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Section I, Chapter IX continued

Table of Contents

235

HISTORY OF VENEREAL DISEASES

Mental deficiency showed an under average of cases with previous venereal history, while alcoholism, drug addiction, and neurological conditions showed an over average. (See Table 25.) The remaining five groups, especially representative of abnormal mental states, were practically the same in that they gave a venereal history in about 25 per cent of the cases. This is probably under the average of young men in general. As elsewhere, the colored gave higher averages than the whites, especially in reference to syphilis.

ALCOHOLIC HABITS

From the percentage of intemperate men, 5.7 per cent, and of abstainers 48.6 per cent, among cases of psychoneuroses, it appears that alcohol does not play a prominent rôle in these disorders. (See Table 26.) In regard to the use of alcohol, the psychoneurotics, both white and colored, showed up better than any other neuropsychiatric patients except the endocrine cases.

MARITAL STATUS

Twenty-three and eight-tenths of the psychoneurotics had married (Table 27), the proportion being higher than any of the neuropsychiatric group, and more than 10 per cent above the married percentage of Class I men as a whole. The colored showed a still higher married percentage.

HOME ENVIRONMENT-URBAN OR RURAL

There was a slight preponderance of urban as opposed to rural residence among these cases. (See Table 28.)

STATE OF RESIDENCE (WITH GAIN OR LOSS FROM MIGRATION OR IMMIGRATION)

Twenty-four States, namely, Alabama, Arkansas, Colorado, Connecticut, Florida, Illinois, Indiana, Iowa, Kansas, Louisiana, Massachusetts, Minnesota, Mississippi, New Hampshire, New York, North Carolina, Ohio, Oregon, Rhode Island, South Carolina, Utah, Wisconsin, Wyoming, District of Columbia, exceeded the United States distribution rate of 17. (See Tables 29 and 31.) Owing to differences in classification, the neuropsychiatric averages in these States can not be compared with the average attained at the local boards.

NATIVITY

Twelve per cent of the psychoneurotics were of foreign birth, being below the average of Class I men and above the average of foreign born in the total number of neuropsychiatric cases considered.

CORRELATIONS WITH OTHER CLINICAL CONDITIONS

There were only slight variations in the distribution of the psychoneuroses as between either States or races. In one-half the States the average exceeded the United States average of 17 per cent (Table 40). But the average excess was not remarkable. The widest variation in these States in other groups was found in reference to endocrine disturbances, the average percentages of these latter sinking to 1.3 below the United States average of 7.4.


236

In all the States which exceeded the United States rate for psychoneuroses by several points, viz, Arkansas, Louisiana, Mississippi, New Hampshire, Wyoming, and the District of Columbia, there was a marked drop in the endocrine rate.

Of the classified races (see Table 34), in the American Indian and the Mexican the psychoneuroses fell far below the United States average of 17 per cent (see Table 40). Both of them had an under average of endocrine disturbances and an excess of mental deficiency. The Greeks and the Hebrews greatly exceeded the United States average of 17 per cent; and both of these fell below the United States average for endocrine troubles.

TABLE 40.-Per cent distribution of neuropsychiatric conditions in 24 States in which the ratefor psychoneuroses exceeded the United States rate of 17 per cent

State of residence

Psycho-
neuroses

Mental deficiency

Psy-
choses

Neuro-
logical

Epi-
lepsy

Constitu-
tional psycho-
pathic states

Endocrin-
opathies

Drug addiction

Alcohol-
ism

United States 

17.0

29.2

12.1

10.0

8.6

9.7

7.4

3.0

3.0

Alabama

20.1

26.0

11.8

9.9

9.3

7.3

4.0

1.2

.5

Arkansas

21.0

43.7

9.1

7.2

8.4

6.4

1.4

2.6

.2

Colorado

18.2

24.8

14.5

10.7

11.8

9.5

6.4

2.1

2.1

Connecticut

17.8

26.7

15.9

7.7

10.6

10.3

3.1

2.9

4.9

Florida

18.4

31.1

14.5

9.2

11.2

8.8

3.5

2.9

.4

Illinois

20.6

19.9

13.8

10.7

8.3

9.1

9.8

1.5

6.2

Indiana

20.0

23.3

8.8

14.3

7.5

14.5

8.3

.6

2.8

Iowa

17.8

25.3

16.4

9.9

8.4

9.3

8.2

2.6

2.1

Kansas

18.2

21.6

10.4

13.5

6.3

9.8

15.4

2.5

2.2

Louisiana

30.8

28.7

9.1

6.2

12.1

7.6

2.3

2.5

.6

Massachusetts

18.1

25.7

14.4

6.9

10.4

12.2

1.7

2.7

7.9

Minnesota

19.5

22.2

14.0

10.9

7.8

7.1

12.0

2.2

4.3

Mississippi

23.2

35.4

9.8

8.3

10.9

6.7

2.1

3.1

.6

New Hampshire

23.4

27.7

10.2

7.3

10.2

12.4

1.5

2.9

4.4

New York

18.3

19.8

11.6

8.8

10.0

13.1

6.3

8.4

3.5

North Carolina

17.7

46.7

8.0

6.6

9.6

3.9

6.1

.7

.6

Ohio

19.7

23.9

11.3

10.9

7.7

8.6

12.8

2.7

2.3

Oregon

19.1

18.1

19.7

8.9

9.5

16.4

5.3

2.6

.3

Rhode Island

18.8

29.3

9.9

7.2

9.4

9.9

4.0

4.9

6.7

South Carolina

19.6

43.4

7.0

8.2

8.9

4.1

6.1

1.9

.8

Utah

19.2

20.5

18.5

6.0

7.9

12.6

4.0

7.9

3.3

Wisconsin

19.2

27.0

12.6

11.6

6.8

6.2

12.6

.7

3.2

Wyoming

24.3

21.7

8.7

11.3

8.7

9.6

5.2

2.6

7.8

District of Columbia

23.6

16.1

19.9

14.3

6.2

8.79

6.2

2.5

2.5


As between the native and foreign born there were no significant differences. Thus the above correlations furnish little information as to the relationships between the psychoneuroses and mental deficiency; and they do not support the idea of an intricate association between functional nervous disorders and the ductless gland systems. In fact the indications would support the reverse of this idea.

PSYCHOSES

In previous military statistics "insanity" and "mental alienation" were used as terms to express a great variety of pathological behavior defects. Not only mental diseases, but the psychoneuroses, mental deficiency and in fact nearly all mental conditions, with the exception of epilepsy and inebriety, were embraced under these headings. The classification adopted herein permits a finer differentiation of the various conditions than was heretofore possible. Viewed in relation to the three phases of war time-the mobilization, the campaign, and the resulting readjustment and after care-the psychoses or mental diseases proved to be the most important condition in the neuropsychiatric group, so far as the Government is concerned.


237

These patients put heavy burdens on the hospitals and on personnel not only in the United States during mobilization but also in the American Expeditionary Forces; long delays were inevitable in effecting discharge, and most of the patients required one or more trained attendants to conduct them back to their homes. When insane soldiers were returned to the United States from overseas, policy demanded that they be retained in the military hospitals for a period of from four to six months, in order that a reasonable chance be afforded them to recover, and to avoid being sent to "lunatic asylums."

While third in order of frequency during the mobilization in the American Expeditionary Forces the psychoses took over first place in this respect; and after the war they constituted 70 per cent of all neuropsychiatric cases (March 1921). In addition, the Government had assumed a certain responsibility toward the whole Army with respect to ex-soldiers who might, as a result of military service, become insane. This liability deserves serious consideration in reference to future Government policy in these cases and should be considered in reference to what is known concerning the occurrence of insanity in general.

It is only recently that reliable statistics in relation to insanity in the United States have been available, and even to-day they are available for certain localities only. Many of the States make inadequate provision for the insane, and consequently are not in a position to collect statistics concerning them. New York is an exception. The hospitals of the State of New York are adequate in that all patients for whose admission application is made are received; and the New York State Hospital Commission has for years maintained an excellent statistical department. From its statistics certain important information has been gained as to the occurrence of insanity in civil populations, which are comparable to the population of New York. These may be made use of for the purpose of checking the numbers of insane which come to light as a result of the mobilization of troops, of home service, or of foreign service.

The New York statistics are compiled for quinquennial age groups from 20 to 70. There are practically no admissions before 20 years of age, and data are not separately compiled for the advanced age periods. The rate of admission is approximately 1 per 1,000 population each year. On the basis of data compiled from reports of the State hospitals, together with those of the 1910 census, it appears that approximately 1 in 25 males will become insane during the life period of the group. So heavy an incidence of mental disease will surprise many, and may lead to some reconstruction of popular ideas in relation to the effects of the World War in the production of mental disease.

The mobilization affected an age group of 20-30 years. There were discharged or rejected approximately 15,000a cases of insanity in the 4,500,000 men examined, a ratio approximately of 3 per 1,000. This is, on the one hand, a smaller age group than produces the 1 per 1,000 yearly admissions in New York State hospitals; on the other hand, the time was one and one-half years and in addition included, in many States where the hospitals are inadequate, cases which, in localities where hospitals are adequate, would have been in State hospitals and so inaccessible to the draft. It may be surmised that the

aThis number is estimated from the most reliable sources available and is approximately correct.


238

incidence of insanity among mobilized troops did not greatly exceed the normal incidence of insanity throughout the country as a whole in the civil population. In other words, the Government, through the War Department, brought to light about the same amount of insanity as would have been brought to light had the various States been provided with proper facilities for identifying and caring for their insane.

To compare the incidence of insanity in the Army as finally formed, and especially in the American Expeditionary Forces, is more difficult, as there we are dealing with a selected group-a group from which many cases had been eliminated by the examinations at draft boards and at camps.

The total admissions to Base Hospital No. 214, A. E. F., for mental cases invalided home during approximately one and one-half years, was 2,694.2 During the year 1918, when the mean annual strength of the American Expeditionary Forces was about 1,000,000, the admissions numbered 1,359, or 1.4 per 1,000 troops. It will be noted that this incidence is only 0.4 per thousand higher than the yearly admissions to the New York State hospitals. The group from which the incidence rate is made up was selected, in that many insane cases, but not all, had been eliminated from it in the United States, and it was a younger group as to years, in that it included the age period 20-35 only.

Previous observations as to the relations between war and insanity have left out of account the steady, yearly, and so far inevitable, production of mental disease in every population. When an identified mechanism like an army has unearthed these cases, the inference has been drawn that the army produced them. It would, of course, be absurd to maintain that change of environment, and especially the absence from home and friends such as is necessary to foreign service, did not cause mentally predisposed persons to break down. But the preceding statements make it plain also that much of the insanity which a war discloses is not caused by the war, but is merely a part of the psychological evolution of a people. If we profit by the lesson and make better provision for the insane, we will have fewer to deal with during war time.

This subject is also extremely important from the point of view of after-the-war compensation. There is certain to be a yearly development of mental cases in veterans for the next 30 years. In determining the responsibility of the Government for these cases, the amount of insanity that is "normal" every year for the community should be borne in mind.

CLINICAL CLASSIFICATION

Including the alcoholic psychoses, the distribution of the different forms of psychoses discovered in the Army during the World War was substantially the same as that found among admissions in the same age groups in civil hospitals.

In the distribution certain differences are to be noted as between the whites and the colored. (See Table 6.) The negroes presented a greater number of atypical and undiagnosed forms. They developed only five cases of alcoholic insanity, and a slightly higher percentage of insanity with mental deficiency than the whites. They were lower both in dementia præcox and manic-depressive pyschoses and higher in epileptic psychoses.


239

METHODS OF DISCOVERING CASES

Relatively more negroes than whites were discovered immediately. (See Table 8.) A smaller percentage of psychoses were discovered at the routine neuropsychiatric examination than of any other clinical group. The delay in identification was due partly to the fact that continued observation is so often necessary for the recognition of mental disease, and partly because mental symptoms, dormant at the time of enlistment, are brought to the fore by the change in environment.

In the routine examinations neuropsychiatrists were obliged to rely chiefly on past history (previous commitments, etc.) and on the soldier's appearance and manner. Such patients came to attention of medical officers attached to organizations with especial frequency. Mental symptoms appeared while the patients were under treatment for some other condition, or they sought medical advice in the same way they got to civil hospitals, because they are depressed, thinking of suicide, feel that they are not being treated right, and similar ideas.

Commanding officers also were more instrumental in the identification of mental cases than of any other group except the constitutional psychopathic states. Absence without leave, strange attitudes and actions, inability to get along with others, and epileptic attacks were among the causes that brought these soldiers to the attention of their commanders.

One conspicuous conclusion derived from these particular statistics is that an observation period is essential for discovering mental cases. Such examinations as were held by draft boards can not hope fully to accomplish the object in view. More time, more extended facilities than are possible there are necessary, if the insane are to be kept out of the Army, or if the Government is to be saved from ranking with the disabled veterans men who were insane prior to entrance in the Army.

LENGTH OF SERVICE PRIOR TO DISCOVERY

The information available under this heading substantiates what was stated above in regard to the comparative delay in the appearance of psychoses in the military service.

As shown in Table 10, mental cases gave longer service than any other neuropsychiatric group, the negroes rendering a shorter service than the whites. This might be put in another way: A longer time was required for their detection than for the detection of other neuropsychiatric patients. Twenty-two and three-tenths per cent had not been detected before the expiration of six months training period, as compared to 9.4 per cent of the mental defectives. The insane were considerably above the average of the whole neuropsychiatric classification in respect to length of service. For example, 52.6 per cent of the whole group had been identified in less than one month, as compared with 36.7 per cent of the mental cases identified in the same period, and 86.7 per cent of the former had been identified before six months, as compared to 77.7 per cent of the latter. As regards extreme length of service (Volunteers), the mental cases were also the highest, with the exception of alcoholics.


240

The inferences which follow seem justifiable from the figures. In a relatively greater number of cases, breakdowns resulting from purely mental causes do not make themselves immediately apparent; although delayed, their appearance is none the less inevitable, inasmuch as the psychoses occupy third place in order of frequency in the whole neuropsychiatric classification. It would seem, therefore, that it was not the first shock of being dislocated from a civil to a military environment that brought the psychosis to notice, but rather the continued separation, the continued strain of service conditions, even though these latter are gone through with in the home area. In considering service as an aggravating cause of psychoses, it should not be left out of account that, even under civil conditions, in the age groups between 20 and 50 years, there is a regular occurrence of insanity of about one per thousand each year, and also that the greater bulk of the cases, as shown in the succeeding paragraph, gave a history of time of onset a year or more before entering the service.

TIME OF ONSET

In approximately one-half of the cases, the time of onset of the psychosis was determined. (See Table 11.) In these 3,512, or 87 per cent, the psychosis antedated entrance into the Army.

Table 11 shows that 3,063, or 87.3 per cent, of the cases of psychoses gave a history of development of more than one year prior to enlistment, a smaller percentage than any other neuropsychiatric group. This is in accord with former knowledge as to the nonappearance of psychoses in very young persons. Of the 712 cases in which the symptoms developed after entering the service, in only 92 was the onset immediate; i. e., two months or less after arrival at camps. It is evident that it is not the abrupt change from home surroundings to camps that precipitates the psychoses.

RECOMMENDATIONS FOR DISPOSITION

As between the whites and the negroes, there were only slight differences either as to the recommendations or dispositions of insane soldiers.

As a group, a higher percentage (91.4 per cent) of cases of psychoses were recommended for discharge than for any other clinical condition. (See Table 12.) A medium number of cases was recommended for treatment, but few for limited service and still fewer were returned to duty.b

There were 39 deaths from psychoses distributed as follows:

White

Colored

White 

Colored

Senile

1

---

Manic-depressive

10

2

With cerebral arteriosclerosis

1

---

Dementia præcox

7

1

General paralysis

2

---

35

4

Alcoholic

12

---

With other somatic diseases

2

1

bDuring demobilization, instructions were issued from the Surgeon General's Office to the effect that patients who had suffered from psychoses, and who had a record to that effect, even though they had made a clinical recovery, should none the less be discharged on surgeon's certificate of disability. This was intended to prevent the reenlistment of such a soldier in future years.


241

DELINQUENCY

The psychoses were second in the order of furnishing delinquency cases, although not entitled to second place by the actual size of the group. Of the total of 7,910 insane, 404, or 5.1 per cent, were referred for examination by reason of misconduct, the highest percentage in any group. This excess is partly explained by the nature of the mental disease itself.

FAMILY HISTORY

More than one-half of the cases of psychoses gave a history of family neuropathic taint of some kind (Tables 13 to 17), but they were exceeded in this respect by epilepsy, endocrinopathies, constitutional psychopathic states, and the psychoneuroses. In both white and colored the character of the taint was 28 per cent mental, others, in order, being nervous diseases, inebriety, and mental deficiency. The psychoses showed more mental disease in the family than any other clinical group.

AGE

With the exception of a somewhat higher percentage of white as compared to the colored in the younger age group, the information as to age in cases of psychoses has no particular significance. (See Table 20.)

EDUCATION

Excluding the mental defectives, the cases of psychoses, as a group, were below the general neuropsychiatric average in education as regards grades, but the percentage approached the average as regards high schools and, with the exception of constitutional psychopathic states, the psychoses had the highest percentage of attendance at college. The group average was lowered by the colored. For example, 32.5 of the colored had had no schooling at all, as compared with 7.2 per cent of the white, and the number of insane negroes who had been in college was very small. (See Table 23.)

ECONOMIC CONDITIONS

There were more cases in comfortable circumstances among the insane than among the mental defectives, constitutional psychopaths, epileptics, alcoholics, or drug addicts. Both white and colored were below the average as to marginal circumstances. (See Table 24.)

HISTORY OF VENEREAL DISEASE

Mental cases presented nothing worthy of special remark in reference to the history of venereal diseases that has not already been stated. (See Table 25.)

ALCOHOLIC HABITS

Insane soldiers gave a more frequent history of intemperance than the members of any other clinical group except alcoholics themselves. (See Table 26.) Also, a relatively small percentage of them were abstinent. Among drug


242

addicts alone was the percentage of abstinent persons lower. This evidence as to the relationship between intemperance and insanity is conditioned somewhat by the fact that the present classification includes 292 cases of alcoholic insanity. In the psychotic group the whites admitted a greater alcoholic indulgence than the colored.

MARITAL STATUS

Mental cases as a class were well below the neuropsychiatric average in respect to marriage, but still above that of Class I men. When the white and colored cases are contrasted it is seen that among the colored the single were relatively less frequent and the married relatively more frequent. (See Table 27.)

HOME ENVIRONMENT-URBAN OR RURAL

Mental cases are to be classed among those with a preference for the cities. (See Table 28.) Of the whole group, 59 per cent gave urban residence and 41 per cent rural. Among the colored these percentages as to urban and rural were reversed, owing to the higher percentage of rural residence among the general colored population.

STATE OF RESIDENCE (WITH GAIN OR LOSS THROUGH MIGRATION OR IMMIGRATION)

Twenty-four States exceeded the United States distribution average of 12.1 per cent for psychoses for the whites. (Tables 41 and 42.) It is not possible to determine the full significance of this excess, since, owing to differences in classifications, these statistics can not be compared with those of the local boards.

TABLE 41.-States of residence of cases of psychoses

State of residence

White

Colored

State of residence

White

Colored

Number

Per cent

Number 

Per cent

Number

Per cent

Number

Per cent

Alabama

130

11.8

49

5.0

New Hampshire

14

10.2

---

---

Arizona

20

16.7

2

33.3

New Jersey

191

13.4

7

11.3

Arkansas

80

9.1

20

5.4

New Mexico

19

5.5

---

---

California

297

17.4

3

8.6

New York

746

11.6

11

6.8

Colorado

70

14.5

---

---

North Carolina

112

8.0

20

5.3

Connecticut

97

15.9

1

7.7

North Dakota

33

12.6

---

---

Delaware

11

12.0

2

5.0

Ohio

427

11.3

8

4.7

Florida

71

14.5

18

13.8

Oklahoma

141

11.8

3

1.8

Georgia

205

13.4

37

8.3

Oregon

60

19.7

---

---

Idaho

42

25.5

1

50.0

Pennsylvania

621

11.0

22

7.8

Illinois

546

13.8

16

11.0

Rhode Island

22

9.9

1

10.0

Indiana

157

8.8

5

11.6

South Carolina

51

7.0

34

6.2

Iowa

155

16.4

5

20.8

South Dakota

32

10.5

---

---

Kansas

95

10.4

2

3.9

Tennessee

127

9.6

25

3.6

Kentucky

130

6.9

8

4.6

Texas

285

17.6

43

12.6

Louisiana

87

9.1

46

6.7

Utah

28

18.5

---

---

Maine

30

7.7

---

---

Vermont

15

13.3

---

---

Maryland

92

10.4

21

4.9

Virginia

133

9.2

47

8.2

Massachusetts

224

14.4

1

4.8

Washington

78

17.7

---

---

Michigan

288

13.5

6

13.0

West Virginia

99

8.2

10

12.5

Minnesota

165

14.0

1

9.1

Wisconsin

170

12.6

---

---

Mississippi

85

9.8

47

6.4

Wyoming

10

8.7

---

---

Missouri

233

8.5

10

3.6

District of Columbia

32

19.9

7

7.7

Montana

56

20.8

---

---

State unascertained and others

454

---

17

---

Nebraska

77

15.5

---

---

United States

7,354

12.1

556

6.6

Nevada

11

18.3

---

---


Percentages are based on total neuropsychiatric cases of each color from each State.


243

TABLE 42.-Per cent distribution of neuropsychiatric conditions in 21 States in which the rate for psychoses exceeded the United States rate of 12.1 per cent

State of residence

Psy-
choses

Mental defect

Psycho-
neuroses

Neuro-
logical conditions

Epi-
lepsy

Constitu-
tional psycho-
pathic states

Endocrin-
opathies

Drug addiction

Alcohol-
ism

United States 

12.1

29.2

17.0

10.0

8.6

9.7

7.4

3.0

3.0

Arizona

16.7

15.0

12.5

18.3

10.8

11.7

6.7

4.2

4.2

California

17.4

22.0

16.7

12.2

7.7

12.7

2.7

3.3

5.3

Colorado

14.5

24.8

18.2

10.7

11.8

9.5

6.4

2.1

2.1

Connecticut

15.9

26.7

17.8

7.7

10.6

10.3

3.1

2.9

4.9

Florida

14.5

31.1

18.4

9.2

11.2

8.8

3.5

2.9

.4

Georgia

13.4

33.3

13.0

11.5

7.9

11.8

6.1

2.5

.7

Idaho

25.5

26.7

10.3

8.5

7.9

6.7

14.6

---

---

Illinois

13.8

19.9

20.6

10.7

8.3

9.1

9.8

1.5

6.2

Iowa

16.4

25.3

17.8

9.9

8.4

9.3

8.2

2.6

2.1

Massachusetts

14.4

25.7

18.1

6.9

10.4

12.2

1.7

2.7

7.9

Michigan

13.5

29.2

12.0

10.9

8.6

11.6

11.2

1.1

2.3

Minnesota

14.0

22.2

19.5

10.9

7.8

7.1

12.0

2.2

4.3

Montana

20.8

16.7

16.0

11.2

11.9

8.9

7.8

3.7

3.0

Nebraska

15.5

25.1

14.7

12.9

7.6

9.4

10.7

2.6

1.6

Nevada

18.3

18.3

11.7

18.3

8.3

6.7

1.7

1.7

15.0

New Jersey

13.4

27.6

16.6

6.8

12.6

11.2

5.7

3.0

3.2

North Dakota

12.6

38.5

14.1

9.2

8.0

10.3

3.8

.4

3.1

Oregon

19.7

18.1

19.1

8.9

9.5

16.4

5.3

2.6

.3

Texas

17.6

25.5

14.8

12.3

13.4

8.8

2.3

4.1

1.1

Utah

18.5

20.5

19.2

6.0

7.9

12.6

4.0

7.9

3.3

Vermont

13.3

33.6

16.8

10.6

8.8

10.6

3.5

---

2.7

Washington

17.7

26.1

14.1

8.2

7.5

9.5

9.3

6.8

.9

Wisconsin

12.6

27.0

19.2

11.6

6.8

6.2

12.6

.7

3.2

District of Columbia

19.9

16.1

23.6

14.3

6.2

8.7

6.2

2.5

2.5


NATIVITY

The psychoses cases had foreign-born percentage in 13.5 per cent of instances. This is above that of neuropsychiatric cases in general.

CORRELATIONS WITH OTHER CLINICAL CONDITIONS

When describing the correlations of mental deficiency it was shown that its distribution average tends to rise when that for the psychoses is below average.

Table 42, which tabulates 24 States in which the white insanity average exceeded the United States average of 12.1 per cent, affords an opportunity of noting the converse of this and also of noting the action of the conditions allied to insanity, viz, psychopathic states, alcoholism and drug addiction, in the States when the insanity average is in excess. This table shows that the converse holds true as far as mental defect is concerned, as the average for mental deficiency in these 24 States is 24.9 per cent, 4.3 per cent below the United States average for that condition. There were, however, four States, viz, Florida, Georgia, North Dakota, and Vermont, in which mental deficiency average surpassed the United States average of 29.2. The converse of the proposition did not hold true in relation to the other clinical conditions mentioned.


244

TABLE 43.-Nine races in which the distribution rate for psychoses exceeded the United States white rate of 12.1 
per cent

Race

Number classified

Mental deficiency

Psycho-
neuroses

Psychoses

Neuro-
logical condition

Epi-
lepsy

Constitu-
tional psycho-
pathic states

Endocrin-
opathies

Drug addiction

Alcohol-
ism

United States (white) 

---

29.2

17.0

12.1

10.0

8.6

9.7

7.4

3.0

3.0

Armenian

69

37.7

15.9

14.5

11.6

10.1

8.7

1.4

---

---

Dutch

328

26.2

14.9

13.1

11.6

10.4

10.1

10.4

1.5

1.8

German

4,351

28.0

17.5

12.7

9.6

7.4

10.0

10.9

1.6

2.4

Greek

281

23.8

24.9

13.9

8.9

13.5

8.2

5.3

.4

1.1

Hebrew

1,314

17.2

25.2

14.9

7.5

7.1

15.4

5.6

6.7

.5

Scandinavian

1,256

23.6

17.6

17.3

10.1

6.8

8.4

10.5

1.9

3.9

Scotch

579

12.4

18.3

12.3

16.6

9.3

10.7

10.4

4.7

5.4

Slavonic

2,474

37.0

15.3

14.5

7.3

6.6

10.0

5.7

1.2

2.5

Mixed

23,604

27.5

18.4

12.2

10.2

8.7

9.9

7.2

3.7

2.3


Of the classified races, eight presented an excess of distribution average of psychoses. (Table 43.) Of these all but one, the Slavonic, were below the United States average for mental defect; all but the Greek and Scandinavian showed an over average in constitutional psychopathic states; only the Scandinavian and Scotch showed an over average in alcoholism; the Hebrew, mixed, and Scotch were the only ones which showed an over average in drug addiction.

Of the foreign-born races (see Table 34) the Scandinavians, Irish, and Germans showed an over average for psychoses. Of these three, all showed an under average for mental defect, constitutional psychopathic states and drug addiction; two, the Scandinavian and Irish, an over average for alcohol.

NERVOUS DISEASES AND INJURIES

This group is made up of so many quite diverse clinical conditions that few generalizations concerning it are possible. When the syphilitic cases are excluded the other clinical conditions have little in common. The information of importance concerns the distribution of different diseases of the nervous system, organic for the most part, among a given age group of men. This information is to be found in Table 6.

CLINICAL CLASSIFICATION

Table 6 requires no further explanation in the present connection except in reference to the cases of the late effects of syphilis. To determine what these effects are, in men of the given age period, the cases of general paralysis, an unquestioned syphilitic disease, may be added to the syphilitic cases in the present group. The result is as follows:

General paralysis 

530

Syphilis, central nervous system 

2,462

Tabes dorsalis 

333

Total

3,325


245

The number 3,325, which is 4.8 per cent of the total number of 69,394 cases, shows the relative position occupied by the late effects of syphilis of the central nervous system. If syphilis of the nervous system had been tabulated as a separate clinical group, it would have occupied eighth place, in order of frequency, in 10 clinical groups. The distribution of the syphilis of the central nervous system, of tabes, and of general paralysis among negroes was about the same as among whites. This is in apparent contradiction to the general opinion as to the immunity of the negro in relation to these diseases. Some immunity, however, he must possess, inasmuch as, with a so much higher rate of venereal infection in the negro, he does not exceed the whites in the later serious consequences of syphilis.

METHODS OF DISCOVERING CASES

Three thousand one hundred and forty-seven, or 47.2 per cent, of the cases were detected at the routine examinations and 2,324, or 34.9 per cent, by medical officers, as was natural in view of the objective symptoms presented by these cases. (See Table 8.) Relatively few were referred by courts-martial and psychologists.

LENGTH OF SERVICE PRIOR TO DISCOVERY

As shown in Table 10, these cases were identified with remarkable promptness.

RECOMMENDATIONS FOR DISPOSITION

Six thousand and twenty-three of the cases were recommended for discharge, the remainder being recommended for treatment, duty, or limited service. (See Table 12.) There were 33 deaths. After the war 3.3 per cent of the patients in hospitals of the Bureau of War Risk Insurance (March, 1921) were of this group.

DELINQUENCY

Of the 6,916 neurological cases, 19 were reported by reason of misconduct. Of these 19, 12 were found to be cases of cerebrospinal syphilis. One was a case of multiple sclerosis, mistaken perhaps for a malingerer.

HISTORY OF VENEREAL DISEASES

The inclusion of the effects of syphilis of the nervous system in this group makes the percentage of cases with a positive history of infection (43.4 per cent) higher than in any other group, except the drug-addiction group (Table 25).

CORRELATION WITH OTHER CLINICAL CONDITIONS

The correlation of diseases and injuries of the nervous system with other conditions gives little information of importance.


246

TABLE 44.-Per cent distribution of neuropsychiatric conditions in 21 States in which the rate for epilepsy exceeded the United States rate of 8.6 per cent

State of residence

Epilepsy

Mental deficiency

Psycho-
neuroses

Psychosis

Neuro-
logical conditions

Constitu-
tional psycho-
pathic states

Endocrin-
opathies

Drug addiction

Alcohol-
ism

United States 

8.6

29.2

17.0

12.1

10.0

9.7

7.4

3.0

3.0

Alabama

9.3

36.0

20.1

11.8

9.9

7.3

4.0

1.2

.5

Arizona

10.8

15.0

12.5

16.7

18.3

11.7

6.7

4.2

4.2

Colorado

11.8

24.8

18.2

14.5

10.7

9.5

6.4

2.1

2.1

Connecticut

10.6

26.7

17.8

15.9

7.7

10.3

3.1

2.9

4.9

Florida

11.2

31.1

18.4

14.5

9.2

8.8

3.5

2.9

.4

Kentucky

8.8

41.1

14.0

6.9

11.8

9.4

4.2

1.2

2.6

Louisiana

12.1

28.7

30.8

9.1

6.2

7.6

2.3

2.5

.6

Maine

9.2

51.5

13.0

7.7

5.4

8.9

.5

1.3

2.6

Massachusetts

10.4

26.7

18.1

14.4

6.9

12.2

1.7

2.7

7.9

Mississippi

10.9

35.4

23.2

9.8

8.3

6.7

2.1

3.1

.6

Montana

11.9

16.7

16.0

20.8

11.2

8.9

7.8

3.7

3.0

New Hampshire

10.2

27.7

23.4

10.2

7.3

12.4

1.5

2.9

4.4

New Jersey

12.6

27.6

16.6

13.4

6.8

11.2

5.7

3.0

3.2

New York

10.0

19.8

18.3

11.6

8.8

13.1

6.3

8.4

3.5

North Carolina

9.6

46.7

17.7

8.0

6.6

3.9

6.1

.7

.6

Oregon

9.5

18.1

19.1

19.7

8.9

16.4

5.3

2.6

.3

Rhode Island

.4

29.2

18.8

9.9

7.2

9.9

4.0

4.9

6.7

South Carolina

8.9

43.4

19.6

7.0

8.2

4.1

6.1

1.9

.8

Texas

13.4

25.5

14.8

17.6

12.3

8.8

2.3

4.1

1.1

Vermont

8.8

33.6

16.8

13.3

10.6

10.6

3.5

---

2.7

Wyoming

8.7

21.7

24.3

8.7

11.3

9.6

5.2

2.6

7.8


EPILEPSY

The data in the annual reports of the Surgeon General for years prior to the World War indicate that epilepsy was the most important neuropsychiatric condition coming to the attention of recruiting officers. The present statistics indicate that four neuropsychiatric conditions are much more frequent and that epilepsy constitutes only 9.2 per cent of the problem. This fact, together with the almost uniform distribution throughout different communities and races, both foreign-born and native, constitutes the most important information furnished by the present inquiry as to this mysterious disease.

CLINICAL CLASSIFICATION

Of the 6,388 cases classified with respect to the different types of epilepsy, in 3,875, or 60.6 per cent, the information desired was not furnished by the examiners. (See Table 6.) Grand mal was put down as occurring in 2,093 cases, petit mal in 294, grand and petit mal in 31, and Jacksonian in 95.

METHOD OF DISCOVERING CASES

The epileptic group is one of the smallest in which cases were referred for examination by courts-martial and psychologists. (See Table 8.) With the exception of the psychoses, the epileptic group had the smallest percentage (1,963, or 31.7 per cent) found in the routine examinations by psychiatrists. The patriotism of epileptics was a matter of common remark, and they were inclined to conceal their defects. A somewhat larger proportion of negroes than of whites was found in the routine psychiatric examinations. Perhaps they were more frank than the whites. Epilepsy is a conduct disorder, in that it so often first comes to light by the attacks. Consequently, a relatively larger proportion of epileptics (1,660, or 26.8 per cent) was reported by commanding officers. This is also true for organization medical officers.


247

LENGTH OF SERVICE PRIOR TO DISCOVERY

Five thousand five hundred and eighty-nine cases, or 90.5 per cent of all cases, were discovered before the expiration of six months. (See Table 10.) In this respect epileptics gave briefer service than alcoholics, neurological cases, psychoses, and psychoneuroses, and about the same length of service as the others. The negroes were detected much sooner than the others, which confirms the difference between negroes and whites, as remarked in the preceding paragraph. There were relatively fewer epileptics who served more than one year, than alcoholics, neurological cases, and psychoses.

TIME OF ONSET

The epilepsy was of long standing, 4,417 cases, or 97.5 per cent of the ascertained cases, being of over 1 year duration, and 3,452 cases, or 76.2 per cent, being over 5 years duration. (See Table 11.) In this respect there are few differences between the whites and colored. Only 38 cases were reported as originating after entering the service.

RECOMMENDATIONS FOR DISPOSITION

Six thousand one hundred and seventy-nine cases, or 96.7 per cent, were recommended for discharge-a larger percentage than any other group. (See Table 12.) Only 209 cases out of the total were recommended for treatment, duty, or limited service.

There were 930 cases of epilepsy reported in the American Expeditionary Forces. It may be said in this connection that some of these cases reported from France during the war period were looked upon, after their arrival in this country, as not true epilepsies, but hysterical conditions. Five deaths from epilepsy were reported.

DELINQUENCY

Only 53 of a total of 6,388 cases of epilepsy were reported for examination to explain the cause of misconduct. It would thus seem that epileptic symptoms, for the most part, were recognized immediately for what they were.

FAMILY HISTORY

Epilepsy gave the highest ratio of neuropsychiatric family history (61.9 per cent), exceeding that of endocrines by 0.9 per cent. (See Tables 13 to 17.) In the family histories of epileptics, the existence of inebriety was comparatively low. It was higher among the colored than among the whites. From the limited number of epileptic cases analyzed, it appears that the history of nervous disease in family was the commonest form of neuropsychiatric taint. The percentage of positive cases is higher among negroes than among whites.

AGE

The present statistics add little to what already was known in reference to age of epileptics, with the exception that the whites averaged somewhat younger than the negroes. (See Table 16.) Like mental deficiency, epilepsy


248

had a relatively higher representation in the younger age groups and a relatively lower representation in the older age groups.

EDUCATION

In Table 23, it is shown how far below the average in education the epileptics are. They came second to mental defectives in respect to having no schooling at all and in representation in the grades.

ECONOMIC CONDITION

There was a somewhat higher proportion of epileptics in comfortable circumstances than mental defectives, alcoholics, or drug addicts-10.5 per cent as compared to 4.6 per cent, 7.8 per cent, and 9 per cent, respectively. (See Table 24.)

HISTORY OF VENEREAL DISEASES

One thousand six hundred and twenty-four cases, or 25.4 per cent of the epileptics, admitted having had venereal disease of some kind. (See Table 25.) The percentage was much higher among the colored. Four thousand three hundred and sixteen white epileptics, or 81.9 per cent of the white epileptics, denied having had any venereal disease, while 448 negro epileptics, or 40.2 per cent of the negroes, made such denial. One hundred and eighty-two white epileptics, or 3.5 per cent of white epileptics, admitted syphilis, while 819 white epileptics, or 15.5 per cent of white epileptics, admitted gonorrhea. Among the negro epileptics 273, or 24.5 per cent of them, admitted syphilis, and 557, or 50 per cent, admitted gonorrhea.

ALCOHOLIC HABITS

There is practically no difference between the white and colored epileptics in reference to alcoholic habits. (See Table 26.) Two thousand seven hundred and forty-six, or 46.1 per cent, declared themselves as abstainers, this being a considerably higher percentage of abstainers than was found among drug users, neurological cases, insane, and constitutional psychopathic states. In fact, abstainers were more common among epileptics than among any other group, except psychoneuroses (48.6 per cent) and the endocrine group (49.3 per cent). In other words, epileptics were third on the list of the different clinical groups found in order of abstinence and seventh on the list found in order of intemperance.

MARITAL STATUS

Of the draft registrants placed in Class I, 86.8 per cent were single. The epileptics ran below this, 75.8 per cent being single. (See Table 27.) There was a higher percentage of single men among alcoholics, psychoses, psychoneuroses, endocrine cases, mental defectives, and constitutional psychopathic states than among epileptics.


249

HOME ENVIRONMENT-URBAN OR RURAL

The distribution of epileptics as to home environment was about the same as that for the population as a whole.

STATE OF RESIDENCE (WITH GAIN OR LOSS FROM IMMIGRATION OR MIGRATION)

Table 44 shows 21 States in which the distribution rate for epilepsy exceeded the United States rate of 8.6 per cent. The distribution average in these 21 States was 10.6 per cent. Only four States exceeded 5.16 per 1,000 rate for epilepsy at the draft boards (see Table 5), showing a greater disagreement between the results at draft boards and camps than in other conditions.

CORRELATIONS WITH OTHER CLINICAL CONDITIONS

The variations in the distribution of epilepsy throughout both States and races are slight. In the 21 States in which the United States average of 8.6 per cent was exceeded the average excess was not remarkable, and the excess in individual States did not correspond with any excess or decrease in other clinical conditions worthy of special remark. (See Table 44.)

Among the classified races (see Table 34) epilepsy showed a high distribution rate in the Negro, Dutch, French, Greek, Italian, and Mexican; as between the foreign born and native born there were no marked differences. It seems as though this protean disease, epilepsy, were a condition inevitably and more or less evenly distributed throughout the whole human family, being little influenced in its distribution by race or environment.

CONSTITUTIONAL PSYCHOPATHIC STATES

This group is composed of young men who were unstable, undependable, ill-balanced emotionally, changeable, and in general asocial. Their asocial qualities were manifested in an inability to carry out the requirements of organization or in more definite antisocial acts. A considerable number had criminal records, and the tendency to recidivism, to do the same thing over again, whether the thing done was antisocial or not, was pronounced. These persons were for the most part fairly normal in respect to pure intellectual performance and presented few physical symptoms. They were recognized chiefly by their past records, which came to light either on the questioning the examiners put them to, on arrival at camp, or when they were referred for examination for some infraction of discipline. As so many of them were normals, absence without official leave was a common complaint brought against them.

The difference between psychopaths and psychoneurotics was distinct. The former never came under attention in the Army service because of their own choosing; that is, they did not come to the doctor suffering from symptoms, as did the psychoneurotics. They came as delinquents, disciplinary cases, conduct disorders, and inefficiency, because they were referred by company commanders or by the military police. They made no complaints themselves as to their own condition; in fact, they did not think that there was anything wrong with them. The psychoneurotics, on the other hand, were quite con-


250

vinced that there was something wrong with them. The psychopaths did not seek treatment but had treatment forced upon them. The psychoneurotics turned their fears, inefficiency, and inferiority into hysteria, neurasthenia, and anxiety. With the constitutional psychopaths the defects were on a little higher plane, being defects of character, in sense of responsibility and in ability to work in harmony with others. It was a less simple type of inferiority, on a higher intellectual level, and characteristic of a more intelligent group of men. In other words, the constitutional psychopaths represented the fundamental defect of character and development of moral and ethical standards as generally accepted and the psychoneurotics broke at a lower level, often associated with actual physical disability, such as stooping posture, prominent abdomen, flat feet, a tendency to flushing, sweating, and all those physical symptoms indicative of a poor physical constitution as well as poor mental endowment.

It was a fortunate thing for the Army that so many of these cases were recognized and discharged in the early part of the war. Their elimination accounts, in large measure, for the low delinquency rate among our troops.

CLINICAL CLASSIFICATION

The classification of constitutional psychopaths, as is shown in Table 6, is beset with great difficulties, if it is not an impossible task. Sexual psychopaths, especially homosexuals, constitute a more or less typical group, but to attempt to differentiate statistically between criminalism, nomadism, inadequate personality, etc., could be done only in a very intense inquiry. So the grouping as given in Table 6 is only to show how this great and important group tends to subdivide itself. It may be noted that there is little difference between the whites and the colored, with the exception that the colored show a higher percentage of sexual psychopathy than the whites. This condition, sexual psychopathy, including homosexuals, seems represented by a very small number, 190 cases in all.

METHOD OF DISCOVERING CASES

The social history of changing occupations, criminal records, unsuccessful meeting of life previously, made the prompt identification of these cases comparatively easy, and 41.8 per cent of them were found at the routine examinations. The delinquent tendencies common to this group explain why more cases were reported by commanding officers (31.8 per cent) and as a result of delinquency (1.1 per cent) than in other groups. (See Table 8.)

LENGTH OF SERVICE PRIOR TO DISCOVERY

Table 10 gives the length of service of these cases. It will be noted that the colored were identified much more promptly than the whites.

TIME OF ONSET

Table 11 shows the essentially constitutional character, as opposed to being created by environment, of these cases.


251

RECOMMENDATIONS FOR DISPOSITION

Practically the same proportion of constitutional psychopaths as of the psychoses were recommended for discharge, and a relatively high percentage were recommended for limited service. (See Table 12.) Low percentages were recommended either for treatment or for duty. Six deaths were recorded. As between the whites and the colored, a slightly higher percentage of colored were recommended for discharge and were discharged; as an exception to the general rule, a slightly higher percentage of whites were recommended for limited service than of colored. After the war these cases disappeared as such, for few mentions of them were found in March, 1921, as patients in the hospitals of the Bureau of War Risk Insurance. It seems probable that, as soon as the opportunity offered, they resumed the life of change and nomadism that the mobilization had interrupted. The evident criminal tendencies of the group lend some support to the supposition that these are the persons who add to the criminalism which so often follows wars.

DELINQUENCY

Among those reported for delinquency, 272, or 18.2 per cent, were constitutional psychopaths. In relation to the total number of constitutional psychopaths, this was a percentage of 4.5 per cent, the largest of any one group except the psychoses.

FAMILY HISTORY

With the exception of endocrine cases and epilepsy, constitutional psychopathic states gave a higher percentage of neuropathic heredity than any other group. (See Tables 13 to 17.) This percentage was considerably higher in the colored than in the white. Nervous diseases were relatively more frequent in the family in these cases than other conditions mentioned.

AGE

The constitutional psychopaths formed essentially a young group. (See Table 20.) A higher percentage of them were under 20 than any other group and only 2,556, or 41.8 per cent, of them were between 20 and 24 years, as compared with 62 per cent of Class I men in that age group; while 2,050, or 33.6 per cent, were between the ages of 25 and 29 years, as compared with 38 per cent of Class I men in that group. Negroes were somewhat older than the whites. (See Table 21.)

EDUCATION

The superior mental qualifications of constitutional psychopaths is shown by the statistics on education or schooling. (See Table 23.) They ranked above the average soldier as to college education. They were slightly below as regards high school and grades, though many more were without education. As far as other neuropsychiatric cases were concerned, the constitutional psychopaths seem to have been better educated than any except, perhaps, alcoholics.


252

ECONOMIC CONDITION

In this respect the constitutional psychopaths occupied about the median among neuropsychiatric cases. (See Table 24.)

HISTORY OF VENEREAL DISEASES

As in other clinical groups the negro greatly exceeded the white in the percentages of positive history of venereal diseases. (See Table 25.) As a group the constitutional psychopaths occupied about the median among neuropsychiatric cases.

ALCOHOLIC HABITS

These cases ranked fourth in order of intemperance (Table 26), with practically no difference between the white and the colored.

MARITAL STATUS

Like mental defectives, constitutional psychopaths showed a relatively small number of married men and a larger number of single men. (See Table 27.) The youth of these patients should be remembered in this connection. They were much more frequently divorced than the defectives. The colored constitutional psychopaths showed a higher proportion of married and a smaller proportion of divorced than the whites. As a group, 83.3 per cent were unmarried, as compared to 86.8 per cent of Class I men.

HOME ENVIRONMENT-URBAN OR RURAL

After the two other antisocial groups, alcoholism and drug addiction, the constitutional psychopathic group stood third in reference to proportion from urban environment, the percentage being 63.6 per cent. (See Table 28.)

STATE OF RESIDENCE (WITH GAIN OR LOSS FROM IMMIGRATION OR MIGRATION)

Eighteen States (Table 45) exceeded the United States distribution average of 9.7 per cent for constitutional psychopaths. At draft boards, 12 States (Table 5) exceeded the United States rate for draft boards, of 0.15 per 1,000 men examined. In so vague a condition as constitutional psychopathic states, an absolute agreement in the results obtained by two different sets of examiners is hardly to be looked for. Nevertheless of the 13 States which equaled or exceeded the average rate at draft boards, nine-California, Maryland, Michigan, New Hampshire, New York, Pennsylvania, Rhode Island, Utah, and Vermont- exceeded in the neuropsychiatric examinations in the camps.

CORRELATIONS WITH OTHER CLINICAL CONDITIONS

Eighteen States (Table 45) exceeded the United States distribution average for this condition. The excess of the average was 2.2 per cent. In these States the only averages of the other clinical conditions to show changes worthy of note were mental deficiency and endocrine disturbances. These both fell below.


253

In the classified races (Table 34) the only significant changes referred to the Negro and the Mexican. These two races are conspicuous by low averages in the constitutional psychopathic group. In reference to the foreign-born as opposed to the native (Table 33) both the German and Irish foreign-born show a lower percentage of psychopaths than the native.

TABLE 45.-Per cent distribution of neuropsychiatric conditions in 18 States in which the ratefor constitutional psychopathic states exceeded the United States rate of 9.7 per cent

State of residence

Constitu-
tional psycho-
pathic states

Mental deficiency

Psycho-
neuroses

Psychoses

Neuro-
logical condition

Epilepsy

Endocrin-
opathies

Drug addiction

Alcohol-
ism

United States 

9.7

29.2

17.0

12.1

10.0

8.6

7.4

3.0

3.0

Arizona

11.7

15.0

12.5

16.7

18.3

10.8

6.7

4.2

4.2

California

12.7

22.0

16.7

17.4

12.2

7.7

2.7

3.3

5.3

Connecticut

10.3

26.7

17.8

15.9

7.7

10.6

3.1

2.9

4.9

Georgia

11.8

33.3

13.0

13.4

11.5

7.9

6.1

2.5

.7

Indiana

14.5

23.3

20.0

8.6

14.3

7.5

8.3

.6

2.8

Kansas

9.8

21.6

18.2

10.4

13.5

6.3

15.4

2.5

2.2

Maryland

10.7

44.9

13.3

10.4

7.6

4.5

4.4

1.6

2.5

Massachusetts

12.2

25.7

18.1

14.4

6.9

10.4

1.7

2.7

7.9

Michigan

11.6

29.2

12.0

13.5

10.9

8.6

11.2

1.1

2.3

New Hampshire

12.4

27.7

23.4

10.2

7.3

10.2

1.5

2.9

4.4

New Jersey

11.2

27.6

16.6

13.4

6.8

12.6

5.7

3.0

3.2

New York

13.1

19.8

18.3

11.6

8.8

10.0

6.3

8.4

3.5

North Dakota

10.3

38.5

14.1

12.6

9.2

8.0

3.8

.4

3.1

Oregon

16.4

18.1

19.1

19.7

8.9

9.5

5.3

2.6

.3

Pennsylvania

12.0

27.0

15.3

11.0

9.3

7.6

9.9

2.8

5.2

Rhode Island

9.9

29.2

18.8

9.9

7.2

9.4

4.0

4.9

6.7

Utah

12.6

20.5

19.2

18.5

6.0

7.9

4.0

7.9

3.3

Vermont

10.6

33.6

16.8

13.3

10.6

8.8

3.5

---

2.7


ENDOCRINOPATHIES

The present statistics furnish only a partial record of the endocrinopathies identified during the mobilization, for the reason that only a portion of these cases came under the special observation of neuropsychiatrists. Many of the cases, it is not known how many, were regarded as medical and were disposed of as such. For this reason the present statistics give only a partial idea of the extent of this problem, especially in the central (lake) and northwest regions of the United States. The importance of the nervous aspects of these troubles, however, is shown by the fact that so many were referred to neuropsychiatrists, and also by the frequency with which a neurotic family history was given.

CLASSIFICATION

Of the 4,805 cases of endocrinopathies, 4,501, or 93.7 per cent, concerned the thyroid gland primarily, and 205, or 4.3 per cent, concerned the pituitary gland. (See Table 6.) As between the whites and the negroes, the whites had a higher percentage of thyroid involvement, and the negroes a higher percentage of neurocirculatory asthenia.

In view of the classification as given above it seems probable that only the outspoken cases were included in this group. Examiners may have missed some of the less conspicuous evidences of endocrine troubles either classifying them under some more evident disability or passing over the symptoms altogether.


254

METHODS OF DISCOVERING CASES

As shown in Table 8, two-thirds of the endocrinopathies were discovered at the routine examinations-the largest percentage thus discovered in any clinical group. They were medical rather than behavioristic, and with the exception of cases of alcoholism, a smaller percentage of these cases than of any others were referred by commanding officers.

LENGTH OF SERVICE PRIOR TO DISCOVERY

The nature of the condition rendered the time required for identification short; 92.5 per cent had been identified before the expiration of six months; 97.2 per cent of the colored had been identified in that space of time. (Table 10.)

TIME OF ONSET

The endocrinopathies were among the cases of longest standing; 97.7 per cent had existed for from one to five years or over before entering the service. (See Table 11.) The percentages were practically the same for both white and colored. Only 28 cases developed after entering the service, and of these 12 developed during the first six months.

RECOMMENDATIONS FOR DISPOSITION

As endocrinopathies so frequently create a partial rather than a complete disability, the percentage of them, 87.3, recommended for discharge, was smaller than that for many other conditions. (See Table 12.) Eleven and nine-tenths per cent were recommended for limited service. Two deaths were recorded.

As between the whites and the colored a slightly higher percentage of the latter were recommended for discharge and a slightly smaller percentage of them were recommended for limited service.

DELINQUENCY

Only 6 cases out of the 4,805 in the endocrine group were reported for examination by reason of misconduct.

FAMILY HISTORY

Although not generally classified with nervous diseases, the endocrinopathies gave a high percentage (61.0 per cent) of neuropsychiatric taint in the family, being exceeded in this respect by epilepsy alone. (See Tables 13 to 17.) The colored gave a somewhat higher percentage than the whites.

Of the neuropsychiatric conditions in the family, the order as to frequency was nervous diseases, inebriety, mental diseases, mental deficiency. The percentage of mental diseases, in the families of endocrinopaths was lower than the average for the other groups.


255

AGE

The bulk of these cases, both white and colored, were in the age group of the draft. They had a relatively small representation under 20 years and over 30 years. (See Table 20.) It seems probable on the one hand that they did not volunteer, and on the other, that they could not stand the strain of service. (See Table 21.)

EDUCATION

The white endocrine cases were somewhat below the average white soldier in relation to school and college attendance but above the average of neuropsychiatric cases. (See Tables 22 and 23.)

ECONOMIC CONDITION

After the psychoneuroses and neurological conditions the endocrinopathies made the best showing in regard to economic conditions, 15.6 per cent of them being in comfortable circumstances. (See Table 24.) This relatively favorable showing was due to the whites.

HISTORY OF VENEREAL DISEASES

Table 25 shows the endocrinopathies to have the smallest number of histories of venereal diseases. Of the whites, 2.9 per cent admitted having had syphilis, and 13.1 per cent gonorrhea. The colored percentages were much higher.

ALCOHOLIC HABITS

The percentage of intemperate men among the endocrinopathies (5.1 per cent) was lower than for any other group, and they furnished the highest percentage (49.3 per cent) of abstinent men. The colored had higher percentages as to intemperance and moderate drinking, and a low percentage in relation to total abstinence. (See Table 26.)

MARITAL STATUS

Eighty per cent of these cases were single, which was above the average for neuropsychiatric cases. (See Table 27.) The endocrinopaths had the lowest percentage of divorces.

HOME ENVIRONMENT-URBAN OR RURAL

Somewhat less than one-half of these cases, 44.4 per cent, lived in rural surroundings, a fact which will appear again in the paragraph on State of residence. (See Table 28.)

STATE OF RESIDENCE (WITH GAIN OR LOSS THROUGH IMMIGRATION OR MIGRATION)

Seventeen States (Table 46) exceeded the United States distribution average of 7.4 per cent for endocrinopathies, the distribution average in these States being 11.4 per cent. These States are chiefly those in the central and north-


256

west part of the United States. The Gulf States were remarkably free. (See Table 29.) For example, the average distribution in Florida, Alabama, Mississippi, Louisiana, and Texas was 2.7 per cent as compared with 11.4 per cent in the 17 States which exceeded the United States average. If endocrinopathy, as used herein, corresponds with the classification of "goiter" and "exophthalmic goiter" as employed by local boards, there is substantial agreement in the results found by draft boards and by the neuropsychiatric examiners at camps.

TABLE 46.-Per cent distribution of neuropsychiatric conditions in 17 States in which the ratefor endocrinopathies exceeded the United States rate of 7.4 per cent

State of residence

Endocrino-
pathies

Mental deficiency

Psycho-
neuroses

Psychoses

Neuro-
logical conditions

Epilepsy

Constitutional psychopathic states

Drug addiction

Alcohol-
ism

United States 

7.4

29.2

17.0

12.1

10.0

8.6

9.7

3.0

3.0

Idaho

14.6

26.7

10.3

25.5

8.5

7.9

6.7

---

---

Illinois

9.8

19.9

20.6

13.8

10.7

8.3

9.1

1.5

6.2

Indiana

8.3

23.3

20.0

8.8

14.3

7.5

14.5

.6

2.8

Iowa

8.2

25.3

17.8

16.4

9.9

8.4

9.3

2.6

2.1

Kansas

15.4

21.6

18.2

10.4

13.5

6.3

9.8

2.5

2.2

Michigan

11.2

29.2

12.0

13.5

10.9

8.6

11.6

1.1

2.3

Minnesota

12.0

22.2

19.5

14.0

10.9

7.8

7.1

2.2

4.3

Missouri

8.5

33.8

15.9

8.5

11.4

6.3

9.4

3.0

3.3

Montana

7.8

16.7

16.0

20.8

11.2

11.9

8.9

3.7

3.0

Nebraska

10.7

25.1

14.7

15.5

12.9

7.6

9.4

2.6

1.6

Ohio

12.8

23.9

19.7

11.3

10.9

7.7

8.6

2.7

2.3

Pennsylvania

9.9

27.0

15.3

1.0

9.3

7.6

12.0

2.8

5.2

South Dakota

16.1

33.1

14.4

10.5

12.8

6.6

3.9

.3

2.3

Virginia

10.9

45.5

12.1

9.2

7.0

5.8

7.4

1.2

1.0

Washington

9.3

26.1

14.1

17.7

8.2

7.5

9.5

6.8

.9

West Virginia

15.7

38.6

12.6

8.2

9.1

6.3

7.8

1.1

.7

Wisconsin

12.6

27.0

19.2

12.6

11.6

6.8

6.2

.7

3.2


CORRELATIONS WITH OTHER CLINICAL CONDITIONS

Seventeen States (Table 46) exceeded the United States distribution rate for endocrinopathies of 7.4, the average distribution percentage in these States being 11.4 per cent. The distribution average in these 17 States for the different clinical conditions showed no marked variations, mental deficiency, alcoholism and drug addiction fell further below the United States average than the others. The United States endocrine average was especially exceeded in the North and Northwest. In most of these States the distribution average for alcohol and drugs was well below the United States average for these two conditions.

Of the classified races (Table 34) five, namely, the Dutch, English, German, Scandinavian, and Scotch, were all much over average in relation to endocrine troubles. These races showed an under average in mental defect, except the English, whose rate just equaled the United States average for mental defect.

As between native and foreign born, the foreign born German, Scandinavian, and Irish have a lower distribution average than the native; with the Italians the reverse is the case. (See Table 33.)

DRUG ADDICTION

By a drug addict is understood one who has become so habituated to habit-forming drugs-chiefly derivatives of opium-that when suddenly deprived of them he falls ill with painful symptoms and can not work. This falling ill and inability to work is essential to the definition of drug addiction. Many, if


257

not most, of the habitués, as long as they are supplied with what they have become dependent on, can work and keep in fairly good health. But they go to pieces shortly after withdrawal. It is in this way that the diagnosis of drug addiction is chiefly made-not by direct examination, but by the so-called withdrawal symptoms.

The drug addict has always been unpopular with the Army. He can not by any chance make a reliable soldier unless cured of this habit, and the Army has no facilities for curing him, for cure means not only hospital treatment during the period of withdrawal, but a long time of vigilant watching afterward. Most drug users are proselytors, eager to make others acquire the habit that enslaves them, and so in any community, and especially in a military community, they create a focus which fosters bad morale and disobedience. Before the World War our Army refused to accept applicants for enlistment who were drug addicts. But it could take no such attitude under a draft act because of the danger of drug-taking being feigned as a means to exemption; and also because, if physically sound drug addicts ran into the thousands-no one knew how many there would be-to have rejected all of them would have entailed too great a loss of man power. So, from the beginning, drug addicts were not accepted, but were rejected conditionally, so that if the numbers of them proved sufficient to justify it, they could be recalled.6

As a class drug addicts were not conspicuous as malingerers. Some recruits brought syringes, etc., with them, and others had punctured their skin for the purpose of giving the impression of being old "needle fiends." But most of these were malingerers pure and simple, and not drug addicts at all. And the number was small. The unbridled stories circulated in the newspapers in the early days, that many young men were acquiring the habit for the purpose of evading the draft, were entirely baseless. According to the total draft figures, drug addiction occurred in 0.54 men per 1,000 examined.

METHODS OF DISCOVERING CASES

By direct examination alone the only positive reliable evidence of habit are scars and abscesses from needle punctures. Failing to find these the most skillful physician can not be sure that addiction exists from any objective examination. In consequence, drug addiction belongs to the class of conduct disorders-the blight becomes evident more from the way the patient behaves than from medical examination. It appears from Table 8 that considerably less than half of the cases were identified by the psychiatrists in routine examinations. This is explained, partly, by the fact that routine examinations did not disclose the condition, and partly because the addict brought to camp with him a sufficient supply of heroin or morphine, or whatever he took, and could carry on for a time. More cases of alcoholism, neurological and endocrine disorders, and constitutional psychopathic states were found out at the start than of drug addiction. Other medical officers, on the contrary, discovered them frequently when they reported to hospital for treatment of symptoms of withdrawal or for independent disorders. Commanding officers also found them frequently. Drug addicts concerned psychologists but little, and few also came to light through the courts-martial or guardhouses.


258

LENGTH OF SERVICE PRIOR TO DISCOVERY

The drug addicts gave the shortest service prior to discovery-84.9 per cent of them were detected before the expiration of three months, and only 3.8 per cent served more than a year. (See Table 10.) This prompt identification may be explained in part, at least, by the fact that these soldiers could not get drugs in the cantonments and so were forced to disclose themselves. Police regulations for the suppression of the traffic seem to have been effective.

TIME OF ONSET

Not all those who tamper with drugs acquire the habit, even when the tampering occurs in the social ways by which drug addiction is most established. Many persons try drug taking, do not like it, and give it up after a short time. Some months are required for the habit to become fixed. But within that time the habit usually does become fixed and the fact that no cases developed in the service indicates definitely that there was not great prevalence of drug taking among troops. Ninety-eight and eight-tenths per cent of the drug addicts (Table 11) had been such for a year or more before they were mobilized. This is in full accord with what was known previously, namely, that the drug habit is a long-standing affair, meriting, on account of its very chronicity, being classed with the other degenerative neurotic conditions. The long establishment of the habit in the cases reported, furnishes additional proof that practically no habits were formed for the purpose of evading the draft.

RECOMMENDATIONS FOR DISPOSITION

Of the drug addicts discovered 90.2 per cent were recommended for discharge. (See Table 12.) This percentage was higher for the colored than for the white. One death was reported.

The almost complete eradication of drug habitués from our troops is shown by the fact that hospital admissions in the American Expeditionary Forces for this cause numbered but 70 for the years 1917-18-19.

DELINQUENCY

Only 21 cases of drug addiction were reported for examination as to misconduct. This is approximately 1 per cent of the total 2,020 drug addicts.

FAMILY HISTORY

As a class, drug addicts, both colored and white, were among the more intelligent of the neuropsychiatric cases, and their answers to questions as antecedents have, therefore, a fair chance of being correct. (See Tables 13 to 17.) Among them, the distribution of family neuropathic taint was about the same as among alcoholics. It was notably less than in endocrine disturbances and epilepsy. From this it seems evident that while many drug addicts are neurotically predisposed individuals, they, with alcoholics, are less so than the other members of the neurotically degenerate group.


259

Table 47 gives specific information as to which of four specified conditions had existed most frequently in the families of 907 drug addicts. The importance of the direct inheritance of tendency to inebriety is shown by the percentage 24 of history of family inebriety. A similar condition exists among alcoholics (33.3 per cent) and drug addicts share with alcoholics the lowest percentage of mental disease in the family, of all neuropsychiatric cases. But even then it is found in approximately 10 per cent of all cases. It will be observed that the history of mental disease in the family is much more frequent among negro drug addicts than among whites. Family history of mental deficiency, 2 per cent, is higher than in alcoholism, psychoneuroses, or constitutional psychopathic states. Table 48 shows a relative excess of inebriety in fathers.

TABLE 47.-Family history of neuropathic taints among cases of drug addiction

Neuropathic taint in family

Total

White

Colored

Number 

Per centa

Number

Per centa

Number

Per centa

Nervous disease

266

14.9

239

14.8

27

15.6

Mental disease

177

10.0

149

9.2

28

16.2

Inebriety

429

24.0

382

23.7

47

27.2

Mental deficiency

35

2.0

33

2.0

2

1.2

Total taints

907

50.7

803

49.7

104

60.1


aPercentages are based on the number of cases with each specified taint among the total cases with ascertained family history.

TABLE 48.-Classification of family neuropathic taints among cases of drug addiction accordingto disorder and relatives

WHITE

Neuropathic taint in family

Number of cases

Number of relatives

Father

Mother

Grandparents

Siblingsa

Collateralsb

Nervous disease

239

53

106

7

99

25

Mental disease

149

26

29

15

45

87

Inebriety

382

247

22

13

134

96

Mental deficiency

33

7

8

---

24

9

Total

803

333

165

35

302

217

COLORED

Nervous disease

27

2

16

1

7

2

Mental disease

28

4

4

4

3

13

Inebriety

47

24

3

1

20

11

Mental deficiency

2

---

---

---

2

---

Total

104

30

23

6

32

26

Total white and colored

907

363

188

41

334

243


aSiblings include brothers and sisters.
bCollaterals include uncles, aunts, and cousins.

AGE

The two groups, drug addiction and alcoholism, contain the smallest number of individuals under 20 years of age of any of the neuropsychiatric conditions. (See Table 20.) In contrast to alcoholism, the greatest number,


260

83.2 per cent, of drug addicts were found in the age period of 20 to 30, although negroes averaged somewhat older. Thus, while averaging older than the ages of Class I men, they were much younger than alcoholics. As a disability, drug addiction is established much more rapidly than alcoholism. They are primarily youngsters who congregate together evolving, meanwhile, a special vocabulary of their own, especially necessary since the enactment of laws limiting the use of drugs. The vendor must know the gangs' members. The members of these gangs are almost invariably young men. In the round-ups of addicts which take place from time to time only here and there will be observed anyone more than 30 or 35 years of age. The others are of about the same age as those found in the Army.

The fact that drug addicts are so rarely met with after 35 years of age raises an interesting question as to prognosis. What becomes of them? If the current belief that drug addicts are incurable, that they never break the habit, is correct, the only alternative explanation is that they all die. But this explanation is not correct, because there has never been a high mortality among drug addicts. It must be, therefore, that drug addicts, as they grow older, either do break the habit, or else get adjusted to small doses such as it is possible for them to obtain easily, and so keep out of trouble. In either event, it would seem that in their maturer years persons who have taken drugs cease to be much of a burden either to themselves or the community.

EDUCATION

The information as to this point bears testimony to the comparatively high mental development of drug addicts. (See Table 23.) There were fewer drug addicts (4.2 per cent) without any education at all than in the other groups, and the percentage of those who reached the grades is higher for all other conditions except alcoholism. Few drug addicts, however, reached high school, and a very small percentage, indeed, got to college. This rather abrupt breaking off of the education of drug addicts who were so well represented in the grades, may find some explanation in the succeeding paragraph.

ECONOMIC CONDITION

Drug addicts (91 per cent), alcoholics (92.2 per cent), and mental defectives (95.4 per cent) were in poorer circumstances than representatives from the other neuropsychiatric groups. (See Table 24.) Mental defectives are in poor circumstances because they not only are unable to earn much themselves, but also because one or both parents are so frequently inferior in wage-earning ability. The same facts may hold true for both drug addiction and alcoholism, although in the latter the habits alone are sufficient to account for the indigence.

More drug addicts were in comfortable circumstances (9 per cent) than alcoholics (7.8 per cent) or defectives (4.6 per cent). All the other neuropsychiatric groups presented a higher percentage in comfortable circumstances than these three. It would seem that economic condition is to be held to account, to a certain degree at least, for the sudden cessation of education on the part of drug addicts. Economic conditions force them to forego high school and college.


261

VENEREAL DISEASES

Among drug addicts venereal disease prior to entering the service was more frequent than in any other neuropsychiatric conditions-56 per cent as compared to 38.8 for alcoholism and 18.5 per cent for endocrine disturbances. (See Table 25.) Among the colored cases the percentage was even higher. Twenty-three per cent of all drug cases admitted syphilis. This is higher than in any other group except in the nervous disease group, in which syphilis is included. The history of gonorrheal infection (47.5 per cent) was the highest of all in drug addicts.

This frequency of venereal disease among drug addicts brings up an important consideration as to the action of drugs in the spread of venereal disease. Alcoholic intemperance has always been put down as the chief extraneous factor in the spread of venereal disease. Of course alcoholic intemperance is more widely disseminated throughout the community, and occupies a more especially important position in relation to the spread of venereal disease than drug taking, but as an actual incitant of behavior which results in venereal infection, alcohol seems materially less active than habit-forming drugs.

ALCOHOLIC HABITS

With the exception of alcoholism, relatively fewer drug addicts were abstainers than were found in any other neuropsychiatric group. (See Table 26.) With the exception of the neurological and mental deficiency groups there were proportionately more moderate drinkers among the drug addicts (48.9 per cent). After the alcoholism and the psychoses, they gave the most frequent history of intemperance.

MARITAL STATUS

The endocrine, mental defective, psychoses and constitutional psychopathic groups contain substantially more single men than the others. (See Table 27.) In the remaining group the proportion of single men was about the same throughout. Exceptions to this must be made in the case of the colored drug addicts who had more married men and fewer divorces. In this connection, however, it should be remembered that the colored drug addicts averaged older than the whites. The married drug addicts did not seem to get along very well domestically, as the divorces among them were more frequent than among any group except the alcoholic and the nervous disease groups.

HOME ENVIRONMENT-URBAN OR RURAL

Table 28 shows that 91.4 per cent of the drug addicts come from cities having over 2,500 inhabitants. Among negroes the percentage was 95.4 per cent, as compared with 36 per cent of colored neuropsychiatric cases as a whole, and 27 per cent of the colored population as a whole. Drug addiction is the urban variety of neuropsychiatric disorder par excellence, being followed by alcoholism (82.8 per cent), constitutional psychopathic states (63.6 per cent), and nervous diseases (62.1 per cent). This overwhelming preponderance of narcotic drug habits among city dwellers suggests several interesting observations. One of them is the folly of estimating the number of drug addicts in the country as a whole from the numbers found in cities. In the past it has been


262

inferred that in New York, for example, where drug addicts are registered in accordance with the State law, the distribution rate in New York might be made to apply for some State, such as Kansas, which has no very large cities.

Another inference concerns control. Inasmuch as drug addiction is essentially an affair of large municipalities, its local control, in addition to Federal, should be placed in the hands of municipal authorities. The problem of suppressing it is local, and is essentially a municipal and not a State problem. This point will come out plainly when the different localities are compared, as then it will appear that cities in some sections of the country have a much higher distribution of drug addiction than others.

Another inference to be drawn from Table 28 is that drug addiction is essentially a matter of social custom. It is well known that some drug addicts acquire the habit after the administration of morphine or other pain-relieving drugs by physicians. The drugs have been given after surgical operations or during the course of painful diseases. The physician either has been careless in not stopping the medicine soon enough, or the patient has continued the use of the drug without the physician's knowledge, or in spite of it. But such a mode of origin of drug addiction comprises only a small proportion of the cases. This is known to be so from analyses of the histories of individual drug addicts, and would seem to be proven by the great preponderance of drug addiction in cities as compared to rural districts. If maladministration of drugs by physicians was a common cause of the habit, we would expect to find the same rate of it in country as in city communities, as country doctors and city doctors treat their patients in very much the same way. But as this is not so, the conclusions seems plain that it is the urban atmosphere which fosters this variety of inebriety through example, imitation, and social associations, in much the same way that alcoholic intemperance is fostered.

TABLE 49.-State of residence of cases of drug addiction

State of residence

White

Colored

State of residence

White

Colored

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Alabama

13

1.2

1

0.1

New Hampshire

4

2.9

---

---

Arizona

5

4.2

1

16.7

New Jersey

43

3.0

12

19.4

Arkansas

23

2.6

1

.3

New Mexico

1

.3

---

---

California

56

3.3

20

57.1

New York

541

8.4

33

20.5

Colorado

10

2.1

---

---

North Carolina

10

.7

1

.3

Connecticut

18

2.9

1

7.7

North Dakota

1

.4

---

---

Delaware

9

9.8

14

35.0

Ohio

101

2.7

6

3.5

Florida

14

2.9

1

.8

Oklahoma

88

7.4

8

4.9

Georgia

38

2.5

1

.2

Oregon

8

2.6

4

100.0

Idaho

---

---

---

---

Pennsylvania

157

2.8

17

6.0

Illinois

59

1.5

---

---

Rhode Island

11

4.9

2

20.0

Indiana

11

.6

1

2.3

South Carolina

14

1.9

---

---

Iowa

25

2.6

4

16.7

South Dakota

1

.3

---

---

Kansas

23

2.5

4

7.8

Tennessee

46

3.5

5

.7

Kentucky

22

1.2

4

2.3

Texas

66

4.1

5

1.5

Louisiana

24

2.5

2

.3

Utah

12

7.9

---

---

Maine

5

1.3

---

---

Vermont

---

---

---

---

Maryland

14

1.6

---

---

Virginia

17

1.2

3

.5

Massachusetts

42

2.7

3

14.3

Washington

30

6.8

---

---

Michigan

24

1.1

3

6.5

West Virginia

13

1.1

2

2.5

Minnesota

26

2.2

---

---

Wisconsin

9

.7

---

---

Mississippi

27

3.1

---

---

Wyoming

3

2.6

---

---

Missouri

82

3.0

30

10.8

District of Columbia

4

2.5

1

1.1

Montana

10

27.3

2

50.0

State unascertained and others

49

---

2

---

Nebraska

13

2.6

3

27.3

  United States

1,823

3.0

197

2.3

Nevada

1

1.7

---

---


Percentages are based on total neuropsychiatric cases of each color from each State.


263

TABLE 50.-Per cent distribution of neuropsychiatric conditions in 12 States in which the ratefor drug addiction exceeded the United States rate of 3 per cent

State of residence

Drug addiction

Mental deficiency

Psycho-
neuroses

Psychoses

Neuro-
logical conditions

Epi-
lepsy

Consti-
tutional psycho-
pathic states

Endo-
crino-
pathies

Alco-
holism

United States

3.0

29.2

17.0

12.1

10.0

8.6

9.7

7.4

3.0

Arizona

4.2

15.0

12.5

16.7

18.3

10.8

11.7

6.7

4.2

California

3.3

22.0

16.7

17.4

12.2

7.7

12.7

2.7

5.3

Delaware

9.8

22.8

12.0

12.0

14.1

7.6

8.7

6.5

.5

Mississippi

3.1

35.4

23.2

9.8

8.3

10.9

6.7

2.1

0.6

Montana

3.7

16.7

16.0

20.8

11.2

1.9

8.9

7.9

3.0

New York

8.4

19.8

18.3

11.6

8.8

10.0

13.1

6.3

3.5

Oklahoma

7.4

33.3

15.6

11.8

12.7

6.7

6.7

4.0

1.9

Rhode Island

4.9

29.2

18.8

9.9

7.2

9.4

9.9

4.0

6.7

Tennessee

3.5

43.0

14.3

9.6

11.9

8.0

3.8

5.1

.8

Texas

4.1

25.5

14.8

17.6

12.3

13.4

8.8

2.3

1.1

Utah

7.9

20.5

19.2

18.5

6.0

7.9

12.6

4.0

3.3

Washington

6.8

26.1

14.1

17.7

8.2

7.5

9.5

9.3

.9


STATE OF RESIDENCE (WITH GAIN OR LOSS FROM MIGRATION OR IMMIGRATION)

Drug addiction constituted 2.9 per cent of the total of neuropsychiatric cases; 3 per cent for the whites, and 2.3 per cent for the colored. (See Table 49.) Among the colored the average of 2.3 per cent was greatly exceeded in the States of Arizona, California, Delaware, Iowa, Massachusetts, Missouri, Montana, Nebraska, New Jersey, New York, Oregon, and Rhode Island. Illinois furnished no cases among the colored. Among the whites the following States exceeded the United States average: Arizona, California, Delaware, Mississippi, Montana, New York, Oklahoma, Rhode Island, Tennessee, Texas, Utah, and Washington. (See Table 50.) Of the total, New York furnished more than one-quarter of the cases; and more than half were furnished by the States of New York, Ohio, Pennsylvania, California, and Missouri. These statistics show how essentially local drug addiction is.

CORRELATIONS WITH OTHER CLINICAL CONDITIONS

In preceding paragraphs on correlation it has been indicated that drug addiction, in common with psychoses and alcoholism, tends to sink below the distribution average in both States and races, when mental deficiency rises above it. How far the converse of this holds true in the States is shown in Table 50, which enumerates 12 States that exceed the United States distribution average of 3 per cent for drug addiction. For all these clinical conditions named, the converse holds true as far as the average of the whole 12 States is concerned. For example, the average for these States for mental deficiency is 25.8 per cent, for drug addiction, 5.6 per cent. The converse does not hold true for every State. As to mental deficiency, Mississippi, Oklahoma, and Tennessee exceed the average; as to psychoses, 6 fall below; as to alcoholism, 5 fall below.

Of the classified races (Table 34) six-Indian, Hebrew, Irish, Italian, Scotch, and mixed-exceed the United States distribution rate for drug addiction of 3 per cent. Of these six, all but the Indian and the Italian fall below the mental deficiency average. No foreign-born race reaches the United States average of 3 per cent for drug addiction.


264

From this it appears that drug addiction is antagonistic to mental deficiency, with the tendency to group itself with the conditions which indicate a higher mentality, such as psychoses and alcoholism. This tendency is less marked than in alcoholism. It further appears that those born in America are more prone to drug taking than those born abroad. It might be advisable to consider both alcoholism and drugs under a common title of inebriety.

Perhaps the two conditions are interchangeable means of expressing a common mental tendency or predisposition. For example, the foreign-born Irish drink heavily and are little given to drugs; while the native Irish drink much less than their foreign born brothers do, but take drugs more freely. (See Table 33.) There seems to be a distinct tendency for drug taking to become higher in native as opposed to foreign born stock, a fact to be explained, perhaps, by the proselyting traffic in drugs which exists in the large cities in the United States. It may be that drug taking is an expression of a tendency to inebriety which finds particularly favorable conditions here.

ALCOHOLISM, INCLUDING THE ALCOHOLIC PSYCHOSES

The most noteworthy facts, established as to the distribution of chronic alcoholism among recruits, were the small number found, the excess among volunteers as compared to drafted men, the excess of alcoholism in communities and races low in mental deficiency, and the excess of mental deficiency in communities and races low in alcoholism-a fact especially clear as regards negroes.

It must be understood that, as used here, the term chronic alcoholism signifies more than intemperance, and the term alcoholic, more than a drinking man. Alcoholic, as used here, means a person physically sound in other respects, who has become poisoned by alcohol to a degree to be unfit to bear arms. Of the total 69,394 neuropsychiatric cases under consideration, 1,858, or 2.7 per cent, were chronic alcoholics. (See Table 6.)

How many intemperate men were accepted for service and made good under military conditions we have no means of knowing; we know only the number of those whose habits had brought about disabilities so serious that the Government did not think it worth while to try to reconstruct them. These, during their brief time of service, caused comparatively little trouble. They were quickly identified and discharged.

The relatively small number of cases identified raises the question whether all possible ones were included, or if other reasons existed which might explain it. It should be remembered that the number 1,858, as given in Table 6, does not include the 292 cases of alcoholic psychoses. To express fully the effects of alcohol on recruits these 292 cases should be added, making a total of 2,150 camp cases. If the local board cases approximate 1,000 the grand total of alcoholics for the mobilization of approximately 3,500,000 men examined would be 3,150, or less than 1 per thousand.

This result is so small, so far below any estimates that had been made, that one immediately inquires if the youth of the men of our army had something to do with it; for it is well established that a long period of steady drinking is necessary for the development of alcoholism, a fact substantiated by the present statistics; and in our Army, at least, the average age of alcoholics was shown to


265

be above the average age of recruits. In response to this it may be said that approximately one-half of the alcoholics identified were not drafted men, but were volunteers, a group which averaged higher in age than drafted men. If the 1,199 alcoholics who were volunteers are subtracted from the 3,150 total alcoholics, there remain only 1,951 cases of drafted men who were found alcoholic. Even if only one-third of the draft had reached the age most favorable to alcoholism, the above number of them is so small that it is plain that alcoholism can not be considered as affecting to any degree the military strength of the United States.

Among negro troops alcoholism practically did not exist-there were only 29 cases, including 5 cases of alcoholic psychoses, as compared with 4,055 cases of mental defect. The great disparity between these two conditions in negroes made it necessary, in constructing United States distribution averages, to leave the negro out of account, and to make the averages on the basis of whites.

TABLE 51.-Percent distribution of neuropsychiatric conditions in 17 States in which the rate for alcoholism, including alcoholic psychoses, exceeded the United States rate of 3.5 per cent

State of residence

Alcoholism (including alcoholic psychoses)

Mental defect

Psycho-
neuroses

Psychoses

Neuro-
logical conditions

Epi-
lepsy

Consti-
tutional psycho-
pathic states

Endo-
crino-
pathies

Drug addiction

United States

3.5

29.2

17.0

12.1

10.0

8.6

9.7

7.4

3.0

Arizona

5.0

15.0

12.5

16.7

18.3

10.8

11.7

6.7

4.2

California

6.0

22.0

16.7

17.4

12.2

7.7

12.7

2.7

3.3

Connecticut

5.7

26.7

17.8

15.9

7.7

10.6

10.3

3.1

2.9

Delaware

8.7

22.8

12.0

12.0

14.1

7.6

8.7

6.5

9.8

Illinois

7.0

19.9

20.6

13.8

10.7

8.3

9.1

9.8

1.5

Massachusetts

8.8

25.7

18.1

14.4

6.9

10.4

12.2

1.7

2.7

Minnesota

4.9

22.2

19.5

14.0

10.9

7.8

7.1

12.0

2.2

Montana

3.7

16.7

16.0

20.8

11.2

11.9

8.9

7.8

3.7

Nevada

18.3

18.3

11.7

18.3

18.3

8.3

6.7

1.7

1.7

New Hampshire

4.4

27.7

23.4

10.2

7.3

10.2

12.4

1.5

2.9

New Jersey

3.6

27.6

16.6

13.4

6.8

12.6

11.2

5.7

3.0

New York

4.3

19.8

18.3

11.6

8.8

10.0

13.1

6.3

8.4

Pennsylvania

6.0

27.0

15.3

11.0

9.3

7.6

12.0

9.9

2.8

Rhode Island

7.2

29.2

18.8

9.9

7.2

9.4

9.9

4.0

4.9

Wisconsin

3.9

27.0

19.2

12.6

11.6

6.8

6.2

12.6

0.7

Wyoming

7.8

21.7

24.3

8.7

11.3

8.7

9.6

5.2

2.6

District of Columbia

3.7

16.1

23.6

19.9

14.3

6.2

8.7

6.2

2.5


CLASSIFICATION

The only effort made to classify the different varieties of alcoholism was to separate the alcoholic psychoses from the chronic form of poisoning. As has already been stated, in grouping the whole neuropsychiatric material, the alcoholic psychoses were considered as belonging to the psychoses. If they were omitted from an intensive study on alcoholism in troops, the result would be an incomplete picture, and so, in this section on alcoholism, the general statistical information includes the psychoses due to alcohol.

METHODS OF DISCOVERING CASES

The neuropsychiatric examinations were usually near the head of the list of the camp examinations, and consequently were in a favorable position as regards the prompt identification of conditions which presented physical


266

symptoms. Of all the neuropsychiatric groups, alcoholism and endocrine disturbances presented more physical symptoms than the others. These two groups, therefore, furnished the highest proportion of cases detected by the routine examinations, 63.9 per cent in the case of alcoholism. (See Table 8). Of the other methods of discovering cases, 26.9 per cent of the cases were referred by other medical officers, these cases being in large part those requiring treatment for such conditions as delirium tremens. Only 8.9 per cent were referred by commanding officers and only a few cases by the courts martial and by the psychologists.

LENGTH OF SERVICE PRIOR TO DISCOVERY

The alcoholics were sifted out very promptly. Table 10 shows 71.6 per cent of all alcoholic cases were identified before they had been in service one month, which is the shortest service rendered by any one group.

TIME OF ONSET

Only five of the cases of alcoholism and six of alcoholic psychoses gave the date of onset after entering the service. (See Table 11.) The large majority of cases whose time of onset was ascertained gave a history of alcoholism for more than five years before entering the service. The essential chronicity of alcoholism which disabled for military service is thereby shown.

RECOMMENDATIONS FOR DISPOSITION

As the greater number of the cases of alcoholism were of long standing, they were considered as of little value to the service, and 1,844, or 85.8 per cent, were recommended for discharge or rejection, and 306, or 14.2 per cent, for treatment, duty, and limited service. (See Table 12.) Excepting the epilepsies and psychoses, recommendations for discharge and rejection ran higher among the alcoholics than in any of the other groups of neuropsychiatric cases.

DELINQUENCY

Thirty-one cases of alcoholism were referred for examination as to misconduct. These constituted 2.1 per cent of the total neuropsychiatric misconduct cases.

FAMILY HISTORY

Of the 1,873 cases analyzed under this heading 744, or 39.7 per cent, have a history of some hereditary neuropathic taint. (See Tables 13 to 17.) These figures indicate the clearest neuropathic inheritance of any neuropsychiatric group. The negro cases form an exception. When individual family neuropsychiatric conditions are investigated, it appears that inebriety takes precedence of all others. Family inebriety occurs with a greater relative frequency among alcoholics than among any other group. Alcoholism in fathers appears especially prominent.


267

AGE

Table 20, which gives the ages of the cases of alcoholism, shows that 36.2 per cent of the cases were between the ages of 30 and 34. The increased ages of alcoholics found in the Army when compared with the statistics relating to the other groups is as follows:

Age, 30 to 34:


Per cent

Alcoholism

36.2

Nervous diseases and injuries

19.5

Psychoses

16.0

Drug addiction

14.5

Psychoneuroses

12.8

Constitutional psychopathic states

12.8

Mental deficiency

9.7

Endocrinopathies

9.4

Epilepsy

9.4


The ages of alcoholics can not be considered without noticing the conditions affecting volunteers and drafted men, a subject referred to elsewhere.

EDUCATION

Table 23 indicates that 89.6 per cent of the cases did not pass beyond the grades; that 8.2 per cent entered high school, and that an additional 2.1 per cent entered college. When compared with the statistics of the other groups of neuropsychiatric cases, with the exception of mental deficiency, one finds the smallest percentage to enter high school and college among the alcoholics. On the other hand they shared with drug addicts the distinction of being only a little behind the average soldier in having had some schooling.

ECONOMIC CONDITION

Only 170, or 7.8 per cent, of the alcoholics were in comfortable circumstances. Not one of the 29 colored alcoholics was in comfortable circumstances. The whites were 4.5 per cent below the average for all neuropsychiatric white cases. With the exception of mental defectives, the percentage in comfortable circumstances is lower than for any other group. Next in order come drug addicts.

HISTORY OF VENEREAL DISEASES

Venereal infections of all kinds were far more frequent among the white alcoholics than among any other group of neuropsychiatric cases, except the drug addicts and the group of nervous diseases and injuries. Among the colored this did not hold true. (See Table 25.)

MARITAL STATUS

Marriages were about as frequent among the alcoholics as among the other groups of neuropsychiatric disorders; divorces, however, were twice as frequent among them. (See Table 27.)


268

HOME ENVIRONMENT-URBAN OR RURAL

One thousand seven hundred and one, or 82.8 per cent, were from the urban districts. The percentages for urban residences were largest for alcoholics and drug addicts. (See Table 28.)

STATE OF RESIDENCE

Seventeen States exceeded the United States distribution average of 3.5 per cent as to alcoholism, viz, Arizona, California, Connecticut, Delaware, Illinois, Massachusetts, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Wisconsin, Wyoming, District of Columbia. (See Table 51.)

When the States exceeding the neuropsychiatric (camp) rate for alcoholism are compared with the States which exceeded the local board rate, as given in Table 5, it is found that a substantial agreement exists between the results of examinations by local boards and at camps. In 11 of the States mentioned-California, Connecticut, Delaware, District of Columbia, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Rhode Island, and Wisconsin-the average alcoholic rate was exceeded at both draft boards and at camps. One State, Pennsylvania, which exceeded the camp rate, just equaled the local board rate. Of the States in which the camp examinations showed an over-average and the draft board examinations did not, in four-Arizona, Montana, Nevada, and Wyoming-the numbers covered in the camp examinations were too small to be of great significance. In Illinois there was a distinct disagreement between the two sets of figures. There were only four States-Maryland, Missouri, New Mexico, and Vermont-in which an excess in the average at draft boards failed to correspond with an excess at the camps.

It would seem, therefore, that in general an excess of alcoholism in the population of any State was remarked by both draft examiners and camp examiners.

NATIVITY

Two hundred and sixty-four, or 12.3 per cent of all cases, of alcoholism were foreign born. This is considerably below the percentage of foreign born in Class I men (17 per cent) and above the percentage (10 per cent) of the foreign born in the whole neuropsychiatric group.

CORRELATIONS WITH OTHER CLINICAL CONDITIONS

In the discussion of mental defect, attention was drawn to the fact that in States and races where mental defect was over-average, alcoholism was under-average. The converse of this also holds true. Among the 17 States (Table 51) which exceeded the United States distribution average for alcoholism, none exceeded the United States distribution rate for mental deficiency. One only, Rhode Island, equaled it. The others all fell below.

Further correlations of alcoholism with other clinical conditions show few rates of particular significance except in the cases of psychoses. The latter


269

appear to have an excess distribution rate in States high in alcoholism. In explanation of this, two hypotheses are possible: That intemperance increases insanity, or that men of the psychotic group are prone to excess in alcoholic indulgences. The correlation of alcoholism with other conditions in both native and foreign-born races is in agreement with those observed in the States. In other words, among races in which the alcoholism rate is high, the mental-deficiency rate is low, while the rate for psychoses is usually high. (See Table 34.) An exception is to be noted in the case of the Irish, where the alcoholism rate is high, but the rate for psychoses is below the average except for the foreign born.

REFERENCES

(1) Defects found in Drafted Men. Statistical Information. Compiled from the Draft Records. Washington, Government Printing Office. 1920.

(2) Based on: History of Base Hospital No. 214, by the commanding officer. On file, Historical Division, S. G. O.

(3) Psychological Examining in the United States Army. Memoirs of the National Academy of Sciences, Volume XV. Washington, Government Printing Office, 1921, 553.

(4) Second Report of the Provost Marshal General, to the Secretary of War, on the Operations of the Selective Service System to December 20, 1918. Washington, Government Printing Office, 1919, 118.

(5) Ibid., 159.

(6) Special Regulations, No. 65, W. D., 1918.

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