Twenty or twenty-five years ago it was a common assumption that psychiatric clinical material was mainly contained in institutions for the insane. With increasing knowledge of mental disorders, however, it eventually became evident that vast amounts of psychiatric material, often unrecognized as such, existed outside of institutions. The question thus arose, What is the precise amount and nature of the extramural psychiatric material?

To find an answer to this question surveys of mental disorders have been undertaken in various communities. One such survey, recently carried out in Nassau County, N. Y., under the auspices of The National Committee for Mental Hygiene, embodies method and viewpoint gained from the experiences of similar previous undertakings. The following account is abstracted from the report of that survey.1

To-day the question of the prevalence of mental disorders is no longer an academic one. One no longer asks: What is the percentage of "insane," or "feeble-minded," or "mentally defective" persons in a given community? But rather, What instances of social maladjustment, sufficiently marked to have become the concern of public authorities, are, upon investigation, to be attributed mainly or in large measure to mental disorders?

All efforts hitherto made in coping with the problems of vice, crime, pauperism, and disease have met everywhere with only partial success at best; the difficulty has been due to lack of any clear knowledge of underlying causes. In the meantime a great deal of evidence has been accumulated in the course of psychiatric progress showing that these social phenomena are in large part causatively related to mental disorders; thus the main object of the survey became to study the nature of this relationship.

1 A. J. Rosanoff. Survey of Mental Disorders in Nassau County, N. Y. 1917.

In all 1592 mentally abnormal individuals were found, constituting 1.37% of the total population.1 These were classified as follows:

Table 10

Insane...

394

Epileptic...

72

Feeble-minded...

634

Constitutional psychopathic states...

492

The same cases were also classified sociologically as follows:

Table 11

Retardation in school,truancy,unruliness,etc...

189

Sex immorality.................................

116

Criminal tendency...

81

Dependency....

280

Inebriety, including drug addictions....

324

Other social maladjustments.....................

439

No maladjustment...

163

Of these cases 946, or 0.82% of the entire population, were judged to require institutional care, whereas only 365 were receiving such care.

The survey has shown very clearly that for the bulk of cases presenting psychiatric problems the benefit of psychiatric study, judgment, and treatment is not available. These cases are now in the hands of the police, overseers of the poor, justices of the peace, church and private charitable organizations, and general medical practitioners.

1 These figures do not include an estimate of cases in the schools, which would raise the percentage to 1.72.

Similarly, psychiatric problems in cases among school children are left without attention or, seemingly, even deliberately avoided. The medical examination of children in schools takes into account height, weight, chest expansion, eyes, ears, nose, tonsils, teeth, etc., but not mental condition. Save by way of rare exception, where a special class is provided for persistently retarded children, mental abnormalities or peculiarities receive no attention on the part of the educational authorities. This is prejudicial not only to the interests of the abnormal children, but of the others as well. It is clear that more special classes are required; small school districts could form unions for the joint establishment and management of such special classes.

An extraordinary opportunity of gaining an idea of the magnitude and nature of extramural psychiatric problems was furnished by the experience in the organization of the National Army in the World War. The following statistics represent the numbers of various neuro-psychiatric cases per 100,000 recruits discovered and rejected by local draft boards or medical officers in training camps:l

Table 12

Mental deficiency...

1445

Epilepsy...

516

Constitutional psychopathic states...

55

Dementia praecox...

77

Manic-depressive psychoses...

21

Other psychoses...

137

Psychoneuroses...

153

Alcoholic psychoses...

3

General paralysis..

9

Malingering...

1

There is not a general hospital, health board, army post, school, charitable institution, police station, court of law, prison, or large industrial organization in the country, but which has daily to cope with psychiatric problems.

1 These figures, kindly furnished by Dr. C. B. Davenport, are from records of examination of 2,753,922 recruits.