
cannot be changed, these people suffer more from the effects of
their conduct than from their subjective attitude towards them-
selves or their environment.

"Thus, as Kraepelin points out, alcohol is an important fac-
tor in producing the final downfall. Extravagance, profligacy,
sex excesses, bad companionship, and so forth, are the factors
which combine to cause the social difficulties. The suggesti-
bility of these individuals, their intelligence and insight, which

546 THE KINGDOM OF EVILS

is usually adequate for their needs, can be made use of in
acquiring and strengthening the habits which the individual
would never be able to gain if left to himself.

"What is desired, therefore, is a system of mental and emo-
tional exercises for the purpose of habit formation. This
might be designated as orthopsy chics. This term is further
applicable in that a good many of those cases are instances not
of disease in the sense of an acquired, deteriorating process, but
rather comparable to physical deformities. For the present,
our experience in orthopsychics is limited. We have had a
few cases in which, after a preliminary survey at the Psycho-
pathic Hospital, a course of training has been applied, which
has consisted above all in arousing the interests and appealing
to the pleasure-loving side of the individual. It is a well-
known fact, for instance, in dealing with wayward young
people that even under the most advantageous circumstances
and even with the most favorable and friendly environment,
the individuals do not do well. This appears to be due to the
fact that the emotional impulses are of short duration and leave
no strong impressions behind them. Therefore, when the
novelty of a situation has worn ofif, there is nothing to hold the
interests of the delinquent and tide over the tedious days of
monotonous routine.

"We have proposed in a number of cases (and have carried
it out to some extent in a few) to arrange to change the en-
vironment of each individual before the novelty has quite worn
off. The length of time in which an individual stays in each
home varies in each instance, and must be determined carefully
each time. We are all so prejudiced by our early ethical
training that it is difficult to be ])erfectly objective in dealing
with these people. It is hard to eliminate pedagogic and purely
academic demands for that which we consider right. None
the less, this must be done, and in every instance, in every
disagreement, at every change in the routine of the individual,
emphasis must be laid on the fact that it is done from a medical:
point of view, that is, from a point of view of theirapy and!
help, with kindly feelings toward the patient, and' never- as a.
corrective or as a punishment, and al)Ove all. never- vind'ictiVel'y.,

"Education and training, therefore, rather than punishment
are the methods that hold out a chance of success. These indi-
viduals are not able to team by experience. They receive the
equivalents of punishment in their daily life, which are suffi-
cient to influence the formation of adequate resistance in a
normal individual. In these individuals, while they often recog-
nize the full significance of those circumstances in which their

THE KINGDOM OF EVILS 547

delinquencies placed them, their experi-inces have no corrective
influence.

"To punish such an individual, therefore, is to increase his
defeat rather than to strengthen his defenses. It is like admin-
istering alcohol to the patient suffering from delirium tremens.
It is like injecting diphtheria toxin into the circulation of a
patient suffering from diphtheria. We may draw a final anal-
ogy from immunology in applying this therapy :

"The first duty is protection against the immediate effects of
the acute attack. In our cases, this means freeing them from
their immediate difficulties, supplying them with food and lodg-
ing, helping them to recover from alcohol and drug intoxica-
tion, relieving their physical symptoms, curing them of venereal
disease, and building up their physical health.

"In the second place, immunization : This is often in the
nature of after care, and cannot be achieved at once, but can
be accomplished by a building up of the defense habits, by
training, and not by overwhelming an already breaking organ-
ism with the hostile conditions, but by gradually strengthening
their habits so that they will meet the particular unfavorable
conditions without fear of breakdown. In the group of emo-
tionally unstable, this offers great hope."

The relation of social worker to patient (or client) seems
to be causing the development of a new professional attitude.
The ideal attitude of the established professions, such as medi-
cine, education, theolog}', is one of authority and impersonal
friendliness. The effective attitude for the professional social
worker is essentially the same, but the proportions of authority
and friendliness are reversed, and the friendliness is less im-
personal. The social worker (except the probation officer)
carries no such authority as the institutions of hospital, school,
and church bestow, but must rely for prestige upon her ability
to help. The friendliness of her relation to the patient, in
sticcessfut treatment, i"s of a high degiree;- for almost imme--
diiately she secures an exceptional intimacy with the patient's,
whol'e interior and exterior situation. The patient responds to.
this sudden intimacy by regarding her as a near friend. To
influence him throughout the intricacies of social adjustment
she must preserve this regard. She must identify herself with
him, directing him from his own point of view, giving him
the counsel of "a friend" not merely the advice of "an au-
thority." On the other hand she must preserve enough of

548 THE KINGDOM OF EVILS

the element of authority to be a decided and respected influence.
This continuous intimate relationship is apt to make the social
worker very sympathetic ; but even in the most appealing cases
she must combine with her sympathy an objective impersonal
attitude that will leave her judgment free. When it is said
in justification of a social worker "she puts her heart into her
work," it must not be forgotten that the patients have a claim
upon her head as well. The social worker must find a way
to be at the same time a personal friend and an impersonal
adviser.

The fact that the social worker stands to the patient in the
light of a friend might seem to argue the importance of hav-
ing but one worker deal with a case throughout the period of
social treatment. But this In our experience is not so impor-
tant as it might seem. A change of workers can be made with-
out loss and may even be an advantage. In any case under
long-time treatment, with the changing stafif of a hospital, it
is unavoidable that there should be several different workers
in succession. Some of our most successful cases have had
as many as six or seven social workers, and three or four
workers not infrequently deal in turn with one case (see cases
8, 32, 94). The success of the transfer of a case to another
person depends of course upon the skill of the workers con-
cerned and upon their consideration for the feelings of the
patient. In some cases the patient likes his new social worker
better, and in most cases he feels it is some advantage to have
acquired a new friend. There may be of course some loss in
a case where tlie patient has gradually come to confide in the
first worker ; but such loss is apt to be overestimated. The
bringing in of new ideas and influences through a new worker
may be a positive advantage to the treatment.

The patient will feel decided opposition to the transfer if
he has formed an excessive attachment to the social worker,
but this relationship is not to be encouraged in any case. An-
other reason for objection from the patient may be that he
fears opposition from the new worker in something which he
has been allowed to persist in doing. On the whole we believe
the best results come from teaching the patient to look upon
the social agency or the hospital as the source of help and direc-
tion, medical and social, and inspiring him by uniformly con-
siderate treatment to feel confidence in every member of the

THE KINGDOM OF EVILS 549

Staff who deals with him. This might appear as a theoretical
principle too ideal for application, were it not that it is a con-
clusion derived from actual experience. We have found the
point of view to be of more importance than the personality
of the worker (see also case 8).

MEDICAL TREATMENT IN SOCIAL CASE WORK

We do not deal systematically with medical treatment in
this volume. Hamilton Green (case i8) was an "eye" case —
a man with severe astigmatism. No doubt the treatment of
the astigmatism is indispensable in the handling of Hamilton
Green. Yet it would be improper to think of Green as merely
an eye case or of the treatment of his eyes as the essential
thing in his case. Good but subordinate effects were gained
by baths for Agnes Jackson (case i). In fact, the excellence
of hydriatric treatment in cases of dementia praecox has been
pointed out by our colleague, H. M. Adler, in his analysis of
the effects of baths in different forms of excitement (contrary
to expectation, Adler found that better effects of an important
nature were secured in cases of dementia praecox than in cases
of manic-depressive psychosis). It would be natural to draw
hydrotherapy into the foreground in this or in other cases
v/ith which we are familiar. The baths serve to draw patients
to hospitals, and an unfailing stimulus to the size of the out-
patient clinic is the establishment of a good hydrotherapy sys-
tem so associated with the clinic that proper hydriatric pre-
scriptions can be made for systematic treatment. It does not
do to scoff against these baths as some observers are apt to
scoff. Possibly they are not essential to the treatment of any
form of mental disease whatever (always excepting forms of
excitement) ; possibly they are not even indispensable aids in
treatment in many cases; but though they may be neither
essential nor indispensable in treatment, baths remain impor-
tant aids to any clinic. Moreover, it must be conceded that
the true effects of hydrotherapy have never been scientifically
measured by the metabolic chemists or otherwise.

Similarly with dental treatment which comes especially
into question in the case of Margaret Dolan (case 38) whose
dental defects and indigestion complicated a mental situation
which was itself the result of a well-founded wrong. Despite

550 THE KINGDOM OF EVILS

all Margaret Dolan's financial trouble and the death of her sis-
ter, she recovered with social aid. Another dental case was that
of Nathan Rosenthal (case 49). The dental complication was
subordinated here also, but this always subordinate influence
was still important. Social workers so often ask what the
effect of dental treatment is upon mental diseases; owing to
the fact that extraordinary claims have been made on behalf
of dental work (especially extraction) in cases of mental dis-
ease. The public prints have in recent years been full of such
claims. The rational answer to this question is that a few
cases are marvelously benefited by proper dental treatment.
These improvable cases are no doubt those in which pyorrhea
or other infection about the teeth is responsible for mental
symptoms through a process of septicemia (with bacterial in-
vasion of the blood) or toxemia in which bacterial poisons find
their way into the blood. Michael Piso (case 62) suffered
extensively from pyorrhea but the dental treatment thereof was
only a part of the total treatment of Piso which served in the
end to raise his wages and procured relatively complete family
adjustment with abolition of jealousy.

Occupational therapy is a means of treatment of the in-
sane in institutions and of psychopaths outside of institutions.
In war time groups of occupational therapeutists were trained
to get ready for contingencies of disease amongst our Ameri-
can soldiers; and the work of these occupational therapeutists
was so good and the outlook for their need under civilian con-
ditions is so well established that the work is likely to be con-
tinued. An extensive literature has been built up around this
form of therapy. Instances of its employment are afforded by
Agnes Jackson (case i) and Kevork Ardinian (case 26),
though both cases illustrate relative failure rather than suc-
cess in occupational therapy. A successful instance of its use
is John Flynn (case 19).

Our group of cases is decidedly not representative of the
values of occupational therapy and it would be a highly
meritorious work for someone to collect a series of clearly diag-
nosticated cases of severe or mild mental disease and defect
for the purpose of tracing the exact ways in which occupa-
tional therapy works in the different forms of psychopathy.
For example, the reasons for the relative failure of occupa-
tional therapy in Agnes Jackson and its absolute failure in the

THE KINGDOM OF EVILS 55 1

case of Kevork Ardinian are different reasons and conse-
quently do not have a word to say against the general values
of such therapy. We should not forget that in the background
of our minds the main value of sending the feeble-minded sub-
ject to a school for feeble-minded is the elaborate occupational
therapy which he wall there secure. Perhaps it is not too much
to say that the theory of occupational therapy will be built
up from the work of the schools for the feeble-minded.
Workers in Massachusetts and in the country at large are
familiar with the principles of such therapy for the feeble-
minded as developed by Dr. Walter E. Fernald at the Massa-
chusetts School for Feeble-minded in Waverly. These methods
were first proposed and in part carried out by the eminent
early worker with the feeble-minded, Seguin. An effect
of the new theory of occupational therapy for the feeble-
minded as proposed by Seguin, Fernald, and others is the
proposal by Madame Montessori for new methods of educa-
tion of the normal. We can forbear to insist that such workers
as Seguin and Fernald are working along lines more in the
interest of the normal than in the interest of the abnormal.
These men and all mental hygienists are not making the frontal
attack upon education which the teachers of the normal are
making; but the flank attack by these mental hygienists may
yet prove as successful as the more obvious forms of frontal
attack.

Whilst we are talking of occupational therapy it is impor-
tant to remember also the work for the chronic insane as car-
ried out in the industrial shops and on the farms by victims
of dementia praecox and other forms of mental deterioration.
Colonies for the systematic development of the working powers
of chronic patients have been established by some state gov-
ernments, either separately or in connection with existent and
exceptional units. From this source also it is to be hoped
that new theories concerning the fundamental principles of
work and industry may accrue. There is hardly any better
way to evaluate the excellence of state institutions for the
insane than to ask to see the industrial shop work and the
farm work of the hospital patients. The best hospitals have
efficiency recording devices which stimulate their officers to
the securing of higher quotas of active workers and to increase
in the number of hours of patient-occupation. Not so much

552 THE KINGDOM OF EVILS

can be told from striking exhibition of arts and crafts by par-
ticular patients as from the statistical story afforded by the
annual reports of institutions. Occupational therapy is a most
important branch of mental hygiene. The theory of it is in-
complete. The value of what has been done is not doubtful.

EDUCATION FOR PSYCHIATRIC SOCIAL WORK

What difference will it make to the world whether we con-
sistently unfold the social side of the mental-hygiene program
and develop a group of trained psychiatric social workers?
The functioning elements in the mental hygiene of the present
day appear to be three in number, all indispensable though of
different scope and values. Mental hygiene would of course
be nowhere without the psychiatrist or neuropsychiatrist as
its professional leader. In mental hygiene conditions are the
same as in the general field of preventive medicine and public
health. After all, the things to be dealt with in the present
phase of civilization are diseases and defects, and the fact that
mental diseases and defects come in question does not mean
that physicians lose their responsibilities or can by any means
hand them over to psychologists or social workers. To be
sure, not all physicians have yet seen the light of their duties
in public health and there may be a few moribund psychiatrists
that do not see their responsibilities in mental hygiene. But
the topic of mental hygiene engrosses the interest of national
technical associations that deal with mental and nervous dis-
eases and plentifully scatters the literature, quarterly, monthly,
and weekly, with propagandist articles of high level. Even
certain daily newspapers carry mental hygiene topics under
the medical banter.

But let not the physician nor the psychiatrist feel that
mental hygiene begins and ends with medicine or psy-
chiatry. The recent extensive review of ten years' activities
in mental hygiene by Dr. Lewellys F. Barker shows the almost
universal relativity of mental hygiene, and discovers hardly a
field of human activity to which mental hygiene is not germane.
But the practical relations have so deepened and solidified in
certain places that their intensive values almost outstrip the
extensive relation which Barker so broadly expounds. By
practical relations are meant those above specified in addition

THE KINGDOM OF EVILS 553

to medical relations ; namely, the relations with the psychologist
and the social worker.

For the moment it is not our duty to discuss the values of
the psychological examiner in the field. Those values do
not need to be justified. Recent analyses of concrete work
in our field have shown that the psychologist can often do
more in an hour's contact with the patient than the social
worker or even the psychiatrist can do in ten, twenty, or even
one hundred hours of contact. The trouble is that the psy-
chologist runs out of technique and method after his hour is
up. He can do nothing more in the second hour of contact
with a human being with whom he is in sympathy. Accord-
ingly the work of the psychiatrist and of the social worker,
though less intensive and powerful during the first hour of
contact with the patient, lasts much longer and may in the long
run effect far more. Both from the standpoint of prescrib-
ing medical or social adjustments and from the standpoint of
making these adjustments really work in a compound environ-
ment. Let no one, and especially let not the psychiatrist or
the social worker, look with contempt or with uneasy appre-
hensiveness on the work of the psychologist. But the psy-
chologist is a scientific rather than a practical person. He
has at his command more the method of a science than the
technique of an art. He differs in his relation to our topic
from the psychiatrist and from the social worker, both of
whom are primarily engaged in the practical arts of medicine
and social work. To be sure, the difference between applied
science and the technique of a highly advanced art is so very
slight that a pragmatist might well inquire whether they were
not identical. Now and then a psychologist will be found
claiming himself to be a sort of practitioner. He claims to
become a sort of social or psychic technician rather than a
methodologist at work at the fundaments of things. But on
the whole the psychologist remains "-ologist," a man of science,
and after he has exactly applied his strict categories in a brief
time to the problems of the patient or to the classifications
of an applicant for work, his province as a psychologist comes
to a sharp limit, beyond which hrs activities are little more
than those of an educated layman.

We trust that in all this we shall not be charged with be-
littling psychology which as a science, and as in some sense

554 THE KINGDOM OF EVILS

the deepest of sciences, must in the long run prove as broad
a field as that o£ medicine or even as the fields of physics
and chemistry. There is nothing that one would like better
than to contribute to psychology as a science. Nevertheless
psychology contributes method rather than technique, is work-
ing at the fundaments and generalities rather than the outcrops
and specialties of social work.

What then shall we say about the social worker? In the
first place there may be some lingering doubts in the minds of
physicians, or administrators, of politicians, of various chari-
table authorities, whether there is a definite field of social
v/ork, but we take it that the National Conference of Charities
and Correction, recently renamed the National Conference of
Social Work, proves in all its recent transactions that there is
a field of social work. It is in point that Isaac Ray, perhaps
the greatest of the early American psychiatrists, was one of
the founders of the Social Science Association. Nowadays
we think more of social arts than social science and it was
rather a service to our cause to have the National Conference
name itself a Conference of Social Work, though the phrase
is at first sight bungling enough. The object of these workers
in selecting that title was not that they felt themselves the only
workers in the world but that they did not wish to be dubbed
"scientific" and, as we in the American scene so constantly
say, impractical.

It is entirely clear that social work is taken by most of its
votaries and propagandists as an art and not as a science.
This, it seems to me, is as it should be. The social worker
has in some ways identical aims and purposes with those of
the psychiatrist. Both are practical workers engaged in social
and medical arts which to some extent fuse and overlap but
which in the long run will not interfere with each other any
more than the physician and the nurse, or the public-health
man and the public health nurse, will interfere with one an-
other. Two psychic bodies can occupy the same place at the
same time without breaking any important laws of the world's
construction. It is perhaps hard to get both the physician on
the one side and the social worker on the other to acknowledge
the indispensability of each in a field where a single authority
appears to be necessary — the field, namely, of the family dis-
rupted by its central or subordinate psychopathic figures.

THE KINGDOM OF EVILS 555

Let US assume in this argument that the physicians and the
social workers in general agree upon their respective duties
with respect to the same corpus vile.

What now about the medical social workers? Is not med-
ical social work a very special and limited field within social
work in general ? Is not social work, the technical or applied
side of sociology, an economic rather than a therapeutic field?
Will not the bulk of the problem be settled on an economic
line? What the statistical truth here is remains obscure. All
medical social workers will agree that whatever the statistical
truth about mere economics as applied to social difficulty, there
is enough to do in medical social work to require a large corps
of especially trained medical social workers. There is now
in its early years of development an association of medical
or hospital social workers, the American Association of Hos-
pital Social Workers, which is to meet an affiliation with the
National Conference of Social Work. The medical social
workers form, as it were, a neat little trades-union of their
own. They do not require laudation or special support from
any source. Medical social work has justified itself.

What about psychiatric social work? Every medical social
worker should obviously receive a large amount of social psy-
chiatric training in his or her school of social work, and
a fortiori should receive more and more if the mental hygien-
ists are right in thinking that more than one out of every two
cases of social trouble is a psychiatric case. Should there
not be courses developed in connection with every school of
social work that shall give a sufficient fundamental training
to social workers in psychiatry to allow them to effect proper
contacts in their practice? This is undeniable and we are
heartily in accord with a program for giving the psychiatric
touch SO' far as that is possible to every social worker. It is
almost inconceivable that social-work courses have not, for a
decade past, developed in their curricula lectures and demon-
strations dealing with the common, nay universal, phenomena
of syphilis, feeble-mindedness, epilepsy alcoholism, and even
somewhat concerning the obscure field of the so-called psycho-
pathic personalities.

Of course the social worker might readily get beyond the
range of everyday medical practitioner in these regards, at
all events if we consider the medical practitioner of elder

556 THE KINGDOM OF EVILS

vintages. But this comparison is a bit odious and it is cer-
tainly not the duty of those who make the curricula of schools
for social work to dampen their ardor just because medical
schools have grievously neglected psychiatry.

Another question of deeper interest to the close student
of mental hygiene is the question whether there ought not
to be special schools or curricula that deal with psychiatric
social work with the endeavor to produce a special brand of
social workers, — ^psychiatric social workers. It is a matter
of history that Smith College, with the assistance of Dr.
Spaulding, the New York School of Social Work through
Dr. Glueck, and the Pennsylvania School for Social Service
through Dr. Taft did actually develop courses for training
psychiatric social workers. These courses were developed
during the war fervor. They attracted and are attracting
women as a rule with college degrees with very special interests
in the humanities and with a point of view perhaps a bit less
economic than the point of view of the ordinary social worker.
The infusion of this blood, a little more radical and fiery than
the sober reform blood of the type of social worker familiar
to us all, no doubt, will have some rather surprising results,
but we think the advantages of novelty and freshness of point
of view may counterbalance the disadvantage of oversobriety
and conservatism.

The comparative youth of sociology, of applied sociology
(social work), of applied medical sociology (medical social
work), and of the putative new branch (psychiatric social
work) entails a certain fluidity of nomenclature at first not
unserviceable. Nor would it be necessary or even desirable
to fix at the outset a nomenclature for logical compartments
of an undeveloped art, as we might thus condemn the art to
stasis or bad cuh-de-sac. We raise the question, therefore,
only on the practical ground of whether or no specialists, pro-
fessional or technical, have been developed or are in course of
development in this field of sociology. For, if so, that is, if
the new art has found its shoulder-to-shoulder workers, then
it is high time to state the principles of their alignment, and
the nature of curricula and practical experience necessary for
these workers.

We assume that medicine and applied sociology are profes-
sions with their professors and practitioners having due recog-

THE KINGDOM OF EVILS 557

nition in university degrees, M.D. and Ph.D., respectively,
and in commonly accepted titles, physician and sociologist.
On account of the recency of sociology's foundation, every-
body is prepared to accord to many workers without the degree
Ph.D. just as good and perfectly equivalent dignity. Nor
should such a contention as that sociologists will more and
more tend to be Ph.D. bearers be regarded as propaganda of
Professor James' "Ph.D. octopus," since everybody is now
aware that novelty, in medicine, sociology, or any other branch,
is perhaps more likely than not to come from some distant
science. Thus the teaching branches of medicine are more
likely to get novelty from, e.g., chemistry, or physics, than
from their own more limited fields. And the teaching branches
of applied sociology are very likely to profit more from
anthropology or psychology than from the recognized rounds
of sociological research as narrowly conceived, e.g., in the field
of social statistics. Perhaps even it might be said that many
branches of didactic medicine and sociology would get more
food for new thought from each other than each from itself.
We are not here talking of the technique of research, but of
the sort of training which allows us to concede that such and
such a person is entitled to rank as a professional sociologist
alongside the physician.

There are, to repeat, persons to whom we accord an equal
professional rank as didactic or practical masters of their
fields — physicians and sociologists. But every profession must
develop apprentices or ancillary workers of various sorts. Thus
medicine has developed the nurse. Applied sociology, we
make bold to say, has developed quite on the same level —
the social worker. One has to be bold For many social
workers, perfectly modest as to their own private capacities,
have developed a surprising group-consciousness concerning
the proper dominance of the ideal social worker in all social
maladjustments. This group-consciousness of social workers
often leads to a not unwarranted derision on the part of physi-
cians, judges, men of the world. The point here is probably
simple: just because not every eminent sociologist is a Ph.D.
and because many sociologists prefer to call themselves
"workers" (from the American habit of denouncing theory
and suspecting all "-ologists" of carrying lugs), many humbler
persons conceive that there is no theory behind their prac-

558 THE KINGDOM OF EVILS

tice, no sociology behind their social service. It is as if, on
the one hand, physicians seeing that medicine is so much a
matter of nursing should announce themselves as a kind of
nurse; it is as if, on the other hand, nurses seeing that the
physicians are so ignorant of many practical matters should
suddenly conceive that nurses were after all a sort of physi-
cian. Practically, too, in the present phase of social-service
development, social workers are apt to be of a finer grain and
a more finished higher education than the majority of nurses,
and accordingly the social workers are inclined to develop a
feeling of group-superiority to nurses. This attitude is of
course a matter of dispute as to its justifiability, but is none
the less existent. But we conceive that, unless a person wishes
to go to the length of special training of professional grade,
he can hardly claim equivalence to a man of professional
training. We conceive that professionally trained social
workers, of the Ph.D. level or equivalent, will finally admit
themselves to be sociologists, albeit applied sociologists. And
we hope that further there will be a group-consciousness de-
veloped of social workers iDelow the "-ologist" grade with
an attitude resembling that of nurses to their work — an atti-
tude, according to temperament, of humble pride or proud
hum.ility with respect to their acknowledged leaders, the ap-
•^lied sociologists. Nor should the term profession be made a
stumbhng-block : if nursing is a profession, so. ought social
work (below the level of sociology) to be ackno^vledged a pro-
fession also : this last is a matter of terms only.

But no two sciences or arts can in these days long exist
without fruitful contacts. Pathological and sociological prog-
ress have gone hand in hand. Many a physician is, we say,
really and by temper a sociologist : many a sociologist develops
so deep an interest in, e.g., sanitation problems that he becomes
in effect a physician, at least an expert in public health.
Social medicine and medical sociology have much in common :
either could receive the term theory of the public health
without special error of definition.

Not to linger over the definition of public health, hygiene,
and preventive medicine as against the non-medical branches
of sanitary science and art, it is clear that both social medi-
cine and medical sociology have brought to life auxiliary
groups of practical workers, viz., the public health nurse and

THE KINGDOM OF EVILS 559

the medical social worker. It is clear, too, that just as
social medicine and medical sociology are different in their
points of view, so the aides in the practical work of each field
are likely to have a different point of view. If the lively
growth of the public health nurse group sometimes threatens
to engulf the medical social worker {e.g., by proposals that
the same curriculum will do for both), the fact is that no
such forced union will ever take place, judging by the quality
and nature of the persons each field has so far attracted.

Now it is obvious that the public health nurse of today is
no better prepared to be an aide to a psychiatrist than the
ordinary physician is trained to deal with psychopathic cases.
Should there not be a group of nurse-like human beings who
should be aides to psychiatrists in much the same sense as
public health nurses are aides to the public health physicians?
On the other hand, should not there be a special group of
social workers skilled in the psychiatric side of medical soci-
ology? Such a trained mental hygiene aide would be then an
assistant to the psychiatrist in medical treatment, — a special
type of public health nurse trained in the care of mental dis-
eases. She would be equipped with an understanding of social
conditions and remedies to the extent that such appreciation
of social problems has been found desirable for the public
health nurse. She should not be confused with the psychi-
atric social worker whose function is to assist in social diag-
nosis and treatment under sociological direction. In short, we
think it will be possible to show that the point of view of
medicine and the point of view of social work are at bottom
sundered from each other, so that the physician and the
sociologist, the nurse end the social zvorker, the mental hygiene
aide and the psychiatric social worker, will always remain per-
sons with somewhat separate sentiments. It is worth while
to insist that these sentiments though separate are not neces-
sarily opposed to one another. It is even possible that within
a single personality a worker can be an effective individualist,
on the one hand, and an effective social-groupist, on the other ;
that one can be both a physician and an applied sociologist
successfully; but the success attained will probably be like that
in which the right (or medical) hand will not know what the
left (or social) hand is doing.

So much for our theory of the future of education for psy-

560 THE KINGDOM OF EVILS

chiatric social work. The present practice follows a middle
course, — the trained psychiatric social woricer today is not,
as a rule, the applied sociologist of Ph.D. grade, nor yet the
practical worker bearing the same relation to sociology that
the nurse bears to medicine, but something of both.

The special training courses for psychiatric work now given
in several schools (Smith College Training School for Social
Work; New York School of Social Work; Pennsylvania
School for Social Service) are graduate courses covering a
period of approximately two academic years. Such courses
approach the requirements for the A.M. degree. There are
persons who think that the degrees A.M. and Ph.D. may not
reasonably be offered in social work on the ground that such
education is practical rather than scientific. Even if it be
granted that social work is a form of applied science, there
are probably forces at work in a good many universities and
colleges that regard with suspicion all science that has the
flavor of practicality.

To meet the demand for social workers for the neuropsy-
chiatric hospitals of the army, the plan of the Smith College
Training School of Psychiatric Social Work was conceived
by us, in 191 8, as a war-emergency course. Intensive courses
of instruction were given at Smith College during eight weeks
of the summer, and the students were then distributed among
four cities — Boston, New York, Philadelphia, and Baltimore
— for six months of practice work in various hospitals and so-
cial agencies. Some experienced social workers were admitted
for the summer course only. The following year Smith Col-
lege continued the course as a permanent school under the
name of the Smith College Training School for Social Work.
The length of the course was changed from eight to thirteen
months, and training for other branches of social work also was
undertaken. The work falls into three divisions — a summer ses-
sion of eight weeks of theoretical instruction combined with
clinical observation; a training period of nine months of study
and practice carried on in cooperation with hospitals ; and a
concluding summer session of eight weeks of advanced study.
The summer sessions are held at Smith College, Northampton,
Massachusetts. The practical instruction is arranged by plac-
ing students with hospitals in different cities, under super-

THE KINGDOM OF EVILS 561

vision, locally and centrally, by the staff of the Training
School.

This method of preliminary instruction followed by con-
tinuous practice was the outgrowth partly of the necessity for
training quickly a larger number of workers than could be
provided with practice facilities in any one city, and also
partly of our experience with an apprentice course given for
several years at the Psychopathic Hospital. We found that
a student who was on duty continuously, giving full time to
case work without the distraction of class work, acquired ex-
perience and skill more quickly and more confidently. If the
student gives full time in the hospital, is on duty regularly
and without interruption, she becomes completely assimilated
into the organization and so gains in depth of experience as
well as in drill and discipline. Moreover, a student who has
received preliminary instruction can from the beginning do
more responsible case work. It is doubtful whether prac-
tice work with social cases can be carried on satisfactorily
along with intensive instruction, for human problems cannot
be regulated so that experience will run parallel to theoretical
instruction. On the other hand, the concentration of study in
two periods at the beginning and end of the practice work
permits a high degree of mental application. A thread of
theory running through the practice period, in the form of a
weekly class, required reading, and preparation of a thesis,
serves to unite the two study periods.

The potential student then should in the first place be a
somewhat educated person, that is, the possessor of an A.B.
degree or else equally well educated by less formal methods
than a full college course. She will need both the qualities
requisite for all forms of intellectual work and the qualities
requisite for all forms of practical work. Further, she must
have the qualities that all social work requires — interest in
individuals and a liking to follow them into the scenes of their
daily lives, an impersonal attitude, the power of intelligent
sympathy, a high degree of disinterestedness, and the capacity
for sustained purpose. In addition, the special qualifications
that the psychiatric social work requires in a marked degree
are patience, analytical ability, and capacity for objective
observation.

562 THE KINGDOM OF EVILS

A course in preparation for psychiatric social work presup-
poses the college branches — biology, psychology, sociology,
economics, and government. The content of the special grad-
uate course given at the Smith College Training School in-
cludes social psychiatry, the theory of mental tests, the essentials
of medicine, social psychology, government as related to social
work, organization of social work, and the theory and practice
of social case work. Theoretically it might seem desirable to
add such a course to a foundation of one year in general social
work, where the student would acquire the technique of social
case work and a knowledge of the organization of social work.
But there is reason to think that the best results are obtained
at present by admitting students at once to specialized training.
Schools of social work have not in the past given a place in their
general training to principles of mental hygiene, so that train-
ing in social work is apt to be deficient in the psychiatric point
of view, which it is desirable for the student in psychiatric
social work to acquire as early as possible.

Principles and technique of case work may be acquired as
readily in psychiatric cases as elsewhere. Nor is the experi-
ence of the student working on psychiatric cases limited to
psychopaths, for all the members of the family come within
the field of action.

A NOTE UPON LEGAL ENTANGLEMENT AS A
DIVISION OF EVIL

RoscoE Pound

In civilized society the individual must adjust not only to his
fellowmen and to groups of his fellowmen but to the political
organization of society and to the legal order. Maladjustments in
the latter respect, whether due to fault of the individual or inde-
pendent of his fault, whether inevitable because of inherent diffi-
culties in the administration of justice through law or remediable
by improved and better-operated legal machinery, are Litigia in
Dr. Southard's sense. Briefly, he means forms of social malad-
justment involving contacts with the law. For he conceives rightly
that mere involvement in a legal controversy is an evil, and an evil
to which we are naturally subject in society quite as much as to
disease or to poverty. The legal machine, like any other machine,
in the nature of things will operate mechanically, and in that
mechanical operation the just as well as the unjust are likely to
be caught.

Conditions of controversy and legal entanglement may be ag-
gravated by or may result from some of the other main types of
evil. But as disease or poverty or ignorance may be of inde-
pendent non-culpable origin, so conditions of controversy or legal
entanglement may arise quite without fault of him who suffers
therefrom. Moreover, whether we turn to the reported decisions
of the courts, or to the reports of legal aid societies or to the
accounts of actual experience of judicial administration of justice
which lawyers have put in the form of fiction, we may find abun-
dant testimony that those who for any reason become entangled in
legal controversy may suffer as acutely, without moral fault on
their part, from evils not easily separable from our social and
political and legal organization as their fellows who are burdened
with disease or poverty, or ignorance. In Ten Thousand a Year
and in Farmer Bumpkin's Law Suit, two lawyers have painted
in enduring colors what it means to be a party to a hard fought
law suit.^ The story may be told no less vividly from the actual

^ The effect of protracted litigation in paralyzing the energies and sap-
ping the vitality of a litigant is set forth by Dickens in Bleak House
and by George Eliot in The Mill on the Floss,

563

564 A NOTE UPON LEGAL ENTANGLEMENT

records of the courts. No doubt the social worker encounters legal
entanglement as a complication in cases primarily involving other
evils. But it may serve better to demonstrate Dr. Southard's point
if we look exclusively at cases of legal entanglement pure and
simple or cases where involvement in legal controversy is the pri-
mary factor.

One may find himself seriously involved in legal controversy,
without fault on his part, either as a matter of pure misfortune or
as the victim of the culpable action or inaction of others. In the
first category (pure misfortune) four all too common cases may
be noted : mistaken identity, circumstantial evidence, the chance
that one may be a casual eyewitness of another's crime, and in-
heritance of a bona fide litigated claim. The case of Lesurques,^
positively identified by numerous witnesses and executed for a
crime of which the event showed he was wholly innocent and for
which the real perpetrator was afterwards brought to justice, and
of Adolf Beck,^ twice convicted and subjected to imprisonment for
crimes with which he had absolutely no connection upon mistaken
identifications by the victims and only saved by the apprehension
of the real offender for like crimes committee while Beck was
in custody, stand out in the annals of the criminal law. But
Lesurques and Beck were men of a certain social position, of edu-
cation and of some means. How many such cases occur where the
accused cannot invoke such resources and thereby bring the in-
justice to light we may but conjecture.* At the very least we must
admit a potential danger of legal entanglement through mistaken
identity as something never to be overlooked. How an innocent
person may be the victim of appearances and of circumstantial
evidence has been a fruitful theme for dramatists and novelists
and is continually illustrated in the courts, despite all provisions
for careful deliberate trial of the facts and presumptions of inno-
cence.^ Less serious, but bad enough, is the condition of the up-
right and busy or upright but indigent citizen who chances to be
an important witness to the commission of a felony. Mr. Train
has told us from first-hand observation what the witness must go

^ As to Lesurques, see Fouquier, Caiuses cclchres de tons les peuples,
III, no. 12; I Green Bag, 72.

* See Report of the Committee of Inquiry into the Case of Mr. Adolf
Beck, 1904. Not only was Beck imprisoned for crimes with which he had
no connection, but he lost his property through inability to preserve it while
in prison.

* For the more notable older cases of mistaken convictions, see Loeiifler,
Die Opfer mangelhaftcr Justic, 3 vols., Jena, 1879.

"Examples are collected in Hellwig, Jtisticirrtiimer, 1914. For an
American case, see People v. Tcipcr, 186 App. Div. 830. Teiper was ac-
quitted upon a retrial.

A NOTE UPON LEGAL ENTANGLEMENT 156 ^

through with if he is able to give sureties to appear and testify.^
If he cannot give security, he is likely to be committed to jail to
secure his appearance as a witness and to suffer almost as much
as if he had actually offended." But it is quite as possible to be
caught innocently in the mill of civil litigation. One type of case
is inheritance of a bona fide litigated claim. Dickens pictured what
this means in Jarndyce v. Jarndyce, and the Gaines case in the
United States may serve to show how impossible it is for fiction
to rival fact. The litigation which occupied the whole of her long
life came to Mrs. Gaines as an inheritance in 1813. In 1886 she
died at the age of eighty and bequeathed it to her grandchildren,
having outlived her children. In 1891 it finally came to an end
and the inheritance for which she had struggled all her days came
to her heirs. In the meantime the case had been fourteen times
before the Supreme Court of the United States and had been
fourteen times before the highest state court or the United States
Circuit Court on points of sufficient importance to call for reported
opinions.^ The reports are full of cases of which the Gaines case
is but an extreme example.^

As to the second category (cases where one is the innocent vic-
tim of the fault or default of others) at least seven important
types are of common occurrence, (i) Cases are legion in which
the innocent have been drawn into ruinous litigation because of
judicial vacillation. Thus the chronicler of the Gaines case tells
us : "The decision in 12 Howard being thus overthrown by this
last decision, ruin was the consequence to many who confided in
its soundness and purchased ... on the faith of that decision." ^°

* Train, The Prisoner at the Bar, chap. 7, entitled, "If the Cook Should
Steal the Teapot.

' California endeavored to meet this situation by a constitutional pro-
vision that witnesses should not be unreasonably detained. Under that
provision it was held that a witness might be released on habeas corpus
after he had been held for ninety days and the hearing of the prosecution
had been put off repeatedly. Ex parte Dressier, 67 Cal. 257. Compare Ex
parte Petrie, i Kan. App. 184.

* See Payne, A Celebrated Case, 14 Rep. Georgia Bar Association, 219,
'E.g., the case of Patience Swinfen, a widow whose father-in-law left

her his property as a tardy reparation for driving his son from home at the
time of his marriage. Nine years of litigation, involving ten reported deci-
sions, were required to enable her to hold the property. See Burnham,
Some Famous Litigants, 6 Green Bag, 399, 400-402. For an American case,
see Giles v. Little, 2 McCrary 370; Giles v. Little, 104 U. S. 291 ; Little v.
Giles, 118 U. S. 596; Little v. Giles, 25 Neb. 313; Little v. Giles, 27 Neb.
179; Giles V. Little, 134 U. S. 645; Chase v. Miles, 43 Neb. 686; Lincoln
Transit Co. v. Rundle, 34 Neb. 550; Roberts v. Lewis, 134 U. S. 153 —
thirteen years of litigation over the meaning of a gift to a widow in her
husband's will.

'" 14 Rep. Georgia Bar Association 239. Compare : "But in the mean-
time many whose purses were not long enough to keep up the fight yielded

566 A NOTE UPON LEGAL ENTANGLEMENT

(2) Again the mere delay which is too common in all litigation,
may be aggravated to the substantial ruin of litigants.^^ (3) One
may be involved in protracted and even ruinous litigation through
the roguery of a plausible impostor. The Tichborne case in
England, ^yhich charged a goodly inheritance with a burden for
generations to come, is the classical example. But the United
States may furnish examples of its own.^^ (4) One may also be
the victim of a protracted prosecution based on false testimony
adduced to shift responsibility from the guilty to the innocent. ^^
(5) Again one may be the victim of governmental dishonesty and
be compelled to spend his days in vain endeavors to procure justice
from a state that cannot legally be compelled to pay its just obli-
gations.^* (6) One of the most common types is willful aggres-
sion which compels him whose rights are infringed to engage in
prolonged and expensive litigation whether he will or no. Thus
it often happens that the victim of a malicious defamation or a
malicious prosecution must vindicate his reputation and his honor
in order to live a human life among his fellowmen. A striking
instance of what this may involve is afforded by the well-known
Jones County Calf Casc}^ In that case a farmer who had been
maliciously prosecuted by an organization found himself entangled

to judgments in ejectment in the federal court based on the first opinion in
the federal Supreme Court, and sued their grantors upon covenants of war-
ranty. As these grantors had not felt able to continue the litigation, they
were compelled to pay damages, although, in the event, they had conveyed
a good title." Pound, Principles of Procedural Reform, 4 Illinois Law
Rev. 491, 492-494 (referring to the litigation described at the end of note 9).

""Hundreds of causes were remaining to be heard; thousands of
suitors had abandoned proceedings, and many were ruined under grievous
oppression merely because they were unable to afford the money or the time
necessary to enable them to proceed. Even those who found the means and
expended the money and time necessary to get their causes ready for hear-
ing, were kept in suspense for an unreasonable length of time, uncertain
whether they were thereafter to be rich or poor; many,_ f rom the tardy
steps of justice, were unable to form or settle their plans in life, and were
kept in a state of the most harassing wretchedness." Duffus Hardy, Life
of Lord Langdale, I, 349.

"E.g., Flora v. Anderson, 75 Fed. 217. For a sketch (founded on
fact) of the position in which innocent persons may be put by a plausible
impostor, see Mark Twain, The Major's Story.

"Those who have studied the case attentively believe the Frank case to
be one of this sort. See Connolly, The Truth about the Fralnk Case, 1915.

" Mark Twain has given us a picture of the condition of such a victim
in The Great Beef Contract. See Fleischmann, The Dishonesty of Sov-
ereignties, 22 Rep. N. Y. State Bar Association (1910), 229. Compare the
twenty-six years of litigation to which holders of coupons of Virginia bonds
were subjected, McCullough v. Virginia, 172 U. S. 102, and prior cases set
forth in the opinion of Mr. Justice Brewer.

^Proceedings, Iowa State Bar Association (1920), 141-156.

A NOTE UPON LEGAL ENTANGLEMENT 567

in twenty-five years of bitter litigation and was able to clear his
character only through persistence under discouragements which
would have worn out an ordinary litigant. (7) Finally there are
cases of what may be called parasitism — cases where swindlers and
extortioners, who have learned the possibilities of using the ma-
chinery of the law as a means of oppression, deliberately involve
their victims in legal entanglements, in the confidence (often but
too well founded) that they are too poor or too ignorant or too
busy to be able to extricate themselves and will thus become an
easy prey. The reports of Legal Aid Societies are full of such
cases. ^^ The innocent man of scanty means but high sense of duty
who seeks to help a near relative out of trouble and finds himself
caught in the web of litigation, the wage-earner whose wages are
held in an illegal attachment in the endeavor to take advantage of
his necessities and coerce him into what he is not bound to do, the
innocent victim of get-rich-quick swindlers who invests his savings
in worthless "securities" and finds himself involved in elaborate
winding-up proceedings, the loyal friend or relative who becomes
surety for a borrower from an unscrupulous and exacting lender
at extortionate interest — all these are but too well known.

It will not do to say that the state provides an elaborate and
expensive machinery for administering justice and that the law
operates to prevent conditions of controversy with one's fellowman
from being or becoming a serious type of evil. Public agencies for
preventing or suppressing vice, public health service, public poor
relief and public education do not prevent us from recognizing that
vice and disease and poverty and ignorance are evils with which
civilization must contend. Strife is one of the oldest evils in social
history and is the one toward which politically organized society
first directed its powers. Yet the legal order has but mitigated this
evil. It is by no means abolished. Moreover, the machinery
which the state has set up to obviate strife and put an end to
controversies has many possibilities of injury for the innocent, the
unwary and the impecunious. In part these possibilities of injury
are inseparable from legal administration of justice ; they grow out
of difficulties of proof and infirmities of judgment which are in-
cident to human action. In part they are due to reparable defects
in our legal system and judicial organization. In either event con-
ditions of legal entanglement, involved in the endeavor of the state
to put down strife, adjust controversies, and administer justice, are
not the least of the evils with which men must reckon in social
life and of which, therefore, the social worker must take account.

^^ See Smith, Justice and the Poor, gff.

APPENDICES

APPENDIX A*

Case 46
PSYCHOPATHIC HOSPITAL

SOCIAL SERVICE
NUMBER 2004
FILE NUMBER 7938

0. P. D. NUMBER 3562 NAME Harold Gordon t

Residence Soldiers' Home, Derby, Mass.

Correspondent Mrs. Bessie Driscoll, 49 Glenwood St., Chelsea

Sex M Age 45 Color W.

Civil Condition S Place and Date of Birth U. S.

Religion P Occupation Steamfitter

Time in Boston 45 In Mass. 45 In U. S. 45

Previous addresses

When known to social service 1/16/18
When discharged from social service 7/1 /i8
Reason for being known to social service Employment
Report from confidential exchange No record

Name of father George Gordon

Address 61 Jackson St., Maiden, Mass.

Name of mother Jennie Drake

Address 972 Irving St., Chelsea, Mass.

Name of spouse

Address

Names and ages of children or siblings

Admitted to house 1/4/17 Authority Vol.

Discharged 1/10/17 Admitted to O. P. D. 1/16/18

Diagnosis Luetic hemiplegia ; Condition
Vascular lues

Social symptoms Date 2/5/18

Cohabitation
Industrial disability
Unemployment

Social diagnosis Disease Date 1/20/18

* These case records are printed as written by the social workers without revision,
f All names used in this record arc fictitious.

571

^7^

APPENDIX A

PSYCHOPATHIC HOSPITAL

SOCIAL SERVICE
CASE NO. 2004

FILE NO. 7938 NAME Harold Gordon

ADDRESSES
Patient:

Soldiers' Home, Derby, Mass.
49 Glenwood St., Chelsea.

Relatives and friends:

Brother-in-law, George Price,

12 Newbury St., Charlestown, Mass.

Brother-in-law, Xavier Price,

27 Tuttle St., Charlestown, Mass.

Patient's mother, Mrs. Jennie Gordon,
972 Irving St., Chelsea, Mass.

Patient's father, George Gordon
61 Jackson St., Maiden, Mass.

Paternal aunt, 61 Jackson St., Maiden, Mass.

Employers:
Mr. Yale,
SYz Glenwood Court, Boston, Mass.

Young & Daniels,

241 East 52nd St., New York City.

Mr. David F. Hyde, F. Q. Crawford Co.,
Quint St., Boston, Mass.

Patient's wife's employer:
Mrs. Howell,
73 Quirk St.,
Chelsea, Mass.

Patient's wife:

Bessie Driscoll,

49 Glenwood St., Chelsea.

APPENDIX A

573

CASE NO. 2004
FILE NO. 7938

PSYCHOPATHIC HOSPITAL

SOCIAL SERVICE

NAME Harold Gordon

EXPENSE SHEET

Paid
1/23 Marriage certificate. .. .$ 1.02

1/29 Loan 50

5/1 Wedding 11.00

12.52

Received

2/6 From patient $ .50

5/1 " " i.oo

S/io " " 11.02

12.52

CASE NO. 2004
FILE NO. 7938

PSYCHOPATHIC HOSPITAL

SOCIAL SERVICE

NAME Harold Gordon

SUMMARY
1918

January 20.
Social History:

Patient is a single American man 45 years old, a veteran of the Spanish
War. He lives at the soldiers' home, Derby. There are no expenses
incurred there and patient has a little money which he has received from
the Steamfitters' Union. Patient is a steamfitter by trade and for 11
years prior to illness worked as such, making approximately $5 a day.
In October, 1916, patient became ill and as a result now drags one leg
and is slow and awkward on his feet. Patient's mother lives alone on
Irving St., Chelsea, having 3 small tidy rooms. She has a small saving
of her own. Patient's father was a Civil War veteran. Lives with his
sister in Maiden, Mass. The separation from his wife was due to the
fact that patient's mother wanted him to go to Maine to live with his
married daughter. Patient's father refused and, as a result, patient's
mother went to Maine without him. She apparently is a difficult woman
to get along with and soon friction occurred between her and her son-
in-law ; as a result she came back to Chelsea and, disliking patient's sister,
has refused to go to Maiden, She feels that her husband should come

574 APPENDIX A

to her and says that his pension is being used to help take care of his
sister. Patient visits his mother every little while.

Patient has been having sex relations w^ith Mrs. Driscoll, a widow
with a daughter 13 yrs. old. She lives at 49 Glenwood St., Chelsea.
Patient stays two or three nights a week and Mrs. Driscoll is now prob-
ably pregnant by patient. Patient claimed at first that he was married,
but later confessed that he was not. Mrs. Driscoll does housework by the
day two or three days a week and her brothers pay her rent. Her
brothers are wealthy ; one owns a machine and is manager of the Hartford
Tire Company on Coolidge St,

Physical History:

October, 1916, patient had a shock and was taken to the City Hospital.
January, 1917, patient came to this hospital and was under treatment for
neurosyphilis and has reported regularly for treatment. He claims to
have had syphilis 18 yrs. ago. When patient first came to us he was
practically crippled and could not use his arms or legs to any extent.
Now he has control of his arms and control of one leg. He must report
regularly for treatment.

Mental History:

October, 1916, patient became very dizzy and confused; felt that he
might throw himself into a furnace when he attempted to throw wood in.
He was admitted to this hospital in January. Shortly after his admission
his confusion subsided and there have been no returns of symptoms.
Since, he has apparently been a steady worker and faithful, working
better, however, as an assistant than when sent off on a job of his own.
MN

RESULTS

January 18 to April 18, 1918.
Social:

Patient and woman with whom he had been having irregular sex
relations were married February 9. the money for the wedding service
being loaned by the Social Service Department. Patient's wife was ex-
amined at the Boston Dispensary and suspected of being 2 months' preg-
nant. Patient's brother-in-law feels that patient's wife has always been a
drag on them and they wish they might be well rid of her. Felt that her
marriage would merely mean one more person to support. They refuse to
assist her in any way if she marries, but later promised visitor that if she
loaned money to them they would be ready to pay it back should patient
fail, but felt they should at first be made to understand that they must
stand on their own feet. Patient and wife have moved to an apartment at
5 Yale Terrace; the rent is $35 a month, but as they do janitor work they
receive same rooms for $20. Work has been obtained for patient, F. Q.
Crawford & Co., and patient is making between $17 and $18 a week. He
has been raised and is now second to the foreman. There is a chance for
overtime work with extra pay, but patient tires easily and has not yet done
any overtime.

Physical:

Patient reports regularly for treatment and is improving.

APPENDIX A 575

Mental:

Patient slowly improving. Feels better and gets tired less easily. He
hopes soon to be able to take up his old work as steamfitter. He has had
a position ofifered to him, but felt that he should not undertake it just yet.
Patient shows poor judgment, especially in money matters. He has a
happy attitude that everything will be all right and will occasionally spend
money for a steak and be obliged to borrow money for food the next
couple of days. Patient is rather proud of himself for having stuck by
his wife and married her. He occasionally will say, "H I hadn't done this
for Bessie I need not have worked ; I could have stayed at the soldiers'
home all my life, they would have had to take care of me." On the other
hand patient seems proud of the fact that he is able to support a home and
does not want his wife's brothers to think he has any intention of sponging
on them.
MN

HISTORY
1918
January 16.

Patient's story: Patient and alleged wife. Airs. Bessie Driscoll, seen
together at hospital. Patient states that he is living at the Soldier's Home
in Derby, being a veteran of the Spanish War. He is without any visible
means of support. His wife is living at 49 Glenwood St., Chelsea. She
has three rooms, for which her two brothers, living in Charlestown, pay
$15 a month rent for her. She has one child, now 11 years old, by her
first husband. Patient claims he was married about six months ago, but
cannot give the exact date or place of ceremony. He is a Protestant, and
his wife is a Catholic. His wife claims to be about two months pregnant,
at least she has had no menstrual periods for the past two months. She
talks of having an abortion, but apparently has no real intention of doing
so.

Patient is a steamfitter by trade, having worked steadily for Mr. Yale,
5H Glenwood Court, Boston, 11 years ago, then going to New York City,
working there for Young and Daniels, for 10 years. He returned then to
his former employer, where he worked until he was taken ill in October,
1916.

Patient tells of how crippled he was one year ago, — even six months
ago, — and how slowly and gradually he has regained the use of his arms,
and how he feels encouraged that before long his left leg will be cured.

Names and addresses of friends and relatives were obtained. Visitor
promises to look up possible openings whereby patient may make use of his
trade without the undue fatigue which would occur were he to resume
steamfitting.

Patient is well groomed, pleasing in appearance, affable personality,
though somewhat apathetic. Mrs. Driscoll appears nervous, less intel-
ligent, and less attractive.

January 18.

Soldiers' Home, Derby, Dr. Pearson, visited. Informant states that
patient has been under their care from Jan. 25, 1917, to the present time.
As a Spanish War Veteran, he is entitled, while disabled, to receive room
and board free. He receives no pension, but is permitted to leave prac-

5/6

APPENDIX A

1918

tically whenever he requests. Patient as a rule receives a pass for the
duration of two or three days a week.

Informant considers patient irresponsible, claiming that he put him
on a job to run an elevator, the pay being $8 a month, and patient went ofif
several times, leaving the elevator with no one to man it. This was done
in spite of the fact that informant explained to him how embarrassing it
was at mealtime to have no elevator in order to assist the feeble men to
and from their meals. Patient seemed indifferent, and after three or four
months on the job, informant took someone else. Informant states that
it will be nearly impossible to find work for a man of patient's type.

January 18.

Impression: Somewhat cynical, but willing to cooperate in any pos-
sible way.

January 18.

Employer, Mr. Yale, 5^ Glemvood Court, visited. Informant states
that patient was a good worker, steady, no drinking, and that he would
take him back to-morrow at $5.50 a day, if patient would come. He states
that patient did his best work when he was on a job with others. If
given a small job to do himself, informant felt responsible to oversee the
job. He stated that probably patient could not take charge of men, but
was a willing and energetic and fast worker.

hnpression: Informant seemed to have no interest in patient as an
individual, but would be interested if patient were physically able to work,
as there is a great demand for steamfitters at the present time,

MN/S

January 18.

City Hall lisited. No record of marriage certificate is recorded.

January 18.

Alleged xvife, Mrs. Bessie Driscoll, 49 Glemvood St., visited.

Informant stated that she had known patient for about two years, and
told that she was not married to patient of her own accord. During this
time she has been having intercourse with patient, and claims that her
standing by him after he had had the paralytic stroke is one big factor in
patient's recovery.

Patient visits informant about once a week for a period of two or three
days. Informant claims to be without passion, and that patient is very
easily excited. Informant states that she does cleaning two or three days
a week, which gives her $4 to $5. Her two brothers pay her rent, and
their wives give her shirtwaists, and help her out in little ways. She has
one child dependent upon her. Her attitude toward her brothers is that
they must not know her condition until after she is married, because, as
she says, "they look up to me, and know I know better." She states that
they are better educated than she is, — that they went to High School and
business colleges. She went only as far as the 8th grade, being 16 years
old when she left. During her schooling she was obliged to be out long
periods of time owing to illness of first her own mother, and then of her
step-mother. Her step-mother died when she was 16, and she brought up
her two brothers. Six years later she married, and two years later, at the
time of her confinement, her husband was electrocuted at work. The
brothers take the little girl at times, as for vacations ; and once, four years
ago, when informant had an operation at the Boston City Hospital for
fallen womb. As soon as patient is able to work informant is willing to

APPENDIX A 577

1918

marry, but does not wish to give up $15 a month, three attractive rooms,
etc., with no apparent means of support ahead. She feels also that patient,
who has a big appetite, had better stay at the Soldiers' Home until he gets
work. Informant states that patient's mother, living at 972 Irving St.,
Chelsea, is very hard to get along with. She calls her "an indifferent, old-
fashioned Yankee, who cares more for the dollar than for anything else."
She states that patient's mother is jealous because she feels that when
patient gets to work he is going to give money to informant rather than
to her. Patient's mother has a small income of her own which enables
her to be independent. Patient's mother was in Maine visiting her only
daughter. Her husband refused to go to Maine, and he is now living with
a sister in Maiden.

Second impression: Informant seemed excited over her condition,
not for her own sake or reputation, but because of her family. She
appears more kind-hearted and intelligent than at the first interview.

January 23.

Patient's mother, Mrs. Jennie Gordon, 9/2 Irving St., Chelsea, Mass.,
visited. Informant has three basement rooms in a congested district, but
the rooms are immaculately neat — even the floor looking as if scrubbed
daily. Informant is a frail, delicate-appearing woman. She gave for her
reasons for living alone that her married daughter's husband in Maine did
not really want her, so she thought she would come back to Chelsea.
She went to see her husband at his sister's, 61 Jackson St., Maiden, Mass.,
and invited him to come and live with her. This was six months ago, and
he has never been to see her. She claims that he is feeble, and is in-
fluenced by his sister who wants, and probably needs, his pension of ^33.
He is a Civil War veteran. She says she does not know whether or not
she would live with them if they wanted her to. She has small savings of
her own, and realizes that she is entitled to share in her husband's pension.

Patient was spending the day with his mother. He took the "laissez
faire" attitude that everything would be all right when he went to work.

Patient walked out with visitor, and was asked what plans he had
made about marriage, etc. He promised, to see "Bess" and talk the matter
over with her.

February 5.

Brothers of patient's fiancee, George and Xazier Price, Hartford Tire
Co., 851 Coolidge St., visited. George is the manager and has an office to
himself. Xavier very prosperous looking. Informants stated that Mrs.
Driscoll had never been able to support herself, and that they had for years
paid her rent and given her a little money besides. Stated that they had
no use for patient, felt that they did not want him in their home, because
they knew that their sister had had a Wassermann taken and felt
that sexual relations must have taken place between her and patient. In-
formants asked if they would back the loan for the wedding fee. Xavier
stated that when they made out checks for this month's rent he would put
in some extra money. George said he would too, but on second thought
they both said they thought it would be better for patient to understand
that he could not get any help from them and both refused, stating, how-
ever, that if visitor loaned the money and did not get it back they would
pay visitor, but did not want their sister to know. They feel if their sister
marries it only means one more for them to care for. They want the
marriage plans discontinued. Mrs. Driscoll's condition is ascertained and
brothers both agree that marriage is the wisest thing.
MN/MCW " " -

5/8 APPENDIX A

ACTION TAKEN
1918

Patient to report at regular stated intervals, at present two weeks
apart, for medical treatment. Patient to get lighter work.

January 23.

Eviployer, Mr. David F. Hyde, Supt., F. Q. Craivford Co., telephoned
to. Informant states that he would interview patient in regard to work.
Patient sent with note to Mr. Hyde. See letter No. i. Employer, Mr.
Hyde, telephoned visitor. He stated that he would employ patient pro-
vided a recurrent stroke was not likely to occur, as they have insurance
for employees over a limited period of time, and he did not wish to employ
men if the risk was too great. Visitor had informant connected with
Dr. Traiser by phone.

January 23.

Patient seen at Men's Club. He states that he is to begin work at the
F. Q. Crawford Co. to-morrow, salary $15 a week.

January 24.

Patient's fiancee, Mrs. Driscoll, taken by visitor to the Gynecological
Clinic of the Boston Dispensary. Dr. Kellogg examined her. Patient is
probably three months pregnant, and is to return in one month. Mrs.
Driscoll wants to get married quietly. This costs $16, $11 if announced
three consecutive weeks in the church. Application for license made at
the City Hall. License may be obtained on the 29th.
MN/S

January 29.

Patient to clinic. Seen by Dr. Traiser. Patient not to return for 3
weeks. Patient said that his work was lighter than steamfitting. Patient
promised loan for wedding fee. Patient loaned $0.50. Patient stated that
"Bess" had been to Worcester to attend the funeral of her uncle.
MN/MCW

January 30.

Patient to Men's Club. Patient enjoyed himself and talked a good
deal of the time. The conversation was on the war and patient remi-
nisced on the Spanish war.

MN/MCW

January 30.

Patient's fiancee, Mrs. Driscoll, visited. Says patient is to be married
on the nth. Is much upset about patient's disregard for rnoney. She
anticipates quarrels on the subject after they are married. Said the $0.50
visitor gave him on way to work he spent, saving only. $0.05 and expected
her to give him money to go to work on next day.
MN/MCW

February 5.

Patient's fiancee's brothers called on. They are willing to help if the
sister asks them to help, but feel that patient should handle his own afifairs.

Impression: Fair-minded but disgusted with their sister and what has
been going on between her and the patient for some time.
MN/MCW

February 6.

Patient's fiancee, Mrs. Driscoll. to hospital. In an upset condition
bcrause patient had struck her daughter. Thinks she canngt marry

APPENDIX A 579

1918

patient and that it is best for her to have an abortion. Feels that if
patient continues to spend money as he does now that they will soon be
in debt if they are married. Patient advised not to marry if she feels
that way and told of agencies that can help her if she does not marry.
MN/MCW

February 6.

Employer, Mr. Hyde, seen. Employer stated that patient was a good
worker and that he would see that he received a raise. The raise would
be $0.02 an hour, giving patient $0.33 an hour.

February 8.

Cooperative Work Shop, Miss Manson, telephoned to. Promised to
consider the case and have visitor get Mrs. Driscoll some work.

February 9.

Visitor called on Mrs. Driscoll. Mrs. Driscoll stated that patient had
been very kind to her and her daughter and they would be married at eight
o'clock on the nth.

February 11.

Visitor attends ivedding at St. Francis' Church and gives patient check
for $11, wedding fee.
MN/MCW

February 13.

Cooperative Work Shop, Miss Manson, telephones that patient has
received work.

February 13.

A worker in training takes her washing to patient's wife.

February 20.

Visitor called. Patient's wife stated that her brothers had not helped
her out on this month's rent, but that she and patient were saving so that
they could pay it soon. Patient's wife promises to go to the Lying-in
Hospital to-morrow.

March 2.

Patient's zmfe brings in Steamfitters' Union papers to be filled out
by administrator.

March 6.

Papers filled out by Dr. Phillips, stating patient treated here for
neurosyphilis and under treatment since Jan. 21st.
MN/MCW

March 16,

Wife in. Stated that patient is 2nd in charge of his room. That he
and foreman like each other very much,

MN/MCW

March 25.

Cooperative Work Shop, Miss Manson, telephoned to. States patient's
wife has been in 3 times for work; does not work well, but she improves
each time. She has asked for work for her husband's mother. Visitor
stated what she knows about patient's mother.
MN/MCW

April 10.

Patient in for treatment. Patient stated that he is feeling better and
that family are now living at 5 York Terrace, Chelsea. Have 5 rooms,

58o

APPENDIX A

1918

electric lights and steam heat, for which they pay $20 a month. Rent is
really $35 but they do the janitor's work for the balance. Patient states
that he earns about $16.50. He could make more money, but gets tired and
therefore does little or no overtime work for which he would get 1J/2 extra.
Patient hopes soon to be able to return to steamfitting, but promises not
to do this until the doctor feels it is the wisest and best thing to do.
Patient stated that wife will not go to the Lying-in Hospital. She will
either go to St. Catherine's Hospital or be confined at home.

Visitor has urged patient's wife to go to the Lying-in Hospital, but
she has many friends who have been to St. Catherine's and she can be
confined by a Catholic doctor. Patient's wife is persistent in this in spite
of the fact that Miss Dean, Supt. of the Lying-in Hospital, says she might
have a Catholic priest called in if she so wished.

Patient stated that they had had no help from wife's brothers and
that they were not looking for it and did not want it. Said that they v,^ere
planning to visit them some time, but that they felt that since the brothers
owned autos they could take the initiative. Patient working and improving
and shows no mental disorder and they are both capable of making their
own plans. Patient reports regularly for treatment. $11 to be collected.
MN/MCW

May I.

Patient in for treatment. Gave visitor $1 on $11 owed for wedding
fee. Patient very much pleased with new apartment, but feels they will
have to move before another winter as the boilers are not sufficient to give
enough heat to the entire building. Patient claims that his wife has the
money. He does not know what she does with it, but he is constantly
after her to pay the visitor back. He says she is pretty stingy and said
he had to pay for 2 treatments in order to get the extra $1 so that we
could start in paying visitor. Will try to bring more soon.

May 10.

Patient in. Paid balance of $11.02.

May 13.

Patient's zvifc in. Patient's wife delighted with new apartments. Feels
now that as soon as a few more dishes, etc., are obtained she can invite her
relatives to come and see her. They have none of them been to see her
since she was married. She wants to have everything fixed up and then
invite them. H they refuse, well and good; she won't bother them any
more. She seems very proud of the fact that she has never asked them for
money since she was married. Informant is 6 months pregnant, but as yet
has not felt any life. Has an appointment with a private doctor who will
confine patient at St. Catherine's. Will let visitor know results. Liformant
does not believe she is pregnant. Informant is anxious that husband ob-
tain work in some other department, as she feels that working in the base-
ment is not good for him. She says that he gets very, very tired. As yet
they have received no money from the Steamfitters' Union and seem to
feel that now they may not. Informant has some money saved up toward
confinement expenses, but promises to bring in money for visitor. Visitor
urged upon her the importance of this, stating that she probably would
have less money rather than more later on.
MN/MMM

May 13.

Patient to clinic. Patient is anxious to obtain new work. He feels
that dampness where he is working does not agree with him. Visitor

APPENDIX A 581

1918

refers him to Mr. Shackley of the Y. M. C. A. and gives him notes to

Mr. Young, Library Bureau, and to Mr. Nason, Simplex Company,

Danvers.

June I.

Case closed: Patient has shown no mental symptoms and seems well
pleased, industrious, and able to obtain a new job whenever he wishes to.
His wife is expecting confinement soon, has money saved up to see her
through, and is insistent upon having a private Catholic doctor and refuses
to go to B. L. I. or in fact to any hospital.

Patient reports regularly for treatment and is told to let visitor know
if he gets into difficulties.
MN

582

APPENDIX A

Case 89
PSYCHOPATHIC HOSPITAL

SOCIAL SERVICE
NUMBER 293s
FILE NUMBER 1 1 201

0. P. D. NUMBER NAME Joseph Fangillo *

RESIDENCE 28 Central Ave., Arlington
Correspondent Mrs. Theresa Fangillo

Sex M Age 42 Color

Civil condition M Place and pate of birth

Religion C 3/4/1876

Time in Boston Life Occupation Bookkeeper

Previous addresses Long St., Mat- In Mass. Life In U. S.

tapan

When known to social service 1/28/19

When discharged from social service

Reason for being known to social service History

Report from confidential exchange No record

Name of father Henry C. (deceased)

Address

Name of mother Nell Bonelli (deceased)

Address

Name of spouse Theresa Costelli

Address 28 Central Ave., Arlington

Names and ages of children or siblings

W
Boston,

Life

Children :
John— 13
Emma — 4J^

Admitted to house I, 1/24/19;

II, 2/24/19; III, 4/9/19
Discharged 1,2/13/19; 11,4/5/19;

III, s/8/19

Siblings :

Mrs. Bonelli — about 50

Theresa — about 45

Antonio — about 47

Mrs. Cavalaro

Mrs. Mardini
Authority I Vol., II Vol., Ill

Vol.
Admitted to O. P. D.

Recovered
Unimproved

Diagnosis I. Manic Depressive Condition I.
II. Psychasthenia De- II.

pressed
III. Psychasthenia
Social symptoms Date 3/1/19

Unemployment
Industrial decline
Worry
Social diagnosis Disease Date 3/1/19

* All names ttsed in this record are fictitious. In this case an unusually detailed
record was kept, as it was one of a group of cases included in a study of the psy-
chopathic employee in industrv.

APPENDIX A 583

PSYCHOPATHIC HOSPITAL

SOCIAL SERVICE
CASE NO. 2935

FILE NO. II20I NAME Joseph Fangillo

ADDRESSES
Patient's telephone:

Can be reached at Arlington 2640

Mrs. Giordani,

28 Central Avenue,

Arlington, Mass.
Family Physician:

Dr. Sullivan

Arlington 1786
Patient's sister:

Mrs. Bonelli,

97 Main St.,

Boston.
Patient's brother:

Antonio Fangillo,

Bradbury, Vt.
Patient's sister:

Mrs. Cavalaro

Hamilton St.,

Chelsea, Mass.
Patient's cousin: Place of employment:

Nicholas Tosi, 60 Manhattan St.,

930 Hamberg St., Boston, Mass.

Dorchester, Mass.

Tel. Dorchester 946-W
Wife's sister:

Mrs. Jennie Riley,

43 How^ley St.,

Roslindale, Mass.
Patient's wife's another: (Can be reached by telephone of

Mrs. Costelli, neighbor in same house — Beach

10 Victoria St., 1459-M)

Boston, Mass.
Wife's sister:

Bertha Costelli,

10 Victoria St.,

Boston, Mass.
Patient's sister:

Mrs. Mardini,

Cedar St.,

Cambridge, Mass.
Patient's sister:

Theresa Fangillo

Lives with her sister, Mrs. Mardini.

5^4

APPENDIX A

PSYCHOPATHIC HOSPITAL

SOCIAL SERVICE
CASE NO. 2935

FILE NO. II20I NAME Joseph Fangillo

SUMMARY

1919

February 12.
Social:

Patient is a man of 42 — born in Boston of Italian parents. He com-
pleted a 3-year high school course at 15, and then took a year of advanced
work there, after which he completed a business course of 6 months.

He then did various kinds of office work, followed by bookkeeping.
He was a bookkeeper for the Stratton Piano Company, Boston, for 16
years, starting at low wages and working up to $35 a week.

After being for 2 months in 191 1 at the Boston State Hospital, he
spent 2 summers on a small farm in Bradbury, Mass., which he has partial
use of for ^2^ a year. Then for a year he was manager at the Marko
Cafe. For the past 3 years he has been one of three partners in a liquor
concern which proved fairly successful, each member clearing $1,000 a year
in addition to his salary. Patient withdrew from this work before Christ-
mas, 1918, and has been without a position since.

Patient is married, having a son, 13, in high school, and a daughter,
4^, at home. Family rents a 4-room flat in Arlington for $14 a month.
The rooms are on the first floor and sunny, neat, and comfortably fur-
nished, and there is a fair-sized garden.

Physical:

Patient's mother died of spinal meningitis. Otherwise the family
history is not of interest, except perhaps the fact that patient's brother had
a breakdown 15 years ago similar to patient's.

As a child patient had typhoid and diphtheria, and 2 accidents. In
one he was run over and his legs were in a plaster cast for 9 months.
There are no results now. In the other his head was hit.

He is of strong build and is in good physical condition at present. He
has worn glasses since 19 years of age, his eyes having troubled him more
than usual of late. They have been treated only by an optometrist who
says his vision is low but perfect with lenses. The 'Wassermanns of his
blood and spinal fluid are negative. He admits gonorrhea and soft chancre
years ago for which he had treatment.

Mental:

Patient was a good student at school. He was graduated from a
3-year course at high school at 15, and then took a 4th year there followed
by a business course of 6 months.

APPENDIX A 585

I919

His work at the Stratton Piano Company was responsible work, and
patient had the ability to keep the position until 6 years ago. He has
always been inclined to worry, however, and about 10 years ago developed
a sex phobia, becoming afraid even to meet women on the street. This
worried him excessively. He has always been especially fond of outdoor
sports and of reading both fiction and books on economics. His wife had
urged him to mix more with others although he has not been especially
seclusive.

In 191 1 he became nervous and fearful, and at the advice of his private
physician left work and went voluntarily to the Boston State Hospital
where he was given a diagnosis of psychasthenia. While there he had
hydrotherapeutic treatment. After 2 months' care there, he was discharged
and went to work on his farm oil and on for 2 or 3 years.

Patient has always been of even disposition, not moody, enjoying com-
panj-, though being somewhat quiet. He enjoys his home, children, and
reading. He is not sensitive or irritable. He has always been inclined
to worry.

Both patient and the Stratton Piano Company agreed that he was
unable to return to them. Patient was unhappy while in the liquor busi-
ness. He found the work and the environment uncongenial. After with-
drawing from this in December, 1918, he became worried and apprehensive
about the future and felt some former fears return. He attempted to keep
his self-control through walks of 10 to 15 miles, but was unsuccessful,
became depressed and hypochondriacal. He came to this hospital as a
voluntary patient.

RESULTS

February 12 to May 12.
Social:

There has been no income, but patient's wife says most of the $500
saved remains, as she and the children spend about half of the time living
with her mother, who apparently stands most of the expense during the
visits. Her mother lives in the East End, Boston, and is supported by a
son and daughter, both single.

Patient's wife tried work a few nights, dipping chocolates at $1 for
3 hours in a candy factory, but was readily persuaded of the inadvisability
of this. She has devoted a large part of her time to visiting patient at
the hospital and taking him out for walks.

When patient was last discharged from the hospital, she took Emma
and patient to their little farm in Bradbury, but returned to her mother's
on his re-admission to the hospital. She has considerable understanding
of patient's condition and, though somewhat worried about the future, is
making a very brave fight and is always cheerful in the presence of
patient.

Physical:

Patient has continued well physically. His eyes have not yet been
examined by an ophthalmologist.

Mental:

Patient was discharged from the hospital 2/13/19 much improved, and
visited his brother on a farm in Bradbury, Vt. He got along well for a

586

APPENDIX A

1919

week, but after an idle Sunday his fears returned and he was readmitted
to the hospital 2/24/19. He seemed worse after this second admission, but
pulled himself together sufficiently to try his farm at Bradbury, being
discharged from the hospital 4/5/19. He worked there outdoors a few
days when his old sex phobia returned, and he was so discouraged about
this that he returned to the hospital, readmitted 4/9/19. All through his
stay at the Psychopathic he has worked hard on the wards, pleading con-
stantly for hard work.

His chief fear all spring has been that prohibition will not be put into
effect, and that therefore he has lost out by giving up his liquor business.
Although he can reason with himself that he is fortunate at all events to
be out of the liquor business, this fear still possesses him so much that
he dreads reading the newspapers. In the last few weeks, however, this
fear has decreased considerably, and he feels that he has it pretty well
under control.

He is very anxious to get well and repeatedly says he will do anything
in his power to do so. He frequently aslcs whether visitor thinks he will
ever get well.

On 5/8/19 patient was discharged to the Middlesex State Hospital as
a voluntary patient, Dr. Lawson, his examiner, feeling that he would do
much better there with the increased facilities for recreation and team-
work outdoors.

May 12 to September 30.
Social:

Patient remained at Middlesex until July 14 when he went to live at
his camp in Bradbury. His wife and children preceded him there by a
few weeks, patient visiting them often during his stay at Middlesex.
Patient's wife has canned a quantity of vegetables for the winter. Her
family have been frequent visitors to the camp and have brought them
food for the family. Patient plans to move back to Arlington about
October i, the rent having been paid all along by his wife's relatives
who feel very kindly toward patient as do his relatives also. Both patient's
family and his wife's family are superior Italian people of ambition and
thrift. Patient's mother-in-law has a large household to cook for, as her
single son and daughter, both working, and a married daughter, son-in-law,
and their two children live with her, and in addition the patient's wife and
children are frequent visitors.

Patient is one of six siblings. The oldest, a sister with whom patient
lived several years before his marriage, has several grown children able
to support the family without her husband's assistance, who is now a semi-
invalid. A brother is on a farm in Brayton, Vt., and two of his sisters
live together, one of them married, the other working.

Patient has done his own farm work this summer as well as hiring
out to neighboring farmers frequently. John has begun his second year
at high school in Arlington and Emma was sent to school for a few days,
but is now kept home for a week or two until the family canning is finished
at camp and the family move to Arlington for the winter.

Physical:

Patient is in excellent physical condition as a result of outdoor work.

Mental:

Patient improved considerably at Middlesex, doing six hours pick-and-
shovel work there a day most of the time and farm work at his camp

APPENDIX A 587

week-ends. Early in August efforts were made to get him into the employ
of the Gray Motor Company, Dorchester, in the fall, but the employment
manager has found no vacancy. The Schuleman Paper Box Factory in
the East End, which prides itself especially on its humane handling of its
employees and where another patient is apparently very happily placed,
stated early in September they would be glad to interview patient. As a
result, patient came down from camp a few days ago to visit Schuleman's.
They agreed to take patient on any time but patient feels that though they
are most considerate the chances for advancement are not large. Patient
says he knows "beggars can't be choosers" but says "I would like some
place where I could begin work and work hard if I felt that I could learn
some useful trade or where I could be sure of advancement provided of
course I merited it." This indicates a desire to plan for the future which
he has not manifested before.

Patient reports that occasionally he has "fear spells" but much less
frequently and of shorter duration. He is full of hope for the future and
sure he will be entirely well after getting into new work. His eyes look
very bright now instead of apathetic.

September 30 to December 12.
Social:

Early in October patient's family moved to Arlington for the winter
but still visited the farm frequently week-ends. The children are in school.
Patient remained in the country until the end of November picking apples
and coming to market in Boston frequently. The family has on hand quite
a little fruit for the winter and patient earned most of the expenses of
the summer by his farm work. His wife remains very philosophical.

While in the liquor business, $300 was borrowed from patient, and a
brother owes him $700, and a brother-in-law $200. He hopes to be paid
some of this soon. He has two $1,000 semi-endowment life insurance
policies. Patient's wife returned to candy dipping this fall at $1.25 for
three hours in the evening, planning to stop when patient is regularly
employed.

Efforts have been made to find patient suitable work through the
Y. M. C. A., State Employment Office, Bureau for Returning Soldiers and
Sailors, and Bryant & Stratton's. He applied definitely for clerical posi-
tions at the Riverside Book Shop and at Schuleman Paper Box Factory,
Stratton Piano Company have no openings for patient.

Physical:

Patient's eyes have not been examined as Dr. Jacobs advises no
examination for the present.

Mental:

Dr. Jacobs agreed to see patient because doing research in psycho-
neuroses, and saw patient early in October. He felt patient's diagnosis
was between manic depressive depressed and psychasthenia or a combina-
tion of both, but that patient was rapidly recovering and soon would be in
as good shape as after his attack several years ago. Every three months
or so he should report to some psychiatrist to make sure he is not over-
working. He says there is no reason why patient should have to try work
different from his former clerical work but em.phasizes the necessity of
patient's having a hobby. His fears are so slight now that they can be
disregarded. Patient gives the credit of getting well to his wife. He has
been a little afraid of attempting bookkeeping again but has been per-
suaded to do so.

588 APPENDIX A

The Riverside Book Shop felt they could not consider patient, as the
work was especially nerve-racking, there being only women among the
customers and help and books being behind. They also felt that patient
must be rusty at bookkeeping as he had not done any in five years.

The Schuleman Paper Box Factory was ready to consider patient for
clerical work but patient felt the chances for advancement were not great
enough. When he was finally convinced of the desirability of the job, the
job was no longer open.

December 12, 1919, to March 12, 1920.
Social:

Patient and his family spent a few days at Christmas with her rela-
tives. The children received about $35 in Christmas gifts and patient $25
from his farmer friend, James. His brother has paid back $50 but no
other debts have been paid him. His wife is still working at candy
dipping at $1.25 for three hours. The children were sick at the end of
January, John with influenza and Emma with stomach trouble, and patient's
wife was tired out at this time. She still keeps up good courage. The
relations with the landlady have been a little strained but not markedly so.

Patient did not get a job until February 11, when he has since held a
temporary position as bookkeeper at $25 a week. Many agencies assisted
in helping to look for suitable work for patient but clerical openings for
men have been exceedingly scarce, especially without stenography and type-
writing.

Physical:

Patient had a slight cold but has otherwise been well.

Mental:

Patient looked up many openings on his own initiative as well as
those suggested by agencies and visitor. On patient's part the following
were reasons for not taking the jobs offered: too much responsibility, and
not enough chance for advancement. He kept up good courage although
admitting more and more discouragement at not being able to get a job.
He admits he feels much better since working, and feels sure he will be
perfectly well when a permanent position presents itself, efforts to obtain
which are now being made.

HISTORY

January 29.

Patient seen on ward.

Impression : pleasant, intelligent, good insight into condition.

Patient says that in his family his brother had a "nervous breakdown"
15 years ago, which seemed similar to patient's present trouble. Brother
was worried, broke down ; went "up country" where he recovered. Patient
did well at school, going through High School and finishing a commercial
course in 6 months. He finished the two courses in as short a time as
possible because he had little money. He had his commercial training at
the Comer Commercial School, Somerville, now out of existence.

Patient has worked as private secretary and for 16 years as book-
keeper in the Stratton Piano Company, a very good position of responsi-
bility and from which he has recently been given a good recommendation.

APPENDIX A 589

I919

When he went to the Boston State Hospital in 191 1 they would not re-
employ him at the Stratton Piano Company on his return.

He stayed out of work for 2 or 3 years, and for one year was manager
of the Marko Cafe, and for 3 years was in the liquor business from which
he retired in 1918. The business was fairly successful, each of the three
partners making $1,000 a year besides their salary. Patient retired because
he disliked the business and because he felt it would be better to get
started in another position some time before prohibition comes in July,

Patient seems to be happily married. His wife has ingenuity and a
happy disposition. Of his children, John, 13, is in the high school.
Emma, 4^^, is at home.

Patient likes to be among people, but he is particularly fond of reading
both fiction and books on economics. His wife has urged him to mix
more with others and he realizes that one is better mentally when not
alone too much. He is particularly fond of outdoor sports, likes farming,
walking, etc. He and his wife go out together occasionally in the evening;
he seems to have several friends.

Patient says he had children's diseases. At the age of 9 he was run
over across his body and in a plaster cast for 9 months. He believes he
has no serious results of the accident. Patient has suffered from neuritis
for some time. His eyes also have troubled him. He has been to several
doctors for treatment, among them being Dr. Baker from the Patton
Building. He has been under medical care of Dr. Francis.

Patient says that at the time of his going to the Boston State Hospital
he was run down physically and nervously. He went voluntarily and
seemed to improve under the treatment of the baths he was given. After
leaving there he could not return to his former position and so for 2 or 3
years he lived "up country," renting 2 or 3 rooms and being given all the
land he wanted to farm. He improved here and he seemed stronger until
suddenly about 2 or 3 weeks ago he felt a "fear spell" come on him ; things
worried him which he was unable to drive from his mind. He felt that
he had made a mistake in leaving the liquor business ; that he was not well,
etc. He realized that he had to fight this off' and for three days he had
been taking long walks, sometimes for 18 or 20 miles a day. He suc-
ceeded in driving it off but in 2 days it returned again. He could not sleep,
but felt he had to be up walking all the time ; but even while walking he
could not keep himself from worrying. He became discouraged, intro-
spective, and disappointed. He went to Dr. Sampson for advice, asking if
it were not possible for him to come here. The doctor agreed and patient
wanted to come immediately on Thursday, January 25. The doctor per-
suaded him, however, to wait until morning. He came here voluntarily
without telling his wife or children where he was going.

At present he does not sleep well, but says he is feeling stronger and
says he is much better able to control his thoughts and keep himself from
worrying. His main desire now is to get strong so that he can be able
to take a position, preferably not in the bookkeeping line because of his
eyes.

His wife said that if he is not better she will break up the home and
go to live with her mother or go to work herself, but he feels that he can
take a good position when the opportunity comes.

January 28.

Neighbor, Mrs. Giordani (28 Central Avenue, Arlington) telephoned
to. Informant lives in flat above patient's family and has known patient

590 APPENDIX A

several years. She says that since leaving Boston State Hospital in 191 1
patient has been "fine" until about 6 weeks ago when he said that he felt
nervous and that the "same trouble was coming on" again. He was told
to mix in more with others and thus he would feel better. He did this ;
he continued to be nervous, however — he could not keep quiet and seemed
to have to keep going all the time. He was a little irritable.

Informant believes patient does not drink. He has complained at
times of his eyes. He has always been quiet — has always been pleasant.
She does not know that patient has been sensitive or that he has been
fearful of enemies or suspicious of friends.

January 29.

Present illness:

Previous to patient's attack in 191 1 he had been complaining of neu-
ritis in his wrist. For this he took medicine. He stayed home for a week
but found even at the end of that time that he could not return to work.
He was advised by Dr. Francis to go to Boston State Hospital, where he
did go voluntarily ; remaining two months. While there he was given
baths, which patient considered most satisfactory treatment. While still
at hospital informant used to take him out to walk and would occasionally
take him home to spend Sunday. Upon his return home he could not work
(even had not his former position been filled). Informant believes he was
run down physically at the time. The succeeding summer he spent "up
country" on a friend's farm, where he dug and worked outdoors, and
where his condition improved. He and informant spent the next winter
at patient's sister's home. The following summer he spent again at the
farm and in the autumn of that year he returned to work for the first time
in two or three years.

Informant feels that the three years patient spent in liquor company
have been a contributing factor in his second attack. This business
brought him into contact with a much less desirable class of men than he
had known when a bookkeeper, the environment about his place of work
was not pleasant, and patient did not, moreover, like the liquor business.
For some time he had been considering withdrawing from the company
and finally did witlidraw just before Christmas, 1918. This business worry
has been the only matter over which patient need have felt trouble; he had
nothing at home to cause him worry.

Patient intended to get into some other form of employment, but on
a night after Christmas a "spell" similar to one in 191 1 returned, which,
according to patient, was much less severe than in 191 1. After three days
it wore away, for patient said he was resolved to resist it and fight it off.
In 2 days, however, it returned, to wear away again. On Wednesday,
January 22, patient felt well in daytime but was worse at night ; on
Thursday night he hardly slept at all and he decided to come here for care
at this hospital.

Informant denies hallucinations, delusions, or fears in patient. She
says his mind, even at the present time, has always been clear and normal.
Patient's nerves alone need some sort of treatment. Informant feels that
patient has improved while being here and that in two or three weeks he
will be well enough to return home.

February i.

Dr. Lazi'soji, patient's examiner at hospital, consulted. Stated that
patient has insight. Informant has not gone into his sex history, but does

APPENDIX A 591

1919

not feel that the reasons for his leaving Stratton Piano Company are of
vital significance in his condition. Patient's prognosis is good. Patient
has initiative and can himself state what work is best for him.

February 3.

Patient seen on zvard. Stated that a friend of his has a farm in
Bradbury, Mass. For the use of a few rooms there patient pays $25 a
year. He has gone up there several summers in succession. Patient has
between $500 and $600 left. Has known his wife since she was 7 or 8
years old. "Went with her" about 10 years. For details of patient's work
see "Industrial History" enclosed.

February 4.

Patient's wife seen at hospital. States that she is of a worrying nature
— trying to look on the bright side. Both her children have stomach
trouble from time to time. Her family doctor is Dr. Sullivan of Arling-
ton. Treats them from time to time for gastritis. Patient's wife often
takes the children to her mother's for the week-end, opposite Station 2,
East End. Informant's father is dead and her mother is supported by a
son and daughter who live with her.

February 12.

Place of employment, Stratton Piano Company, 288 Bagley St., Mr.
Dawson and his father seen.

March 15.

Dr. Malcolm, Optometrist, Rice Building, telephoned to. Informant
stated that he has treated patient for several years, the last time being
December 16, 1918. At that time his vision with compound lenses in both
eyes was perfect (20/20) though without lenses was 15/20 in each eye.
Sees no reason why patient could not do any kind of work he pleased as
far as his eyes are concerned. Stated that patient's lenses should be
changed about once a year, though he would like to see patient soon as
he had added a little to patient's prescription on December 16 for near
work and would like to know how this affected patient.

May 24.

Patient's mother-in-lazv, Mrs. Costelli, 10 Victoria St., Boston, visited.
Sister-in-law, Bertha Costelli, also seen.

Impression of Mrs. Costelli : Looks intelligent, kindly, and healthy,
but speaks almost no English.

Impression of Bertha Costelli : Intelligent, warm-hearted, and ex-
ceedingly interested in patient and his wife.

Impression of home : Exceedingly neat and well furnished, up three
flights. The street is a blind alley consisting of tenements crowded closely
together.

Mrs. Costelli cooks for ten people including patient's wife and child.
Bertha Costelli and her brother, both of whom are single, and a married
sister with her husband and two children. Patient's wife is always afraid of
intruding. Informants do not feel that she is, however. Bertha Costelli
stating that the Italians are more sympathetic with their friends in trouble
than other races.

Both patient and his wife are splendid people and devoted to one
another. Informants see no reason why patient should worry. Bertha
regrets that her mother has always worked, having started at the age of 6
on a farm in Italy and refusing to rest now.

592 APPENDIX A

1919
May 24.

Patient's older sister, Mrs. Bonelli, gy Main St, visited.

Impression : Informant is an intelligent, refined Italian, devoted to her
family and to patient.

Impresbion of home : Very neat and well furnished, on the first floor
of a tenement house at the better end of Alain St.

Patient has always been studious, ambitious, and conscientious. Patient
was with informant 4 years before his marriage 15 years ago. He pre-
ferred being with informant to living with his mother. Informant sees
patient and his family often. At bookkeeping he worked much overtime
and toward the last wore 2 and 3 pairs of glasses at a time. Informant
ascribes his first illness to overwork. She thinks that now he is in better
physical condition than when he broke down 6 years ago.

All the relatives on both sides are very sympathetic with patient.
Patient has always made friends easily and had many. Informant would
do her share financially if help was needed, but patient's wife's family are
aiding at present.

Informant is the oldest child, followed by Antonio who has a farm
in Brayton, Vt., and has been recently married. Patient is next followed
by a single sister who lives with the youngest, Mrs. Mardini, Cedar St.,
Cambridge, Mass. Patient has not been overly religious.

Informant's husband has not worked in the past 2 years. He was
formerly a laborer and insisted on giving his children a good education.
Visitor saw one daughter who is a High School graduate and attended
Bennett's Business School.

January 29.

Dr. Francis, E. Boston 488-lV, telephoned to. Informant says cause
of patient's trouble is that he went "sexually wrong" about 10 years ago.
Informant would not make more definite statement over telephone except
to say that patient was abnormally sexually excitable, — if he saw a female
approach on the street he would have to cut down a side street, so strong
was his sexual instinct. He brooded and worried over this until it became
a mania with him and this was the sole cause of his having to leave the
Stratton Piano Company where he had a good position. He was at the
Boston State Hospital for a short time and has been better in recent years.

Patient used to be cheerful and optimistic before marriage. Infor-
mant says his married life has been only fairly happy, and that recently
patient has had great financial worry. His trouble dates from his mar-
riage. In recent years patient has grown coarse and vulgar, contrary to
his former personality. Informant feels that the fact that patient had to
"rough it" while associated with liquor business was a good thing for him.

Informant says that patient has complained of nervous trouble, having
"wandering pains" over body. Informant titled this "neuritis" or "neur-
asthenia," but believes the pains were psychogenic.

Informant says patient did not have syphilis, but that his worry over
his sexual desire is cause of his nervous condition.

January 29.

IVife interviewed at hospital.

Impression : Pleasant, intelligent, self-possessed. Seems to be co-
operative, yet at times noncommittal, perhaps desiring to shield patient.

APPENDIX A 593

1919

Family History:

Grandparents : Unknown to informant.

Mother : Died at 75 probably of pneumonia — bright, cheerful, of ex-
cellent disposition.
Siblings :

1. Sister, Mrs. Bonelli, 97 Main St., Boston.

About 50 years old. Is well and has several children.

2. Sister, Theresa, about 47. Unmarried.

Works in box factory. When 3 or 4 years old she had spinal
meningitis, as a result of which she lost the sight of one eye
and became quite deaf in both ears.

3. Brother, 47. Married. No children. Is well and works in

Brayton, Vt., on a farm.

4. Patient.

5. Sister, Mrs. Cavalaro, Hamilton St., Chelsea. Mass.

6. Sister, Mrs. Mardini, Cedar St., Cambridge, Mass.

Married. Well; good disposition.
Informant knows of no constitutional disease, nor of any mental or
nervous trouble in family. Family is normal.

Personal History:

Developmental : Not known to informant.

Educational :

Patient graduated from High School (which was then composed
of 3 grades) at 15. Being too small to take a position he spent
next year in the "advanced course." He then went to Comer's
Commercial School. He seems to have been noticeably bright in
school.

Economic :

Patient's work at Stratton Piano Company satisfactory to all con-
cerned.

Marital :

Married 15 years. Lived previously on Long St., Mattapan. Has
two children:

Boy> 13 — ist year High School ^ Both children are well and
Girl, 4j4 — fond of dancing ] bright in intellect.

Habits :

Patient is not a drinker. He takes only an occasional glass of
liquor. Is only moderate smoker. No drugs. Informant knows
of no infectious blood disease.

Personality :

Even disposition, not moody. Is fond of company and enjoys
people. He has friends in to call and he and informant go out
together not infrequently. Is quiet, however ; likes to be home
with his children and likes constantly to read. Is not sensitive nor
suspicious. Is not hot-tempered nor irritable. Patient has always
been rather inclined to worry.

Medical :
Informant knows of no serious illnesses. Patient has been at no
other hospital beside this except Boston State Hospital. He has
been under care of Dr. Francis for several years. No fainting
attacks.

594 APPENDIX A

ACTION TAKEN
1919
February i.

Patient seen on ward. Anxious to remain another week to get a hold
on himself. Thinks he will be much better ofif after his stay here and after
he gets to work. Says he worries when not working. Is anxious to do
any sort of work whatsoever. He had his eyes examined as recently as a
few weeks ago by Dr. Malcolm and had his lenses changed.

February 3.

Patient seen on ward. Will stay several days longer.

February 7.

Neiucomb's Ink Co., Mr. Pierce, employment manager, telephoned to
regarding possible opening for patient. Stated that he had a position
which would involve general picking up about the place^ which might do
for patient. Asked that patient be sent to him.

February 8.

Patient and zvife sent tvith note from Social Service to Newcomb's Ink
Company. On his return patient stated that Mr. Pierce had not been
aware that the position was already filled by one of the foremen.

February 8.

Netvconib's Ink Company, employment ma)iagcr Mr. Pierce, telephoned
that without his knowledge the position had been filled by a foreman.

February 10.

Patient seen on ward. Stated that he would like to visit his brother
on a farm in Brayton, Vt.

February 11.

Newcomb's Ink Company, employment manager Mr. Pierce, telephoned
to. He has no openings but will let Social Service know if he has a little
later.

February 12.

Patient seen on zvard. Stated that his brother is to call for him
2/15/19 and take him to the farm of this brother's fiancee in Brayton, Vt.
Patient has felt better since contemplating this. Social Service agreed to
think this plan over and talk it over with Dr. Lawson.

February 12.

Dr. Lazvson, patient's examiner at hospital, seen. Thinks plan a good
idea. Would like to see employer, Mr. Dawson, regarding patient's sex
tendencies. Patient has not spoken of this to informant.

February 12.

Patient's wife seen. Took patient out for about two hours to-day as
she has done for a number of days.

February 13.

Patient discharged to-day from hospital as he suddenly decided he had
sufficient grip on himself to make the plunge now. He will go in a day
or two to the farm of his brother. Patient's wife agreed to let Social

APPENDIX A 595

Service know how patient gets along. After a few weeks there patient
plans to return to Boston and would like Social Service to look for a job
for patient in the meantime.

February 25.

Patient's wife telephoned that she visited patient 2/22/19. Found him
doing fairly well though he still has "fear spells" at times. He is working
hard all day. Has not yet planned on date to return to Boston. Will
telephone when she has further news of patient..

February 25.

Patient was readmitted to hospital yesterday, this fact not being known
to Social Service or patient's wife at the time of her telephone message.

February 25.

Patient's wife later visited patient. She was somewhat worried over
patient's apparent relapse, but is hopeful of a good recovery, and puts
forward a cheerful face to patient.

February 25.

Patient seen on ward. Somewhat depressed and disappointed that
work has not cured him. Is determined to put forth every effort to get
well, but is doubtful whether he will recover. Spent the time in Vermont
in doing farm work, cutting ice, hauling wood, etc. On Sunday 2/23/19
patient was idle and had time to worry considerably, and yesterday he was
too nervous and excited to work. His brother told him he was a "fool"
to return to the hospital and urged patient to "stick it out," but patient felt
he could not.

February 25.

Dr. Lawson, examiner of patient, seen. Stated that she will go into
patient's sex history this time.

March 3.

Dr. Lawson, patient's examiner, seen. Patient is very depressed to-day
and is having hydrotherapeutic treatment. Informant has talked with
patient about sex matters. Patient gives no history of anything of the sort
disturbing him in several years.

March 7.

Patient seen on ward — very depressed to-day ; easily weakening.
Knows he should not worry about giving up the liquor business, but has
an idea that prohibition may not be put into effect. Realizes fully that the
liquor business did not agree with him. Also realizes that his present
worry is inconsistent. Has a fear of being sent to the State Hospital.
Reassured patient on this point. He is "pining" for good hard work.

March 7.

Superintendent of Nurses, Miss Murray, seen and urged to give pa-
tient more work on the wards.

March 10.

Patient's zvife seen dt hospital — looking more tired than usual. Stated
that for the past week she has been working nights at a chocolate factory
on Bar St., dipping chocolates at the rate of $1.00 for each night of three

596 APPENDIX A

hours, 7 to 10. She was anxious to earn car fares in this way and was
getting lonesome at home.

Social Service pointed out other sides to the question ; namely, that
patient would resent her working now whether or not he finds it out until
later, and that her children need her at home, especially as she visits
patient at the hospital daily. Also urged against it from the point of view
of her own health. Suggested that she think the matter over. She stated
she now felt she would not return to work. When asked the name of the
firm, she would give no further details than to state that only a few
employees work there. Informant did not seem at her ease. Social Serv-
ice made an appointment to visit at her home 3/12/19 in the morning, and
she and Emma will be at home. Emma is now staying with wife's sister,
Mrs. Riley, 43 Howley St., Roslindale.

Later, when Social Service saw informant on the ward, informant
beckoned in uneasy manner to her to state that she hoped Social Service
was not going to visit the neighbors. Social Service stated that they haa
no intention of visiting neighbors now.

March 10. _

Patient's examiner, Dr. IVarren, consulted. Stated that in his esti-
mation patient can do any kind of work ; is strong physically and could
stand indoor work. Informant is willing for patient to leave the hospital
at any time he wants to ; the sooner patient starts to work the better. In-
formant does not know what patient's vision is and says patient does not
know what he fears during his "fear spells."

March 10.

Patient talked with on zvard — very depressed; still afraid he did not
do the right thing in leaving the liquor business, and that perhaps he
should not have settled to the disadvantage of his partners, even though
they had previously robbed him. Does not like to think of leaving the
hospital soon, as he is afraid lie might attempt to make away with himself.
Assured patient that he could not expect to be entirely well until after
getting to work.

March 12.

Home visited.

Impression of home: Very neat, sunny, well-furnished rooms; four
in number besides pantry, on first floor of a frame house. Situation on a
high hill in Arlington, five minutes' walk from Grant College.

Patient's wife and Emma at home. Patient's wife visited patient
yesterday and found him exceedingly depressed. Her courage was good
until then, but she has been considerably worried in the last twenty-four
hours. Tears came into her eyes easily during the visit. She insisted on
serving a little luncheon to visitor, which was well prepared and nicely
served.

Landlady dropped in for a few minutes, a very intelligent, kind,
neighborly person, evidently knowing the details of patient's illness.

Emma obviously has adenoids, and docs not look exceedingly well.
She seems bright but quite restless, a very affectionate and winning child.

Patient's wife has given up her work at the factory. She would hate
to have to give up her present home, but does not see any necessity of it
for several months at least. The rent is $14.00. Family has lived in this
house five years — landlady occupying the second floor. Patient's wife left
with visitor to go to hospital.

APPENDIX A 597

1919

March 12.

Newcomb's Ink Co. visited. Mr. Pierce out. Was shown through
factory by Miss Martin, his office assistant, and by one of the foremen,
Mr. Gordon. Both stated that they felt sure Mr. Pierce would take
patient if he could make room for him, unless he had some plan of his
own to the contrary.

The factory is very well lighted and roomy, and the atmosphere is
kindly. Miss Martin will let Social Service know in case Mr. Pierce can
fit patient in soon.

March 12.

Patient seen on ward. Seemed very cheerful.

March 14.

Patient seen running down the steps from one floor to another of the
hospital. His face was beaming and he stated that he is feeling very well
to-day. His wife brought his former partner in, with whom patient
settled one or two matters on his mind. He has been cleaning windows
with the attendants to-day and has spent a good part of the day doing this.
Willingly agreed that work was good for him.

March 24.

Patient's wife seen at hospital. Informant says patient was still de-
pressed yesterday and does not feel equal to getting out or seeing an
employer. Visitor asked wife to urge patient to go out for a walk.

March 25.

A. F. Gainshoro's employment manager, Cambridge, telephoned to.
Informant stated that they are not in need of anything but skilled ma-
chinists. He suggested telephoning to the Federal Steel Trades Cor-
poration.

March 25.

Federal Steel Trades Corporation, 83 Aubiirndale St., employment
manager Miss Fiske telephoned to. Informant stated that openings have
been very few and she has no suggestions at unskilled or clerical positions.

March 25.

Patient's examiner, Dr. Warren, telephoned to. Informant stated that
he still feels patient should soon return to work, and that he has stressed
this whenever he talked to patient. Informant has not talked much with
patient recently, but will do so soon.

April 5.

Patient discharged to wife and O. P. D.

April 9.

Patient admitted to house as voluntary.

Aprilio.

Patienfs wife seen at hospital. She was disappointed that patient has
not been able to hold his own away from the hospital, but feels that a
longer time here will eventually set him on his feet.

598 APPENDIX A

1919
April II.

Patient interviewed on ward. He is discouraged over the fact that his
fears return as soon as he leaves the hospital. He clings constantly to the
hope that his disease will be cured eventually. He tries to keep his
thoughts ofif of himself, and forces himself to read the newspaper, although
in so doing he reads the news concerning "Prohibition," and concerning
the fact that the new law may possibly not go into effect after all. This
worries him, as he feels remorse over the fact that he may have made a
mistake in retiring from the liquor business. He is anxious for work and
for reading material.

April 15.

Four current magazines sent up to patient.

April 15.

Patient's wife seen at hospital. She goes walking with him every day
and feels that he is slowly improving. She is buoyant and full of encour-
agement which patient seems to appreciate.

April 17.

Patient's wife seen at hospital while she was waiting to take patient
to walk. \i in the near future patient is considering leaving the hospital
again, she will let visitor know.

April 21.

Patient seen on zvard. He was pleased with the magazines. Said he
read eagerly every word of them.

April 22.

Patient and wife seoi on leaving hospital for a walk and told of the
return of Miss May, former visitor.

April 24.

Patient and is.nfc reported to visitor before going out for a walk.
She takes patient walking several hours a day now. He says this is the
only time he enjoys during the day, as it is the only time he is free from
fear spells, even when working at the hospital. He still cleans windows
daily.

April 28.

Patient seen on zvard. He is much improved though still fearful re-
garding prohibition. He reads the papers daily in an effort to throw off
this fear. The farmer on the land on which patient's camp is located in
Bradbury has written urging patient and family to move out. He will get
the ground plowed and all ready for patient. Patient likes the idea and
thinks his wife will go up soon to see about this. Visitor urged that wife
do this 3/30/19 and that patient get to work there soon.

April 28.

Patient's examiner, Dr. Laivson, consulted. Informant stated that she
has not talked with patient in several days, but that a week ago she advised
his going to another hospital, such as Middlesex, to get into a more suit-
able atmosphere. At such a hospital she feels there is more opportunity
for exercise, recreation, and work with "gangs." She does not consider
patient in fit condition to work in the community as yet. She had hoped
patient would act on this recommendation himself.

APPENDIX A 599

1919

May I.

Patient and his wife talked with visitor before going out for a walk.
Dr. Lawson, patient's examiner, has advised his care at Middlesex and told
patient she would see Dr. Lang about this. Patient thinks it would be a
good thing, as he could do outdoor work under supervision, and he hopes
he will be allowed there to frequently visit his country home, Bradbury,
near by.

The farm patient visits consist of 20 acres belonging to an Italian
who has a frame house there divided up for seven families which he rents
to patient and others, all of whom grew up together. Patient pays $25
rent a year, having the use of 2 rooms. He can plow all the land he wants.
Patient would consider also being discharged from the Psychopathic Hos-
pital and going to Bradbury, reporting frequently to the O. P. D. Visitor
agreed to talk with the doctors about this. Patient says very emphatically
that he will do anything in his power to get well.

May 3.

Patien. seen starting out for a walk with his wife. He is still hesitant
about going to Middlesex, stating that he is not sure they will keep him
outdoors sufficiently. Visitor told him she would write the Social Service
worker there, and that as Dr. Lawson had told him he would work there
outdoors a great deal, there was no ground for hesitation. Patient agreed
to decide by 5/5/19.

May 8. _

Patient and his zvife talked zvith in the morning. His wife told him to
do whatever he thought best ; but he has been considerably hesitant. He
had been advised by some one to report to the Middlesex Clinic at the
Homeopathic Hospital 5/6/19, where he could personally ask the super-
intendent what the chances of outdoor work were. He did not go there,
however, as he decided to try longer walks daily, his wife reporting to the
Psychopathic early in the morning.

Visitor assured patient that Dr. Lawson did not approve of his making
plans of his own at present. Patient agreed that she was right, and
decided to take a trip to Middlesex to-day with his wife to ask the super-
intendent about the nature of his care should he stay at Middlesex.

Patient's wife stated that for a number of weeks she and the children
have been living with her mother at 10 Victoria Street. Her expenses
have been light, consisting of rent in Arlington and occasional food at her
mother's, besides carfares. She said most of the $500 was still left but
would not be definite.

Patient agreed to stay at Middlesex if conditions seemed satisfactory.
Later he was admitted to Middlesex as a voluntary patient.

May 13.

Patient's^ wife telephones that she visited patient as recently as 5/12/19
and found him very contented. He has not yet been put at outdoor work
but the weather has not been suitable. Superintendent said he would have
to know patient better to decide whether he could let patient of¥ for fre-
quent visits to his farm in Bradbury.

Patient's wife has received a long blank to be filled out regarding
patient's mental history. Visitor agreed to help her in filling out the blank.

600 APPENDIX A

1919
May 16.

Patient's wife reported to hospital with a blank to be filled out. As
she is going to Aliddlesex to-morrow, visitor advised that she take the blank
with her to be filled out at Middlesex. She has taken the children with
her this afternoon for a week-end in Bradbury but is returning to Boston
after that.

May 23.

Patient's wife telephoned that she found patient doing fairly well when
she saw him 5/18/19. She is going up to the country again to-day, planning
to stay until the end of next week. John will continue to attend school,
living with his grandmother.

May 24._

Patient's mother-in-laiv, Mrs. Costelli, 10 Victoria St., Boston, visited.
Informant invited visitor to supper, but visitor had already eaten. Her
daughter, Bertha Costelli, says that Emma needs her tonsils removed
because she has great difficulty at night in breathing. Bertha's single
brother has just paid patient's rent in Arlington and Bertha expects to pay
the rent a little later, as informants do not want patient to give up his
home yet. They are not discouraged about patient, although Mrs. Costelli
has lost some weight worrying about him.

June 2.

Patient sent a friendly letter by visitor.

June 19.

Patient heard from. The letter was written at his camp in Bradbury
where he was spending Saturday and Sunday. He says he is much im-
proved although still bothered with those "fear spells" at times. He was
planning to return to Middlesex from the camp. His stay at Middlesex
is more satisfactory than at the Psychopathic, as he can work outdoors
with pick and shovel and keep busy with other indoor work.

Patient's wife is due in Boston on the 25th to attend John's graduation
in Junior High School.

June 30.

Patient's zvifc reported to visitor at the hospital. A letter to another
patient named Fangillo had been forwarded from the Psychopathic Hos-
pital to patient's sister on Main Street for patient early in June. Patient's
sister had been busy and neglected to forward the letter to patient. Patient
had just heard from hospital asking that the letter be returned. Patient's
wife came in at once this morning to straighten out the matter. She is
looking well and says she feels well. Patient is constantly improving and
is spending the week-ends at their camp in Bradbury. He works six hours
a day with pick and shovel at Middlesex and sleeps very well. He is now
in the parole ward.

Informant's relatives visit her at the camp occasionally and before
long her mother as well as her married sister will stay for some time at
the camp. Her relatives bring her food and patient has planted quite a
few vegetables which will be maturing before long. Her money is holding
out very well and she says she has nothing to worry about. She has not
attended to Emma's tonsils and adenoids, claiming that she has been too
busy. In spite of visitor's arguments to the contrary she seemed to think
this matter should have to be put off until later in the summer or fall.

APPENDIX A 60I

Emma will attend school in the fall. Informant agreed to keep visitor
closely informed as to patient's progress. She has jokingly told patient
that the next thing he would worry about would be his future work.
Patient told her that he would ask advice from the Psychopathic Hospital
when he was ready to work and that he was sure work could be found for
him at which he could keep well.

June 26.

Patient's wife heard from. Letter states that she is too busy to come
to town for her son's graduation and states that her husband is improving
though still worrying somewhat.

July 8.

Patient written to. Letter was sent to reassure patient.

July 29.

Patient heard from. Letter states that he was discharged from the
hospital on the I4tli of July and that he is feeling much better though still
"very nervous and irritable." He is busy with his garden and in the past
two weeks has put in thirty hours' work for the neighboring farmers.
He expects to stay there until November i, doing work for the farmers
whenever it is available. He expects to improve rapidly now and sug-
gests that visitor may be able to help him in selecting a line of work later.
He has not decided what line of work to take up yet. The family are well.

August 7.

Gray Motor Company, Dorciiester, employment manager, Mr. J. San-
born, written to. Letter asks whether informant could place patient in the
fall, stating that patient would be willing to start at any type of work, but
would aim to work toward clerical work or a combination of clerical and
physical work.

August 13.

Patient's wife telephoned. She came to town to do some errands,
coming with a friend by automobile. Patient is doing very well. He
sleeps fairly well but not yet perfectly. He takes fishing trips and enjoys
the farming. When he left the Boston State Hospital the doctors warned
him not to leave the country too soon. Informant plans to come to Boston
by October i, probably starting Emma in for a month of school at
Bradbury. However, informant may possibly come to Boston earlier, if
patient is well enough to come, spending the week-ends at the camp.

August 13.

Jackson's employment manager, Mr. Broivn, visited. Informant
states that he has but few men on the clerical force and that all the
vacancies are filled.

August 18.

Gray Motor Company telephoned to. In the absence of Mr. Sanborn,
chief ot the education department, word was left for him to telephone
visitor regarding patient.

August 21.

Gray Motor Company, employment manager, Mr. Sanborn, heard from.
Letter states that visitor's letter of August 8 has been held up pending

602 APPENDIX A

1919

their decision concerning patient. At present, they are completely filled
up ; but if a vacancy occurs whereby they can use him to advantage they
will let visitor know.

September 4.

Patient zmttcn to. Letter asks patient whether he is ready to start in
at work at any time visitor has suitable position.

September 9.

Schuleman Paper Box Factory visited. Visitor attended the "Shop
Committee Meeting" which is held every week, all the foremen and execu-
tives being present to discuss their needs and grievances. Two weeks
before visitor had gone through the factory. There are about 250 em-
ployees and the firm prides itself on the fact that they all feel like "one big
family." The foremen are called by their first names. Obviously the
employees are treated very considerately and they seem unusually happy.
Mr. Jones, superintendent, stated he would be glad to have a talk with
patient and place him to best advantage in the factory, though he is not
sure that the work will lead to clerical work. Mr. Chase, efficiency expert,
and Miss Macpherson, nurse, were also talked to about patient. They are
all interested in another patient from the Psychopathic Social Service,
John Flynn, who has been there two weeks and is giving the greatest
satisfaction.

September 10.

Patient zvritten to. Letter describes the factory of Schuleman's and
suggests that patient come to Boston soon to see about an opening there
even though he may not be ready to stay on in Boston as yet.

Note:

The firm is glad to take employees known to reliable social agencies
as they consider that as good as knowing their families. In so far as
possible, they employ neighborhood people because the families are acces-
sible.

September 11.

Patient's wife telephoned. She is in town to-day and to-morrow, start-
ing Emma in at school. The family expect to stay at camp three weeks
longer. Patient will answer visitor's letter soon. He is doing pretty well.
Informant will telephone again to-morrow as she can hardly hear where
she is to-day.

September 16.

Letters to patient, addressed Bradbury, Mass., returned unclaimed.
They were remailed to patient to Box 13, R. F. D., Bradbury, Mass,

September 19.

Patient writes that he has just heard from visitor. He will be at the
hospital on September 22 in the morning. He would come in to-day, but
his potatoes are rotting in the ground and he has about thirty bushels to
dig immediately. John is going to high school. Emma went to school for
a few days, but is now at the camp for about a week until things are in
shape for the winter.

APPENDIX A 603

1919
September 22.

Patient reported to visitor in the morning, haviirg jllst come down
from camp. He looked better physically and decidedly improved nerv-
ously. His eyes were bright and he was full of hope for the future. He
occasionally has "fear spells," but he gets over them rapidly and he thinks
that when he is at work they will vanish entirely. He has been doing
farm work for several of the farmers in the vicinity as well as at his own
camp. At present, patient's wife and his mother are at the camp putting
up tomatoes. His son John would rather live at home in Arlington than
with his grandmother. Yesterday he was out to the camp and returned
last night to stay in Arlington. He gets his own meals and the landlady
keeps an eye on him. Patient is sure he gets into no mischief and says
he is a thoroughly reliable boy.

Patient is ambitious to undertake work which gives promise of ad-
vancement. Visitor talked with him about the opening at Schuleman's
which in many ways appealed to him. He agreed to go down to the plant
at once and interview Mr. Jones, superintendent. He is planning to return
to camp this afternoon and will let visitor know result of his interview
either by letter or telephone.

September 24.

Patient writes that he had a nice talk at the Schuleman Paper Box
Factory with Mr. Jones and Mr. Chase (efficiency expert) and was shown
over the factory. Mr. Jones said patient could begin work any time,
starting with at least $16. Patient has thought the matter over carefully
and feels that though the people there are all very nice the chances of
advancement do not look especially bright. He says, "I would like some
place where I could begin work and work hard if I felt that I could learn
some useful trade or where I could be sure of advancement, provided, of
course, I merited it." At the factory apparently the most he could aspire
to was to be a "machine man." Patient asked for visitor's advice, stating
that though he knows "beggars cannot be choosers," he does not want to
make a false start and have to change again in a short time.

September 24.

Gray Motor Company, Dorchester, employment department, telephoned
to. The employment manager, Mr. Sanborn, is away for a few days,

September 27.

Patient written to, stating that visitor would give him more definite
advice about his work in two or three days.

September 29.

Gray Motor Company, Mr. Sanborn, employment manager, telephoned
to. Informant states that there is no opening there for patient.

September 30.

Prospective employer, Schuleman Paper Box Factory, visited. By in-
vitation, visitor addressed the Shop Committee Meeting on the subject of
mental hygiene of industry, explaining her work at the Psychopathic
Hospital in particular. The superintendent, Mr. Jones, stated that he
would employ any patient visitor sent to him and if there was no opening
he would "make one." He was interested in talking with patient the
other day. Informant had in mind clerical work for patient to advance to
and thinks patient could very soon be placed at such work there, as there is

604 APPENDIX A

an opening now. It is informant's custom, however, to have every office
employee advance from the factory force. He did not tell patient about
the prospect of clerical work, however. Visitor agreed to let patient know
just what the probable opportunity was and to get in touch with informant
again. The nurse, Miss MacPherson, states that should opportunities, for
any reason, at the factory seem limited to patient, there is always a chance
of his advancing from the paper box factory to the Schuleman Candy
Factory, where there is a large clerical force.

September 30.

Patient written- to, giving the result of the interview at Schuleman's
this morning and stating that, though visitor did not want to force patient
to consider this opening, she felt the opportunities of advancement were
very good and the atmosphere there especially suited to patient. Her letter
explained the chances of advancement to the Schuleman Candy Factory
from the paper box factory.

October 7.

Patient zvrites that he has heard from visitor, but has not yet come to
a decision. He is very anxious to get to work soon, saying, "I certainly
feel the position I am in at present." Patient would come in October 6,
but he has promised a farmer to pick apples until October 8. Patient will
come to see visitor October 8.

October 8.

Patient reported to visitor in the morning, bringing with him a satchel
full of apples for visitor from the farm. His wife plans to come to
Arlington to stay on October 13, but patient plans to follow her a few days
later unless he has a detinite jol) in town before that. He is still unde-
cided about the kind of work he should undertake, feeling that possibly
indoor work will be too confining, and that his eyes might not permit of
confining work. He stated that he would be glad to see Dr. Jacobs this
afternoon for advice about his work and tliat he would be glad to see
the employment manager at the Cole Rubber Company relative to possible
employment there later, visitor explaining that the employment department
is especially good there. Patient took with him a letter of introduction
from visitor.

Patient says that when his mother died she left about $1,000, of which
she gave $600 to patient's sister who is blind in one eye, the other siblings
receiving about $200 each. As a matter of fact, most of them owed
patient's mother at that time so that the full amount of $200 per person
was not available. Patient loaned his share to help out and $80 is still
due him from this time from a brother-in-law. Patient's brother Antonio,
in Brayton, Vt., wrote patient's wife shortly after Antonio's marriage this
summer about his marriage. Patient's wife was too busy to write at that
time and Antonio has not written patient since. Patient feels friendly
toward all of his relatives, but apparently cited these instances to explain
that often others were more considerate of one than one's own relatives.
Patient feels especially grateful to his friend "Henry" who owns the farm
where patient has been all summer. It is not clear how much money
patient still has on hand, but he says that he paid most of his expenses this
summer from the work he did on the farm. He has on hand a large
amount of fruit for the winter.

Patient still has occasional "fears," especially when not busy, but sa.vy
they are very mild.

APPENDIX A 605

1919
October 8.

Cole Rubber Company, assistant employment maitager, Mr. Carlton,
telephoned to, who stated there is only one vacancy in the clerical depart-
ment now, which is for a man who is accustomed to figuring costs. There
are only three or four laboring jobs open, which are all excessively heavy.
Informant would be glad, however, to talk with patient relative to future
employment.

October 8.

Patient reported to the hospital in the afternoon to see Dr. Jacobs.
Dr. Jacobs states that there really is no "medical problem" as far as patient
is concerned. In other words, patient's diagnosis is probably something
between manic depressive and psychasthenia or a combination of both, but
patient is rapidly recovering. He will soon be in as good condition as
after his attack of years ago. Every three months or so he should report
to some psychiatrist to make sure that patient is not overworking. Dr.
Jacobs feels that there is no reason why patient should have to try work
different from his former clerical work and that patient could now hold a
responsible clerical position. Patient should have a "hobby," as recreation
is quite essential for him. In the past, when at clerical work, patient had
practically no recreation. Patient's fears are so slight now that they can
practically be disregarded.

October 8.

Schuleman Paper Box Factory, Superintendent, Mr. Jones, telephoned
to, who stated that there is temporarily no work open for patient in the
office as another patient from the Psychopathic Hospital, Martin O'Connor,
is, for a time, doing clerical work there. However informant feels that
before long he will need further help and says that at almost any time he
could arrange things to take patient on. It was mutually agreed between
informant and visitor that patient look around for other openings and if
patient was not successful, informant would make place for him at
Schuleman's.

October 8.

Patient reported to visitor that Mr. Carlton at Cole's was very nice to
him this morning but stated frankly that there was no opening now and
took patient's name, agreeing to let patient know should an opening turn
up. Patient had a very satisfactory interview with Dr. Jacobs. Patient
says he is not as sure as Dr. Jacobs that he can go ahead and do book-
keeping right away, but as Dr. Jacobs says he can, he will try to believe it
himself. Visitor agreed to look into other openings which would be dis-
tinctly clerical and to let patient know if a good opening was found before
he plans to return to Arlington. Patient's wife has said she would gladly
go to work to supplement the income this winter, but visitor assured
patient this would undoubtedly not be necessary. Patient left the hospital
considerably relieved by Dr. Jacobs' advice.

October 14.

Psychopathic Hospital Staff, Dr. Jacobs, states that patient's eye con-
dition should not be attended to now, as patient would probably not like
any glasses ordered now. Patient will probably have another breakdown
in about five years.

October 16.

Patient's wife telephoned stating that she has bee'n in Arlington all
week, but goes to camp for the week-end to-morrow. Patient will probably

6o6 APPENDIX A

1919 . . . . .

remain at the camp as long as weather permits until a definite openmg is
found for him. The family are well.

October 23.

Patient left some apples for visitor at the hospital in her absence.

October 30.

Patient's zurife telephoned that patient will probably return from the
farm the first of next week to stay. As to-day is a school holiday in
Arlington, informant and the children will go to the camp for the week-
end. Visitor stated that several openings had been looked into for patient,
but that visitor delayed about writing patient until the right opening pre-
sented itself. Informant agreed to have patient get in touch with visitor
the first of next week.

November i.

Federal Employment OMce, 4 Cherry St., registrar, Mr. Brown, tele-
phoned to, regarding clerical openings for patient. Visitor had personally
interviewed informant during the week regarding openings and had tele-
phoned several times since. There have been no suitable openings for
patient.

November 5.

Patient's wife telephoned that as the weather has been so pleasant
patient will remain in the country until next week. Informant prefers to
wait until next spring about Emma's tonsils, but agreed to speak to Emma's
school teacher about this.

November 17.

Patient's imfe telephoned that patient is still in the country and will
remain there for a few days more unless visitor sends for him. He no
longer talks of himself, but is planning for the future. He is busy packing
and shipping apples. Informant is now housecleaning. She seemed
pleased to know that the hospital feels she has done a great deal toward
patient's recovery and assured visitor that her family as well as the hos-
pital had done a great deal also.

November 17.

Y.M.C.A. Employment OMce, Mr. Grafton, telephoned to. Infor-
mant will keep patient in mind for a clerical position. The coal strike has
temporarily pulled down business so that openings are few. Informant
asked to have patient drop in to see him when next in town.

November 24.

Federal Employment Office, 4 Cherry St., registrar, Mr. Brown, visited,
who had no suitable openings for patient.

November 28.

Patient reported to visitor. He came to town to stay on November 26.
Patient has been busy bringing apples to town with "Henry," the farmer
at whose farm patient stays. They came to market from three to five
times a week. Patient is now ready and anxious to get to work, but a
little fearful of clerical work. His face clouded somewhat at the mention
of clerical work, patient asking visitor whether she thought he could safely

APPENDIX A 607

1919

do clerical work. He is insistent that he shall never have a recurrence
of his disease. Visitor reminded him of Dr. Jacobs' advice about his work.

His wife has been working since she came to town this fall at a candy
factory in the East End, near her mother's home. She dips chocolates
from 6:4s to 9:45 P. M. daily at $1.25 for three hours. She did likewise
in the late spring before coming to the camp, but did not tell patient about
this imtil during the summer. Patient asked visitor definitely not to tell
his wife he had spoken of this. Visitor told patient that his wife had told
visitor about her working early in the spring and that now she would
doubtless speak of it when visitor called. Patient's wife says she would
miss work now if she stopped as she enjoys the companionship of the
women there. Financially the family is getting along "O. K." though
patient does not know the exact amount left, as his wife manages. He
plans to collect about $300 due him from individuals who borrowed from
him when he was in the liquor business, and he says his brother-in-law
still owes him about $200 from his mother's estate, which he will also try
to collect. Patient loaned his brother Antonio about $700 several years
ago. At one time patient paid Antonio's board at the rate of $7 a week,
giving him from $2 to $3 a week besides. Patient is glad he laid in a
supply of clothes a year ago considering the cost of living now. He has
always provided in advance when possible.

Patient's wife and children are not insured, but patient carries two
semi-endowment policies under the National Life Insurance Company. In
case of death a thousand dollars is due from each of them, but before that
time, if he lives a number of years, a few hundred dollars is payable in
addition to patient.

Patient plans to join either the Arlington or Boston Y. M. C. A. and
will look at once into the possibilities. He is determined to have exercise
and recreation to keep him well. Patient was given a number of letters
of introduction to the Y. M. C. A. Employment Bureau and the State
Public Employment Office, where he expects to report to-morrow morning.
Patient understands that clerical openings are scarce for men at present
and is very glad to have Mr. Boylston, Bureau for Returning Soldiers and
Sailors, keep him in mind for suitable clerical openings.

Patient says he is feeling better all the time and finds he is best when
working hardest. Only occasionally does he have "fears," but he is able
to control them.

November 28.

F. M. C. A. Employment Bureau, Mr. Grafton, telephoned to. In-
formant knows of no clerical openings now.

November 28.

Federal Employment Office, 4 Cherry St., Mr. Brown, telephoned to.
Informant knows of no clerical openings now.

November 28.

Bureau for Returning Soldiers and Sailors, Mr. Boylston, telephoned
to. Informant knows of no clerical openings for patient now, but hopes
to have some soon and will let visitor know when he has a suitable opening
for patient. He does have openings from time to time into which the
discharged soldiers do not fit.

December i.

Y. M. C. A. Employment Bureau, Mr. Grafton, telephoned to. In-
formant sent patient to apply on November 30 at J. K. Hodge's Hay, Grain,

6o8 APPENDIX A

1919

& Seed store in Chelsea, where there was a vacancy at office work at $18.
Patient has not reported to informant since. Informant referred to
patient as a "nice chap."

December 2.

Patient telephoned that he had been trying to reach visitor for the last
twenty-four hours to report. Mr. Brown, of the Federal Employment
Office, took patient's name and asked him to report in a few days. Mr.
Grafton of the Y. M. C. A. took patient's name and said he would let
patient know when he had a suitable opening for him. The only openings
the Y. M. C. A. had were suitable really for boys. Patient agreed to report
to-morrow again and visitor agreed to get in touch with the Bureau for
Returning Soldiers and Sailors.

December 3.

Patient telephoned, stating that he plans to go to the Federal Employ-
ment Office this afternoon. He is watching the advertisements in the
papers and looking about somewhat.

December 3.

Federal Employment Office, 4 Cherry St., Mr. Brown, telephoned to,
who knows of no openings for patient to-day. Patient reported to in-
formant this morning and will report again to-morrow morning.

December 3.

Jackson Commercial School, Mr. Ware, visited, who spoke of an open-
ing at the Riverside Book Shop. Miss Martin there is looking for a first-
class bookkeeper to straighten out the accounts now handled by two
women, who together are paid $45 a week. Miss Martin would probably
pay patient $30 a week. Patient should apply at once, stating that he
heard of the opening through a friend. Informant could not recommend
patient as he does not know him.

December 3.

Patient's home visited as no response was received by telephone.
Patient was home taking care of Emma and George Giordani. Patient's
wife went to the Arlington Theatre to the movies, and John, on returning
from school, did likewise. Patient felt he could not leave the house until
his wife returned, and telephoned the Riverside Book Shop to see whether
• he ought to apply this afternoon. Miss Martin's sister answered the
phone, stating that Miss Martin was leaving for New York to-night.
Patient gave visitor's name, which she said she did not know, and asked
patient to write her his experience. Patient's wife then returned home
and went with visitor to the street car. Visitor agreed to get in touch
with the Riverside Book Shop soon.

December 4.

Riverside Book Shop, Miss Martin, visited. She at once asked whether
patient had been a patient at the Psychopathic Hospital and then said she
had troubles enough of her own without employing someone from there.
Visitor then talked brieily on the subject of the prevalence of psychiatric
conditions and need of treatment. Informant was then attentive and
agreed to look up patient's references, although, she explained, she con-
sidered the work "nerve-racking" as all the customers were women and
all of the help, except one, were women and the books were behind.

APPENDIX A 609

1919

Informant felt also inclined to think that patient must be rusty in book-
keeping if he had done none in five years. Informant is leaving for
New York this morning and will not be back until next week.

December 4.

Stratton Piano Company, Office Salesman, Mr. Blair, visited as visitor
was passing by. Mr. Dawson was not noticed until almost the end of the
interview and visitor did not remember Mr. Dawson's name so could not
ask for him. Informant stated that patient's work was first-class and that
patient was confidential clerk, only one man being over him. Patient
knew all that was going on in the office. Informant knows of no openings
in the piano line now, but thinks patient's experience would serve him
equally well in the lines of furniture or installment work. The firm would
give patient an excellent recommendation at any time.

December 4.

Patient seen at the Federal Employment Office, 4 Cherry St., Mr.
Brown had no opening for patient then. Patient expects to join the
Y. M. C. A. as soon as he is working. There is a swimming tank there
but none in the Arlington Y. M. C. A. Patient is reporting to the Y. M.
C. A. Employment Bureau, Mr. Grafton, this afternoon, and visitor agreed
to look into the openings at the Y. M. C. U.

December 4.

Y. M. C. U. Employment Bureau, Mr. Howland, visited. The bureau
places only non-union men and fills no factory or laboring positions.
Informant will be glad to see what he can do to find a suitable position
for patient and visitor agreed to send patient in to-morrow morning.
Informant states that though clerical openings are not abundant they are
to be had.

December 4.

Patient's home telephoned to, leaving word for patient to report to
the Y. M. C. U. to-morrow morning.

December 5.

Jackson Commercial School, Employment Office, Mr. Ware, telephoned
to, reporting developments on the Riverside Book Shop. Informant sug-
gests getting in touch with Miss Martin early next week again.

December 5.

Y. M. C. U. Employment Bureau, Mr. Hoivland, telephoned to, who
was favorably impressed by patient. Informant says he is sure he can
find a suitable opening for patient soon. Patient is willing to do selling
or clerical work.

December 8.

Riverside Book Shop, Miss Martin, telephoned to. She is sure that she
could not take patient on.

December 8.

Bureau for Returning Soldiers and Sailors telephoned to. Mr. Boyls-
ton has left, but his successor, Mr. Max, suggested that patient might find
an opening at Henley & Coolidge, Accounts Engineers, 350 Rice Building,

6lO APPENDIX A

1919

as this firm has been advertising for bookkeepers and the bureau has sent
one or two candidates. Informant agreed further to keep patient in mind
for an opening.

December 8.

Patient's wife telephoned to, asking patient to telephone visitor to-
morrow morning.

December 8.

Patient written to, suggesting the opening at Henley & Coolidge.

December 9.

Patient telephoned that none of the agencies have found an opening
for him yet. The Y. ]\I. C. A. sent him to a garage at Freeman Square,
Chelsea, where a bookkeeper was needed, but they really wanted only a
boy for a job.

December 10.

Patient telephoned to. He has found no suitable openings, but expects
to through the help of the agencies interested in him. If he needs advice
during the visitor's absence until January 2, he will get in touch with the
Social Service or Dr. Jacobs. When visitor complimented him on his
success in getting well he said his wife deserved all the credit. Patient
expects to sell two pianos by Christmas, netting him about $75.

December 20.

Patient was mailed a Christmas card.

1920
January 2.

Patient's wife telephoned to. Patient is planning to see visitor soon.
Informant, patient, and the children were with her family several days at
Christmas time. Patient has not yet found work, but is not discouraged

January 3.

Patient reported to visitor, bringing a two-pound box of candy as a
Christmas gift, which his sister had given him. She works at Young, Cobb
& Sanborn and each year gives patient candy. Patient's wife is still work-
ing. Patient has made the rounds of the various employment agencies,
having added the Commercial Reference Association and the International
Reference Association. The only definite positions offered him have been
through the Y. M. C. A. One of these positions was suitable only for a
young fellow ; the other is pending, a position as ledger clerk at $25 a week
at Hudson Shoe Polish factory in Mattapan. Patient has applied there and
telephoned regarding the opening several times, but each time has been told
that no decision has been made. Patient will telephone soon. The last
few days patient has felt somewhat discouraged, but has been able to con-
tinDl Eiimself. He has not sold the pianos as yet, as the purchasers find that
they are twice as expensive as they thought.

The children received a total of about $35 for Christmas from rela-
tives and patient received $25 from his friend Henry on the farm. Patient's
brother has paid him $50 of what he owes. Patient agreed to telephone
visitor soon and plans to continue consulting the employment agencies.
Mr. Brown of the Federal Employment Office has shown the most interest
ia him, but he has had no suitable openings.

APPENDIX A 6ll

1920
January 3.

Jackson Commercial School, Mr. Ware, telephoned to. Informant
knows of no openings for patient now, stating that there are less clerical
openings for men now than there were last fall. Informant would be glad
to help out at any time he can.

January 3.

Hudson Brothers, Mattapan. telephoned to. Employment Manager,
Mr. Beers, was out and person answering, apparently in the superintend-
ent's office, would give no information about the firm, but suggested getting
in touch with Mr. Beers.

January 5.

Patient telephoned. He is willing to have visitor use her judgment
about consulting Hudson's.

January 5.

A fornvcr Mattapan A. C. worker states that the Mattapan A. C. con-
siders Hudson's factory a very poor place to work. The employees are
underpaid and the girls working there are looked upon as hardly respect-
able by other working girls.

January 7.

Y. M.C. A. Employment Bureau, Mr. Grafton, telephoned to. In-
formant states that the outlook in the office line is bad. It is hard to fit
patient in other than clerical position because he has had no experience.
Informant will keep patient in mind, however, and try to place him.

January 7.

Federal Employment Office, Mr. Brown, telephoned to. Informant
offered patient two jobs, both of which patient felt were too far away.
It is not the fault of either informant or patient that former has not
realized before that patient would consider other than clerical work. He
will continue to keep patient in mind, looking out for both clerical and
other openings.

January 7.

Hudson Brothers, Manufacturers of Shoe Polish, Mattat^an, visited at
2 :3o p. M. The employment manager, Mr. Beers, was out. The telephone
girl asked whether visitor would see some one else, but when visitor said
she would see the superintendent, was informed that Mr. Beers was also
superintendent. The advertising manager spoke to visitor, but said he
could do nothing about the opening for patient as this was up to Mr. Beers.
Visitor asked to be shown over the factory, but the advertising mapagei;-
stated that no visitors were allowed as the process was, secret..

January 7.

Bureau for Returning Soldiers- and Sailors, Clerical Department, Mr.
Max, visited. Informant would be glad to talk with patient and try to
place him. He seemed more than willing to advise visitor regarding cler-
ical openings,

January 7.

Patient telebhoned to in the evening, asking him to report to Mr. Max,
to-morrow morning. Patient had not found any openings.

6l2 APPENDIX A

1920
January

Patient telephoned that he reported to the Federal Employment Office,
4 Cherry St., this morning. Mr. Brown told him that though there was
labor trouble at Root's patient might find an opening there. Patient ap-
plied at Root's and the employment manager, Mr. Fielding, told him to
come in again the next morning. Patient asked visitor's advice, but visitor
advised against the firm as paying poorly and not giving much promise of
advancement for patient. Patient finds it difficult to go all over town
looking for a job. He has not reported to Mr. Max, but will do so at
once. He answered an advertisement in the Globe to-day at a team firm
as ledger and trial balance clerk.

January 9.

Patient telephoned that he reported to Mr. Max yesterday, who was
ready to send patient to the Loyal Shoe Company but on finding patient
was not an ex-service man felt he could do nothing for patient. Visitor
agreed to get in touch with Mr. Max again.

January 9.

Bureau for Returning Soldiers and Sailors, Mr. Max, telephoned to.
Informant did not fully understand visitor's work as predecessor, Mr.
Boylston, did not explain it to him. In only rare instances has informant's
bureau placed men not ex-service. If patient is interested in a job as chief
accountant at the International Optical Company, Lexington, informant
would be glad to get in touch with the employment manager there, Mr.
Bates, as informant has no service man willing to go out of town to take
the job.

January 10.

Patient telephoned to, explaining the opening at Lexington. Patient
agreed to talk it over with his wife and report later.

January 10.

Patient telephoned that he feels the opening would be too responsible
at Lexington and he does not care to break down again. In order to live
away from his family he feels he would have to earn quite a large salary.
He agreed that there is no harm done in looking into the opening, by cor-
respondence, at least, and thinks the same opening is offered through the
Federal Employment Office. Patient is getting discouraged about not find-
ing work.

January 10.

Federal Employment Office, Mr. Brown, telephoned to. Informant
has no openings to-day except the one at the International Optical Company,
Lexington. Informant does not blame patient for not being interested in
the opening for the reasons patient gave.

January 10.

Y.M. C.A. Employment Office, Mr. Grafton, telephoned to. The only
opening this morning is one as a bookkeeper at $20 on St. Charles Street.
Informant knows no further details about it, but feels patient would not
consider it as he keeps saying he cannot accept less than $25.

January 12.

Jackson Commercial School, Mr. Ware, visited. Informant states that
there are no openings suitable for patient as all of them combine sten-
ography and bookkeeping.

APPENDIX A 613

1920
January 12.

Women's Educational Association, Appointment Bureau, Miss Black,
visited for possible suggestions about patient. Informant suggests Wood
& Berry Service, 60 Eagle St. ; both Miss Wood and Miss Berry were for-
merly connected with the U. S. Employment Service.

January 12.

Wood &■ Berry, 60 Eagle St., Miss Berry, visited. Informant states
that clerical openings for men are very scarce, but suggested the Under-
wood Motor Company, Sawyer St., and the City Gas Corporation, as both
employing large numbers of male clerks. The latter has taken on night
men lately as business is so heavy.

January 12.

City Gas Corporation, North Street, Chief of Collection Division,
Henry McMillan, visited. No men are employed in the clerical department
and there are now no vacancies in the collection department, though men
are working in the collection department day and night. Their pay begins
at $19.50. _ Informant would be glad to put patient's name on the waiting
list if patient cares to come in to see informant. Suggested the book-
keeping department on Victoria St. as a possibility.

January 12.

City Gas Corporation, 52 Victoria St., Chief of the Bookkeeping Divi-
sion, Mr. Grant, visited. Informant states that there are no openings now,
but he employs about 50 men at bookkeeping and accountancy. The firm is
apt to promote from below but will be glad to see that patient is put on
the mailing list.

January 12.

Patient visited at his home. His son John was at home reading and
seemed a bright, manly fellow. Patient's wife was out. Patient feels that
the landlady has not been quite as cordial to the family since their present
misfortune, but admits that relations are not very strained, as the landlady's
daughter still practices on patient's piano and patient feels free to use land-
lady's telephone.

Patient is discouraged at having so much difficulty in finding work, but
realizes that many others are in a similar predicament. He grits his teeth
in an effort to drive away any fears and has been fairly sucessful. He
feels better after talking with his wife or visitor. He agreed to go to the
Cole Rubber Company to-morrow morning ready to accept any kind of
work. He is anxious to get to work more to have his mind occupied than
to get immediate income. Work out of town, such as ice-cutting, he would
find very dreary. He admitted the futility of work such as elevator work,
hovvever, as he would be no better off on leaving the job than he was on
beginning it. To-day patient answered an advertisement in the Globe by
writing a rubber company who wanted men to learn the business, starting
at %2'i. He applied at Reed's, who needed salesmen, but said 125 applicants
applied, most of whom had to be turned away. Patient was not among the
first so was not successful. He applied at another place which was adver-
tised in the Globe, but on application found that the place had been filled
and that about 20 men had applied.

John cooked visitor some coffee and patient served some Italian
"ravioli," and custard pie, all nicely cooked.

6l4 APPENDIX A

1920
January 13.

Patient telephoned that he applied at the Cole Rubber Company this
morning, but Mr. Carlton there told him that there were no openings.
Patient plans to visit the City Gas Corporation this afternoon.

January 15.

Schuleman Paper Box Factory, nurse Miss MacPhcrson, telephoned
to. Visitor explained that patient had not considered an opening there a
few months ago because at the time the opportunities there seemed limited
to him. In the meantime the patient has had an opportunity to look about
considerably and he would be interested to consider an opening there now.
Informant agreed to see the superintendent, Mr. Jones, about this.

January 15.

Patient telephoned and was interested to hear of a possible opening
at Schuleman's, though he evidently still felt he might have made a mistake
in not making further efforts to get a place at Root's, asking visitor
whether the Schuleman opportunity was as good as Root's.

January 16.

Patient telephoned that he is home this morning as his wife has lum-
bago.

January 16.

Schuleman Paper Box Company, nurse. Miss MacPhcrson, telephoned
that both she and Mr. Jones remember patient well and liked him but that
there is no opening this week. Possibly there will be an opening next
week and informant will let visitor know if there is.

January 17.

Patient telephoned — somewhat discouraged because he has found no
openings. He would like to go to his friend Henry in the country in
Bradbury to help him chop wood and to consult him regarding openings
in automobile factories as Henry is in close touch with some automobile
men. Patient feels he cannot leave his children alone at night while his
wife is working.

January 19.

Patient telephoned that at Ring's Service Bureau this morning he was
told that the John Meredith Company at Milton would take on a number
of new men for general factory work. Patient would like to look into
this opening and agreed to telephone an hour later after visitor had got in
touch with the firm.

January 19.

John Meredith Company, Printing and Lithographing Inks, factory,
Milton, telephoned to. Superintendent Guili, who hires the factory
help, stated that he will take on a number of new men if of the right sort;
that is, having common sense and with good physical strength. The firm
manufactures printing ink and the processes are easy to learn. The pay
is 52 cents an hour for a 48-hour week. On certain processes after two
months the pay is 70 cents an hour. Mr. Guili is not in charge of the
office help but connected visitor with Mr. Mills.

Mr. Mills, Chief of the office force, telephoned to. Informant states
that he has a number of men in his department earning varying salaries

APPENDIX A 615

1920

depending on the responsibilities. He has no openings now, but will be
glad to talk with patient and keep him on his list. Should patient want
to begin at factory work, he would be glad to try and have him advance to
office work when there was an opening if patient were suitable. Visitor
agreed to have patient ask for Mr. Mills, on arrival in Milton to-day. Mr.
Mills states that commuting would be too hard on patient and that it is
somewhat difficult to find a boarding place and very difficult to find a place
for a family.

January 19.

Patient telephoned and seemed interested in the possibilities at Milton.
The family have a friend in Needham with whom either he or the family
could probably live if it was hard to locate in Milton. Patient agreed to
go out to see Mr. Mills at once. Patient did not look into the International
Optical Company, but frankly feels the work there would have been too
responsible.

January 20.

Patient telephoned that he had his usual luck at the John Meredith
Company yesterday. At the factory applicants were talked to in a group
and told frankly that the work was very trying as they would have to work
with all kinds of acids, and with dyes which would color the employee the
same as the tint of the dye. Patient says the smell was "awful" and that
he could never stand it or the change of shifts. The plant runs on a three-
shift basis and patient would have to vary in his shift 8-4, or 4-12 or 12-8.
There is only a late afternoon train besides the i :45, so patient took earlier
train, though he was unable thereby to see Mr. Mills, who was away for
luncheon. Patient saw Mr. Jackson, assistant manager with the John
Rider Company yesterday afternoon. He gave patient the name of a
public accountant who might need an assistant. Mr. Jackson is the brother
of the man who was in charge of the business school patient formerly
attended. Patient will look up that opening to-day.

January 20.

Cole Rubber Company, Employment Manager, Mr. Carlton, sat next to
visitor at a dinner of the Boston Employment Managers' Association, and
stated that though the factory needs female help it has no openings for
male help now. There are, however, a number of men doing clerical work
there.

January 21.

Schuleman Paper Box Factory, nurse. Miss MacPherson, telephoned
to, who said she plans to see superintendent, Mr. Jones, about an opening
for patient this morning.

January 21.

Underwood Motor Company, Sawyer St., Employment Manager, Mr.
Johnson, telephoned to. Informant says there are no openings there for
clerks and that he has the problem of fitting three of his present book-
keepers into general work as they are putting in bookkeeping machines.
Informant volunteered to talk with patient about his work. Visitor agreed
to send patient to him.

January 21.

Jackson Commercial School, Mr. Ware, telephoned to, who stated that
the openings for male clerks grow scarcer and that informant is solicitous

6l6 APPENDIX A

1920

about being able to place some of his students who will be ready in a few

months. If patient has any openings at all he had better take them.

January 21.

■Patient telephoned that yesterday afternoon he applied at Fletcher &
Lothian, Public Accountants, to whom Mr. Jackson referred him. Mr.
Fletcher was out, but patient saw his partner, who talked with patient and
asked whether patient was willing to leave Boston occasionally for six or
seven days to make a trip with the public accountants. Patient told him
he was willing to travel and agreed to come in on January 24 to see Mr.
Fletcher. Patient plans to ask Mr. Jackson to telephone Mr. Fletcher on
January 24 regarding patient's qualifications.

January 21.

Patient telephoned that he had a pleasant interview with Mr. Johnson
of the Underwood Motor Company, but there is no opening there now.
Mr. Johnson took patient's name and agreed to let him know if any suitable
openings developed. Patient plans to visit Mr. Jackson this afternoon and
asked visitor what she thought about his visiting the Gray factory. Visitor
explained that the turnover was so small at Gray's that there was but
little chance of an opening, but that if an additional visit does not tire him
there is no harm done by applying.

January 21.

Y. M. C.A. Employment Office, Mr. Grafton, telephoned to. Al-
though clerical openings are scarce for men, informant has a few such
openings right along. The only thing now which would be possible for
patient is as an assistant to a public accountant. Informant says that
work is quite strenuous at times and dull other times. Patient might find
work a strain at the beginning of the year, the busiest time. Informant
has two such openings, but has had them some time and does not know
whether they have been filled. They are : John J. Seavey, 36 Main St., and
Gerry & Co., 38 East St. Each of these pay from $5 to $6 a day with half
pay when laid off.

January 22.

Patient telephoned and agreed to look up the positions as assistant to
public accountant at once. He will then make the usual rounds of the
employment offices.

January 22.

Schuleman Paper Box Factory, nurse, Miss MacPherson, telephoned
that both the superintendent, Mr. Jones, and she say there are no openings
there now. Both informant and Mr. Jones are very sorry as they remem-
ber patient well most pleasantly. Perhaps in a few weeks there would be
an opening. Mr. Wells, employment manager at the Schuleman Confec-
tionery Factory, is laying off help at present.

January 22.

Madison Razor Company, Employment Manager, Mr. Mahoney, tele-
phoned to. He states that there are no openings in the plant for men at
present. He says clerical openings are scarce for men, but he does not
know why.

January 23.

Patient telephoned that he applied to the public accountant,, Mr. Bates,
but that there is no opening there now. They were nice to patient there.

APPENDIX A 617

1920

Patient is keeping up his courage pretty well, but his wife is beginning

to get discouraged.

January 23.

}'. M. C. U. Employment Office, Mr. Hou.'land, visited. Informant said
Stratton Piano Company gave patient a good recommendation, but that the
tirm said patient's doctor had said he could not stand his former type of
work again. Informant is willing, however, to abide by the advice of the
Psychopathic Hospital. Because of patient's age and also because of scar-
city of positions in general, informant has not been able to place patient,
but suggested that visitor visit the National Baking Corporation, Mr.
Lowney, Manager, who asked informant to have a crippled soldier placed
there. This soldier has been doing very well. Informant suggested that
visitor get in direct touch herself, as Mr. Lowney generally asks informant
for a "hustler."

January 23.

Federal Employment Office, Mr. Browti. visited. He will continue to
try to place patient, but agrees with visitor that the best chance to place
patient probably will be through interesting some employer in him per-
sonally, as otherwise patient's age usually stands in the way. Informant
has allowed patient to look over the cards containing the requests from the
employers so that patient will be convinced informant is doing everything
possible for him.

January 24.

Patient telephoned that he did not go around visiting the other public
accountant, but applied at Ring's Service Bureau and the Y. ]\I. C. A., also
to his friend Mr. Jackson who will get in touch with Mr. Fletcher soon.
Mr. Jackson advised patient to send out some form letters to several public
accountants applying for positions, which patient will do Sunday. Visitor
advised patient to get some work shovelling snow if he was finding the
strain of looking for a permanent position discouraging him. Patient
seemed inclined, however, to continue his search. Visitor asked whether
patient would be willing to consider work in Lawrence and he said he
would.

January 26.

General Anderson Craig, Lawrence, Mass., mill owner, written to,
reminding him that he offered to let visitor see some of the Lawrence mills
some time and asking whether visitor could do so within a few days, stating
that she would like to talk over possible openings for patient.

January 26.

Patient telephoned that he had just telephoned his friend, Mr. Jackson,
who will get in touch with Mr. Fletcher about 11 o'clock this morning.
Patient sent out letters to six public accountants whose names and ad-
dresses he secured from the telephone book. He will make the usual
rounds of employment agencies to-day.

January 26.

Y.M.C.U. Employment Office, Mr. Howland, telephoned to. In his
absence word was left that there did not seem to be any opening at the
National Baking Corporation for patient.

January 27.

Patient telephoned that he has answered an advertisement of the Jen-
kins Graphophone Company, Dalton, Conn., for general factory work.

6l8 APPENDIX A

1920

The Federal Employment Office had an opening for patient to consider
l»ut it required detailed knowledge of the income tax, which patient said
he has not kept abreast. He has received three replies to his letters to
public. accountants, all stating that they need no men.

January 2y.

&ene'ral Atiiers'on Craig, mill owner, telephoned that he could arrange-
for visitor to see the mills any time this week. He is coming to Boston
to-m©rrow and will meet visitor at 4 130 to discuss the plans of the next day.

Janwary 27.

■Howland Business School, 9 Center St., Employment Office, Mr. Fen-
ton, visited. Visitor explained that one of his former students in her
employ had suggested that he might be willing to advise visitor regarding
clerical openings for men. He stated that though clerical openings for
males had been exceedingly scarce for the last six weeks, they have been
on tiie increase and he feels that the high water mark of replacing men by
women has been reached and that firms are now putting on men in place
of women. He suggested as firms frequently inquiring for help. Burton
Tire Company, International Optical Company, Gleason Company, and
Lowell, Johnson & Co., public accountants.

January 28.

Patient telephoned that there was an advertisement in tl e Globe this
morning for a grocery warehouse man on East Street. From the address
patient thinks the firm is Sullivan's. Patient's brother-in-law works for
Sullivan's, so patient will look into the opening through him. Patient
agreed to look into some of the openings that Howland Business School
had suggested and visitor agreed to write the International Optical Com-
pany herself as she knows Miss Henderson in the employment department.
Patient said he would be willing to move to Lexington if the chances of
advancement were good there. Patient seemed interested in hearing about
visitor's plan to go to Lawrence.

January 28.

International Optical Company, Employment Department, Miss Hen-
derson, zvritten to, asking whether there would be any opening for patient
there and what the living conditions for families are in Lexington.

January 30.

Patient telephoned that he was home most of yesterday as John is ill,
having the grippe. He is better, but Emma is sick to-day. If she does not
respond to home treatment, patient will call in doctor. Patient received
one further reply from his letters to accountants which stated that there
was no question but what patient was experienced but that there were more
highly trained people available for this accountant's purpose. Patient will
try to get in touch with firms that visitor suggested on January 28.

January 31.

Patient telephoned that he has a slight cold but that the children are
better. He has received a reply from Dalton, Conn., stating that they
cannot place him anywhere. At this point patient said he certainly had
"bad luck" and "everything seems to go hard." Last night he came home
and told his wife he at last was sure he had a job. Yesterday Mr. Brown
of the Federal Employment Office put him in touch with an opening as a

APPENDIX A 619

1920

bookkeeper for the Dean Blacking & Staining Company at $25 a week.
This morning patient telephoned the firm and was told that they had
settled everything with their present bookkeeper so that a new one was not
needed. Patient is afraid his age was against him and that the explana-
tion given is not the real one. He promised to rest up this week-end from
his cold^

January 31.

Federal Employment OMce, Mr. Brown, telephoned to, who agreed to
let visitor know later what the real situation at Dean's was.

February 2.

Patient telephoned that Mr. Fletcher has not yet returned from Provi-
dence. Patient's family are feeling better. They called in their doctor for
Emma, whose stomach was affected, though she did not have influenza.
Patient's wife has a slight cold and patient is still about the same. He
plans to stay home to-day. He is answering two advertisements in yester-
day's Globe.

February 2.

Y. M. C. A. Employment Bureau, Mr. Grafton, telephoned to. In-
formant states that patient's "appearance and name queer him." Informant
has sent him out on at least a half dozen openings and though they did not
take on patient they did, however, take on some one else. He cited Hud-
son's as an example.

February 2.

Y.M.C.A. secretary, Mr. Doyle, telephoned to, who knows of a tem-
porary position for a man to do chiefly bookkeeping at Union Square,
Chelsea. He will telephone to get the present situation there and report
later to visitor. He volunteered that for some unknown reason it is harder
for a man out of a job to get a job than for a man who has a job to get
another one.

February 2.

Y.M.C.A. secretary, Mr. Doyle, telephoned that he has just got in
touch with the Lambert Real Estate & Insurance Company, Chelsea, and
finds that the position is still vacant. About three weeks ago the firm
asked informant to find a man to hold the position for a few weeks.
Informant sent a man who filled the position very satisfactorily, but has
just left for a permanent position. Although this work is nominally tem-
porary, the firm is a large and growing one, and if patient fits in well,
informant thinks there might be permanent work there. At all events, if
patient takes the position he could make it clear that he might have to
leave at any time for permanent work. Informant could reach neither
Mr. Lambert nor Mr. Hudson, but left word at the office about patient.
Visitor agreed to send patient in to the firm to-morrow to apply for the
position.

February 2.

Patient telephoned to, telling him of the opening at the Lambert Real
Estate & Insurance Company. He agreed to apply first thing to-morrow.

'February 3.

Patient telephoned that he applied at Lambert's, but Mr. Lambert said
a young man was to apply in a day or so whom he would like to interview

620 APPENDIX A

1920

before deciding anything. . It will take two or three days before Mr. Lam-
bert decides.

February 3.

Y. M.C.A., Mr. Doyle, telephoned to, who says that on the face of it
it looks as if Mr. Lambert was not favorably impressed by patient. In-
formant will ask a man under whom patient would work directly at Lam-
bert's details about the situation at Lambert's, as this man lives at the
Y.M.C.A.

February 4.

Patient telephoned that he will make the usual rounds to-day. He
heard from Mr. Jackson that Mr. Fletcher does not need any men now.

February 4.

Johnston-Abbott Mills, Chief Inspector, Mr. Fabian (visitor's brother-
in-law) written to, asking him for advice as to possible openings in Law-
rence for patient.

February 4.

Boston University, Vocational Department, Mr. Warren seen by
chance in the evening. He came over to visitor and asked whether patient
had a job as yet. He suggested that it would be a good plan for patient
to report to him so that informant could have him definitely on the waiting
list for an opening.

February 5.

International Optical Co., Lexington, heard from. Letter stated that
at present the only clerical openings for patient would be in the Traffic
Department at $20 and a probable one in the Shipping Department at
$18, both of which informant thinks wcnild not attract a man of patient's
experience. If he is an Italian, that miglit liar Iiim from office positions
other than in workshops. An application blank was enclosed and infor-
mant states that possibly a better opening in the offices may later occur, of
which visitor will be advised.

February 5.

Patient written to, asking him to report to Boston University, Mr.
Warren, and telling him of the reply from Lexington. Patient has sent the
application blank and visitor stated that she was writing to the Interna-
tional Optical Company telling them that doubtless patient would consider
an opening such as the one in the Traffic Department if promised definite
advancement.

February 5.

biternational Optical Company, Lexington, Miss Henderson written to,
stating that patient would be glad to make the trip to Lexington if there
should be a good opening or if the opening in the Traffic Department gave
promise of advancement. The letter asked that patient be kept on the
waiting list.

February 6.

Patient telephoned. He has not received visitor's letter. He will go
to Boston University to-day and to Wood & Berry, which he did not get
around to as yet. His wife is feeling the strain of the children's illness.
F.mma is not vet un and around.

APPENDIX A 621

1920
February 6.

y. M. C. A. Secretary, Mr. Doyle, telephoned to, who. forgot to inquire
about the Chelsea opening but will telephone Mr. Lambert and report to
visitor later.

February 7.

Patient telephoned. He went to see Mr. Warren at Boston University
yesterday and had a long talk with him. Mr. Warren advised him to apply
at the Harvard Coal Company, Mr. Marsh, regarding an opening there as
a bookkeeper. Patient applied, but Mr. Marsh was not there all day, but
to-day patient found him in. Mr. Marsh was at first very enthusiastic and
thought patient could do the work, but later on, finding patient could not
do typewriting, said he would have to interview three or four others first,

February 7.

Boston University, Mr. Warren, seen at Mr. Jenkins' class for employ-
ment managers, Boston University. He told visitor that there was a
strong probability that one of the professors at the University would take
patient on for temporary work and that informant would get in touch with
patient about this on February 9.

February 9.

Patient telephoned and was advised to get in touch with Mr. Warren,
Boston University, at once regarding the possible temporary opening.

February 9.

Y. M. C. A. secretary, Mr. Doyle, telephoned that he has got in touch
with Mr. Lambert of the Lambert Real Estate Company, who says he has
not interviewed patient and could not find out who has. The opening is
still there and Mr. Lambert would be glad to consider patient if he can
do the work.

February 9.

Boston University, Mr. Warren, telephoned to, who states that the
temporary opening at Boston University has been taken by a "young fellow
just out of high school." Informant would be perfectly willing to have
patient consider the opening in Chelsea.

February 9.

Patient written to, asking him to apply at Lambert's and telling him
that the opening at Boston University had been filled.

February 9.

Patient telephoned to in the evening, asking him to get in touch with
Mr. Lambert to-morrow morning.

February 10.

Patient telephoned that he interviewed Mr. Lambert this morning and
is to begin work there to-morrow morning. Mr. Lambert asked patient
very few personal questions and told patient there would be a couple of
weeks' work. He asked patient whether he was looking around for better
opportunities and patient said he was. Patient was afraid if he put his
salary too high he would not get the job so he gave $25.00 as his price and
Mr. Lambert said "All right, if I have to pay that, I will." Patient seems
pleased that he has a definite opening and agreed to get in touch with

622 APPENDIX A

1920

visitor soon to let her know how he likes it. He agreed to let the various
agencies to which he applied for work know that he is terhporarily em-
ployed, but that he is still looking about for better opportunities.

February 11.

Johnston-Abbott Mills, Chief Inspector, Mr. Fabian, writes that he saw
his employment manager, Mr. John Durand, on February 9, who says he
is taking on men right along and advises that patient call at his office so
that he may talk with him and find out for what work he is adapted.
Lawrence is not an unattractive city for a factory worker and but few of
the workers need to pay carfare.

February 11.

Johnston-Abbott Mills, Chief Inspector, Mr. Fabian, in'ritten to, stating
that visitor would let him know in about two weeks what patient's plans
are and suggesting that possibly at that time patient would be glad to see
Mr. Durand.

February 14.

Patient's wife telephoned that patient asked her to let visitor know
that he liked his work very much and that he is "feeling good" and says
the work is "pretty easy." His hours are 9 to 5 and Saturdays until one.
Emma is well now and expects to return to school on February 16. Dr.
Sullivan said Emma had had a bilious attack which she occasionally has
about a week. He has advised about Emma's diet, and of a number of
things Emma will not eat, such as cereals, and she has just begun to drink
milk. The doctor says that her enlarged tonsils should be removed soon.
Visitor urged her to take Emma to a hospital O. P. D. soon to make an ap-
pointment for tonsillectomy, as otherwise it might be difficult to make one
before summer. Informant agreed to do this. Patient's wife is well now.
Her back bothered her for a few days as she had strained it by some
heavy lifting. Informant agreed to ask patient to telephone visitor on
February 16 at noon.

February 14.

International Optical Company, Lexington, Employment and Service
Department, Miss Henderson, writes that patient's application and visitor's
letter have been received. Informant hopes to be able to find some work
for patient and will keep him in mind, letting him know if she has an
opening which she thinks patient would like.

February 16.

Patient telephoned at noon. He likes his present work which he says
"is easy enough," there being "nothing complicated" about it. His boss is
the head bookkeeper, Mrs. Judson. When asked how he gets along with
her he replied, "I can get along with anybody," and that he pretends he
doesn't know anything and does things her way. He is catching up with
past bookkeeping as far back as last July which has been poorly done by
his predecessors. There seems to be no question of permanent work and
he says he sees about ten days more ahead. He asked visitor to get in
touch with Boston University again, and to look into openings recently
advertised, one at the Federal Furniture Company, 356 Benton St., and the
other at Dunton-Bcrry's.

His wife begins work to-night, intending to keep at it until he has a
permanent job. For the present, patient feels that she is better off there

APPENDIX A 623

1920

than not working as it distracts her mind from somewhat strained relations

with the landlady.

February 16.

Federal Furniture Company, 356 Benton St., telephoned to. The man
who does the hiring stated that the firm is a credit house needing a book-
keeper, but a younger man than patient, as all the office force is young. He
added, "They do all the work I want them to."

February 16.

Dunton-Berry's Department Store telephoned to. The employment
manager was out, but the head bookkeeper, Mr. Hathaway, stated that he
has an opening for an assistant auditor at $35.00. Considerable bookkeep-
ing experience and a man of much common sense is required. There are
about 40 applicants and informant will have to decide on them soon.
Patient should send in a formal application.

February 17.

Patient telephoned to and agreed to write Dunton-Berry's to-day re-
garding the opening in the bookkeeping department.

February 19.

Patient mritten to, suggesting that he take a half day off to apply for
clerical opening at Allison's and enclosing a letter of introduction to the
office manager there.

February 24.

Patient's zvife telephoned that patient would telephone visitor at noon.
Informant would like to live in North Beverly as she has friends of her
girlhood living there. H patient should work in Beverly he would first
commute from Boston before the family moved. They are all well.

February 24.

Patient telephoned stating that he will ask for a day off to look into
openings at the Allison Manufacturing Company and the Johnston-Abbott
Shops. Visitor agreed to mail patient a letter of introduction to the
Johnston-Abbott shops.

Patient is sure his present work is temporary, lasting only a few days
more, as the head bookkeeper practically said that this morning. Patient's
job has been to catch up with her past bookkeeping. She has been careless,
has let things slide, and does not fully understand her work. She has not
made a trial balance for the last eight months. Patient has liked the work,
however, and has felt well except that he has not slept very well. He is
sure that when he has a permanent job he will be O. K.

February 24.

Johnston-Abbott Shops, Chief Inspector, Mr. Doyle, "Written to, stating
that patient would apply soon to Mr. Durand.

February 26.

Patient telephoned that as he has to take off an hour to-morrow morn-
ing to complete a piano deal, he will not visit Lawrence and Beverly until
March i. Yesterday he arranged for his landlady to purchase a piano at
the Hotel Bellingham as a result of an advertisement he saw in the paper.

624 APPENDIX A

1920

This deal will give patient $20 commission. Patient is not yet sure when
the work will terminate but says it may any time.

February 2"].

Boston University, Mr. Warren, seen at Mr. Jenkin's class for employ-
ment managers. He knows of no opening for patient and admits that
patient's age is much against him. Apparently no opening can be expected
from this source.

March i.

Patient telephoned early in the afternoon that he had spent the morn-
ing in Beverly at the Allison Manufacturing Co., but due to the present
difficulties in transportation, could not reach Lawrence the same day. It
is too late, however, to return to his work in Chelsea to-day.

This morning he waited one hour and a half for the office manager,
Mr. Van Horn, who told patient he would look over various clerical posi-
tions to see whether patient would fit in. As most of the bookkeeping is
done by girls, there would be no opportunity at bookkeeping. He was well
impressed by patient's desire to live in Beverly and be permanent with the
firm. He asked patient what salary he would require and patient said he
would start at $25 if there was every opportunity for advancement;
Mr. Van Horn assured patient that no employee was hired at Allison's
without the idea of promotion in mind, and that the firm would not con-
sider paying patient less than $25.

Patient suggested that visitor write a letter to ]\lr. Van Horn, who
had asked patient to get in touch with him in about a week or ten days if
patient had not heard from him.

When patient announced that he was not reporting to work this morn-
ing, the head bookkeeper was quite afraid that patient was leaving and felt
much relieved that his absence was only temporary. Patient feels that he
has given her a number of valuable suggestions for her bookkeeping, and
that there is still a number of days' work there for patient. Patient seldom
sees Mr. Lambert and apparently is responsible only to the head book-
keeper.

Patient plans to visit Lawrence soon, but would prefer to live in
Beverly as his summer camp would be so near by.

March 2.

Allison Manufacturing Company, Manager, Mr. Van Horn, written to,
asking him to let visitor know what he decides about patient, and assuring
him that patient is ready for responsible work.

March 6.

Johnston-Abbott Shops, Chief Inspector, Mr. Doyle, writes that he
spoke to Mr. Durand about patient and hopes patient gets a good job there.
Some of the jobs are good and some seem hard to informant.

March 8.

Patient telephoned that he has not heard from the Allison Mfg. Co.

March 9.

Patient written to, reassuring him about Allison's and urging him to
go to the Johnston-Abbott Shops at once.

March 11.

Patient telephoned that he sees several weeks ahead of work where he
is, and suggested visitor's writing to Allison's to-day. He was very dis-

APPENDIX A 625

1920

appointed not hearing from Allison's. He thinks they may be waiting for
his letter to decide on his merits. He plans to install new bookkeeping
methods where he is. He will write Beverly to-day and visit Lawrence
soon.

March 12.

Patient telephoned that he is very discouraged, having received a letter
yesterday from Allison's, stating that there are no openings now suitable
for patient, but if there are later, they will let patient know. Patient feels
that other men with only half his ability are getting jobs without difficulty.
(Patient apologizes for his conceit.) He wonders whether knowledge that
he has been at the Psychopathic Hospital on the part of employers has
anything to do with it, as he feels Allison's was so enthusiastic when he
saw them ten days ago. Visitor reminded him that Allison's knew of his
relations with the hospital at the time. His wife is not interested in Law-
rence as she knew so many people in Beverly. Patient will, however, go to
Lawrence this morning. He is already in the North Station and has for-
gotten to take visitor's letter with him.

March 11.

Allison Mfg. Co., Office Manager, Mr. Van Horn, written to, asking
why patient was not taken on.

March 15.

Patient telephoned that he was much disappointed with his visit in
Lawrence. He waited a long time for Mr. Durand who had only night
work as a machinist to offer patient. This patient refused though wages
were not discussed. Patient asked for Mr. Doyle as head office man, who
was not so identified, but patient was referred to Mrs. Mahoney in charge
of the clerks figuring the payroll. She told patient she had only young
girls and boys at $15 and $16. Later patient talked with the head book-
keeper, Mr. Hinton, who said most of the bookkeeping was done in Boston.
Patient was not impressed favorably by the place, as even the office looked
dirty and the young employees complained of the poor pay.

On returning to Boston patient applied to the Federal Employment
Office and asked to be kept on the list. In his last letter to Boston Uni-
versity patient asked to be kept on their lists and visitor agreed to remind
Boston University of this.

Patient feels it very much easier for visitor to advise than for him to
carry out the advice, but says he tells himself he must keep up his courage.
He wjll continue to look around for permanent positions as will visitor also.

March 17.

Allison Mfg. Co., Office Manager, Mr. Van Horn, writes that he could
not now_ employ patient "in whom we are mutually interested" as there are
no openings in the accounting division and the bookkeeping is done entirely
by women. Informant wrote patient recently stating that there was no
position now to "capitalize his previous experience" but that he would be
kept on the waiting list until the situation became better defined.

March 18.

Johnston- Abbott Shops, Chief Inspector, Mr. Doyle, written to, ex-
plaining that patient's interview with Mr. Durand was not very satisfactory
to patient and asking informant to keep patient in mind should any suitable
openings appear soon.

626 APPENDIX A

1920

March 25.

Patient telephoned to ask visitor if there was any news regarding
future openings. April i he plans to balance the books at Lambert's and
says there may be more work there after that. When his work is finished
there, he plans to go to the country a day or two, and will stop off via
Allison's on his return home. "What's worth having is worth going after."
He will tell Mr. Van Horn at Allison's that he will gladly start in any-
where in the firm. Patient inquired for Mr. Warren at Boston University.
Patient has done nothing about membership in the Y. M. C. A. because un-
settled as to location. He plans to drop his membership in the Elks which
he never enjoyed and which costs him $12 annually. He feels it too ex-
pensive to play with the Elks. In two or three weeks he plans to go week-
ends to his camp.

March 26.

Boston University, Vocational Department, Mr. Warren, visited. In-
formant had an opening at the B. D. Cole Leather Company, 80 North
Street, where Mr. Kelsey is looking for a bookkeeper at $25. Informant
has sent over about six candidates, none of whom were accepted. One at
$25 was too inexperienced and one at $30 was too expensive, but in-
formant does not know what the drawback was with the others. If patient
applies he can say he heard of the opening through Boston University.

March 26.

Patient zvritten to, advising him to look into the opening at the B. D.
Cole Leather Company at once and report back to visitor.

April I.

Y. M. C. A., Mr. Doyle, telephoned to, who stated that he could quite
easily find out from patient's employer how satisfactory his work is, and
that he will make such inquiries soon.

April I.

Boston University, Vocational Department, Mr. Warren, telephoned to,
who stated that it was more to the point for visitor to telephone the B. D.
Cole Leather Company than for informant as visitor knew patient so much
better. Visitor agreed to do so.

April I.

Patient writes that he has made several unsuccessful attempts to tele-
phone visitor. On March 29 he called on Mr. Kelsey at the B. D. Cole
Company who was very busy and talked with patient but a few minutes.
Patient says "he was rather favorably impressed with me and gave me an
application blank to fill out." Mr. Kelsey did not explain the position in
detail. Patient thinks firm is "a very nice one" to work for. Patient
thinks if Mr. Warren of B. U. would telephone Mr. Kelsey it might help
to get him the position.

April I.

B. D. Cole Leather Company, 80 North Street, Bookkeeping Dcpf..
Mr. Kelsey, visited at 11 a. m.

Impression : Keen business man, human interest probably secondary to
business.

Informant asked visitor her interest in patient. He is considering
patient among two or three other candidates, but said patient did not im-

APPENDIX A 627

1920

press him very favorably. He v^^ould not explain this further than to say
he felt patient might leave for the liquor business at any time prohibition
took a turn and that informant preferred a younger candidate. In favor
of patient he spoke of his neat handwriting. It is difficult novi^ to get good
material as bookkeepers though plenty of poor help is available. The
position is for a m,an to work in as understudy to the head bookkeeper.
His work would be to connect up between the factory and the office and
the candidate would have to learn both the factory and office bookkeeping
methods as well as have eight or nine men under him. Informant agreed
to send for patient if he decided to consider him.

April I.

Federal Employment Office, 4 Cherry St., visited. There is no open-
ing for patient.

April 2.

Patient written to, explaining the result of the visit to the B. D. Cole
Leather Company and advising patient not to expect the opening there
though he can keep it in the back of his mind. Letter advised patient to
visit Allison's soon with regard to future employment.

April 6.

Patient telephoned his wife is a little discouraged about his not having
steady work but she does not say much. Patient will telephone Mr. Kelsey
of the B. D. Cole Leather Company to-morrow to see if there are any
chances there and will write Allison's that he plans to visit on April 12.
Patient's wife has intended to make an appointment at the Children's Hos-
pital for the removal of Emma's tonsils and patient will urge her to do so
soon.

April 7.

Federal Employment Office, 4 Cherry Street, Mr. Brown, visited, who
has no openings for patient as a bookkeeper. Prospects in this line have
not improved.

April 8._

Allison Mfg. Co., Office Manager, Mr. Van Horn, written to. explain-
ing that patient would visit on April 12 and that he would be willing to
start in at any time in any line there, as he was especially interested in
the firm because of its promise of advancement. Letter asked that in-
formant put patient in touch with the employment department if informant
had no openings himself.

April 8._

Patient written to, explaining that visitor was writing Allison's.

April 9.

Y. M. C. A., Mr. Doyle, ^ telephoned,^ stating that patient has adapted
himself very well to conditions, according to patient's employer, and has
helped tide over the situation very well. Patient's work there will soon be
finished and informant will keep patient in mind for a similar opening.

April 12.

Patient reported to visitor at 11:30, stating that his plans had been
changed somewhat. In yesterday's Globe he saw an advertisement for

628 APPENDIX A

1920

various types of help at the Standard Drug Company, among them ac-
countants and bookkeepers. He decided therefore to apply there the first
thing in the morning, and waited with a "seething mob" from 8 A. m. until
10:30 before he was seen. The employment manager had him fill out an
application blank and then told patient that undoubtedly they could fit him _
into the organization and that the man patient should see would not be in
until to-morrow. The employment manager said he would look up patient's
references in the meantime. Patient put down as his minimum salary
$27.50 per week. Patient seemed quite enthusiastic over the interview
there. He plans to go at once to apply at Allison's this afternoon. He
spent the week-end on his little farm and his farmer friend Henry told
patient of an opening at $4 a day to clear the woods on the estate of the
millionaire, Henderson, near Lexington, which would last until the summer,
n no definite opening materializes in a week when patient expects the posi-
tion at Lambert's to end. patient will take this job in the woods, as he does
not want to be idle at all especially considering the high cost of living.
Patient's wife cleaned up at the camp preparatory to living there for the
summer. The family expect to go to camp again next week-end when
patient will do his plowing. Patient says he feels pretty well but still
sleeps only fairly well, waking up early and then only dozing for the rest
of the morning.

Patient is sure his present employer will give him a good reference
and when patient lecently called up Mr. Stratton of the Stratton Piano
Company relative to the sale of a piano, patient was reassured by Mr.
Stratton that he would give patient a good reference at any time. Patient
stated that it was difficult to reach visitor by telephone especially since
there is no booth in his office. He will, however, let visitor know the results
of his applications at Allison's and the Standard Drug Company. He
telephoned the B. D. Cole Leather Company a few days ago and Mr. Kel-
sey said he had filled the position that morning. Patient then asked Mr.
Kelsey why patient had not been selected, adding that perhaps patient was
asking state secrets. Mr. Kelsey did say it was not because of patient's
age but would give no further reply. Visitor agreed with patient that the
position at clearing the woods would be good in case no further opening
was at hand as patient said he would feel free to leave it at any time.

April 20.

Patient's former employer, Lambert Real Estate Co., telephoned to.
Patient left there on April 17. The clerk volunteered that patient had done
very good work and that they thought he was going to work at Allison's
and live at his camp.

April 20.

Patient's zvife telephoned to. Patient went out to Lexington to-day to
look up Allison's and will be home to-night. Visitor left word for patient
to write at once or telephone regarding his work plans. Further details
could not be discussed over the telephone.

April 22.

Patient's zvife telephoned. A week ago patient was told at Allison's
to report April 20 as the firm thought they could then place him in the
stockroom. He planned to return home the evening of April 20 for his
work clothes if put to work, but nothing has been heard from him. It_ is
probably about a half hour's ride from his camp to Allison's, from which
he planned to comniute. loformant's plans will depend upon how well

APPENDIX A 629

1920

patient likes Allison's if he is working there. She will try to get news of
patient for visitor as soon as possible.

lApril 26.

Patient reported to visitor, stating that he is well and busy, but that
he still has vague fears at times, which he, however, has been able to con-
trol. His wife is still working, and his wife's sister is still helping some-
what financially. For example, she visited patient's camp last week-end,
bringing out a good supply of food, and paying patient's son's transporta-
tion. Patient hopes to pay her back later.

Patient asked visitor's advice about his work. The last two times he
applied at Allison's, word was sent to him from Mr. Van Horn that he
was too busy to see patient, and that he should report back in a week.
Patient wondered therefore if that was the real explanation or whether
the firm has no interest in patient.

The Standard Drug Company, where he reported again to-day, said
that patient's name is on the waiting list. They have selected no clerks
or bookkeepers as yet, this being up to the department heads.

Mr. Lambert has sent for patient, asking patient what salary he would
require to do the work he did temporarily as a permanent job. The present
bookkeeper has already become nervous on the job since patient left,
because she finds it beyond her ability to keep the books straight. Patient
stated $35 as his salary and said to visitor if no other opening was avail-
able, he would take it, but he feels it is a "nerve-racking" job. The em-
ployer keeps one book where three are really necessary, hence making the
bookkeeping complicated. Three books, though simpler, would entail extra
work which the employer is unwilling to pay for. Complications come in
through the fact that there are really three different funds to account for
and the employer is constantly borrowing from one fund for another. If
patient took the job, he fears he would need to start on overtime, but visi-
tor firmly said he could not do this, and if overtime is necessary must have
assistants. The present bookkeeper Mr. Lambert plans to shift into other
work in the office. Patient wonders how she would feel toward patient's
keeping her position. He suggested to Mr. Lambert that both Mr.
Lambert and the insurance man spend too much time in the office, and
that if patient took the position he thought he could undertake some of
their office work, such as answering general questions about real estate,
and making appointments for interested parties with his employer. Mr.
Lambert will decide by noon of April 28 whether he can pay patient the
salary of $35 or not.

Patient would prefer working for some large firm such as Allison's,
as he feels a smaller firm can offer only a less secure job. After visitor's
telephoning Allison's, patient agreed to get in touch with visitor late to-
morrow morning.

April 26.

Allison Mfg. Company, Lexington, OMce Manager, Mr. Van Horn,
telephoned to, and stated that patient had reported the situation correctly
to visitor, and that informant is very sorry he has been too busy to spend
the hour required to see whether patient would fit into the stockroom. He
is not willing to have patient take another position without informant's
looking into the possibilities at Allison's, however. Informant agreed to
telephone visitor to-morrow at 4 o'clock what the situation is.

April 27.

Patient telephoned late in the afternoon, and agreed to do so again
to-morrow morning as Allison's had not been heard from.

630 APPENDIX A

1920
April 28.

Allison Mfg. Co., Lexington, OfUce Manager, Mr. Van Horn, tele-
phoned to at 10:30 A. M. Informant apologized for not telephoning visitor
yesterday. He had the memorandum on his desk and had done the pre-
liminary work ; namely, to see where patient would fit in.

At present there is no clerical opening for patient, but he can definitely
be taken on in the stockroom giving out orders. _ This work is largely
physical and is paid at an hourly rate, where patient would earn about
$20 a week. Holidays and Sundays as well as vacations are not paid
for. Informant would keep patient in mind while he worked in the stock-
room for advancement to clerical work either in the stockroom or else-
where. They are hard pressed now in the stockroom for clerical help but
informant has not been able to "sell" patient to them for clerical work
because of his age. Informant is confident, however, that clerical work
will develop for patient later when his abilities are recognized in spite of
his years.

Visitor stated that unless she notified informant to the contrary, patient
would report to him on April 30. Informant said that at that time he
would introduce patient to the employment department and arrange for
patient to begin work on May 3. At first informant suggested that if
patient had a good opening at Lambert's, he had better take it, but when
visitor spoke of patient's fear of only temporary work there, informant
admitted that at Allison's permanency could be expected.

April 28.

Patient telephoned and seemed somewhat depressed at the salary
ofifered to start with at Allison's. Visitor reminded him that he could
hardly have a better person than Mr. Van Horn interested in him, and
pointed out the advantageous features of Allison's. Patient will telephone
Lambert's about 12:30 to-day and will telephone visitor to-morrow morning.
Patient himself will be allowed time by Lambert's to make a decision.
Visitor told patient it was up to him to make the final decision.

April 29.

Patient telephoned, much discouraged. Mr. Lambert had telephoned
to patient's brother-in-law in patient's absence yesterday that he could not
meet patient's figure. Patient feels Allison's should offer him more as a
starting figure (in fact, Mr. Van Horn told him he could expect a minimum
of $25), and that the promise of advancement there is not definite enough.
He is wondering whether he should telephone Mr. Lambert, but finally
decided he would later. As Mr. Lambert had said he would be v/illing to
pay $1,000 more a year, patient does not understand why he is "balking at
$35 a week." He thinks all there is for him to do is to make the rounds
of the employment ofliccs. Visitor tried to assure him that the hardest
part of his task was surely finished ; namely, that he had gone the rounds
of the employment offices and now had a good employer interested in him
and that he could hardly hope to find a better firm than Allison's.

Visitor suggested that patient come out to talk with Dr. Jacobs. He
first said he would gain nothing, and spoke in the tone of a spoiled child.
When visitor reminded him that Dr. Jacobs was the doctor to sanction
responsible work for him, he admitted he could lose nothing by coming,
out to see Dr. Jacobs and would do so.

April 29.

Patient reported at 3 p. m. to see Dr. Jacobs. Visitor first discussed
the case with Dr. Jacobs, who felt that patient could rightly be discouraged

APPENDIX A 631

1920

with an ofifer of only $20 a week. After seeing patient, the doctor reported
to visitor that patient is in very good condition, apparently now having full
control of any fears. He is a typical psychasthenic, being introspective,
overconscientious, hesitant about making decisions, and lacking self-confi-
dence. Dr. Jacobs says patient's present problem to decide would be hard
for a normal healthy person, and that if patient were not somewhat worried
over prospects, considering his age, his judgment could be questioned. He
told patient that he did not know the merits of the Allison opening, but
that it likely was a good proposition for the summer at least.

Patient reported to visitor that he could get Dr. Jacobs' point of view;
namely, that he must use "mental suggestions" to himself, but that it was
harder to carry out than others realized. He will go to Allison's to-morrow
morning and look into the situation for himself. If the promise of ad-
vancement is definite enough, he will take the position. He will write
visitor to-morrow evening before going to camp for the week-end. He
feels considerably worried about the support of his family as he hates to
have his wife working, or his relatives assisting.

He telephoned Mr. Lambert this morning but found him out, but does
not plan to telephone again as patient says "I have forgotten all about that
place now," evidently considering the deal closed there.

May 3.

Patient writes that he is to start in at the Allison Company on May 3,
beginning in the stockroom, stating that "Mr. Van Horn promises to see
that I get proper advancement if deserving of it."

May 3.

Patient written to, stating that visitor feels he has made a wise choice,
expressing the need of recreation, and asking him to report frequently
regarding the progress of his work.

632 APPENDIX A

Case 94
PSYCHOPATHIC HOSPITAL

SOCIAL SERVICE
NUMBERS 562

FILE NUMBER 5720 NAME Harriet Nelson Farmer*

0. p. D. NUMBER 3838

Residence 44 Stevens St., Roxbury.

Correspondent Mother, Frances Ordway Farmer, at above address.
Sex F Age 28 Color W

Civil condition S Place and date of birth England,

Religion Protestant 1887

Occupation Compositor (typeset-
ter)
Time IN Boston 22 yrs. In Mass. 22yrs. In U. S. 22yrs.

Previous addresses

107 Downing Street, Boston

63 Revere Street, Boston
When know^n to social service 11/30/15; 3/12/18; 6/9/19
When discharged from social service 12/31/17; 4/24/18
Reason for being known to social service Supervision
Report from confidential exchange No record

Name of father Henry (deceased)

Address

Name of mother Frances

Address 44 Stevens St., Roxbury

Name of spouse

Address

Names and ages of children or siblings

Frederick (died in infancy)

Florence, 34

Benjamin, 32

Bernard, 30

Patient, 28

Admitted to house 10/31/15 Authority Chap. 174

Discharged 12/8/15 Admitted to o. r. d. 1/19/16

Diagnosis Condition Unchanged

Not insane — not feeble-minded

(Psychopathic Personality)
Social Symptoms Date 3/1/16

Inebriety

Fabrication

Lying

Suicidal attempt

Non-support of mother

Insufficient wage

Friendlessness
Social Diagnosis Date 3/1/16

Vitia (Bad Habits) + Morbi (Disease)

* All names used in this record are fictitious.

APPENDIX A 633

PSYCHOPATHIC HOSPITAL

SOCIAL SERVICE

NO. S-562 NAME Harriet Nelson Farmer

ADDRESSES
Patient:

Gordon Home,

55 Dix Street.
Relatives:

Mother, Mrs. Frances Ordway Farmer,

44 Stevens St., Roxbury.

Sister, Florence Farmer,
44 Stevens St., Roxbury.

Employer, Miss Nancy Stowell, Charles St,

Brother, Benjamin Farmer,
Newton St., Nashua, N. H.

Brother, Bernard Farmer,
Dover, Mass.

Minister, Mr. Young, Channing Church,
Day St., Roxbury.
Residence, York St., Roxbury.

PSYCHOPATHIC HOSPITAL

SOCIAL SERVICE

NO. S-562 NAME Harriet Nelson Farmer

EXPENSE SHEET

Expenditures
12/24/15 Tie for Christmas. . .$ .25
1/26/15 Material for sewing

(for another patient) 1.29

2/19/16 Theater tickets 1.50

4/5/16 Theater tickets i.oo

4/6/16 Bath spray 59

4/8/16 Out-of-work pay 50

$5.13

634 APPENDIX A

PSYCHOPATHIC HOSPITAL

SOCIAL SERVICE

NO. S-562 NAME Harriet Nelson Farmer

SUMMARY
1916

January 30.
Social History:

Patient is an English woman of 28, who has lived in the United States
22 years ; in Boston 22 years. She has a sister, aged 34, and two brothers,
32 and 30 years of age. Patient was eight years old when her mother
separated from her father because he was found to be maintaining another
wife and family in the city. Children were boarded about a year by a
children's agency until the mother, who was and still is an invalid, gained
strength to reestablish the home. Family were then supported by two
older children. Several years ago both brothers married and left patient
and sister to support the mother. In April, 1914, the mother was unable
to keep up her housework and the home was broken up. Patient lived in
lodging houses in the West End and sister and mother with a married
brother. A year later, April, 1915, patient was asked by mother and sister
to keep house with them, but she refused to go home to live until June,
1915, when she was unable to support herself on her low wages. Financial
struggle of the family has always been great. Patient did not contribute
after leaving home and only $2 a week when she returned.

The mother is a frail woman, able to get about only on crutches. She
is religious, generous, and open-hearted. The sister has worked in the
same dressmaking establishment for many years. She is an earnest, up-
right, and matter-of-fact woman of excellent character. The older brother
who lives in Nashua has a wife and two young boys. The brother in
Dover has a wife and a daughter aged ij^. He is a machinist and ir-
regularly employed. Several years ago he was discharged from one firm
for attempting to steal money from the safe. The family are all willing to
do whatever they can for patient and the mother especially is fond of her.
They are discouraged al)OUt her. They reprove her little and allow her to
have her own waj- because they arc afraid of her tales of abuse.

The mother and sister have two rooms, a bath and a kitchen in a
house on a pleasant, quiet residence street of Dorchester.

Patient went to school in Boston through the grammar grades.

Up to a year ago patient had been a typesetter in the same place for
eleven years and earned $12 a week. Since then she has worked in two
candy factories for $5 a week. Previously she worked in an office and a
laundry, a short time in each. Patient has about $50 savings.

She is an ardent Episcopalian, though she was brought up a Unitarian.

When the home was first broken up, a woman prominent in the Boston
school department was interested in the family and became guardian to

APPENDIX A 635

1916

the children. For the past two years St. James Church with the aid of

York House has tried to supervise and guide patient.

Physical History:

Patient had normal birth and development, with exception of walking
a little late. She had measles in childhood, diphtheria at five, and several
attacks of appendicitis (no operation). Patient wears glasses. She has
some headaches. Her teeth are in bad condition. She is subject to neu-
ralgia. Examination here shows a poorly nourished condition. Question
of anemia. Wassermann test, blood serum negative.

In appearance, she is short and slight, and is usually pale. She is the
wiry type with normal endurance.

Father died in Westboro State Hospital of general paralysis. Mother
is an invalid and has had spinal curvature from childhood. About twenty
years ago she was treated for syphilis contracted from patient's father.
Heredity otherwise negative or unknown.

Mental History:

Patient was an average scholar. She reads much good literature, Les
Miserables and other classics. For the past two years patient has been
excessively alcoholic, drinking alone in her own room and going several
times to priest, or York House workers, under the influence of liquor.
She has been untruthful and unreliable, telling many things about mis-
treatment by her family which have no basis in fact. She has told scan-
dalous stories about the Episcopal priest to whom she confessed and about
the other church members. She has fabricated stories of attentions of
men. For a time, an unattractive young man paid her attention, but he
soon let her alone. Patient talks constantly and is aggressive toward
people with whom she comes in contact. Girls in church club would not
come if she were to be there. She is lazy, slovenly, and thoughtless. At
home, she leaves all the housework to her mother and sister, and expects
them to sew and wash for her as well. She stays in bed late. Patient and
sister are uncongenial, but patient is fond of mother. She is depressed
at menstrual periods.

A short time before admission, she had put her name and address into
a package of peanuts while working in a candy factory. As a result, she
entered into correspondence with a man in Springfield whom she decided
to marry. He turned out to be 65. Patient showed much disappointment
at the outcome of this affair.

Patient was sent to this hospital after an attempt at suicide. On this
day, nothing unusual had been noticed in patient's behavior. She had
never threatened suicide, and had not shown great depression. After going
to town that morning, she lunched with her mother, who then went to her
room to rest. A few hours later the mother was notified that patient had
taken Paris green, and had gone immediately to a doctor's ofifice. She was
taken to the City Hospital, and from there was sent here for observation.
Patient said she had bought the Paris green for an insecticide and took it
because she felt discouraged with her own life and her mother's physical
condition.

In typesetting patient was fair, but was considered physically not fitted
for the work. She was laid ofif from monotype with the introduction of
more linotype machinery.

In other places of employment she was liked and considered good.
Each place she left for a better place.

Examination here shows her to grade 15 years plus on the Point Scale
and 125^ years on the Binet.

636 APPENDIX A

1916

Diagnosis: Not Insane — Not Feeble-minded (Psychopathic Person-
ality).

November 30.
Recommendations in regard to :

Social Condition: Patient should be kept away from her own home
except for visits. Her family should be made to understand and tolerate
her peculiarities.

Keep her supplied with interesting handwork. Send to theater occa-
sionally and try to have her be with girls her own age through living with
them and through church clubs.

Next season try to arrange for night high school or some industrial
class. Suggest books and keep patient supplied with list of free lectures.

Physical Condition: Regularity of meals and a proper diet should be
arranged. Encourage daily bathing.

Further medical care at a general hospital ( ? of anemia) is recom-
mended. Teeth should be filled.

Mental Condition: Encourage and commend patient in all her efforts.

Congenial work should be found and signs of mental or "physical
fatigue watched for.

Patient should report to Out-Patient Department monthly in the begin-
ning. Special attention should be given to any depression lest it lead to
drinking. Patient's complaints and difficulties with family should be mini-
mized and her friendly attitude maintained.

SUMMARY OF RESULTS IN SIX MONTHS

April 5.
Social:

Since leaving the hospital, patient has lived at the Gordon House in a
double room. Every Saturday afternoon and Sunday she has spent at
home and last two months she has been staying over night. Occasionally
she has spent the day at her brother's in Dover. For two months she has
been giving her mother 50 cents or $1 weekly. She takes her dainties often.
She has put about $10 in the bank.

From December 28 to March 11 patient worked at piece work in a
factory where the work was irregular and where she could earn a maxi-
mum of about $7.50 a week. On March 11 patient started time work in
another factory where she pasted labels and packed bottles for $6 a week
with advance in wage later. This work was uncongenial to her and on
April 24 she found a position in her old trade of typesetting at $8.

Evenings patient stays in, usually either reading or sewing. She has
been with her sister to a church entertainment, to the theater, and some
public meetings. Occasionally she goes to the Settlement House forum
meetings.

In the House the girls like her and come into her room evenings.
They have spreads and very jolly times. In February her roommate, a
blind girl to whom she was devoted, left, and she had a young Polish girl
until Slay, when she has been alone. At work, she has made some girl
friends.

APPENDIX A 637

1916

In January patient joined her people's Unitarian Church, but she has
attended only comparatively few times. She went to the Episcopal Church
fairly regularly for four months without telling her family, but now goes
less often.

Physical:

On discharge, patient was referred to the Massachusetts General Hos-
pital with a question of anemia. She was in the hospital from December
13 to 17 and was found to be not anemic. She has had her teeth cleaned
and some fillings done at the Harvard Dental School at times when she has
been out of work. She has reported monthly to the Out-Patient Depart-
ment.

Patient eats two meals at the House, and usually fruit and cocoa at
night. Luncheon she takes with her to work.

Patient walked to and from work a distance of about three miles in
her first two places. Now she walks occasionally though it is about five
miles. At present work she sits on a high stool, but stands from choice
some of the time. She goes to bed earlj^ particularly when work has been
physically fatiguing. A bath spray has facilitated daily bathing.

Patient had difficulty with menstruation and has been to consult Dr.
Green, a woman physician at the hospital, about it.

Mental:

There has been no evidence of patient's telling lies or elaborate fabri-
cations. She exaggerates her own good efforts in everything she does and
gives accounts of her excellent conduct. There has been no open conflict
between her sister and herself. Patient has not been drinking, nor has she
mentioned suicide.

She has appeared to be happy and fairly contented except for her
desire to stay at home over Saturday nights. This had not been allowed
for several months because patient would stay in bed late and impose
on the family. Her mother's invalidism worries her and often she gets
discouraged or sad over it.

Her last roommate was a rather stupid and ill-mannered girl and
patient took much pleasure in training her manners and habits.

Patient has shown herself to be very generous. She was glad to make
two garments for another patient known to visitor and she has made
several presents for visitor. She is good with handwork of all sorts and
enjoys spending her time this way.

When discouraged and blue she had two long talks with the Chief of
StaflF.
HA/C

PSYCHOPATHIC HOSPITAL

SOCIAL SERVICE

NO. 8-562 NAME Harriet Nelson Farmer

HISTORY
1915
December 3.

Patient's story: Patient gives following places of employment:

1. T. S. Davis, 180 Young St., office work. Left for better wages.

2. One year 1904-5 — Charter Hill Laundry. Laundry work. (Place
burned.) Left because work was too hard.

638

APPENDIX A

I915

' 3. Nine years to November, 19:4 — Sampson Press. Left with intro-
duction of a new machine requiring fewer girls.

4. December, 1914 — G. I. Eaves, candy work. Left because rush sea-
son was over.

5. February, 1914-October, 1915 — Tyson Brand Co., Cross St., Cam-
bridge, packing. Left because employees were rough and wages low.
$'.50 a week.

Schools were as follows :

r. James B. Baker School (Grammar School), finished 1904.

2. East Boston High School (night), 1905.

3. Dixon's Commercial School (night), 1905, complete course.

Patient has always lived with her family until August, 1914, when they
broke up because of mother's ill health. She has a married brother,
Arthur, aged 32, living on Newton St., Nashua, N. H. Of his wife patient
is fond and feels at home there. He has two boys. Another brother,
Bernard, is married and has one girl and lives in Dover. Patient does not
know his wife well nor feel at home with her. They have asked her to
come and stay there when she leaves here, but she is anxious to go to
work. "I think I might go insane if I stay out of work nuch longer."
Patient and her sister Florence are not congenial. Sister is "older and
more set in her ways" into which she tries to draw patient. Sister goes
out and takes an interest in suffrage and such things while patient prefers
to be at home and quiet.

Since family broke up housekeeping patient has lived in lodging houses,
first at 107 Downing St. Room was $3 and when she took a $2.50 one in
the same house it was ill-kept and had Ijugs and vermin. On September 18,
1914, she moved to 63 Revere St., where she stayed until June, 1915. At
that time she returned to her family (mother and sister) who started to
keep house.

Patient's family are Unitarians. She was confirmed in Christ
Church, East Boston. The minister there. Rev. Y. K. Elden, has since left,
but she keeps in close touch by correspondence with Mrs. Elden. Patient
has been going to St. James Church, Cambridge St., for a little over a year.
Confessions she has made to Father Cramer and ha^i confidence in him
until lately. When she confessed drinking he sent her to see Miss Kendall
at York House, but patient did not feel she could enter there. She has
seen Miss Kendall a good deal and trusted her. Has since heard that Miss
Kendall said she was "mentally deranged" and this has hurt patient's feel-
ings. Father Cramer told her she must do exactly as he said if he was to
help her, but patient was unwilling to do this. At one time Father Cramer
sent an immoral girl of 16 to her for advice. Patient thinks he must have
had confidence in her to do such a thing. Lately, however, he has prom-
ised to see her, and has not done so, and said he went to Roxbury and
found no one home, when in reality he saw her mother and upset her
terribly. Her confession he used in his sermon. After the latter incident,
she made up a lot of things to confess just to see whether he would tell
them, and he did. Patient will discontinue connection with this church.
She feels she ought to go to the LTnitarian Church because Mr. Young, the
pastor, is taking an interest in her and offering to help. She cannot believe
their doctrines nor be satisfied with the service.

Patient goes out about two nights a week. The other nights she goes
to bed 8 or earlier. She gets up about 6. Always she sleeps well and has
a normal appetite. When she had a room, she cooked her own meals there,
and on Sundays, when she went to see her mother at her brother's, they
filled a travelling bag with home-cooked things for her. From August,

APPENDIX A 639

1915

1914, to May, 1915, patient took a glass of port wine ($1 a quart) a day to
brace herself. She took raw eggs also. She found the wine made her
nervous so she stopped it. Had one glass a few days before admission.
She has no desire for it.

Patient averaged two books a week as well as all the books for which
she set up type. She reads good books, naming as examples Last Days
of Pompeii and Gilbert Parker's novels. She owns a number. Em-
broidery she likes to do and makes all her own clothes, mostly by hand,
and trims her hats.

She likes to be alone and has never made any girl friends with the
' exception of Miss Kendall of York House. For six months in 1914 she
knew Karl Cauldwell and was engaged to him, but he left town and wrote
he would not see her again. Afterward, she found out he was not a good
sort so has not cared that he went away. She had the friendship of Frank
Illington, who in September, 1914, went away to study for Roman Catholic
priesthood. He left his books to her. He was a fine, good young man.
At one time patient belonged to the Girls' Friendly Society but dropped out
because the meetings ceased to interest her. She never mixed with girls
at St. James Church because she thought them two-faced. She would like
industrial classes where work with the hands is done, but she does not care
for dancing or exercise. Says she is a good girl.

Patient does not want to live away from home, but realizes it is better
since she worries too much over her mother's suffering. She would want
to go home every week.
HA/C

December 2.

Employer, Mr. D. I. Stern, Snpt. of Sampson Press, seen at Cambridge
St., Dorchester. No exact record kept of patient, but informant remem-
bered her well. He had always taken an interest in her because he felt
that she was delicate and that she was not suited to factory work. Exact
dates of employment not kept. Informant thought she had been there for
about five or six years. She was a compositor and set up and also cor-
rected type. For the first few years she was in piece work and may have
been paid from $7 to $17 per week, depending upon her speed. Later that
system was abolished and for about a year she was a "weekly worker,"
and received $12 per week. The hours are from 7 :20 to 5 with an hour
for luncheon and every Saturday afternoon off. Patient was quite inter-
mittent in her work. No record was kept of that either. Patient worked
in a large, light, well-ventilated, clean room with about 75 other workers,
men and women. The visitor saw this room and the processes used by
the patient. There is no heavy lifting in the work. The patient selected
type and arranged it in "sticks," these in turn being placed in a long pan.
After the proof had been read it was returned to her. She then cor-
rected_ any mistakes in setting up the type. Each worker sits on a high
stool in front of a slanting desk arrangement on which the type is de-
posited. Theonly element of strain seemed to be that of remaining seated
most of the time. A fair degree of skill is required in composition. The
worker must have a good knowledge of the English language and be able
to spell and punctuate fairly accurately. Patient was a fair worker, but
"not distinguished" in speed or accuracy. She reached "about the middle
mark" in efficiency. _ The informant thought her chief fault "lack of pep
and steam." He said she did not seem to have physical energy. She was
fairly attentive to her work and was not "a gad-about."

At the time when the piece-work system was abandoned a great many
girls were dropped. In the natural course of events patient would also

640

APPENDIX A

1915

have been dropped because she was not particularly valuable, but when she
told him that there was financial trouble at home and that "it was up to
her" he let her stay on as a weekly worker. He felt that the work was
too great a strain upon her and told her that she ought to get some kind
of work in a private family and some place where she could be out of
doors. She looked anemic. Informant heard that there was one member
of the family who caused a lot of trouble and in addition there was illness.
Patient was often out because of sickness.

She was always quiet and tractable, but if anything annoyed her she
"got up and acted like a normal person." Informant thought that she was
very proud and that she would take all trouble on her own shoulders and
never give way under it. At one time she gave all the financial assistance
that was given to her family. Her eyesight was poor and she had occa-
sional treatment for it. Patient's work showed no deterioration. Patient
resigned to take another kind of position. Informant would not care to
take her back because she was not suited to the work, and was not par-
ticularly efficient.

Informant confirmed his own memory by talking with Mr. Quinn,
patient's foreman, who gave a very similar report.

Impression : Unusually intelligent and understanding man, obviously
interested in the welfare of his employees.
MBS/C

December 3.

Teacher, Miss Neide, seen at James B. Baker School, Roxbury. She
did not have patient, but had had her l^rother, Benjamin, in her class. On
her recommendation. Miss Neide's brothers, "The Three Neides," took
Benjamin to work in their confectionery concern. He was there several
jears and it was finally discovered that he liad been taking supplies for
some time. He stole from the safe the last thing. The queer part was
that he seemed to have no sense of the wrong of it. They all thought he
might be "not responsible."
HA/C

York House Matron, Miss Kendall, who has known patient about two
yearSj seen. Patient has l^een to her, to Miss Hunt, another matron, often.
She has never had a sensible conversation with patient. She is most
erratic, talks at great length aliout the men she intends to marry, or about
injuries which various people have done her. Nothing that she says can
be relied upon for she tells a different story to everyone. For example,
she told Miss Kendall not to see her mother, because mother is a Unitarian.
Mother was very cordial to Miss Kendall. She is very bold and boastful
about her drinking. Has said she drank as much as two quarts of port
wine in one night. She usually drinks alone. Has been seen under the
influence of liquor though not actually drunk. She seldom takes anything
without immediately going to one of the priests of St. James' about it.

Patient told the story of her father having contracted syphilis and
having died in Westboro State Hospital. One maternal aunt was insane.
Father disappeared at one time for several weeks. When he returned he
gave mother syphilis. She soon found he had a wife and five children by
the name of Farmers, living in the West End. Mother is now suffering
from syphilis and tuberculosis. After death of father, patient and brothers
and sisters were placed in home, patient going to Home for Orphan Chil-
dren. Miss Kendall has not had the opportunity to verify these stories.

Patient has said a good deal about having men in her room and Miss
Kendall has thought her to be immoral. Karl Cauldwell was a diseased-
looking man; his face was covered with sores.

APPENDIX A 641

In packing peanuts, patient put her name into a package. In Septem-
ber she had a letter from a man in Springfield who had bought the peanuts.
She corresponded several weeks with him and then told Miss Kendall she
wanted to marry him. Associated Charities in Springfield found he was
about 60 and had a wife and children, and was somewhat "oflf" on the_ sub-
ject of women. Patient saw this letter from the Associated Charities a
few days before she took poison. She had often said before that she
would do so, but in an offhand way.

At home patient is troublesome. She stays out very late several nights
a week and is quarrelsome.
HA/C

December 4.

Guardian, Miss George, of Public Schools, high school teacher,
says she was made guardian of patient and other children when father
died. She has known the family 25 years. When they first came to her
attention through the children at school, they were underfed and it was
found the family had been living on stale bread and water for several days.

Patient has never been a help to her family in a financial nor any
other way. She should not go home now because she is too great a care
and worry to her mother and sister. Mother has been sick all of 25 years
Miss George has known her.

Patient graduated from grammar school at 17. Was a scholar below
average.

HA/C

December 4.

Father Superior and Father Cramer of St. James' Church (Episcopal)
seen. Patient has been known to them about two years, and was at that
time drinking heavily. She has never been seen when she was unable to
walk, but oftentimes was markedly under the influence of liquor and very
unsteady on her feet. She has denied immoral sex conduct and they have
no reason to believe she has been immoral. She has a "diabolical" and
malicious way of starting and spreading scandal. She will tell one tale to
one person and another to some one else. Among the parishioners, she is
talkative and always ready to make friends. She is not bold. The girls
of the church will have nothing to do with her because of her conduct,
and have completely frozen her out. If she came to meetings, they would
not.

The priests feel that sex is the basis of the whole matter. If she had
married when younger she probably would have been comparatively nor-
mal. At one time last winter, Karl Cauldwell kept company with her and
they were engaged. He was an uninteresting, somewhat slow young man,
but not objectionable or bad. During the time patient kept company, she
was a normal individual. He soon discovered what she was like and dis-
appeared. Patient has been much worse since that, in February, 1915.
Otherwise, her conduct has not shown any fluctuations.

Patient has taken her transfer letter from the church so is no longer
a member of their parish.

Impressions : Father Cramer is a young man, probably looks younger
than his years.

Father Superior did most of the talking and gave general statements
chiefly. Interview was in the church, where the two fathers were on duty
for hearing confessions.
HA/C

642

APPENDIX A

1915
December 6.

Landlady seen at 63 Revere St. Patient roomed there as stated and
was recommended bv Frank lUington. She had not known patient drank,
until after patient had gone and Mr. IlHngton returned. He mentioned it
and she then remembered smelling liquor on patient's breath once. In
the beginning she was friendly with some church girls, but later had a
falling out and asked landlady not to let them go to her room. Patient
never made friends with other lodgers. "There are twelve rooms, two or
three let to middle-aged men, and most rooms let for many years to same
persons." Landlady never heard of her going out with men nor did she
observe her coming home with any. She never had any in her room.
Patient was out after twelve some nights when she went home and also
she always went home on Saturday for Sunday. Other nights patient
stayed home and sewed. She does this well.

Patient was a good lodger and always paid her rent ($2 a week)
promptly and made no trouble. Landlady would not take her back now
she knows she drinks. She had thought her queer because she talked so
much, mostly about her disagreements with church people.

Landlady and her husband, old people, have lived in this place for
years and have good old furniture and china and very homelike rooms of
their own.

Impression: Unusually honest, frank, and dependable old lady. A
well run, respectable house.

December 6. ^^

Employer, Mr. Ra-vson, Mgr. T. S. Davis & Co., "Money to Loan,'
seen at his office, 180 Young St., Boston. Says he was there when patient
was there for about six months in 1904. She did sirnple clerical work and
some bookkeeping and informant can remember nothing except that patient
was satisfactory and left for better wages in a laundry.

Impression: A middle-aged man of refined appearance and manner.

December 6.

Employer, Miss Ingham, in charge of packing room at G. L Evans &
Co., "Utopian Chocolates," seen at 98 Vernon St., Boston. She says pa-
tient worked under her several months, from September, 1914. through the
Christmas rush season, and was entirely satisfactory, always on hand
promptly. Informant knew patient was a church memljer and other women
working there also lived near patient in South End and went to St. James.
The women here arc all Americans. Patient might be reemployed after
the rush season, but informant thinks it would not be wise for patient to
work there during the rush. Patient wrot« to informant _ several times
since leaving, but informant has not answered or seen patient. _

Impression : Young, but mature American woman, refined in appear-
ance, manner, and speech, well dressed and of vigorous build.

Factory : Only the office seen. This was very neat and there were two
other women of refined appearance.

December 6.

Employer, Mr. L S. Henderson, Supt., Tyson Brand Co., salted nuts,
etc., seen at the factory. Cross St., Cambridge. He says patient was one
of the first to apply on opening of new factory last February. She \vas
entirely satisfactory and was especially prompt at work. She did packing
at a bench with Americans though there are some Italians. She earned
$5.50 per week and might have had piece work if she had stayed and
earned as much as $7.00 a week. He noticed particularly that she took no
notice of the men about the factory as many women do. He would re-
employ patient at any time.

APPENDIX A 643

1915

Impression : A young man of refined appearance and manners.

Factory : A new brick building, very well lighted, in neighborhood of
other factories.
AEL/C

December 7.

Sister Florence seen, in town after work by appointment. Patient's
conduct has been the greatest trial to sister and mother. She talks so fast
and so much it makes her mother nervous. She is superior and will never
take any advice from them. Her connection with a different church is
partly responsible because she has acted independently in this respect. She
thinks she can in all others. She is stubborn.

Sister believes she drank a good deal with people whom she visited
in South End.

Patient had a better chance than any of other children. She was the
only one who graduated from grammar school. She was not petted and
spoiled because she was the youngest. In money matters she is brighter
than her sister, being quicker to add up her figures to get results.

Sister has worked years for Miss Nancy Stowell. Her physical health
is not as good as patient's.

Impression : Open-minded, practical, and thoroughly sympathetic. She
is a young woman of small stature and a somewhat nervous manner.
HA/C

December 8.

Family's minister, Mr. Young, Channing Church, seen. He says that
the family feel that patient has gained nothing through her connection
with St. James Church, and that it would be better if she discontinues
going there any more. No matter what there was to be done at home,
or how sick her mother was, patient always dropped everything to attend
services. She was told that she must go every week.

The remainder of the Paris green was found in patient's trunk. She
has very few clothes.

Sister Florence works for Nancy Stowell, dressmaker, on Charles St.
Miss Stowell is very good about calling sister to the telephone.

Impression: Reliable, earnest man of about 35 years of age.
HA/C

December 17.

School report received.
HA/C

December 2;^.

Dixon's Commercial School reports no record of patient.
HA/C

1916
January 21.

State Board of Insanity telephoned to. They have no record of father,
James Farmer.
MPC/C

January 21.

Patient's mother seen at home. Says that patient has always had her
own way ever since she was a child; that she has had more opportunities
and used them less than any other member of the family. Patient is only
member of the family who went through the Grammar School. Patient
was very ill during the voyage from England and has never been strong
since, although she was a very healthy baby. Informant's husband, from
whom she was separated, has been dead for 12 years. They have always

644 APPENDIX A

1916

had all they could do to get along. Patient always told people that she
"slaved" at housework, l3Ut informant says that she never did any at all,
not even to helping with the coal for the fire, etc. As informant has for
many years been a cripple (six operations, one knee removed) she has not
been able to do heavy work.

Five years ago they had to give up their home for a time during
operation on informant's legs. The same thing has occurred a number of
times since, the last time about a year ago. At one time when informant
was "flat on her back" patient locked the door, went out saying that she
would kill herself. Instead she went to her brother's, where she stayed
for two weeks. At another time a year ago last October she and her sister
went to look for a flat. Informant thought that she was able to have her
own home again and that patient would live with them again. While they
were out patient told her sister that she would never live with her family
again. Patient and her sister never got along together. Informant blames
patient who always expected her sister to do everything for her and who
never did anything in return. Patient's brother never liked her.

While patient was living away from home she used to bring her wash-
ing home for her mother to do. She never did it herself. Informant says
that her clothes were always in a disgracefully dirty condition ; that it was
too hard work for her to do again. Informant says that patient always
talks a lot about being fond of her, but she does not show it much in her
actions. Says that patient talks too much anyway. She used to make up
stories about unkind things informant's friends said to her.

Informant thinks that Father Cramer allowed patient too much free-
dom; that if he had been more strict with her she would not have done so
many foolish things. Informant says that patient got in with a poor lot
of girls at St. James Church.

Informant says that when patient came home to live with them, as she
did for a while, she spends all Sunday morning in bed, leaves the room
where she sleeps (the "front" room) in an untidy state, and does not help
with any of the work. Patient's sister gives $5 per week to informant
who pays $3 for rent and makes the rest do. Patient's sister makes all
her own clothes and in the past has made many of patient's. Patient
thinks that she ought to make hers all the time.

Patient went out at all hours even when she lived at home and never
told her family where she was going. They never knew where she spent
her time unless she happened to mention it rather casually.

Impression : A very delicate old lady who cannot walk without
crutches and then with great difficulty. She seems to be quite passive as
though completely worn out with the whole situation with which she
obviously feels unable to cope. She appeared convincing and aroused con-
siderable sympathy.
HA/C

January 22.

J'ttal Statistics OiHce gives following record of father: Died Novem-
ber 5, 1904, at Westboro State Hospital. Cause, General Paralysis. Resi-
dent of Boston, age 46. Inmate i year and 2 months at Westboro State
Hospital.
FJC/C

January 27.

Children's Home Society telephoned to. Patient and family are not
known to them as was stated by sister in medical history in house record.

APPENDIX A 645

1916

March 27.

Mother seen. During the time that the patient lived at home, from
June, 1915, until admission to the hospital, she paid in her $5 wages to her
mother. ]\Iother gave her $1 for spending money, used $3 and put aside
$1 for patient's clothes. Patient later found out that her mother had saved
$8 and was very disagreeable about it. She asked for it several times and
said she saw no reason why she could not take care of her own money,
so that mother gave it to her. She did not tell the family that she had any
money saved. They all went to Nashua, N. H., to visit during patient's
and her sister's two weeks' vacation and patient's sister-in-law found patient
very difficult to deal with. She was disagreeable and lazy and impudent.
While there she wrote often to the old man, Mr. Radnor, with whom she
used to play cards about every week when she lived in the West End. She
also wrote long letters to Father Cramer.

At one time patient was a member of the Girls' Friendly Society, but
she had a quarrel with the leader (Christ Church, East Boston) and gave
it up. Patient is apt to like people very well and talk about them all the
time for a short time and later turn against them.
HA/C

Sister Edith seen by House Historian. See medical record for history.
HA/C

ACTION TAKEN
December 2.

Employer, Sampson Press, would not be willing to take patient back
as he considers her unfit for factory work.

MBS/C

December 3.

Miss Kendall, York House, is willing to take patient into the Gales St.
House to live until she can find work. She feels that St. James Church
people should not let their responsibility end here. Though it seems best
for patient to drop her connection with that church, they ought to stand
expense of sending her away, if necessary.
HA/C

December 4.

Miss Kendall says there is room at the Roxbury House, if patient
should decide to go there for six months. It would probably be the best
plan.
HA/C

December 6.

Family's minister, Mr. Young of Channing Church (Unitarian), tele-
phones. He has expected to take up the care of patient when she leaves.
The family (mother and sister) are unwilling that patient should go to
York House. They are anxious to have her sever connections with the
Episcopal Church for reasons which Mr. Young cannot give by telephone.
His plan is to place patient at the Gordon House of Working Girls. While
she works in the day time, she should have some training business course
at Y. W. C. A. at night as well as club or class work one or two evenings.
He knows several workers at this house, whom he will interest in patient.
He would like visitor to keep in touch with patient also.

Mr. Young feels that institutional restraint of such a girl who has been
allowed so much freedom, will only make her rebellious and produce no
results.
HA/C

646

APPENDIX A

191S
December 7.

Family's minister, Mr. Young, telephones that he will be able to ar-
range for patient to live at Gordon House, 44 Dix St.
HA/C

Mr. Young seen. He has been talking with Mrs. Dickinson, head of
the House, and she will take an interest in patient. Miss Taylor of Canter-
bury Church will do what she can for her and take a friendly interest in
her. Neither one of these people will be able to take definite and com-
plete supervision of patient, and Mr. Young feels that he will not be able
to do so himself.

He will, however, see the patient frequently and will naturally get the
point of view of the family because he sees them often. He will be able
to report to visitor anything which arises in patient's situation. He will
pay for patient's board ten days or two weeks, but feels that she should
have work by that time. He hopes that a definite schedule can be arranged
for patient, so that she will have each evening planned for. He would
suggest her taking some training, such as secretarial, at an evening school.

He would be glad to get some clothes for her so that she will not be
ashamed when meeting the other girls at the House.

Patient taken to Gordon House and Mrs. Dickinson seen. Patient will
go to-morrow morning to the Massachusetts General Hospital, Out- Patient
Department, Female Medical Clinic, for a thorough examination. There
is a question of anemia and tuberculosis.
HA/C

December 10.

Patient writes. She returns to Massachusetts General Hospital for
examination to-day. Girls at Gordon House are not allowed out over night.
See letter.
HA/C

December 11.

Massachusetts General Hospital, Social Sen-ice, Miss Davis, telephones
that patient's lungs are negative, but that she has a severe anemia. Dr.
Dawson advises patient going into the House for a few days. Patient is
reluctant to do this as she says she is devoted to her roommate and does
not want to leave her. Sister is at Out-Patient Department with patient
and she saj-s patient will stay.

Case will be transferred to House Social Service so that visitor may
have reports directly.

Patient and sister telephoned. Patient did not want to enter hospital
to-day and Dr. Young says he is not sure of a bed for Monday ,12/13.
Patient promises to go to Miss Davis on that date and enter hospital if
possible. First asked to be treated by private physician.
HA/C

December 13.

Patient writes. See letter.
HA/C

December 14.

Massachusetts General Hospital, Miss Davis, telephoned to. Patient
was admitted yesterday.

Minister, Mr. Young, and Mrs. Dickinson telephoned to. Arranged
for patient to return to Gordon House on her discharge from Massachu-
setts General Hospital.
HA/C

APPENDIX A 647

1915
December 17.

Sister Florence seen in town by appointment. Patient is being dis-
charged to-day and she will take her to Gordon House. Sister does not
favor any domestic training for she thinks patient's place is at home if she
can behave properly. For some time she has talked of stenography, but
when aunt took a book to her she did not follow up the work by herself.

They like to have patient at home Sundays. She makes mother nerv-
ous because she talks so fast and so much, but they are both fond of
patient and ready to do all they can to help her.
HA/C

December 18.

Massachusetts General Hospital, Social Service, telephones that patient
is not anemic and can go to work. She needs no diet.

Patient seen at hospital. Is always able to find work for herself.
Miss Taylor, Canterbury Church, saw her at Massachusetts General Hos-
pital and said she might be able to get her into a private printing place.
Patient wants to follow her printing trade, as she is used to it.

Patient intends to go home only a half day Sundays because the atti-
tude at home wears on her. Her mother continually gives her good advice
and harps on the past. They are "too strict." She cannot take off her
dress and put on a kimono to rest until it is time to go to bed. She
cannot have company because it wears on her mother. They are con-
tinually suspicious of her conduct.

Last night she stayed at home because she went out to get her things.
They would not let her sleep on the cot in the parlor where she used to
sleep, but had to share her mother's bed, so that all three were in the same
room. Patient said nothing and does not know the reason for this except
that they may not have trusted her to be alone.

At Gordon House, patient likes her roommate ever so much and her
room too.

Sent patient to Harvard Dental School to have teeth examined. She
will look for work Monday.
HA/C

December 23.

Patient writes. See letter and Christmas card.

Patient telephones. Hopes to get work in Newman's, 465 Denver St.,
at typesetting. Wages $12 a week. There is no vacancy now, but she is
promised the next opportunity.

She will go to her own dentist. Dr. Day, Davis Square, Dorchester,
who used to do work half price, since the Dental School is closed for
vacation.
HA/C

December 27.

Patient telephones. She goes to work to-morrow at piece work in
Dalton Fastener Co., 42 Belle Ave., Cambridge (near Kendall Square).
Her first week's wages will have to go to the Mercantile Agency. Girls
earn from $6-$i2, according to their ability and skill. Hours are 7:30-5 ^30
and patient can have her breakfast at Gordon House and take her lunch.

Patient says she had a happier Christmas than for some time. "We
never had happiness in the home before." She stayed all night there.
Patient tells of going to Beacon Hill Christmas Eve to hear the carols.
She went to Charles St. Jail- and was much, interested in that.
HA/C

648

APPENDIX A

1915

December 31.

Patient vurites. See letter.
HA/C

1916

January 10 to January 17.

Patient writes. Asks to be allowed to go home Saturdays for over
night. She writes she has joined the Unitarian Church. See letters.
HA/C

January 17.

Patient sends diet for past week by request.
HA/C

Monday :

BREAKFAST

LUNCH

DINNER

EVENING

LUNCH

Wheatena

Thin egg sandwich

Cold sliced ham

Cocoa

Salt fish hash

Sponge cake

Boiled cabbage

Apples

Cup of coffee

Blueberry cake

Boiled carrots

Oat. cr.

Apple

Mashed potatoes

Beef tea

Uneedas

Tuesday:

BREAKFAST

LUNCH

DINNER

EVENING

LUNCH

Oatmeal

Ham sandwich

Boiled cod and

Cocoa

Fried eggs

Doughnut

cream sauce

Oxtail soup

Mashed potatoes

Apple

Boiled onions

Uneedas

Coffee

Boiled potatoes
Apple tapioca

Wednesday :

BREAKFAST

LUNCH

DINNER

EVENING

LUNCH

Wheatena

Deviled ham sand-

Roast beef

Cocoa

Slice of salt

wich

Boiled lima beans

Oat. cr.

chipped beef

Half slice cake

Carrots

Uneedas

(tissue)

Apple

Boiled potatoes

Beef tea

Baked potatoes

Chocolate blanc

Raised biscuit

mange

Coffee

Thursday:

BREAKFAST

LUNCH

DINNER

EVENING

LUNCH

Corn meal

Roast beef sand-

Beef stew

Cocoa

Salt fish

wich

Cream pie

Oat. cr.

Fried potatoes

Half slice cake

Bread and butter

Uneedas

Raised biscuit

I cookie

Beef tea

Coffee

Cocoa
Apple

Apples

Friday :

BREAKFAST

LUNCH

DINNER

EVENING

LUNCH

Wheatena

Meat pie

Fried fish

Cocoa

3 slices bacon

Tea

Mashed potatoes

Oat. cr.

2 baked potatoes

Corn

Uneedas

Coffee

Bread pudding

Beef tea
Apples
Wash, pie

Saturday:

BREAKFAST

LUNCH

DINNER

EVENING

LUNCH

Hash

Sliced ham

Baked beans

Cocoa

Muffin

Baked potatoes

Piccalilli

Oat. cr.

Coffee

Tea

Bread and butter
Tea

Uneedas
Beef tea
Macaroons

Sunday:

BREAKFAST

LUNCH

DINNER

EVENING

LUNCH

Fish cakes

Tea

Canned cherries

Cocoa

Beans

Roast stuffed pork

Bread and butter

Beef tea

Brown bread

Pickles

Cake

Oat. cr.

Coffee

Bread and butter

Cocoa

Uneedas

Potatoes

Frankfurters and

Squash pie

bread
Orange

$1.37 was spent extra for food.
HA/C

APPENDIX A 649

1916
January 18.

Mrs. Dickinson, Gordon House, telephoned to. She says patient is
doing well. She takes an interest in the life at the House, enjoys the other
girls, and has given no trouble in any way.

Mrs. Dickinson would be willing for her to go home Saturday if
visitor arranges it.
HA/C

January 19.

Patient seen at hospital. Reported at evening clinic to Dr. Hatch.
She is happy and says she is doing her best. Drinking she never thinks of.

The life at the House is great fun. The girls always come into
patient's room toward the end of the evening and leave things to eat,
apples, cocoa. Patient spends her evenings sewing. She mends her room-
mate's clothes as well as her own and she has been doing some crocheting
and embroidery for the nurse of the House, who is engaged. Mr. Young's
church is to have a Fair, and she is making things for that as a surprise.
She seldom goes out evenings though she went once to moving pictures.
Sundays she goes home in the morning and returns in the afternoon. She
washes her own shirtwaists at home, but her other clothes are done at the
House and included in the board. Patient and her mother are devoted to
one another and get on peaceably. Sister treats her better now, but patient
has no fondness for her. Patient took her roommate, Fannie, home with
her last Sunday and the family liked her.

Patient walks to and from work to Kendall Sq., Cambridge. She
sleeps with windows open and eats heartily.

Work has been irregular. The largest wage made was some over
$7, but it has been nearer $5 usually. There are many types of work and
different machines and patient will make an effort to get on a machine
with which she can earn most.

The foreman, Mr. James, is good to her, and when she complained he
shifted her. This week, work has been slack because the firm is starting
a new department next week. The old girls say one is seldom laid off, so
patient will try it out another week. She can earn 80 cents for the other
days this week. The board at Gordon House is $4. Patient owes Mr.
Young $4 and the House $2 from a week she was not working (Mr.
Young only paid the first two weeks). Patient has plenty of clothes.
Mr. Young offered her more, but she did not need them. She still has
some savings, but she does not wish to spend them for current expenses.

Patient is anxious to learn linotype because that was what put her out
of work at the Sampson Press when she was setting type by hand. She
thinks she cannot afford to go to a school for it this year.

Patient tells of a young man, whom she passes every morning going
to work, asking her to meet him some night. She used to pass him when
she worked at Tyson Brand and so she speaks to him. She does not
intend to go out with him. Recently, she met Karl Cauldwell and he
walked home with her. He offered to "keep company" with her again, but
she "threw him over."

Patient seems happy, looks well, and is very friendly toward visitor.
HA/C

January 21.

Minister, Mr. Young, telephoned to. He thinks patient is doing well
and has not been drinking. She is not really self-supporting yet. He was
surprised and pleased to have her join the church.
HA/C

650 APPENDIX A

1916

January 21

Patient's mother seen at home. Informant thinks that patient gets
along with sister somewhat better than previously, but notices no other
change in her actions or attitude. Visitor asked informant about having
patient return to her home to spend Saturday nights. Informant is willing
to have her, but seems to feel that it may not be for patient's best good,
as she thinks that patient is making the necessity of being at home in order
to go to church an excuse to escape the early rising necessary at
Gordon House. Informant says that patient can get to Church Sunday
morning from where she is, that she did it last Sunday with her room-
mate whom she took to dinner at her home. Informant says that on day
patient wrote to previous visitor (i/i) she spent the night at home and
did not go to church the next morning, but read in bed. Informant thinks
that patient will impose upon previous visitor unless she is most careful.
Informant fears that patient will be most disagreeable to her if she finds
out what informant has said. Informant is so tired of having fusses that
she does not give a word of advice to patient now — whenever she does
patient is ugly to her.

Informant suggests that if it is decided to be wise for patient to go
home Saturday nights, it would be advisable to make it conditioned upon
her attending church Sunday mornings, and in order not to make the
patient angry at her family, to have the information obtained from Mr.
Young, the minister. Informant says that patient cannot fool him. Patient
joined the Unitarian Church the first Sunday of January, for which her
mother is glad. Thinks it may do something toward keeping her with the
family.

Informant says that patient .should live as she is now with people and
under rule ; that otherwise she will become untidy again and will bring bad
girls into her room. She thinks that if patient complains to visitor about
conditions as she has at home that visitor should not pay too much atten-
tion to her, but should insist that she live with a roommate.

Informant says that patient was doing fairly well until last week when
she made only $5 l)ecause the machine broke down and there was not
enough work to do. Says that patient was discouraged Sunday. In-
formant thinks patient should try to get a position as monotype corrector
as that is her trade.

Patient has never contributed to support of family, and does not con-
sider the extra trouble it makes when she visits them, either in the matter
of expense or work.

Informant is evidently rather afraid of patient and anxious not to
displease her.
MBS

January 21.

Patient and mother written that she is not to go home Saturdays for
the present.
HA/C

January 24.

Patient writes. See letter.

Patient telephones she is out of work for a day or so. Will go to
Harvard Dental School this morning.

Linotype School sends literature. Evening course $50.

Patient seen at hospital. Is to go back to work 1/26 and to-morrow
will have more work done on her teeth and will spend extra time mending.

APPENDIX A 651

1916

She made $4.40 last week and the foreman has promised to put her
on a good machine when she goes back. She likes it so well there that
she hates to leave and will give the place further trial. Mr. James urged
her to stay on.

Patient wants to go home Saturday nights because it means such an
early rising and such a hurry to get out to Roxbury in time for church
Sundays. She stayed at home Friday night because she and sister went to
an entertainment at Church.

Patient is very friendly indeed and assures visitor she wants to make
as little trouble as possible.

Patient wants to go to Linotype School when she gets well established
in work.

January 25.

Patient writes and asks to be allowed to help and do some sewing for
visitor. See letter.

Patient written to, asking her to make two chemises for another
patient.
HA/C

February 9.

Patient zvrites, 1/26 and 29, 2/5 and 9, and telephones 2/5. She is en-
thusiastic about her work, to which she went back 1/27. She made $1.75
and $1.80 for the first two days and over $7 for the past week. _ She
expects to have all back board paid by 2/20. She has some neuralgia of
the gums and if it is not improved in a few days, she will take time off
to have her teeth seen to. Her roommate, Fannie, has been very sick and
patient had to wait on her. Now she is away for a few weeks' rest.

February 9.

Patient writes, "It may seem strange to many people that my mother's
illness should make such an impression on me, but it does. I am the
youngest and think a whole lot of my mother, but instead of going out
and seeing her enjoy life, I have to see her a cripple holding back her pain
and trying to be happy. ... I am sorry I was so bad, but I will be good
always now to make up for it."

See letters.
HA/C

February 9.

Matron of Gordon House, Mrs. Dickinson, seen. She likes patient
and thinks she is doing her very best. No indications that she has been
drinking. The other girls like her, as she is always bright and jolly.
Informant thinks she is happy there. She has a very lovely roommate, a
blind girl, to whom she is devoted, and at present she is feeling pretty
lonely, as the roommate has gone away to the country for two weeks.
Informant chose this girl for patient's roommate, as she felt she would be
a good influence.

Patient is orderly about picking up her things but the room is apt to
be in need of dusting, but informant makes allowances for this as patient
has to go off so early to work. Leaves the house at seven and does not
come back till almost six.

The factory where she works is being enlarged and temporarily a
good many people are working only part time. Last week patient worked
only a few days and did not earn enough to pay her board. When she
works full time she makes only about $8 at piece work. She is somewhat

652 APPENDIX A

1916

discouraged, and very restless when out of work. Talks of changing to
Gillette Razor Factory, but Mrs. Dickinson is urging hei to stick it out
here in hopes that she will soon have regular full-time employment.

Informant feels she is devoted to her mother, but cannot get on well
with her sister. Has told informant that she never could live with her.
Informant thinks that probably patient teases sister, who retaliates.

There are no clubs or classes in Gordon House to which she can
belong. There is a Friday Night Forum to discuss social questions, but
patient has not attended. She does not go out evenings to movies, only
occasionally for a few minutes to do an errand. Does not go with any
former friends, but seems contented to be with her roommate, and sews
a good deal.
EB/C ■•

February 12.

Patient seen at hospital. Brought visitor a guest towel and face cloth
which she had made as a present. Last week made $8 and was idle part
of two half days. She would have made more, but was slow on account
of a small injury to the tip of a finger.

Patient is lonely with roommate away.
HA/C

February 15.

Patient writes. Is going to a suffrage meeting with sister and a friend
to-night. See letter.

February 21.

Patient and sister sent theater tickets to "It Pays to Advertise" to-
night.
HA/C

March 9.

Patient writes often. See letters.
HA/C

March 10.

Patient seen at hospital. This week has been a bad one at work.
They were laid off more than two hours one day, ij/^ the next, and patient
made only 24 cents this morning. Patient is discouraged and would like to
change to a firm that can give steady work.

Patient made two chemises by hand for another patient, made neatly
and well.

Mr. Steadman, Delle Ink Co., telephoned to. He will see patient to-day
and if she is good will start her there. She would make $6 a week for
about two weeks and then go on to piece work at zzVi per cent over regu-
lar piece work prices which would gradually be reduced until in about four
or five weeks she would be at a regular rate. If she is good with her
hands she might later work into piece work that gives $10 to $13 a week.
HA/C

March 13.

Patient's employer, Dalton Fastener Co., Mr. James, seen at factory.
Belle Ave., Cambridge (near Central Sq.). Says patient returned to fac-
tory on 3/10/16 after employees had been dismissed early to tell him she
had obtained other work, but he had gone, so she sent letter which he
received next day. Patient was entirely satisfactory as a worker and got
on well with other employees. She made about $9 a week on piece
work, which is on ball and socket fasteners for automobile tops, tending
machines, sorting and packing. Informant would reemploy patient when-
ever they need help. She might make as high as $16 a week on piece work.

APPENDIX A 653

1916

Impression : A young man of intelligent appearance and kindly manner,
apparently genuinely interested in the welfare of his employees.

Impression of Factory : Visitor was shown room where patient
worked. A large, very bright room, not crowded with machinery or
workers, but exceedingly noisy. Factory is a new one. Workers can eat
lunch in room where they work, for which tables are cleared and ma-
chinery is stopped for an hour. Women employed are Americans.
AEL/C

March 21.

Patient writes about every other day. She says she likes her work
and is receiving $6 a week for the first two weeks. Hours are 7 :30-i2 ;
12:45-5:30, or 9^ hours a day, and 7:30-1, or 5^ hours, Saturdays; total,
51^ hours a week. She is labelling and packing bottles. The work can
be done faster standing. Stools are provided, but patient stands.

All patient's back board and two weeks' board advanced by Mr. Young
was paid 3/6/16. Patient saved the money which would have gone to
carfares and bought an attractive blue corduroy coat for about $5. Pa-
tient will keep an account book of all week's wages and expenditures.
Board is now $4.

Patient now has a new roommate, Nancy Bornstein (also a patient.
File No. 7246), who is under the care of Miss Stella Farrell, Massachusetts
General Hospital Social Service. She is a great trial to patient who is try-
ing to train her in manners, cleanliness, and industry. Nancy's diagnosis
is Not Insane (Moron — Hysteria). Patient goes with her to see Miss
Farrell.

Last week at visitor's suggestion patient offered her mother $1 which
was refused. See letter of 3/20/16 from patient.
HA/C

March 27.

Massachusetts General Hospital Social Service, Miss Farrell, tele-
phones about patient's roommate who is under her supervision. Nancy is
under Dr. Fenmore's care at Massachusetts General Hospital nerve clinic.
She is to stay on as long as possible at Gordon House.

Patient writes. See letters.

Mother seen at home. Patient has been in church very little in Rox-
bury, about three or four times, and mother suspects that she continues to
go to St. James. When she used to go there she made friends with a girl
who had an illegitimate child, and this child was boarded out with people
who drank. Mother suspects that patient continues to see this girl, because
she asked her sister about making a dress for a baby two years old.
Patient was godmother to this child.

Patient wishes to stay at home Saturday nights and sometimes talks
about going home to live. Mother is very unwilling to say that she does
not want her at home, but it is evident that the patient is a trial to them.
She stays in bed late and does not go to church and does a great deal of
washing and odd jobs about the house which leaves a good deal of dis-
order. She once said she was staying at Gordon House as a punishment.
Mother does not wish to take money from the patient, because in the past
she has "thrown it up at them" for doing so. She does not want to be
under any obligation to the patient. In regard to the incident about the
tea mentioned in her letter of 3/20, mother says that she off-ered to pay
for the tea from the beginning.

Mother thinks that the patient's present roommate is not good for her.

654

APPENDIX A

1916

She always has taken things hard and thinks too much about this girl.
Thinks patient has improved somewhat, especially in her talk, which used
to be profane and disagreeable. Mother thinks that the visitor has a good
deal of influence over the patient, but that patient "puts on" a great deal
of her own goodness.
HA/C

March 28.

Sister Florence met in town. She feels as mother does about the
money, but is willing to have patient give $1 a week if it is necessary.

Patient told her employer at Dalton Fastener Co. that she could not
support her invalid mother on what she earned. She is always misrepre-
senting family situations to sister's friends. Patient and her brother Ber-
nard never got along together and sister is much amused at patient's pre-
tending to take such an interest in him.

Sister will let visitor know the first time patient mentions the money
she gives her mother.

Patient seen at Gordon House. Though 7 130 she is ready for bed.
She gets so tired standing at work that she usually goes to bed or reads
after dinner. Patient bathes once a week at home and will not use the
tub here because everyone uses it.

Patient does not go out evenings, both she and her roommate say.
Nancy relates the fun which they have together evenings, eating oranges
and joking. Nancy is apparently fond of patient and an admirer. She
says "Harriet is smart." Patient is crocheting a large door mat out of
heavy string. She is also making a complicated work bag. Patient has a
library card and reads a good deal. The gas light is at one side and gives
a poor light.

Patient goes to church every Sunday at some Episcopal church and has
been to St. James several times. If she is allowed to go home Saturday
nights, she will go to the Unitarian Church, but she does '..ot take much
interest in it. Patient begs to be allowed to go home Saturdays. She
speaks of living at home later; says one feels freer as to hours and all.

Patient continues on time work at $6 a week (third week) but the fore-
lady praised her work. She has talked to Hilda Tibbets (also a patient
here) and asks if she can do anything for her as she has noticed that no
one talks to her.
HA/C

March 30.

Mother writes. See letter and copy of answer. Visitor suggests pa-
tient go home Saturdays for a trial.
HA/C

March 31.

Patient zvrites. See two letters.

Patient telephones to say she does not want to appear at a staflF meeting
of N. E. Hospital Social Workers' Association, but finally agrees. Patient
will start staying at home Saturday nights.

Gordon House, Miss Dickinson, telephoned to about Saturday arrange-
ment. Patient is in almost every evening or else comes in very early.
HA/C

April 3.

Employer, Mr. Stcadman. Dclle Ink Co.. telephoned to. Patient is
doing average work and though it is usually customary for new workers to
stay six weeks on time work he will allow her to try piece work next week.

APPENDIX A 655

1916

Patient writes 3/30, 3/31, 4/3. See letters. She gave ner mother 50
cents this week.

Patient called at hospital this evening and left a present for visitor — •
crocheted slippers which she had made herself.
HA/C

April 4.

Patient's roommate writes. See letter.
HA/C

April 5.

Patient seen. She gave visitor her gold cross and chain because now
she is a Unitarian she cannot wear it.

Patient presented at a clinic at the Massachusetts General Hospital
meeting of N. E. Hospital Social Workers' Association. When asked to
tell about her experiences she gave a very direct and clear account of how
discouraged she had been before taking poison, of how much it meant to
her to have someone take an interest and encourage her as the hospital
people had, how the life and jolly times at Gordon House had made her
happy.

Patient and her roommate given tickets to see "Grumpy." .
HA/C

April 7.

Patient and her roommate write. See letters.
HA/C

Mother writes that patient gave her 50 cents last week. See letter.
HA/C

April 10.

Patient writes that she has lost her gold watch, the gift of her mother.
She is much discouraged with everything.

Patient telephoned to.
HA/C

April 12.

Patient seen by Chief of Staff, Dr. Adler. He reports that she recog-
nizes that her depression comes in six-month periods. She is now passing
through the period — the previous one came in the fall when she took poison.
She has no appetite, sleeps poorly, is disgusted with work and discouraged
with everything. She is apt to go back to drink.

Patient seen. She wants to get back into printing trade. She cannot
take much interest in ink work.

A shower spray was sent patient last week and she bathes twice a day
now.
HA/C

April 17.

Patient writes to-day and 4/14. See letters.
HA/C

April 20.

Patient telephoned to every day. Her appetite is better. So far sug-
gestions for work have been unsuccessful. She stayed out of Delle's this
morning to go to two places for work. Patient's watch was found 4/16
at church.

656 APPENDIX A

1916

Mr. Norton of Sampson Press seen. They cannot take patient back
because she was second or third rate worker, her attendance was very
irregular, and they have no opening.

Mother seen at home. Visitor had alread)^ explained to sister by tele-
phone last week that this is a critical time with patient. Mother seems to
be a whiney individual. She repeats a good deal of past history in great
detail.

Sister sat up until midnight last Saturday trimming a hat for patient
to wear to church. She never came until after church.

Patient was at home over yesterday's holiday.
HA/C

April 22.

Patient seen at hospital. She feels encouraged about her work because
she made $7 at piece work, even though there was a holiday. She will
continue at least one week more. Then she may stop and try to find
printing or some kind of work at which she can sit. The standing is diffi-
cult at Delle's. Patient has enough money in the bank to pay her own
board while out of work. She cannot remember the exact amount.

Her roommate is more restless and queer of late so that patient has not
had the proper amount of sleep. At midnight she got up and tried to go off
so that patient had to call the matron.

Patient's appetite is good now and she has almost no desire for drink.

She has made two tea aprons for another patient and done them well.
HA/C

April 26.

Patient has written and telephoned tzvice. She has secured work at
Doherty's, 181 Norfolk Ave., hours 7 :30-5 -.30. Thinks the pay will be $7
or $8 per week. She sets type for menus for hotels. She only worked
until 3 :30 to-day. Patient seems very happy over her new work, is much
interested, and "the day simply flies."
MC/C

April 28.

Patient seen at Gordon House. She was tired and had a headache, and
she went to bed early. She had had a tooth extracted. Nancy has refused
to speak to her for several days.
MC/C

April 28.

Gordon House, Mrs. Dickinson seen. She has decided that Nancy can-
not stay at the House any longer and she is waiting to hear from Miss
Farrell. They all like patient very much. She does not think it is best for
oatient to have the care of Nancy.
MC/C

May 2.

Patient seen. At patient's invitation, visitor and patient attended re-
cital at Jacob Sleeper Hall given by Curry School of Expression.
MC/C

May 5.

Patient seen at visitor's residence. She walks to her work every day
now. She has to stay until 4:30 on Saturday afternoons, but will not have
to do this in the summer.
MC/C

May 8. _ ■ .

Patient writes. See letter.
MC/C

APPENDIX A 657

1916

May 8.

Patient telephones. She is worrying for fear she will have to go home
to live. Says she has been "thirsty all day and drinks a large quantity of
water."
MC/C

May 12.

Patient writes. See letter.
MC/C

May IS-

Gordon House, Mrs. Dickinson, telephoned to. Nancy came back to
the House for the night only. Miss Farrell said Nancy had no place to go
so Mrs. Dickinson gave her the room for two days and a night. She did
not see patient at dinner so she probably left immediately after she
came home.
MC/C

May 15.

Patient telephones. She is at her mother's and wants to stay all night
because she is angry because Nancy came back to room with her. She
understood that she was to have a new roommate. Visitor advised patient
to go back to the Settlement House.

Patient telephones later that she has decided to return and is on her
way there now.
MC/C

May 28.

Patient telephones that she fainted at work yesterday because of men-
struation. She is at home and resting to-day.
MC/C

Patient telephones and writes often. See letters. She likes her work
and has made friends with girls at the shop.
HA/C

May 29.

Patient writes details of a medical nature. See letter. She has crav-
ing for drink and takes vinegar and water, lemon and limes, and anything
she can think of.

She goes out to supper occasionally.
HA/C

May 31.

Patient writes and telephones. She tried to work Monday S/29, but
had to leave in early afternoon.
HA/C

June 2.

Patient seen at hospital. She is anxious to live at home now. She
feels dissatisfied with the food at Gordon House because it is too salty and
makes her thirsty. Visitor urged against going home, but left decision
pending.

Patient gives her mother $1 a week; earns $8. She goes on the car
now. She is able to save, out of the remaining $7, $2.40.

Patient says she is going out with a man older than herself. The
affair is a serious one though patient has not yet decided to marry him.
From everything she can hear, he is a good sort. She refuses further
details on the ground that her previous affair with Karl Cauldwell was
broken up by interference from other people,
HA/C

658

APPENDIX A

1916
June 5.

Patient writes that she has decided not to go home to live. This week-
end she thought her mother and sister were very severe and strict with her.
See letter.
HA/C

June 6.

Matron, Gordon House, Mrs. Dickinson, seen. Food is not salty.
They always have fresh meat and fish and only occasionally ham. At
dinner they have potatoes and two vegetables, or one vegetable and lettuce.
Matron has found that patient exaggerates and cannot be depended upon
to keep strictly to the truth. Illustrations given seemed to have discrep-
ancy of detail rather than entire false basis.

There is no one to room with patient at present, but matron will have
it in mind to put some one with her when she can. Patient is well liked
Ijy the girls, is friendly, agreeable to every one, and seems well behaved.
She is in most of the time, but goes home to dinner occasionally on week
nights.
HA/C

June 8.

Patient reported at hospital. Was seen by Dr. Green and given advice
about menstrual period.

Dr. Wilson had a long talk with patient and says he thinks she is fairly
contented ; that there is nothing to the love affair. Patient is doing well.
HA/C

June 10.

Patient writes and telephones. She has a chance to work three even-
ings a week in a store in Kensington, but is advised not to do so, because
of extra wear.

She has given up the young man by going off and leaving him looking
in a store window. He wanted to give her a dog for which she had no
place.
HA/C

June 13.

Patient writes.
HA/C

June 23.

Patient zvrites and telephones often. She went to Y. ]\I. C. A. Enter-
tainment one night with Henry Elkins, whom she knew at Sampson Press.
He is a widower who is going to be married again next month.

Patient is writing short stories, a sample of which shows very word}^
and flowery style with a romantic and imaginative background.
HA/C

June 23.

Minister, Mr. Young, telephones to inquire how patient is doing. He
advises strongly that patient and family both be urged against patient's
ever going home to live.
HA/C

June 23.

Patient seen at hospital. She wanted to explain to visitor about fellow
employees who are not altogether agreeable with her. Patient and Martha
Wilson, who soon leaves to be married, are the only Protestants. Since
the other girls found this out, they have gone cut of their way to be dis-
agreeable and troublesome ; for example, patient will just get her hand full
of type and be seated on her stool, when they decide to get certain trays

APPENDIX A 659

1916

under her stool, so that she has to get down. They 'kick her standing box
to the other side of the room whenever they get a chance. Patient will do
her best to stand it and report to visitor before leaving.
HA/C

July 3I-.

Patient seen often in past month. She continues to write and telephone
often. See letters. She has one friend, James V., who lives across the
street from hospital. She "picked him up" through the window while she
was on Ward V. Went out to suppers, several dances, and to ride with
three or four different men, but would not tell visitor about them.

Patient once brought up question of going home to live, but after two
days' consideration decided against it. Mother and sister have been in
Dover part of month and patient went there for week-ends.

August 15.

Patient seen and writes often. James V. went to Bloomington, 111., to
work two days ago and patient has been quite blue ever since. She takes
no interest in the other men and is going to give them up entirely. One
made improper advances to her by saying something and patient will not
have anything to do with him. Had a long talk with patient On this sub-
ject, but could get no definite accovmt from her of her own affairs. She
has never been "immoral" — her mother would put her out if she were, she
says.

Patient is found to have pinworms. She reported to O. P. D., Dr.
Samuejs, who prescribed for her.

Employer, Mr. Simpson, a foreman at Doherfy Printers, seen. He says
patient's work is good. She has not shown any special discouragement
(patient wrote she thought he saw her crying). He was not planning on
giving her a vacation, but if visitor thinks she needs one he will arrange it.
Employer is not given name of visitor or hospital, nor did he ask. Patient
was not seen.

Impression : Intelligent young man who is kind and sympathetic.
HA/C

August 17.

Mother writes, saying that patient seems to be getting restless and talks
©f going home to live and she fears that as soon as visitor leaves patient
will disarrange things.

Patient taken to dinner. A Mrs. Davis asked her to live with her.
Patient would have the use of the kitchen and better meals. Room rent
would be free. Mrs. Davis is an old friend as well as a fellow employee
at Dalton Fastener Co. Patient also brings up the question of going home
to live, but promised visitor to make no such change during her absence
nor to talk about it to her mother.

Patient told of opportunity to go to Hampton Rest the first week in
September and thinks that she would prefer to go to her brother's in Dover.
She will write him and find out whether he can have her.
HA/C

August 26.

_ Matron, Mrs. Thom-pson, Gordon House, seen. She was surprised that
patient complained of waiting on table because she has never seen her do it,
although patient is supposed to do her share. She has not spoken of it
because weather has been so warm and patient has s_eemed so tired. Patient

66o APPENDIX A

1916

seems worried and unhappy, probably because she would like to be at home,

but has decided to abide by the doctor's advice to stay away.

Patient is to have a roommate, beginning to-night.
MW/C

August 26.

Patient telephoned to at i :30. She has decided to go to her brother's
in Dover for her vacation. She sounded happy and seemed pleased at being
called up.

Hampton Rest written to, saying patient will not take their place.
MW/C

August 31- . .

Patient called at hospital in evening and asked advice about moving
from Gordon House. She is dissatisfied and says the new matron is too
strict. She has asked her repeatedly to wait on table, has not had a place
set for her when patient returned after a week-end at home, and told her
new roommate that patient has spells of depression. Patient thought of
taking her things home this week-end and living there after her vacation
until a new place can be found. Visitor advised leaving things as they are
and staying at the Gordon House until INIiss Bemis returns and new .ar-
rangements can be made. Patient promised to abide by this and went away
happy.
MW/C

September 30.

Patient seen two or three times and writes and telephones often. See
letters. At first she wished to move on return from her vacation at her
brother's in Dover ; she had a new roommate and was content to stay on.
Roommate, Frances Caldwell, is a Church Home girl of 18, young, attrac-
tive, and not undesirable or bad. Patient is very superstitious and believed
what a fortune teller told her, interpreting that brother, Benjamin, was
working against her particularly with mother. She writes she intends to
make over her insurance to visitor.

Patient had one crying spell at work before menstruation period. Has
been to Out-Patient Department and given treatment by Dr. Samuels for
pinworms.

Patient has taken an account book and will keep track of her expenses.
Is interested in doing so.

Room visited and patient keeps it cozy and pleasant.
HA/C

October 31.

Mother visited 10/6. She does not want patient's financial assistance
of $1 because she is apt to throw it up to her that she gives money. Per-
suaded to continue taking it. Patient does not go to Unitarian Church.
When she comes home, she is as disagreeable and vulgar as ever.

Patient seen three or four times. Moved 10/21 to the Inman House,
taking her roommate, Frances Caldwell, with her. Became dissatisfied with
new matron, Mrs. Thompson. Roommate was hot-tempered and saucy and
wanted to leave. Before going patient had a talk with matron who felt
more kindly disposed toward her. Patient has several young men with
whom she goes out to dinner and she claims she is not at the house many
times a week. 10/24 patient was disagreeable and sullen over telephone and
said she was going out on the streets. Wrote next day apologizing. Patient
telephones and writes often. See letters.

APPENDIX A 66l

1916

Matron, Mrs. Thompson, seen. She has nothing to say against patient
and thinks she is a nice girl. They had a good talk before patient left.
Patient was not absent from meals that she noticed.
HA/C

November 30.

Patient seen twice, writes and telephones often. Has made several
things for patients' Christmas tree, crochet baby sacks and slippers.

Patient is going to evening dental clinic at Boston Dispensary, referred
by visitor. Was out of work a day at menses.

She complains of their third roommate, a nurse, who is not sociable
and who they think tries to annoy them and be inconsiderate. Patient does
not make friends with the others in the house and goes out evenings a good
deal with men, coming in early. The boys' living club similar to this gave
a party to the girls which patient seemed to enjoy.

Middle of month patient was determined to go home to live and would
not promise visitor not to move. Three hours later telephoned she would
stay where she was. Patient became angry at family and said she did not
intend to go in to see them again, at least will not sleep there any more.
See letters.

Former friend. Miss Simpson, governess of Mrs. M. C. Saunders' chil-
dren, telephones to inquire for patient and says she expects to go to see her.
She used to know her at St. James Church and had lost track of her until
recently hearing of her coming to the hospital.

Mother writes patient brings her washing home and it is too much for
her to do. (Laundry is not done at this house.) See letters.
HA/C

December 30.

Patient seen, telephones and writes. Has contributed 3 or 4 presents
to the Christmas tree and takes much interest in doing so. The settlement
club at Ferris Memorial, to which visitor referred patient, has not been
active. Once patient went and it was a Jewish holiday and no others were
there and last time only two or three, so that she is discouraged with it.

Patient was referred to Miss Harriet Martin (Boston Society for Care
of Girls) for one of the new Girls' Protective Leagues. These are to be
made from clubs already established, but Miss Martin will keep patient in
mind. Patient has been to church with Miss Simpson. Is now going fre-
quently to Episcopal Church.

December 31.

Patient seen three or four times. At end of month had a large and
serious abscess in her tooth which gave her much pain and kept her from
work a week. Spent a good deal of time at home.

Patient has a laundress and does not take washing home to mother.

See letters.
HA/C

1917
January 31.

Patient seen a number of times. Patient became dissatisfied with In-
man House because Matron, Mrs. Sawtelle, was not considerate of her
when she was sick, because she did not like the third roommate, and be-
cause Frances Caldwell moved to her sister's. Effort was made to have
patient return to Gordon House, but they refused to take her back but
would give no reason, i/ii — After staying home three days patient moved
to Warrenton St. Y. W. C. A. She has been very enthusiastic about it since.

662 APPENDIX A

I917

Patient knows several girls from Gordon House who room there. Patient
introduced them to visitor and they seemed nice, wholesome working
women, friendly toward patient.

Patient was out of work half a week with the abscess. 1/8 she went
to Massachusetts General Hospital Out-Patient Department for advice in
treatment of worms and was given medicine.

Mother wrote 1/8, fearing patient was planning to move home. See
letter.
HA/C

February 28.

Patient seen. Writes often ; see letters. 2/12 patient wrote "best of
friends must part" and "I will not trouble you any more." Interview
brought out fact that because patient was told over telephone that visitor
was "out" she thought visitor did not wish to hear from her. Episode was
smoothed over.

In past six weeks patient has not been going to church much. Is urged
but does not wish to. Later writes she goes to Catholic Church at noons.

Patient made a chemise for a sick patient and called for another girl
patient here to direct her to Y. W. C A.

Friend, James V., who lives on Granville Road, is ill with mastoid and
patient is quite upset over it. She has known him over a year, claiming to
have picked him up while a patient in Ward V. They have been around
together a good deal when he is in town. Patient tells of many invitations
to go out with men,
HA/C

March 31.

Patient seen four times and writes. See letters. 3/4 patient wrote she
was through with visitor and visitor did not go until 3/6 to see her. She
continued to think she was abused in the telephone service, her chief grudge
being that she could not reverse a business call because visitor was out.
Thinks visitor could call her oftener. During month, patient has telephoned
very little. Relationship continues strained through the month over tele-
phone controversy, which patient insists is putting her down. She cites
every instance when visitor said she was in a hurry or was out and enlarges
on it.

Went with patient to see Mr. Mittelman, Vicar of St. Matthew's
Church, and patient promises to go again and has already been to several
services.

At work patient had $1 raise in pay with only two or three others in
the shop, making $9 wage. She is saving money.

First of month Beftha Greenwood (also Social Service case) went to
live across from patient. She had previously lived at Y. W. C. A. and old
girls said horrid things about her so patient was snubbed for speaking to
her. This lasted about ten days and is still a factor with patient's room-
mate, who now seldom speaks to her. Patient takes some pride in having
befriended Bertha, who tells to patient untrue things about visitor and to
visitor things which patient does not do.

April 30.

Patient seen three times. Early in month she talked of moving to a
private family, but decided against it of her own accord. Reported that a
girl in the house had offered her liquor last month.

After present of an Easter lily, patient was friendly and like herself
until 4/24 she. came unexpectedly in the evening and stayed labours. She
was cross and sullen at first and would not look up. She criticized visitor

APPENDIX A 663

1917

and was very disagreeable. Later became jolly and chatty. Seemed to
have come just to "let off steam" at some one and possibly to get a reaction
from visitor, but visitor let her talk. She does not see brother, Bernard,
now and plans not to visit there week-ends as she used to because she thinks
he talks against her and dislikes her visits. Has not seen him since 3/25
at her mother's.

Patient says that last week she has taken a glass of porter every night
(pays 5 cents for it). This week she has not taken it. She goes out and
drinks it alone because it makes her sleep better. She has been restless and
sleepless lately and has a loss of appetite. Patient promises not to drink
at least to 4/30.

She is very discouraged and thinks visitor is only interested in order to
find something on her to put her awa}^. Has an idea which cannot be dis-
pelled that visitor is a probation officer (view shared by Bertha Green-
wood). Thinks she is followed by detectives because she has met the same
man several successive mornings on the way to work. Another man was
seen at Y. W. corner on several nights.

Patient was seen by Dr. Samuels, Out-Patient Department, 4/28, and
had in the meanwhile written she would not drink again. 4/6 patient visits
mother regularly on Sundays, but remains only 30 or 40 minutes and refuses
to stay to meals. Patient v/as in a very disagreeable mood on last visit 4/1
and talked incessantly about quarrels with different girls at Y. W. C. A.
Mother has not received_ any financial aid from patient since Christmas.
For past two months patient has been cool and indifferent toward mother
and sister. The sister usually met patient on way to business, but has not
seen her during the past week. Both mother and sister are worried over
the estrangement.
HA/C

May 31.

Patient seen 3 times. Was rather disagreeable 5/19 but the next day
wentto Marshfield Hills with visitor to see Fern Linnwood (also a Social
Service case), a blind woman who was formerly her roommate. Patient is
really devoted to her and suggests spending her vacation at the same house.
Patient has been on excellent terms with visitor ever since. Does not put
much trust in Bertha Greenwood, and sees as little of her as possible, but
rooming across from her this is difficult to accomplish.

Patient would like to know if mother really needs her contribution.
She would gladly give it, but has a feeling it is not wanted.
HA/C

June I5._

Patient seen twice. It is arranged that she will go 6/24 to Marshfield
Hills with Fern Linnwood for her vacation at the rate of $7 a week.
Patient has promised to room at the Y. W. C. A. during visitor's absence.
The istof the month she insisted that she should live in a private family
and while efforts were being made to find one patient changed her mind.
She wrote that she realized if she came home tired she would make no
effort to get proper food. See this and other letters.

Patient is friendly and responsive to visitor.
HA/C

July 5-

Patient seen at hospital. Patient says that she does not feel that her
week's holiday rested her as much as it ought to have. Since coming back
she has had a headache almost continually. She is quite sure this is from
her eyes. She says she is going to see Dr. Nelson, an oculist on Irving

664

APPENDIX A

1917

Avenue, about them. Visitor urged her to go to the Bennett St. Dispensary
and not spend so much money. She is skeptical of dispensaries. Patient
says she may take three weeks' holiday soon, as work is slack and she feels
the need of more rest. She would like to stay in her room and sleep and
rest. She went to a dance Monday night at Nantasket with her young man
friend. He is continually coming to see her and wanting her to go out
with him. She finds him rather tiresome.
SPE/C

July 20.

Patient seen at work, 292 Nottingham Ave. Patient says the principal
reason that she wanted to change her room was because her roommate was
away and it was quite likely that a transient would be put with her. They
are often brought in in the middle of the night and they are quite often
girls that you cannot trust at all. Patient says that she has a nice room
at the Y. W. C. A. and would hate to give it up as she feels as if it was
quite like home. Says she will wait till Miss Bemis comes back and talks
it over with her. Patient said she had spent a very happy Sunday with
Fern Linnwood, a Social Service case. Patient seems to take a great in-
terest in Bertha Greenwood and plans different things to keep her from
getting into trouble. Patient did not seem as depressed as letter had
indicated.
HA/C

Matron, Y. W. C. A., Mrs. Denecn, seen at 68 Warrenton St. Informant
says as far as she knows patient has been going to her work and doing
perfectly well in every way. A certain crowd of girls in the house were
very noisy on Sunday, but there was no drinking. She knew patient was
not in this crowd as she was away. Informant says she did not ask patient
if she had been drinking as she does not know who it was. Informant
thinks patient is very apt to exaggerate small incidents.

July 21.

Letter received from patient. See letter.
SPE/C

August 2.

Patient writes, asking advice in regard to medical examination. Family
are anxious to have her see physician. Patient insists on woman physician.
MRW/C

August 6.

Neiv England Hospital, O.P.D., telephoned to. Dr. Zcaring reports
no evening clinics.

August 7.

Dr. Margaret K. Dcniing telephoned to at 56 Chenowcth Road. Dr.
Denying will see patient any Wednesday evening on her way home from
work between 5-6:30 p. M. Will accept visitor's recommendation as to what
fee should be.

Patient visited at Y. W. C. A. Patient very communicative and friendly.
Talks much. Physical symptoms gone into. Nothing apparent save painful
and too frequent menstruation with its accompanying depression. Patient
thinks mother unnecessarily worried. Agrees to see Dr. Deming Wednes-
day evening, August 15, and give her frank history. Is rooming at present
with Bertha Greenwood because she did not like transient who was
put into her room. Hot weather created desire for drink, but claims she
took nothing.
MRW/C

APPENDIX A 665

1917
August 8.

Dr. Deming telephoned to.
MRW/C

August 13.

Letter written to patient.

Social summary sent to Dr. Margaret Deming.
MRW/C

August 14.

Patient telephones in much disturbed condition because she has been
told that Miss Bemis is not returning and feels that hospital has been
trying to deceive her. Her point of view is that if the hospital lies to her
in one thing it cannot be trusted in any. Situation finally explained after
10 or 15 minutes' conversation. Patient asks visitor to write Mrs. Deneen
to see if it can be arranged for her to have a single room. Complains of
being much upset by frequent arrival of transients.
MRW/C

August 15. •

Letter written to Mrs. Deneen, Y. W. C. A.
MRW/C

August 15.

Telephoned to Dr. Margaret K. Deming, 56 Chenoweth Road. Dr.
Deming reports that she gave a_ full physical examination to patient last
evening and fiods her lungs and heart negative. Patient eight pounds under
weight. Dr. Deming considers that the pain experienced at the menstrual
periods is due largely to her generally run-down physical condition. Has
given her a tonic and is to see her again on September 5. If patient then
continues to have much pain, Dr. Deming will give a local examination.
Finds no evidence of any tubercular bone condition. Feels that patient is
much relieved to learn this and also to know that her heart is normal.
Patient paid Dr. Deming two dollars for the visit.
MRW/L

August 17.

Letter received from patient. See letter.
MRW/L

August 17. ...

Letter written to patient, urging her to follow Dr. Deming's directions
conscientiously.
MRW/L

August 17.

Letter written to Mrs. Deneen, Y. W. C. A., 68 Warrenton St., asking
her, if possible, to arrange for patient to have a room by herself.
MRW/L

August 20.

Letter from patient, stating that she is going to take a week off to rest.
Liked Dr. Deming and is willing to do what she has advised. Is contented
at the Y. W. C. A., although she still has occasionally longings to be with
her own people. Dr. Deming has advised against this at present.
MRW/L

August 21.

Patient seen at hospital. Mrs. Deneen has given patient a room by her-
self and she feels much better. Is resting this week, getting up late and
going away for day trips. Agrees to see Dr. Dixon about her glasses soon.
MRW/L

666 APPENDIX A

1917

August 23.

Letter from patient.
MRW/L

August 29.

Letter from patient. Seemed depressed.

Letter to patient.
MRW/L

September i.

Letter from patient.
MRW/L

September 4.

Letter from patient.
MRW/L

September 5.

Letter to patient.
MRW/L

September 12.

Patient seen at work during noon hour. Patient looked well and ap-
peared in good spirits. Talked about several young men friends, especially
about one named Young, whom she refused to say where she had met.
SPE/L

September 19.

Patient seen at hospital. Patient appeared extremely "blue," played
with her hands in a nervous way and cried. She said th?t she dreaded
having the operation, but she supposed if it really would help her she would
be willing to go through with it.

Since she broke off with her friend, Young, she says a well-dressed
man has been v»-atching her on the street corner and making remarks to he.'.
She has a feeling that this man may be a detective placed there by Young.

Patient saw Dr. Harmon and after talking with him she appeared
somewhat cheered.
SPE/L

September 25.

Patient seen at hospital. Patient brought hat and shoes to be given
away. She appeared in a much more cheerful mood since last seen in spite
of the fact that a great family friend, whom she called uncle, had just died.
SPE/L

September 27.

Dr. Simpson telephoned to. Informant said that the treatment that
patient needed would only keep her in the hospital two or three days
After that she should have a week or two of convalescent care. Informant
recommended patient going to the Massachusetts General Hospital, the
Women's Free Hospital, or the New England Hospital.
SPE/L

Patient seen at noon. Is willing to go to Massachusetts General Hos-
pital for slight operation recommended by Dr. Simpson. She is very loath
to go to a convalescent home for a week after, but finally consents to go to
the country to board.

She enjoys her single room at the Y. W. C. A. Her family are now
treating her very well and she goes several times a week to see her mother.
She has not been going out with the boys any during the summer. Has lost
interest in such matters.

APPENDIX A 667

Patient is entirely friendly and is in good spirits with the exception of
believing that the matron, Mrs. Deneen, is not kindly disposed toward her.

Foreman, Mr. Simpson, seen at Dohertj', Printers. It will be best for
patient to be away the week of 10/15. He cannot readily spare her for this
time, but is willing to do so in this case of sickness.
HA/L

October 13.

Patieyit ivrites several times, last two letters saying she has decided not
to go to the Massachusetts General Hospital for the operation, as she has
gotten the impression from a friend that this operation is a reflection upon
her "character and her good name" and will "go against her" when she is
married. Patient says that she intends to be married soon.

Patient seen at noon. Consents to go to the hospital when nature of
operation is explained. Ingram Stone wishes her to be married soon. He
is a man of 35, unmarried, and well able to support her. She ha^ known
him since her discharge from this hospital in 1915. Refused to introduce
him to visitor.
HA/L

October 15.

Patient entered the Massachusetts General Hospital.
HA/L

October 16.

Mother seen at home. Patient has come in to see her every two weeks
or month since last January. Last July she paid $1 for two or three
weeks, but has not done so at any other time since January, 1917. She has
taken no meals at the house with the exception of one breakfast. She has
been fairly agreeable and not particularly troublesome. ^Mother seems to
have a better conception of patient's needs and changeableness than previ-
ously, and to accept it as part of her character.
HA/L

Patient seen three or four times, and writes. October 15-21 patient
was in the jMassachusetts General Hospital for a slight gynecological opera-
tion. She paid $ig out of her own money for this. From Oct. 21-26 she
was at home, going Oct. 26 to IMarshfield Hills (Country Week paying
fares), to spend the week-end with another patient, Fern Linnwood, a blind
woman, formerly patient's roommate. She stayed only until the next day
because of a disagreement with the boarding women. Fern later wrote a
disagreeable letter, which has estranged patient from her. See letter.

Brother Bernard's wife had him arrested for abuse and non-support,
and he was in jail a night in the end of October. Patient has been much
upset over this. Agreement was made out of Court, and they are living
together again.

Patient says that in the summer she went into Ukrane's Cafe, Pember-
ton Square, and ordered a drink. The waiter was a long time bringing it,
and patient saw one speak to another, became suspicious that visitor had
posted them not to serve her, but to get the police, and left hurriedly.
She will not go back, and still thinks that visitor was in there to tell them.

Patiejit and Bertha Greenwood (another Social Service case) go sev-
eral nights a week to a Soldiers' Mission on Isham Street.

November 15.

Patient's mother seen. She says that when patient was with them
everything went well. jMother was given some army knitting to do, from
which she is earning $2.30. They find it very hard to make both ends meet.

668 APPENDIX A

1917 . . ...

especially as Florence's sewing season is dull, and living higher. Mother is

not so well lately, and has pains in the side more often.

Patient seen four or five times, writes and telephones. Before Thanks-
giving she drank something a couple of times, but did not tell visitor until
two weeks later. She is most anxious to keep from it and will turn to
some other visitor if she needs assistance in doing so.

She crocheted at the Mission, and was criticized by one of the men, so
that she left. Patient has since been asked by the Matron, Mrs. Mentor, to
return. She goes Saturday and Sunday evenings usually. Last Saturday
she went with another girl to Underwood Chapel and stayed to Sunday
School. Has not been to St. Matthew's church for several months, and no
one has visited her from there, so that she thinks that she is not missed.

For the past two weeks, patient has been around evenings with Fannie
Olson, who rooms across from her. She is a girl known to Miss Yonger,
a social worker in the State House. Patient is afraid that she steals, so
she will not go around the shops with her. They go to the INIission and
Underwood Chapel.
HMA/A

November 15.

Patient's mother seen. She will write the Social Service if patient ever
tries to move home, or makes any definite trouble. She is sometimes dis-
agreeable to them, and on several occasions has spoken to Florence on the
street. Her attitude is about as usual.

Brother Bernard now lives in Dover, Mass., to be nearer his employer,
Introit Dillingham Electric Co..

See letters.
HA/S

December 31.

Case closed. Patient is doing well,
HA/S

1918
January 7.

Rev. Mr. Mittelman seen at St. Matthew's Church, Emmons St. Visi-
tor tells informant that patient had not been going to St. Matthew's Church
lately, but had been going to Underwood Chapel instead. Visitor asked
informant if he would call on patient and get her interested in some organ-
ization. Informant did not remember patient's name, or know that she was
a member of his church. He said he would be glad to do all he could for
her. It was made known to informant that patient was a closed case to
the hospital.
SPE/S

March 12.

.Case reopened. Patient seen at hospital, said she was still living at
Y. W. C. A., 68 Warrington St., but that she was very anxious to move.
She is in debt to Y. W. C. A. for back room and board to the extent of $16
or $17, and would like to have arrangement made by which she could pay
off this debt by paying $1 per week. Said she had between $40 and $50 in
the bank, but did not want to take any money out as she was afraid she
would never be able to save any more. Said she had become very intimate
with a girl named Fannie Olson, who also lived at Y. W. C. A. Patient felt
that this girl had bad influence over her. The girl steals, and spends a great
deal of money for clothes. Patient tries to dress as well as Faimie Olson
and consequently spends all her money for clothes. It was in this way that

APPENDIX A 669

igi8

patient ran u£ bill at Y. W. C. A., as, instead of paying for board and room,
she spent the money for clothes.

Patient seemed anxious to get a furnished room and take her meals
out; thought it would be better for her to live alone, for when she lived
with other girls she always got into difficulties. Said she had a married
brother, Benjamin Farmer, living in North Dunning. She has always gotten
along with him, although recently she has seen very little of him._ Did not
know whether they would consider giving her a home. Would like visitor
to see them and will send visitor the exact address. Patient will stay at
Y. W. C. A. until March 16. Is still working for Doherty Printers, 292
Nottingham Avenue, Boston, earning $10 a week.
MBH/H

Patient said she did not feel very well ; had had a continuous cold all
winter; said she was still subject to crying spells.
MBH/H

March 13.

Mrs. Dawson, Matron of Y. W. C. A., telephoned to. Said patient was
a nice, quiet girl who gave no trouble in the house. Keeps to herself a
great deal and has few friends in the house, although she is liked by every-
one. To informant's knowledge, patient has not been drinking, and has
been home a great deal, and has had several crying spells. Thought patient
was in good condition physically, aside from a hard cold, which she had
had all winter.

Informant said that patient and Fannie Olson had been very intimate,
but quarreled about a month ago when a man who had been going with
patient transferred his affections to Fannie. Patient and Fannie have not
spoken since. Informant said Fannie was a very nice girl and did not
believe patient's stories that Fannie stole could be true. Nothing had
been taken from the house, and if Fannie was inclined to steal she would
have excellent opportunity at the house.

Informant said that patient owed Y. W. C. A. a little over $16. Visitor
asked if patient could pay this back in installments of $1 a week, to which
informant readily agreed. Visitor told informant that patient was consider-
ing moving and informant was sorry to hear this, as she had enjoyed
having patient in the house.
MBH/H

March 14.

Sec letter from patient.

March 14.

Inman House telephoned to. House is closing 3/30/18.

Gordon House telephoned to. Said they would not consider giving
patient a room, as she had caused so much trouble when she was there
formerly.
MBH/H

March 15.

Patient telephoned to. Said she had decided to stay at Y. W. C. A.
Told her that arrangement had been made with Mrs. Dawson by which
patient could pay $1 a week on her back board. Patient agrees to do this
and said she would begin March 16. Said she liked living at Y. W. C. A.
very much. The only reason she wished to move was because she thought
Fannie Olson had bad influence on her. However, she has seen very little
of Fannie lately, so did. not feel it was necessary to move in order to get
away from her.

670 APPENDIX A

T919

Mrs. Deneen, M air on Y. W. C. A., telephoned to. Told her that patient
had decided not to move, and that she would begin paying back $1 a week
on March 16. Informant said she was glad to have patient stay.
MBH/H

April 24.

Patient telephoned. Said she had been sick for a few days, but was
now back at work. Said everything was going splendidly, both at work
and at the Y. W. C. A. Said she was getting along well with the other
girls, and seemed to be enjoying life very much. She is paying every week
on her back board and now owes only about $10.
MBH/H

April 24. ^

Case closed.
MBH/H

June 9.

Case reopened. Patient interviewed at hospital. She came to talk over
her job. She has been working steadily at the same job and living in the
same place, but has recently become discouraged because she has had no
advancement. She feels that the boss is hard on her and gives her a great
deal more difficult and a greater amount of work than he gives to the other
girls in the same department who have been there a shorter time and are
earning more money. Seems quite depressed and discontented. Says that
it is very difficult to get along on her present wage, which is still $10 a
week.

Visitor advises patient to talk things over frankly with her Superin-
tendent before giving up the job, asking him what he can do for her and
calling to his attention the fact of how long she has been there. Patient
promises to do this.
EW/MMM

June II.

Patient telephones. States that she has talked with her Superintendent
who could tell her nothing definite. Promises to see her again on June 14th
and let her know the result.
EW/MMM

June 16.

Patient telephones. Says that the Superintendent was very nice to her
and that he could not raise her wages until fall at any rate because the
work was slack in the summer and he had to keep down expenses. States
that he intended to raise all the girls' wages in the fall and will raise
patient's. Meanwhile he gave her $6 surplus and promised to do what he
could in this way during the summer, also to lighten her work somewhat.
EW/MMM

June 20.

Patient telephones. Things have been going fairly well as the Super-
intendent has lightened her work considerably and given the harder extra
work to the other girls. She has not had overtime work since she spoke to
him. She has not quite decided whether she will stay. Visitor advises her
not to be precipitous in any case. Patient promises to let visitor know
before she changes her job, or if she gets wind of any other position.
EW/MMM

Form I

Name

Residence

Correspondent

Sex

Civil condition

Religion

Time in Boston

Previous addresses

APPENDIX B
SOCIAL SERVICE FORMS

PSYCHOPATHIC HOSPITAL

SOCIAL SERVICE

XCemoraudiuu Slip

File number
O. P. D. number

Age Color

Place and date of birth

Occupation

In Mass. Jn U. S.

Name and address of father

Name and address of mother

Name and address of spouse

Names, addresses, and ages of children or siblings

Names and addresses of relatives or friends

Admitted to house

Discharged

Diagnosis

Provisional diagnosis

Reason for referring to Social Service

Report from the Confidential Exchange

Authority

Admitted to O. P. D.

Examiner

Date

Living conditions previous to admission

Remarks

Visitor's name
671

672

APPENDIX B

Form II

Name of patient
Date

PSYCHOPATHIC HOSPITAL

SOCIAL SERVICE

mqulry Slip

CHECK WHEN
DONE WITH

INITIALS
OF VISITOR

PERSONS TO BE SEEN
(Give full name, address, and relationship to patient here and below)

PERSONS TO BE TELEPHONED TO

PERSONS TO BE WRITTEN TO

APPENDIX B

^7Z

Form HI

PSYCHOPATHIC HOSPITAL

SOCIAL SERVICE

Outluie for History

Date

Name

Address

Age

Date and place of birth

Religion

Civil condition

Referred to hospital by
Brought by
Reason for coming
History obtained by

Medical Record :

Dates of admissions

Dates of discharges

Summary of physical examination

Summary of mental examination

Summary of intelligence tests

Conduct on the wards

Diagnosis

Prognosis

Social History;
Family:

Father j

Mother

Brothers and sisters !

Spouse I

Children !

For each give

Date and place of marriage
Other members of the household
Attitude of the family toward patient
Relatives

Address

Age and date of birth

Nativity

Religion

Time in U. S., in state, in city

Occupation

Intelligence

Character

674 APPENDIX B

Social History : — Continued

Friends and References:
Friends, neighbors
Doctors, lawyers, clergymen
Institutions, courts, social agencies
Hospitals

Work:

{Progress
Wages
Duration of the position
Character of associates

Recreation:
Opportunities
Companions

Schools (in order in which they were attended, with dates) :

Home and Neighborhood:

Character of locality (factory, business, tenement, suburban, etc.)

Character of street ^

Character of building

Character of the home I State as far as possible in specific term.

(i) furnishings

(2) neatness and cleanlinessj
Income and savings

Expenses — rent, insurance, benefit societies, etc.
Attitude of family toward their income

Habits of family in regard to eating and sleeping

Character of patient's bedroom (sleeps alone or with whom)

Character of patient's food

P H VS I C A L H I STORY :

Dcvclopmoital History:

Full term? Normal delivery? \

Prenatal history :

Work of mother during pregnancy

Diseases of mother during pregnancy

Injuries to mother during pregnancy

Mental strain of mother during pregnancy
Birth weight

Feeding — breast or bottle
Age of sitting up
Age of first tooth
Age of creeping
Age of walking
Age of talking
Age of puberty
Illnesses :

General

Convulsions

Injuries

Hospital c^x^

APPENDIX B 675

Physical History : — Continued

Personal Hygiene:

Habits of sleeping (hours)
Habits of eating
Habits of bathing

Heredity :

Relationship between parents

Condition of health and cause of death of —

Father

Mother

Sisters and brothers

Maternal grandparents

Paternal grandparents

Uncles and aunts
Tuberculosis, alcoholism, insanity, f eeble-mindedness, epilepsy, or cancer
Any mental or physical abnormalities in the family
Any exceptional ability in the family

Physical Efficiency:
Lazy or energetic?
Frail or robust?
How easily fatigued?
Susceptibility to pain?

Mental History :

Education :

Age of going to school

School record

Grade and age of leaving

Special t^raining (industrial, commercial, musical, etc.)

Reading

Employment:

Success or failure

Reasons for resignations or discharges

Patient's trade

Work for which patient thinks he is best fitted

Dispositicin and Character :
Likes and dislikes
Habits
Peculiarities
Special abilities

Attitude of patient toward his family
Changes in character
Onset of present trouble

Summary:

Social history
Physical history
Mental history

676 APPENDIX B

Analysis of Social Symptoms

Social Diagnosis

Recommendations in Regard to-
Social condition
Physical condition
Mental condition

History (Interviews) :
Patient's Story

Statements of Others (with impression of informant at the end of each
statement)

III

Action Taken (Chronological record).

SiTMMARY OF Results:

r Social condition
At the end of every three months-< Physical condition

L Mental condition

APPENDIX C
LEGISLATION IN RELATION TO MENTAL DISEASE
Frankwood E. Williams, M.D.

When hospitals for the insane were first opened in this country,
admission to them was as informal and on the same basis as ad-
mission to any other hospital. Provision was made for the com-
mitment by courts of those "so furiously mad as to be a danger
to the community," but patients who desired admission or those
whose friends desired admission for them were admitted freely.

During the early twenties of the nineteenth century, public in-
terest in the care of the insane was aroused and states began to
build public hospitals. This interest had come from England,
where it had been shown that many of the insane if taken from
the almshouses and jails, cages and pens, where many of the
poorer were confined and neglected, and treated in proper hos-
pitals, might be restored to reason. The object in building the
state hospitals, therefore, was to provide this sort of care for those
who could not otherwise afiford it. The hospitals were regarded
with great favor — ^the "state's greatest charity." It was believed
that the earlier a patient could receive treatment the greater was
the chance for his recovery and no obstacles, therefore, were put
in the way of entrance to the hospital. On the contrary, the
friends of patients, and patients themselves, were urged to come
to the hospital as soon after the first signs of mental illness as
possible; and when they came no question as to admission was
raised except the possible one of an unoccupied bed.

This informality of admission continued, in Massachusetts, for
example, for a period of forty-four years, or from the opening of
the McLean Hospital in 1818 to 1862 when a law was passed re-
quiring "in all cases the evidence and certificate of at least two
reputable physicians ... to establish the fact of insanity."

For some thirty years the hospitals had held the confidence of
the community, but in the ten years previous to 1862 there had
begun to develop a feeling first of disappointment and then of
distrust. The disappointment was more or less warranted as the
hospitals had not been able to bring about the happy results the
community unfortunately had been led to expect; the distrust at

677

678 APPENDIX C

this time was not warranted. Nevertheless, the fear became more
or less general that patients were being wrongfully detained in
hospitals and driven mad by their associates, that personal liberty
was becoming of little consequence, and even that it might be
possible to find two physicians who through interested motives
might wrongfully certify to insanity, and that a superintendent
might be bribed to keep the person in confinement. As a result,
legal barriers were year by year built about the hospitals, until by
1874 the hospitals were almost completely isolated from the com-
munity ; admission to them was a formal legal matter to be decided
by court or jury. In consequence, admission was practically im-
possible for patients in the early stages of illness and the hospitals
became asylums for the care of chronic patients about whose men-
tal condition there could be no question, as it was obvious even to
lay judges and juries.^

As the hospitals became more and more asylums for chronic
patients, interest in them on the part of the medical profession
lessened and the hospitals became the prey of the politician, posi-
tions in the hospitals from ward attendant and nurse to super-
intendent becoming the rightful spoils of successful candidates for
public office. This situation obtained for many years and still
obtains in certain states.

Legislatures that had been so aroused against the hospitals in
1874 had learned by 1882 that they had been badly advised; that
it was to the interest neither of the community nor the patient to
deny to the patient the only possible help there was for him until
such time as his illness had become so chronic that any hope that
there might have been in the first place was largely lost. A period
of constructive legislation began about this time. Some states still
have on their statute books the laws passed in this period of dis-
trust, but in the past forty years many of the states have rewritten
their "insanity laws" and in this rewriting two main objects have
been kept in mind — to remove the hospitals from the field of po-
litical spoils and to place them in the hands of reputable physicians
whose qualifications are their professional skill and knowledge of
the special problems involved ; and to make the hospitals as acces-
sible as possible to those who may need them in order that the
hospitals may serve their communities effectively. This desire to
bring the hospitals back into the communities as dynamic forces in
the interest of public health has been greatly increased in the past
few years by the knowledge that has come from medical and social

^ Legislation for the insane in Massachusetts with particular reference
to the voluntary and temporary care laws. By Frankwood E. Williams,
M.D. Boston Medical and Surgical Journal, vol. 173, no. 20, Nov. 11, 1915.
Publication No. 5 of the Massachusetts Society for Mental Hygiene.

APPENDIX C 679

investigations showing the relationship that frequently exists be-
tween mental disease and defect and asocial conduct and likewise
by medical research that has made possible a clearer conception of
the nature of mental disease and indicated means by which such
disease may be not only cured but avoided. The barriers, there-
fore, that had unwisely been built about the hospitals until their
usefulness had been largely destroyed are now being rapidly re-
moved and the hospitals from being institutions of horror are
becoming institutions of hope ; professional skill of a very special
kind instead of being locked inert within hospital walls is being
brought through out-patient departments and social service depart-
ments out into the community where it can be of great service;
and the community instead of drawing away in fear is seeking
from the hospitals advice both in personal and community matters.

This development has been slow, although more rapid of recent
years, and has developed differently and at a different pace in
different states so that one may now find in this country an illus-
tration of almost any stage from the more or less completely
isolated and politically controlled asylum of the sixties and seven-
ties to the most modern type of hospital scientifically equipped and
staffed, with its social service and out-patient departments radiat-
ing to all points in its locality and its advice sought on many dif-
ferent matters.

In bringing about this accessibility of the hospitals three laws
have been found particularly useful. These are known as the
Voluntary Care, the Temporary Care, and the Observation Laws.
In Massachusetts a fourth law, known as the Boston Police Law,
has been found very useful.

Provision for the reception of voluntary patients in state and
private hospitals has been made in the following twenty-nine states :
California, Colorado, Connecticut, Georgia, Illinois, Indiana,
Kansas, Maine, Maryland, Massachusetts, Michigan, Minnesota,
Mississippi, Missouri, New Hampshire, New Jersey, New York,
North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode
Island, South Carolina, South Dakota, Vermont, Virginia, West
Virginia, and Wisconsin.

The law ususally provides that the patient must sign an appli-
cation for admission, that his mental condition must be such that
he can understand the nature of this request as well as the need
of treatment, and that he must be released on a demand in writing
in from three to seven days after such application. In the case of
six of these states his request for admission must be accompanied
by the certificate of one or two physicians, and in some instances
his application must be signed in the presence of a physician.

Fifteen states and the District of Columbia have laws authoriz-

68o APPENDIX C

ing commitment for temporary care and observation. They are
Connecticut, Illinois, Maine, Massachusetts, Michigan, Minnesota,
New Jersey, New York, North Carolina, Oklahoma, Pennsylvania,
South Carolina, Tennessee, Washington, and Wisconsin/

The best examples of Temporary Care Laws are probably those
of Massachusetts, and they may well be used as illustrations here.
Aside from the law permitting voluntary admission, Massachusetts
has three laws that make it possible for a patient to obtain hospital
care and treatment without formal court procedure and a fourth
law under which the legal formalities are slight.

1, Temporary Care Law (Chapter 174, Acts 1915). This law
provides that a superintendent may, when requested by a physi-
cian, by a member of the board of health or a police officer of a
city or town, by an agent of the institutions-registration depart-
ment of the city of Boston, or by a member of the district police,
receive and care for in such hospital as a patient for a period not
exceeding ten days, any person who needs immediate care and
treatment because of mental derangement other than delirium tre-
mens or drunkenness. Such patients are received on application
in writing filed at the time of reception of the patient or within
twenty-four hours thereafter and must be discharged or com-
mitted within ten days unless they make a request for voluntary
care. This law is useful both as an emergency law and as an
observation law as under it physicians may bring to the hospital
for examination and advice patients about whose condition they
have reason to be concerned, but whom they do not sufficiently
understand to warrant a formal application for commitment as
insane or those patients who, although clearly "insane" in a medical
sense, are in such an early stage of their illness that a formal
commitment would not be possible. Treatment is therefore pro-
vided at a time when it is likely to be of greatest help, but which
could not be obtained except for the provisions of this law. The
value of the law as an aid in restoring health and preventing
chronic illness can scarcely be overestimated.

2. Emergency Laiv (Section 42, Chapter 504, Acts 1909). The
superintendent of a hospital may receive and detain, for not more
than five days without a court order, any person "certified to be
one of violent and dangerous insanity or of other emergency" by
two qualified medical examiners. Officers authorized to serve
criminal processes, or police officers, must, on the request of the
applicant or one of the examining physicians, bring such a person
to the hospital. The applicant for this form of admission must
within five days arrange for the commitment of the person so

*Laws controlling commitments to state hospitals for mental diseases,
by James V. May, M.D., Menial Hygiene, vol. 5, no. 3, July, 1921.

APPENDIX C 68 1

received, or for his removal from the hospital. This law makes it
unnecessary in an emergency to "arrest" a sick individual as a
criminal and confine him in a local jail until such time as it may
be possible to bring him before a court for commitment. Courts
are frequently not in session at the time an individual becomes ill.
When holidays fall at the end or the beginning of the week there
may be several days without a session of the court. Through the
provisions of this law, the patient may be brought at once to the
hospital where he can be properly cared for until such time as the
court may convene.

3. Observation Law (Chapter 145, Acts 1919). A person
found by two qualified examiners to be in such mental condition
that his commitment to a hospital is necessary for his proper care
or observation may be committed to a state hospital for a period
of thirty-five days pending the determination of his insanity. This
law is particularly useful in legal and criminal proceedings in
which the question of mental condition is raised. It is useful also
in difficult cases in which more time is needed for a determination
of the patient's mental condition than is provided in the Temporary
Care Law.

4. Boston Police Law (Chapter 307, Acts 1910). Under the
provisions of this law all persons sufifering from "delirium, mania,
mental confusion, delusions, or hallucinations under arrest or who
come under the care or protection of the police of the city of
Boston, shall be taken to the Boston Psychopathic Hospital in the
same manner in which persons afflicted with other diseases are
taken to a general hospital." Cases sufifering from delirium tre-
mens or drunkenness may be refused by the hospital authorities ;
otherwise all such persons are admitted, observed and cared for
until they can be committed or admitted to the hospital or insti-
tution appropriate in each particular case unless the patient re-
covers or is discharged. Chapter 394 of the Acts of 191 1 is com-
plementary to the above in that it provides that no person suffering
from insanity, mental derangement, delirium, or mental confusion,
except delirium tremens or drunkenness, shall, except in an emer-
gency, be placed or detained in a lockup, police station, city prison,
house of detention, jail or other penal institution or place for the
detention of criminals. If, in case of emergency, any such person
is so placed or detained, he shall forthwith be examined by a physi-
cian and shall be furnished suitable medical care and nursing and
shall not be detained for more than twelve hours. In Boston these
patients are sent to the Psychopathic Hospital. In other parts of
the state they are cared for by the board of health of the city or
town in question until they can be admitted to a state hospital or
cared for by relatives or friends.

682 APPENDIX C

A very considerable use of the voluntary and temporary care
laws is made in Massachusetts. In fact, the temporary care laws
have very largely determined the legal status of patients admitted
to the Boston Psychopathic Hospital. During a period of six
years, 6,499 patients, 57.5 per cent of all admissions, were ad-
mitted under the "ten-day" temporary care law. Nine thousand
and seventy-four, or 80.3 per cent of the total number of admis-
sions during the same period, were temporary-care patients of one
kind or another. The voluntary patients represented 1 7.6 per cent
of the 11,289 patients during the period.^

At the request of the Surgeon General of the United States
Army, who during the war found embarrassing the lack of uni-
formity in the various state commitment laws, the National Com-
mittee for Mental Hygiene appointed in 1919 a special committee
to make a study of the various state laws and to recommend such
provisions as it seemed desirable to incorporate in a modern com-
mitment law. The committee was composed of Dr. George M.
Kline, Commissioner, Massachusetts State Department of Mental
Disease ; Dr. Charles W. Pilgrim, Chairman of the New York
State Hospital Commission ; Dr. Owen Copp, Superintendent,
Pennsylvania Hospital, Department for Nervous and Mental Dis-
eases; Dr. Frank P. Norbury of the Board of Public Welfare
Commissioners of Illinois ; and Major Frankwood E. Williams of
the Office of the Surgeon General, Washington, D. C. The
committee recommended in its report voluntary commitment, tem-
porary care, emergency commitment, and commitment for obser-
vation.

* Laws controlling commitments to state hospitals for mental diseases,
by James V. Aiay, M.D., Menial Hygiene, vol. 5, no. 3, July, 1921.

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INDEX

Aboulia, iii (case 17), 419

Accident, fear of, 328 (case 87)

Acquired, 217

Adaptation, 369

Adjustment, of inner to outer

relations, 368
Adler, Herman M., 347, 487, 499,

527, 545
Agoraphobia, 142 (case 24)
Aid, charitable, 231
— financial, 156, 157, 174, 507
— in clothing, 337
—temporary, 108, 196
Alcohol, 237, 253, 446
— and epilepsy, 470
Alcoholic, 24 (case 4) ; 35 (case

6) ; 113 (case 18) ; 211 (case

42) ; 262 (case 62) ; 291 (case

71); 450
Alcoholic deterioration, 263 (case

62)
Alcoholic hallucinations, 250 (case

59).
Alcoholic hallucinosis, 253 (case
60); 257 (case 61); 296 (case

73) ; 471

Alcoholic jealousy-psychosis, 471
Alcoholic psychosis, 245, (case

58) ; 262 (case 62) ; 470
Alcoholism, 109 (case 17) ; 133

(case 23) ; 217 (case 45) ; 245

(case 58) ; 267 (case 63) ; 348

(case 94) ; 446
Alienist, 438, 439; (chart) 441;

443
Almshouse, 221
Ambition, 126, 156
American Association of Hospital

Social Workers, 555
American Psychiatric Association,

437
Antisyphilitic treatment, no (case

17) ; 204 (case 39) ; 457
— during pregnancy, 172 (case 31)
Anxiety neuroses, 483
Apperception, 9

x\rmy, 215, 233, 240, 242, 308, 361
Arrested, 17, 294, 356
Arteriosclerosis, 270 (case 64)
Associates, 541, 542
Attitude, "Borrow no trouble," 285,

351
Authority, 547
— inadequate, 419
— public, 31
Autobiography, 73

Bacon, Francis, 384, 420

Bacon, Roger, 419

Bad habits. See Vitia, definition

of, 412
Bakunin, 435
Barker, Lewellys, F., 552
Baths, 2. See also, Hydrother-

apeutic treatment
Beauty, 404
Bellevue Hospital, 520
Birth control, 357
Bismarck, 433
Blood tests, 459
Bodily disease, 472
Bolshevism, 430, 435
Bosanquet, Mrs., 539
Boston State Hospital, 520
Brain disease, 472
Brodie, Sir Benjamin, 412
Burleigh, Edith N., 520

Cabot, Richard C, 37^, 423. 5I9,

522
Cannon, Ida M., 382, 521
Capitalist, 435
Case, "closed," 74, 85, 109, 164,

191, 214, 254, 300
— "intensive," 526, 534
— "slight service," 526, 534
Character, 397
Character-building, 376, 377
Character-training, 544
Charitable institutions, attitude of,

213
Chorea, 273 (case 65)

699

yoo

INDEX

Clausewitz, 433

Clinic, dental, 20

— out-patient, 42

Clinic manager, 530

Cocainism, 472

Commitment, 106 (case 15)

— for observation, 146, 151

Committable, 149 (case 26) ; 279

(case 68) ; 303 (case 75)
Community, 367
— health of, 459
Compensation, 108, 116, 340
Concussion, 231 (case 49)
Conflict, 12 (case 2)
Congenital, 217 (case 45) ; 223

(case 48) ; 228 (case 48)
Consociates, 541
Constitutional inferiority, 8 (case

2) .

Constitutional psychopathic in-
feriority, 24 (case 4) ; 359
(case 98) ; 487, 490

Constitutional psychopathic in-
feriors, 497

Control, of desires, 53

Convulsions, 104 (case 15) ; 237
(case 45)

Cooperation, 90

Court, 194, 274, 294

— contempt of, 194

Crime, 51, 395, 449

— disease or vice, 178 (case 33)

Criminal law, 395

Criminological system, 249

Criminology, 51

Croix dc Guerre, 307

Crowd, inexperienced, 419

Custom, force of, 419

Cyclothymia, 143 (case 25) ; 295
(case 73) ; 313 (case 81) ; 477

Cyclothymic, 338 (case 89)

Cyclothymic constitution, 21, (case
3); 182 (case 25); 235 (case
52) ; 318 (case 82) ; 362 (case
100)

Cyclothymic tendency, 69 (case 10)

Danvers State Hospital, 520

Darwin, 403

Davis, Michael M., 521

Defective delinquent, 487

Defense reactions, 22 (case 3) ; 30

(case 5)
Delinquency, 8 (case 2) ; ^2 (case

S) ; 52 (case 8) ; 245 (case

S8); 489

Delinquency vs. psychopathy, 14

(case 2)

Delinquent, 66 (case 9)

Dfelirium tremens, 27 (case 6) ;
250 (case 59) ; 252 (case 60) ;
471

Delusions, 254 (case 60)

Dementia, 88 (case 12) ; 271 (case
64) ; 298 (case 73)

— psychological, 473

Dementia praecox, 7 (case i); 10
(case 2) ; 13 (case 2) ; 24
(case 4) ; 88 (case 12) ; 108
(case 16) ; 115 (case 18) ; 148
(case 26) ; 168 (case 31) ; 182
(case 35) ; 215 (case 43) ; 216
(case 44) ; 224 (case 48) ; 293
(case 71) ; 295 (case j:^) ; 300
(case 74) ; 308 (cases 77, 78) ;
310 (case 79) ; 311 (case 80) ;
312 (case 81); 447, 450, 473,
496

— catatonic, 286 (case 70)

— in feeble-minded person, 448

— sexuality in, 286, (case 70)

Dementia simplex, 284 (case 70)

Dental treatment, 549

Dental work, 196 (case 38) ; 231
(case 49)

Deportation, 5, 29, 89

Desertion, 174 (case 32)

Deteriorate, 477

Deterioration, 236 (case 53) ; 298
(case 7s) ; 473

Dewey, John, 512

Diagnosis, change of, 301 (case 75)

— importance to therapy, 364 (case
100)

Diagnostic decision, 118

Diary, 319

Differential diagnosis, 145

Dipsomania, 253 (case 60) ; 501

Disappeared, 354

Disease, definition of. See Morbi,
definition of, 411

— functional, 410

Draft, 241

Dragon-slayers, 427

Dramatis personae, 540

Drug, 446, 450

Dual personality, 310 (case 80)

Dubois, 538

Eccentric, 374, 2,77, 475
Eccentricities, 380, 401
Economic point of view, 381, 518

INDEX

701

Economic unrest, 498
Economics, 369, 384
Education, 188, 407
Educators, 465
Efificiency, 370, zn
Emerson, 406

Empathic index, 17 ; 121 (case 20) ;
256 (case 60) ; 269 (case 63) ;

477
Employment managers, clinic for,

362
Employment obtained, 231
Engineering Foundation, 499, 531
Environment, 369
Epilepsies, 237 (case 53) ; 450, 469
Epilepsy, 13 (case 2) ; 158 (case

29) ; ^2)7 (case 53) ; 238 (case

54) ; 240 (case 55) ; 242 (case
_ 57) ; 446, 469
Epileptic fugue, 10 (case 2)
Epileptic temperament, 469
Epileptics, many eminent men, 160

(case 29)
Epileptiform equivalent, 470
Erotic, 315 (case 81)
Error, causes of, 419
Errores, definition of, 411
Ethics, 364

Eugenic researches, 228
Eugenists, 465
Evil, definition of, 408

Fabrications, 189, 348, 359
Family, 229, 234, 367, 466, 535, 562
— unit of interest, 223
Family adjustment, 266 (case 62) ;

328 (case 87)
Family agency, 151
Family case, 23 (case 4) ; 83 (case

II)
Family conference, 102
Family problem, 115 (case 19) ;

137 (case 24) ; 171, 506, 508
Farmer, Gertrude L., 534
Feeble-minded, 66 (case 9) ; 103

(case 15) ; 125 (case 20) ; 148

(case 26) ; 223 (case 48) ; 227

(case 48) ; 229 (case 49) ;

233 (case si); 335 (case 88);

342 (case 92) ; 449, 487
Feeble-mindedness, 84 (case 11) ;

96 (case 13) ; 97 (case 13) ;

182 (case 35); 263 (case 62);

267 (case 63) ; 284 (case 70) ;

446; 463; 465; (chart) 461;

463- 519

Fenton and Schwab, 492
Fernald, Walter E., 125, 126, 551
"Fit to work," 83 (case 11); 117

(case 19)
Folie a deux, 486
Follow-up, 278, 530
Forme fruste, 14 (case 2) ; 21

(case 3) ; 71 (case 10)
Foster, Josephine Curtis, 183
Fracture, of skull, 233 (case 51) ;

238 (case 54)
Freudian mechanisms, 336 (case

88); 688
Functional, 447

General paresis, 203 (case 39) ;

215 (case 43) ; 216 (case 44) ;

456
— 'Costly delay of diagnosis, 203

(case 39)
— "fatal prognosis," 211 (case 42)
Glueck, Bernard, 518, 556
Gonorrhea 156 (case 28) ; 358

(case 96)
Grail-hunters, 427
Great War, 370, 431, 444, 492, 521
"Great-man" theory, 498
Group, 367, 386
Guardian, 285

Haeckel, Ernst, 403

Hallucinations, 88 (case 12) ; 263
(case 62) ; 305 (case 75)

— hypnagogic, 115 (case 18)

Health, of wife and children, 266,
268 (case 62)

Healy, William, 380, 538, 540

Henderson, L. J., 369

Hereditary, 217 (case 45) ; 223
(case 48) ; 228 (case 48)

Hereditary taint, 6 (case i)

Heredity, 36, 39 (case 6) ; iii
(case 17) ; 155 (case 28) ; 168
(case 31) ; 190 (case 36) ; 217
(case 45) ; 228 (case 48) ; 231
(case 49) ; 240 (case 54)

History, 434

— economic interpretation of, 401,

^34 . .

- — psychopathic interpretation of,

401
Hoboes, 293
Hohenzollerns, 433
Homeless men, agency for, 177
Homosexual, 12 (case 2) ; 51 (case

702

INDEX

Hormones, 378
Hospital wards, 513
Housekeeping, advice about, 264
Hume, David, 404
Hydrotherapeutic treatment, 230

(case 49); 342 (case 91); 549
Hygiene, 379 _
— instruction in, 176
Hyperkinetic, 224 (case 48) ; 226

(case 48)
Hypersexuality, 25 (case 4) ; 58

(case 8) ; 355 (case 96) ; 489
Hyperthyroidism, T^, (case 10) ;

2"]^ (case 66)
Hypnotism, 516
Hypoboulia, 109 (case 17) ; 144

(case 25) ; 419
Hypobulic, 353 (case 95) ; 489
Hypochondria, 118 (case 19)
Hypophrenia, 464
Hypophrenic, 18 (case 3)
Hysteria, 72 (case lo) ; 106 (case

is) ; 143 (case 25) ; 225 (case

48) ; 242 (case 57) ; 335 (case

88) ; 483
— "mechanisms" of, 118 (case 19)
Hysterical, 93 (case 13)
Hysterical paralysis, 226 (case 48)

Idiot, 463

Ignorance. Sec Errores, definition
of, 411

Illegitimate, 96 (case 13)

Illegitimate child, 17 (case 3) ; 98
(case 14) ; 192 (case 36) ; 216
(case 44) : 225 (case 48) ; 273
(case 65) ; 276 (case 66)

Illegitimate children, 87 (case 12) ;
189 (case 36)

Imbecile, 463

Immigrant, 352

Immigration, 5

Indigestion, 195 (case 38)

Individual, 351, 367, 386, 387, 535

Individualization, 328, y]7^ 380, 421,
544

Industrial accident, 83, 240, 339

Industrial Accident Board, 83, 117,

339; 503
Industrial cases, family interests

in, 506, 510
Industrial traumatic neurosis, 115

(case 19)
Inebriety, chronic, 258 (case 61).

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Full text of "The kingdom of evils; psychiatric social work presented in one hundred case histories, together with a classification of social divisions of evil"

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